Health and Social Care: Malnutrition

Lord Hunt of Kings Heath Excerpts

Tuesday 5th November 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Baroness is absolutely right to identify some of the very significant health consequences of malnutrition. This is one of the reasons why it has been taken on board as a top priority by not only NHS England but the care system from top to bottom. The start is to have the right screening and to gather the right data so that we can identify where this needs to be improved. She is right that it needs to be integrated into nursing practice so that we not only prevent malnutrition in the first place but, where it does occur, provide the right support to put it right and the right care where there are health consequences for individuals due to clinical, social or economic problems.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I must confess to the House that I am president of the Hospital Caterers Association. Would the noble Baroness agree that there is no shortage of good advice on dealing with malnutrition and good food in the health service; nor is there a shortage of good catering professionals? The issue is trust boards that will not invest sufficiently in this area. Will she start to instruct the NHS to get serious about this if we are going to deal with this big problem?

[Baroness Blackwood of North Oxford]

The noble Lord is quite right that this is about leadership not only at board level but from the very top. It has been instructive that not only the Secretary of State but the chief executive of NHS England, Simon Stevens, have made it one of their priorities to ensure that the quality of food and food safety standards throughout the hospital and care systems should be improved. This is one of the key ways that we will drive out malnutrition from our health and care sector.

Health Service Safety Investigations Bill [HL]

Lord Hunt of Kings Heath Excerpts

2nd reading (Hansard): House of Lords
Tuesday 29th October 2019 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to follow the Minister, and I thank her for her introduction to this important Bill. I declare an interest as a member of the board of the GMC, a trustee of the Royal College of Ophthalmologists and president of GS1, which has overseen the Scan4Safety programme in the NHS.

I warmly welcome the Bill. As the Minister said in her introduction, the scale of adverse incidents in the health service makes it imperative that we try to develop a systematic approach to safety. In looking for inspiration, I came across something James Titcombe wrote recently. He conducted a remarkable campaign, following the tragic death of his baby under the auspices of the Morecambe Bay NHS Foundation Trust, and he fought and fought to get answers. He wrote:

“Where healthcare professionals perceive a blame-seeking response to incidents and error, the conditions for learning can never exist. It is paramount that the NHS is able to strike the right balance between ensuring there is accountability where appropriate, and fostering a culture where staff can report and openly discuss error with the confidence that they won’t be blamed unfairly”.


For me, that sets the foundation for the whole concept of the HSSIB. The safe space provisions are so important for the confidence of staff, in ensuring that information they provide will be treated fairly, without them feeling that their employing organisation will come after them because they have disclosed it.

I first became convinced of the need for a systematic approach when the former Chief Medical Officer Liam Donaldson chaired an expert group which produced, in 2000, the report An Organisation with a Memory. This then led to the establishment of the National Patient Safety Agency, and I can tell the Minister that that was actually the first organisation in the world to tread this course. The noble Lord, Lord Patel, was its first chair, and I had the pleasure of following him as chair from 2005 to 2007. Very disappointingly, when the coalition Government came to office—it is good to see the noble Earl, Lord Howe, in his place—we had the predictable bonfire of the quangos, which all Governments seem to go through before they set up their own, and the NPSA was abolished. Disappointingly, and remarkably, the decision was made to place the national reporting and learning system, which is the key mechanism by which people reported incidents, within NHS England, with the NHS Commissioning Board. Clearly, putting it within the compass of the organisation responsible for managing the NHS was the wrong thing to do. We should acknowledge that that has now been seen; hence the Bill today and why I welcome it so much.

There are a number of issues. We have the benefit of the organisation having been in shadow form for some time, so we can see the quality of the reports it has already produced. We have also had pre-legislative scrutiny, which has been very helpful in identifying some of the key issues. As the Minister said, the first issue is: what areas should the Bill cover? At the moment, it covers NHS patients, who can be treated in the private sