Mental Health and NHS Performance Update

Lord Hunt of Kings Heath Excerpts

Monday 9th January 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for repeating the Statement, and welcome him to the Dispatch Box.

Of course we welcome any announcement that will help to improve mental health services in this country, as indeed we welcomed such announcements exactly 12 months ago, when the then Prime Minister made similar promises. But it seems that the more Prime Ministers promise, the less the NHS delivers. I remind the Minister that the Government’s record actually shows that we now have 6,600 fewer nurses working in mental health than were inherited. We have also seen a large reduction in mental health beds. I remind him of the report and analysis by YoungMinds just before Christmas, which showed that local children’s mental health budgets were raided in order to plug funding gaps elsewhere in the NHS. The survey revealed that when clinical commissioning groups were asked whether the extra £1.4 billion pledged over five years in 2015 for child and adolescent mental health services was going to be spent on CAMHS, nearly two-thirds of CCGs that responded said they used some or all of the money to backfill cuts or spend on other priorities. This has been replicated on a number of occasions when it comes to pledges made by the Government in relation to mental health. The fact is that they simply cannot guarantee that the NHS will deliver. What certainty do we now have that the pledge made today by the Prime Minister is going to be implemented, given the lamentable record of NHS England and the NHS in responding to similar pleas in the past? Why did the Prime Minister refuse to say this morning that she would ring-fence this money to ensure that it indeed went to the services that she said it had to go to?

I turn to the winter crisis. This morning the Secretary of State said that things have been falling over in only a couple of places, but the reality is that one-third of hospitals declared last month that they needed urgent help to deal with the number of patients coming through the doors; we know that accident and emergency departments have turned patients away more than 140 times; 15 hospitals ran out of beds in one day in December; and several hospitals have warned that they cannot offer comprehensive care. We know that we are going back to the dreadful days of the 1990s, with elderly patients left languishing on hospital trolleys in corridors, sometimes for over 24 hours.

Whatever the labels that charities use, whatever the semantics, the Government cannot deny that the NHS is facing a severe winter crisis, the culpability for which lies firmly with the Government. Does the Minister agree that it was a monumental error to ignore the pleas for extra support for social care in the Autumn Statement? Will he now support calls for the £700 million of social care funding allocated for 2019 to be brought forward to help services to cope this winter? Will he urge the Chancellor and his right honourable friend the Prime Minister to announce a new funding settlement for the NHS and social care in March’s Budget?

I listened with great care to the remarks the Minister made on the four-hour A&E target. The implication is that the Government are running away from the target and are now going to use different definitions for who is going to be expected to have that target met and who is not. I remind the Government that in 2010 they inherited a 98% rate for the four-hour target being met, which the NHS had achieved. Under his Government, the NHS has reduced its achievements in A&E consistently, year after year. As far as I can see, the Secretary of State’s weasel words today about the four-hour target show that the Government are now admitting that they will never achieve that target again. What are the Government doing? We know they are going to change the target and the definitions. On that subject, what guidance has the Minister taken from the Royal College for Emergency Medicines that the so-called new standard is actually appropriate?

I turn to the deaths of two patients at Worcestershire Royal Hospital. They had been waiting on hospital trolleys. Will Ministers lead an inquiry into those deaths? Are they aware whether these were isolated incidents? When does the trust intend to report back on its own investigation?

I have been reading today the draft Herefordshire and Worcestershire sustainability and transformation plan, which Ministers point to as a solution to all their problems. The problems of the Worcestershire acute trust have been known for many years—it simply does not have the capacity to deal with the flow of patients into that hospital—yet the sustainability and transformation plan actually plans for fewer beds in that trust over the next three to four years. How on earth can the Government justify reducing the number of beds in that trust when it is under such tremendous pressure because of a lack of capacity?

There is no doubt that much of the current crisis could have been avoided. Hospital leaders, council leaders, patient groups, MPs across the Commons and noble Lords all urged the Chancellor to give the NHS and social care additional resources in the Autumn Statement, but those requests fell on deaf ears. We now see the dismal consequences. The Government need to do very much better.

[Baroness Walmsley (LD)]

My Lords, I also welcome the Minister to his first appearance in his new role. I add thanks from these Benches to all the health and care staff who gave up their Christmas holidays to care for patients.

We welcome the Prime Minister’s attention being turned to mental health, and the emphasis on the roles of schools and the workplace. The NHS of course cannot do the job alone. However, many people are not getting mental health treatment, getting it late, not getting the right treatment or getting it many miles from home, which prevents their families and friends supporting them. As the noble Lord, Lord Hunt, said, the money is not getting through to front-line mental health services, despite the £1.4 billion secured from the previous Chancellor by my right honourable friend Norman Lamb when he was coalition Health Minister. Why is that?

Is it not true that if there were not a shortage of funding for other services, CCGs would not be tempted to raid the mental health budget? That is what they are doing. FOI requests by Young Minds, as has been mentioned, show that half of CCGs are using money allocated to children’s mental health to prop up physical health services, which are also in crisis. That is wrong. A recent survey of child and adolescent psychiatrists show that a whopping seven out of 10 of them thought that mental health services for children and young people were inadequate. By any calculation, that is a national disgrace.

Will the Minister ring-fence the money that has been promised to mental health and improve transparency with the publication of the mental health dashboards, which are meant to show how much is being spent on mental health services in every area and on what services? The £1 billion that has already been announced for adult mental health is back-loaded to the end of the Parliament. Will the Government bring it forward to deal with the current crisis? Will they at last acknowledge that there must be a cross-party discussion about how to raise the money needed for health and social care? Will they ensure that the lessons learned in Manchester about integration are spread to other areas? That could save money and provide better service. Will the Government provide more funding for social care? As the noble Lord, Lord Hunt of Kings Heath, has said, without that, nothing will improve.

To return to mental health, I acknowledge that funding is not the whole story. The main point of the report from the values-based CAMHS commission, chaired by my noble friend Lady Tyler of Enfield, was that there needs to be a shared set of values and a shared language across all those involved with children and young people’s mental health, thereby enabling the system to have widespread change and a far more joined-up response to mental health issues. Does the Minister agree with that? How could it be achieved?

Health Service Medical Supplies (Costs) Bill

Lord Hunt of Kings Heath Excerpts

2nd reading (Hansard): House of Lords
Wednesday 21st December 2016 Lords Chamber

[Lord Lansley (Con)]

My Lords, I am very pleased to follow the noble Lord and pay tribute to the fact that he has clearly identified some of the issues to which I will refer briefly here at Second Reading but which we will need to look at in Committee. The noble Lord did so very ably and helpfully. I thought that my noble friend the Minister set out the Bill very clearly, which is very helpful to the House. I understand that he is moving on to new ministerial responsibilities, so perhaps I may be the first to say that I know—having had the privilege of knowing my noble friend over many years since we first entered another place together—that his knowledge, experience, expertise and wise judgment on health matters is highly respected and much esteemed throughout the sector. His guiding hand will be much missed but we extend enormous thanks to him for all that he has done not only at the Department of Health but prior to that at the Care Quality Commission.

I draw attention to my interests in the register, and in particular as an adviser to MAP BioPharma—although the company is not directly affected by the provisions of the Bill.

In another place this Bill was referred to as a technical Bill. That is probably not an accurate description. It extends the powers of Ministers and gives them the ability to secure a payment under the statutory scheme which they did not feel they were able to do. It gives Ministers greater powers to control the prices of unbranded generic medicines which they did not have and it gives them a greater power to require information from suppliers. So there is a significant threefold extension of the powers of Ministers.

I completely understand and accept the reasons for the Bill. Ministers were right to bring it forward. There has clearly been a transfer that one might uncharitably describe as gaming between the voluntary and the statutory scheme—more politely it would be called arbitrage between the two—since there are suppliers of medicines, particularly in the hospital sector, that discount their list prices to those purchasers. Therefore, a statutory scheme that simply consists of a cut to the list price does not necessarily have any effect on their prices. So it does not have the intention that the voluntary scheme has. The Bill, quite rightly, closes a potential gap in control of the supply of generics by those companies that are also members of the voluntary scheme.

The Bill also extends information supplied by companies for dispensing and it might be useful in all of those to have a little bit of history, if I may detain your Lordships on that. I remember that before 2010, when I was shadow Secretary of State for Health, we were very clear that what we wanted to do as a potential incoming Government was to give stability to the industry and to that effect we said that we would not change the then PPRS before the renewal in 2014. But we were equally clear that when we got to the new PPRS in 2014, it needed to change and that, as it stood, its objectives were no longer being satisfactorily met. It gave businesses freedom for pricing medicines at introduction—and we should be well aware of the relative importance of this. The noble Lord, Lord Warner, referred to the relatively small size of the UK pharmaceuticals market, with about 3% of the international marketplace for pharmaceuticals, but the UK list price plays a much larger part in reference pricing internationally, with something like 25% of the total pricing effect. So it is very important to the industry to have that freedom of pricing.

However, the effect of the ability to price at the list price is that one has a NICE health technology assessment and evaluation with a threshold applied, which still leads frequently to NICE saying no to medicines. The net effect is that we have a licensed and effective medicine available to patients—but at the list price NICE says no and patients lose out. In our view, back then, this was an entirely unsatisfactory position. It seemed to us that, when an effective medicine is available to patients, it should be available to clinicians and patients through the NHS, and between the Government and the industry a mechanism should be established to ensure that a fair price is paid for the medicine. The patient should get the drug, the industry should get a fair price and the NHS should pay only what is necessary to achieve that.

The lack of access in the short run, as your Lordships will recall, is why we established the Cancer Drugs Fund, after Mike Richards’ report on the relative access in different countries in Europe to medicines demonstrated a significant shortfall in access in this country to cancer medicines in particular. But the intention always was—and I reiterate this, because it is frequently misrepresented—for the Cancer Drugs Fund to end at the beginning of 2014, because the new pharmaceutical price regulation scheme was intended to achieve the access benefit that the Cancer Drugs Fund was achieving in the short run. The fund did not overspend up to 2014; it was retained beyond 2014 and it then overspent, but that was not its original intention. So I do not accept the criticism of the Cancer Drugs Fund.

However, the PPRS negotiation for 2014 did not deliver the changes that were intended. It delivered budget control to the Treasury, freedom of pricing and introduction for the industry and a degree of rate of return reassurance to the industry. So to that extent, the taxpayer was well represented, the NHS may say that it was quite well represented and the industry was well represented—but I am not sure that patients were. What we need is a PPRS that serves patients at least as well as it serves the NHS.

[Lord Hunt of Kings Heath (Lab)]

This is a very interesting exposition, but could the noble Lord clarify that there is a difference between the notional list price, which is used as a marker for many other countries, and the actual price paid by the NHS? Secondly, does he agree that, if the Treasury had not purloined the rebate, we would have had the money and patients would have had access to new drugs?

[Lord Lansley]

The noble Lord makes interesting points, which point to where we were always intending to go—to a point where there was in effect a negotiated price between the industry and the NHS so that there was a proper discount. Now we have a rebate system. There was a lot of debate in the other place about where the rebate money went. It goes back into the NHS through the mechanism of the overall Consolidated Fund, so it is less transparent than is the case in Scotland, for example. However, that does not mean that it is lost to the NHS.

I will anticipate something that I was going to say later. A consultation is taking place involving NHS England and the National Institute for Health and Care Excellence, looking at how they can work together to introduce budgetary impact considerations alongside NICE evaluations to establish what prices the NHS should pay for medicines. That is taking us in the direction we have to go—namely, what is in effect negotiated pricing through the NHS to ensure access to medicines for patients. That is the positive construction of the present consultation. The negative construction is that it will create in effect double jeopardy. In the first instance NICE may say no on the basis of the list price. Then NHS England may add a second reason to say no because of the budgetary impact of new medicines—so there is an inherent problem with that.

I will finish the history for a moment. Where dispensing is concerned, there is a history under the last Labour Government of the pharmacy sector significantly exceeding the planned margin between the wholesale price and the reimbursement price because of a lack of good information. Therefore, we can be absolutely clear that an important purpose of the Bill is to get the margin survey right and provide more comprehensive data on the prices being achieved in the purchasing of medicines so as to make the reimbursement price deliver the agreed gross margin as part of the global sum to pharmacies.

Therefore, I support the Bill and its intended purposes. It will be important that it is used properly. The noble Lord, Lord Warner, made some very good points, including on equivalence between the two schemes. Gilead, a firm in my former constituency when I was in another place, continues to tell me what it thinks about these things and points precisely to the potential disparity between the statutory and voluntary schemes in relation to medicines introduced since 1 December 2013. If equivalence is the intention, we need to ensure that the Bill specifies that.

We are looking for a competitive environment in relation to unbranded generic medicines. The Competition and Markets Authority is pushing for that and the measures in the Bill can help Ministers to achieve that prospectively, as it were, rather than just dealing with abuse. But it is wrong for Ministers to take powers which would allow them to behave non-competitively. There is monopsony in this—monopoly purchasing by Ministers. Where a competitive environment is created—for example, where the price is determined in a competitive tender process—it would be completely wrong in my view for them suddenly to find that a price agreed through a competitive process is overridden by ministerial diktat—as the noble Lord said, Lord Warner, said.

I hope that we will also discuss two other issues. A very important one is to build back into the thinking on the future PPRS, through this legislation, what a future PPRS should have at its heart. Ministers making decisions about pricing structures should have specific reference to affordability. They should also have reference to the ability for patients to access the medicines they need through the NHS; the extent to which the pricing system enables unmet need to be met; and the extent to which medicines deliver relative therapeutic benefit, so that we literally pay for innovation and for therapeutic advance, but do not pay a lot of money for me-too drugs with brandings attached to them. However, we should pay for societal benefit. One can imagine the considerable benefit to society that would be derived from a new drug to treat early onset Alzheimer’s. We should also give explicit support to innovation. As the Bill proceeds, I hope that we will see more detail on not only the regulations but how the consultation between NHS England and NICE is proceeding. Perhaps the Government could also say more about their formal response to the accelerated access review and the life sciences strategy.

I support the Bill and I hope all the issues that I have referenced will be brought forward and discussed, including the structure of the information powers. At the moment, they are too wide-ranging and lacking in safeguards. Strictly speaking, there may be circumstances in which it is necessary for Ministers, if they ask for information, to provide a notice saying for what purposes it will be used and with whom it will be shared. Under those circumstances there should also be the potential for an appeal to the General Regulatory Chamber—but we can look at that in more detail in Committee.

As I say, I support the Bill and I hope we can look in Committee at giving more clarity on some of those issues and perhaps even building in one or two safeguards.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, as the Bill involves the supply of medicines and other goods to the NHS, I should like to start by declaring an interest as president of the Health Care Supply Association and of GS1, the barcoding organisation. I too congratulate the noble Lord, Lord Prior, on his move to the business department. We have very much enjoyed working with him and debating the issues. He has been unfailingly courteous to your Lordships’ House, and I am sure that we have all appreciated the work he has done on behalf of the Department of Health. Like the noble Baroness, Lady Walmsley, I too congratulate the noble Baroness, Lady Chisholm of Owlpen, on her retirement from government and thank her warmly for the work she has done as a Whip. She has taken part in many Dispatch Box debates and we are very grateful to her. I also, of course, welcome the noble Lord, Lord O’Shaughnessy, to his new post. He will enjoy taking the Bill through its remaining stages—perhaps.

As noble Lords have said, the recent fines imposed by the Competition and Markets Authority on Pfizer and Flynn Pharma for charging the NHS excessive prices is a salutary warning to the pharmaceutical industry. We certainly welcome the provisions in the Bill that deal with the small number of companies that have exploited loopholes in current legislation by controlling the price of unbranded generic medicines. However, the Bill misses an opportunity to counter the growing lack of access to new innovative drugs, which is putting the health of NHS patients at risk. I have listened to what the Minister has said, but it seems to me that the cumulative impact of decisions made by his department, and particularly by NHS England, is that there is less and less access. This is a very serious problem, both for the NHS and patients and for the industry and the life sciences sector.

My other concern is that this is a burdensome regulatory Bill. In fact, I am sure that in his new post the Minister will be shocked by the number of regulations that this Bill brings in, without any justification whatever, it seems to me. I hope that as we go through the passage of the Bill, we might look at making some of those regulatory requirements more focused, as the noble Lord, Lord Lansley, suggested.

The powers under the NHS Act currently allow the Secretary of State to make a statutory scheme for limiting the prices or profits of companies that choose not to be members of the voluntary scheme. The Minister has explained that the statutory scheme is less effective in terms of the level of saving that it makes than the mechanism in the voluntary scheme, thus leading to some companies leaving the voluntary scheme in favour of the statutory scheme. I well understand the argument that he put forward. On the other hand, I would argue that the voluntary scheme has served both health service patients and the industry well over the years. It is important that in bringing these measures forward we do not in effect remove the voluntary nature of the PPRS. It would be helpful if the Minister would set out the circumstances under which the powers in Clause 2 would be exercised. Is it intended that the power could be used to change the current voluntary PPRS scheme? Could these provisions be used in the future to restrict the voluntary nature of the PPRS agreement?

I also raise a point referred to by the noble Lord, Lord Warner. Are any perverse incentives likely if companies in the statutory scheme move to the rebate system applying in the voluntary scheme? At the moment, I am informed that companies in the statutory scheme are able to lower their prices directly to the NHS because they are not part of the rebate scheme. In terms of those companies, if the NHS gets the benefit of the lower prices, the department that gets the benefit of the rebate is the Treasury. Is there a risk in switching from the statutory sector to the voluntary sector in terms of the outcome for the National Health Service?

Also, has the Minister assessed the risk that small companies currently in the statutory sector, which may be less able to absorb rebate payments, may leave the market altogether? The noble Lord, Lord Warner, referred to that. I also want to ask about something that the noble Lord, Lord Lansley, mentioned. I understand that the aim is to permit broad equivalence to be achieved between the voluntary and the statutory schemes. Does the Minister think that, to reassure the sector, that should be explicitly stated in the Bill?

Clause 5 extends the power to control the maximum price to other medical suppliers and not just medicines. I listened carefully to what the Minister said, but I am not yet convinced that there is any reason at all for the Government to propose this. The impact assessment, as far as I can see, is silent on the matter. The Minister will know that both the BHTA and the ABHI expressed concerns about the burdens that will be put on the devices and technology sectors. There is also the issue of consultation. It is clear that the major trade associations were consulted, but the industry has a whole host of organisations representing bits of it, such as the continence and stoma industry, for example, which is an important, significant player but was not consulted, despite the implications for it. It comes to the point when the Minister essentially says, “We are going to have these powers, but we do not expect ever to use them”, and they have not been used since 2006. My advice to the Government is to forget it because we seriously question whether Clause 5 should stand part of the Bill.

On regulation in general, I had thought that one benefit of Brexit would be that no longer would we have regulations that the Government consider too burdensome but which they had to agree to, effectively, through the compromises that negotiations in Europe always lead to. I find it curious. This seems to be an example of gold-plating legislation. Clearly, the Government had to deal with a generic problem and introduced this, which is like a Home Office Bill, as the noble Lord, Lord Warner, described it. It is like a Christmas tree. The department found lots of other nice things to put in it, but cannot actually come forward with any strong evidence as to why they should be included. In my naivety I thought that in this Brexit world we would be going for light-touch regulation, but I have to say that this does not look like light-touch regulation to me.

A further example of this is found in Clauses 6 and 7 relating to the provision and disclosure of information. The ABPI has pointed out that the information requirement is onerous and goes well beyond what is necessary, but what is striking is that the provisions are drawn so widely. My reading of the Bill suggests that it applies to any,

“person who manufactures, distributes or supplies any UK health service products”.

The Bill goes on to explain that, so far as England is concerned, it applies to any medical product used to any extent for the purposes of the health service under new Section 264A(1) and any other medical supplies or related products required for the purposes of the health service. We are talking about millions of products. The impact assessment states that the costs have not been quantified for manufacturers, wholesalers and dispensers. Why have the costs not been quantified for these businesses, which number in the tens of thousands? I thought that that was what impact assessments were all about and I thought that the Government had a policy in relation to reducing the regulatory burden on industry. It is very difficult to understand why the department has gone for such a broad-based power and I will certainly be interested in seeing whether it is possible to hone down these clauses and focus on the information that the Government can prove they actually need.

I want to pick up on the issue about access to medicines. What is so striking about the Bill, which is concerned with medicines, is the glaring absence of provisions to increase the uptake of new medicines by NHS patients. Any number of reports, in particular over the past two years, show that we have taken an increasingly restrictive approach to the adoption of new medicines in this country. This goes alongside the current consultation by NICE referred to by the noble Lord, Lord Lansley, with the proposal that if a NICE-approved treatment is expected to exceed £20 million in any of the first three years of its use on the NHS, NHS England can ask NICE to allow a longer period of phased introduction. I think that the noble Lord, Lord Lansley, suggested that this could be okay, but there is a risk of double jeopardy. We need to hear from the Government in this Bill how it is not going to be double jeopardy. The industry goes through all the processes it needs to in order to ensure that a treatment gets through the NICE process. The medicine then has, if you like, an affordability test which is in addition to a cost-effectiveness test, and thirdly, the Minister is taking draconian powers to reduce the amount of money going to the industry generally. That is triple jeopardy. The question I put to the Minister is this: what is the cumulative impact of all these proposals, not only in relation to the actual price but in relation to access to innovative new drugs?

The noble Lord, Lord Lansley, referred to the 2014 PPRS agreement and said that it could have been ground-breaking in relation to access for patients. I agree because it was a very good agreement and one that could have finally opened the door to the NHS giving access to treatments that every other country has access to before we have here. I know that the noble Lord and I seem to disagree about where this rebated money goes, but he will know that the industry agreed to hold drug costs for a five-year period with the bill staying flat for two years and then growing only slowly after that. There have been one or two modifications since then, but that is the broad principle. If drug expenditure by the NHS goes over the agreed level, the industry will pay a rebate at every quarter, and so far it has paid £1.5 billion back. The noble Lord’s argument is that I should not worry about that figure because the NHS gets it. As I see it, what clearly happens is that the Treasury forecasts in advance what the rebate will be. It is also well advertised in advance what the allocation to the NHS will be. In essence, the Treasury gets the benefit because it reduces the contribution it makes to a given figure.

If it had been agreed that the rebate could have been used—perhaps as in Scotland or in another way—to fund much greater access to new drugs, we would have achieved what the noble Lord, Lord Lansley, set out to do. It is a hugely missed opportunity. None the less, I hope the Government, when looking for the next PPRS agreement, will look at the lessons to be learned. I agree with him and my noble friend that clearly we need value for money and certainty but, unless we can deal with this pervading problem of lack of access to new medicines, NHS patients will get no benefit whatever.

We have to link that to the health of the life sciences sectors and the industry. In his new role, the Minister will be as concerned about this as he probably is at the moment. The UK has been one of the foremost countries in the world for drug development. We know that our life sciences was one of the reasons why. The noble Lord, Lord Lansley, suggested that flexibility on pricing on first introduction is also a reason because it acts as a benchmark for other countries, but I have no doubt whatever that the NHS’s failure to adopt new medicines is putting future investment at risk. I do not think we can be complacent. A long time ago, when I was responsible for it, the UK developed about 30% of the top 100 new drugs. That, as I understand it, is now down to 14%. The risk is we can go lower.

We very much look forward to debating the Bill. It clearly has very useful measures on drug costs, but no case has been made to extend its provisions to medical devices and technologies. It looks like gold-plating regulation, which we would like to try to improve, but overriding this is the sense that, until the Bill provides for increasing NHS patients’ access to ground-breaking new treatments, it remains defective.

Consumer Rights (Enforcement and Amendments) Order 2016

Lord Hunt of Kings Heath Excerpts

Tuesday 20th December 2016 Lords Chamber

[Viscount Ridley (Con)]

My Lords, in relation to the tobacco and related products directive, my noble friend mentioned several times the aim of driving down smoking in this country. We are now in a situation in which there are many varieties of tobacco products available to people, many of which do not involve smoking. Could he bear in mind that good intentions in regulation often lead to unintended consequences? Would he ask his officials to brief him on Yale University’s recent research, demonstrating how increases in regulation of e-cigarettes are pushing up smoking rates among young people?

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the noble Lord for his comprehensive analysis of the order before us this afternoon. I declare my interest as president of the Royal Society for Public Health.

We have made great strides in this country in reducing smoking. I am particularly proud of the last Labour Government’s measure in relation to the ban on smoking in public places—and, indeed, of my own amendment in the last Parliament, which the Lords passed, to ban smoking in cars when children are present.

Although the number of smokers in this country has halved since 1974, currently one in five adults still smoke. Enforcing the regulations and legislation relating to the sale, packaging and marketing of tobacco is, therefore, important. In that regard, I want to ask the Minister about progress on the enforcement of the Tobacco and Related Products Regulations 2016 and the Standardised Packaging of Tobacco Products Regulations 2015. Can the Minister confirm that enforcement officers have already had a number of options available to enforce these regulations? Secondly, how much enforcement activity has there been? Thirdly, how good does he assess compliance to be?

I want to pick up the point made by the noble Viscount, Lord Ridley, on e-cigarettes. The noble Lord, Lord Prior, will recall that e-cigarettes were embraced within the tobacco regulations. I want to ask him about the recent alarmist and, I believe, misleading report of the US Surgeon General, on the use of electronic cigarettes by young people, in which he urges greater restrictions on access to vaping products. Would the Minister go so far as to agree with me that it was a pretty shoddy piece of work, which does not seem to be evidence based? Does he agree that it focused on risk to teenagers without looking at potential benefits to adult smokers; that while the science is detailed in the body of the report, the headlines and marketing material are not appropriately caveated; that the report does not put vaping risks into context with smoking or other risks; and that the Surgeon General proposed restrictive policies on e-cigarettes for the supposed benefits to young people without considering the likely harmful consequences for adult vapers or smokers? He also appears to be treating vaping products as just another form of tobacco, which of course is absolutely wrong.

Will the Minister say that the Government will not go down the route that the US Surgeon General has taken? Will he confirm that vaping has been outstandingly successful in helping adult smokers to stop smoking? Will he also confirm that there is no evidence of vaping in the UK being a gateway to smoking for young people? Has he also noticed that, in reality, in the US the most recent data on youth smoking, published, just after the Surgeon General’s report, actually contradicts the alarmist nature of that report, since it shows that vaping is in decline? That point was made by the noble Viscount.

The relevance of raising this in your Lordships’ House today is that the risk is that the kind of alarmist headlines that we heard in our own media in relation to that report might dissuade smokers from switching from smoking to vaping. There are concerns that a large and increasing number of smokers incorrectly believe that vaping is as harmful as smoking, and there is a real danger that smokers may decide not to switch to safer alternatives, such as e-cigarettes, and are potentially missing out on what I can describe only as a very useful smoking cessation aid. Will the Minister reiterate that evidence to date on e-cigarettes indicates that they present a safer alternative to smoking and, for many—for thousands and thousands of people—are a useful cessation tool?

[Lord Prior of Brampton]

My Lords, two questions have been raised. The first related to the existing powers of trading officers, how much enforcement has been going on and how good our compliance is. I hope that the noble Lord will be happy if I write to him with the details as I do not have the figures at my fingertips. We have already had two quite long debates in this House on vaping. I entirely take on board the point made by my noble friend Lord Ridley—namely, that the road to hell is paved with good intentions, and sometimes good intentions have unintended consequences. I have not read the work carried out at Yale University to which he referred, but I will certainly ask my officials to have a look at it. I am very happy to meet him subsequently to discuss its findings.

On the more general point raised by the noble Lord, Lord Hunt, I absolutely reiterate that all the evidence, whether from Public Health England or the Royal College of Physicians, indicates that vaping is much better for you than smoking cigarettes. Of that there is absolutely no doubt, so we should be unequivocal about it. On the other hand, I think the noble Lord will agree that better than vaping is not to vape or smoke cigarettes or anything else at all. Therefore, we certainly should not encourage young people to vape. I cannot comment on the science behind the US Surgeon General’s report, but I think that his concern was that the number of people taking up vaping has gone up by some 900% from 2011 to 2015, and that people may have been caught up in vaping who would not otherwise have smoked. If these people would otherwise have smoked, it is obviously much better that they should vape. However, if they would have done neither, it is much better to have done neither. I think that is the Surgeon General’s fundamental concern. Therefore, the policy in this country is to encourage vaping compared with smoking but not to publicise vaping to young people in the traditional way through risqué advertising and the like. That is probably not a bad balance to strike.

Consumers and businesses benefit from the Consumer Rights Act in all sectors. The Act was introduced to simplify, strengthen and modernise the law and consolidate enforcement powers. It is right that these powers are applied to the specified legislation without further delay and to provide legal certainty for enforcement authorities.

NHS: Community Pharmacies

Lord Hunt of Kings Heath Excerpts

Tuesday 6th December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the fact is that across the NHS we are looking to save £22 billion, and sadly, community pharmacy cannot be exempt from those necessary efficiency requirements. But I repeat that, over time, we will see more and more NHS services delivered by community pharmacies, whether it is a sore throat testing service or the treating of minor ailments.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in these rather strange times, can I take it that the noble Lord’s party no longer believes in competition? This policy is intended to reduce the number of community pharmacies in the high street. Why do the Government want to reduce patient choice when the profession clearly can help reduce demands on GPs and A&E services at a very pressurised time?

[Lord Prior of Brampton]

This party does believe in competition. But it also believes that the NHS’s supporting community pharmacies to a very large extent when 40% of them are in clusters of three or more within 10 minutes’ walk from each other, and paying an establishment fee to each of those pharmacies, is probably not a very good allocation of resources.

HIV: Barriers to Treatment

Lord Hunt of Kings Heath Excerpts

Thursday 1st December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, one of the purposes of the Act promoted by my noble friend Lord Lansley was to remove the Secretary of State, and indeed politicians, from these very difficult clinical decisions. That decision will be made by NHS England, and we expect a positive decision to be made in the very near future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, Ministers cannot evade their responsibility for the NHS in the end. NHS England is not a clinical body; it is a quango wholly owned by and wholly responsible to government. The decisions it has made have been purely about money, and it is continually endorsing crude rationing of services and the restriction of drugs. In the current agreement with the drug companies, the Minister’s Government have received nearly £2.5 billion back in rebates from those companies. Why on earth has his department allowed the Treasury effectively to ambush that money, instead of it being spent, as it should have been, on innovative new drugs for NHS patients?

[Lord Prior of Brampton]

My Lords, I think the noble Lord will agree that there is a clinically driven process, through the specialised commissioning groups and the clinical priorities group within NHS England, that attempts to look at all these drugs in an objective, clinical way. Surely it is better that these decisions on priorities should be made by clinicians acting in that way than by politicians, who are subject to all the pressures of which we are all only too well aware. Of course affordability is an issue in assessing whether a new drug should be commissioned; it always has been and always will be. The £2 billion, which the noble Lord has mentioned before and which I think comes from the PPRS, is taken into account when setting the overall budget for NHS England.

HIV Diagnosis: Clinical Guidance

Lord Hunt of Kings Heath Excerpts

Thursday 1st December 2016 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness is absolutely right. Early diagnosis is absolutely critical. We have made huge progress. The WHO guidelines aim for 90% of people with HIV to be diagnosed. We are at 87%. Sweden is the only country in the world that has hit the 90% target. I point to the It Starts With Me programme, which is based around individual responsibility and is co-ordinated by the Terrence Higgins Trust, which is making great progress.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I very much welcome the initiatives taken by the Government in this area but does the Minister accept that the NHS itself could do more, particularly in accident and emergency departments and in primary care? Would he be prepared to convene a meeting with NHS England to discuss how the NHS could be persuaded to be much more proactive in relation to testing?

[Lord Prior of Brampton]

My Lords, I am very happy to arrange a meeting of that kind. We are expecting an announcement very soon on the PrEP issue and it may be worthwhile having that meeting after that announcement.

Mental Health: Children and Adolescents

Lord Hunt of Kings Heath Excerpts

Wednesday 16th November 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, when I read the noble Baroness’s paper over the last couple of days, I thought the part about schools was the most persuasive. School is clearly critical. The pilot project being done by the Department of Health and the Department for Education, trialling the single point of contact in schools, is very important, as is the PSHE guidance on teaching about mental health at the four key stages of education.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord’s sincerity in this area is not in any doubt. However, he knows that, despite the instructions that Ministers have given to the NHS through the NHS mandate, the health service is actually disinvesting in many mental health services. On Monday, the noble Lord will have seen the King’s Fund report on sustainability and transformation plans, on which he has rested much of his hope about the future of the NHS. Mental health services appear to be very marginal to the focus of those STPs. What action do the Government intend to take on this?

Cataract Operations

Lord Hunt of Kings Heath Excerpts

Wednesday 16th November 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare an interest as a trustee of the Royal College of Ophthalmologists. I understand from the Minister that NICE is preparing guidelines, but in the meantime, will he take this opportunity to condemn CCGs in which there is crude rationing of cataract services? I refer him to the Daily Mail freedom of information survey in July, which showed that under some clinical commissioning groups, a person not only had to have poor eyesight, but had to demonstrate that they had fallen twice in the last year, lived alone and had hearing problems, or that they were caring for a loved one. If that is not crude rationing, I do not know what is.

[Lord Prior of Brampton]

Clearly the case that the noble Lord mentions is totally unacceptable. Where CCGs are rationing access to cataract operations on such a crude basis, we would all deplore that. But as I said, there is variation around the country, and the new NICE evidence-based guidelines will help to address that.

NHS: Cancer Patients

Lord Hunt of Kings Heath Excerpts

Wednesday 9th November 2016 Lords Chamber

[Lord Prior of Brampton]

My noble friend is right; the use of IMRT has increased from around 10% to about 40% in the past year—so it is increasing greatly. There is much less collateral damage with IMRT. We have also, as my noble friend will know, commissioned two proton beam centres, at the Christie and UCLH, which will also make a difference. We have just announced a £130 million investment in new linear accelerator machines. Those three developments will, I think, greatly improve our ability to deliver world-class radiotherapy.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is it not time for a bit of honesty on this? The two targets the Government are missing are the crucial ones of the 62-day cancer treatment waiting time and the two-week wait for referral for patients with suspected cancer. The Government have said that early diagnosis and quick treatment are essential, but those two targets relate exactly to those key points. The Minister knows that, in the mandate for this year, the Government said to NHS England that this must be a priority. But, given the huge funding and staffing pressures on the NHS, is it not time for the Government to come clean and admit that they cannot deliver this?

[Lord Prior of Brampton]

I think I was being honest, actually. I have never hidden the fact that these targets are very tough and difficult to meet. But we have increased activity enormously. We accept that early diagnosis is critical and probably as important as the 62-day referral for treatment target, which is why the 28-day target from urgent referral to diagnosis is so critical and will be one of the four key targets that will be in the CCG assurance framework. I accept what the noble Lords says; early diagnosis is critical. We are making progress and Sir Harpal Kumar, who developed the cancer strategy a year ago, is overseeing performance and progress towards meeting those targets.

NHS Funding

Lord Hunt of Kings Heath Excerpts

Monday 31st October 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for repeating that, but I am afraid that his attempt to gloss over the real story of the Government’s manipulation of NHS funding figures simply will not wash. The Government have been found out by the considerable and Conservative chairman of the Health Select Committee, Dr Sarah Wollaston. She has pointed out that the so-called extra £10 billion can be arrived at only through significant manipulation of the figures, including an extra year in the spending review period, changing the date from which the real terms’ increase is calculated, and disregarding the total health budget.

The Nuffield Trust pointed out in a report this morning that the £8 billion figure—which is the real figure, not the £10 billion figure—

“has been flattered by redefining what counts as ‘the NHS’. In the past, the government used to count NHS spending as the entire Department of Health budget for England. Now it only counts the subset of that spending that comes under the control of the department’s commissioning arm, NHS England. Only ‘NHS England’ is protected with ‘real-terms increases’ while the rest of Department of Health spending will be cut by £3 billion by 2020-21”.

Therefore, not only is the £10 billion or £8 billion a wild exaggeration: but the fact is that the NHS is facing an acute funding crisis, wholesale rationing of services and the denial of life-enhancing medicines to many patients.

I would like to put three points to the Minister. First, I see that he quoted OECD figures, but looking at the latest OECD per-capita spend on health, I note that 18 countries in the OECD group have a higher GDP spend on health than we do in this country. Can he confirm that, compared to any country of equally sizeable wealth, we have fewer doctors, fewer nurses, fewer beds and less access to medicines and new medical equipment?

Secondly, when the Minister says that the £8 billion was what the NHS asked for, can he confirm that the NHS did not ask for £8 billion, but indeed took no part in any discussions? There were discussions with NHS England, which is a government-appointed quango and is not the National Health Service. Can he also confirm that, in negotiations, the Government themselves—including the Treasury—told the chief executive of NHS England that £8 billion was the maximum amount that he could call for?

Finally, on the five-year forward plan—the underpinning of it by sustainability and transformation plans—can the noble Lord confirm that first analysis shows that swingeing reductions are to be made in acute care without any guarantees that community and other services will be put in their place to reduce demand on acute services?

[Lord Prior of Brampton]

My Lords, I will try to respond to those last three points. First, the noble Lord is right: the NHS is—and I would regard it still as—the highest-value healthcare system in the world. It does have fewer doctors and MRI machines—however you want to measure it—compared to many other OECD countries, but its outcomes, on the whole, are very good. I can, therefore, certainly confirm that the NHS is a very high-value healthcare system. As far as the involvement of the NHS in the plan is concerned, it was very much put together by the NHS and signed by all of the arm’s-length bodies at the time. This is a quote from Simon Stevens about the spending round settlement:

“This settlement is a clear and highly welcome acceptance of our argument for frontloaded NHS investment. It will help stabilise current pressures on hospitals, GPs, and mental health services, and kick-start the NHS Five Year Forward View’s fundamental redesign of care”.

This brings me to my last point, the fundamental redesign of care. That was possibly not really recognised at the time of the NHS review, because it is a fundamental redesign of care. As the noble Lord said, it means moving resources away from acute settings into community settings, very much as mental health care was restructured 20 or 25 years ago.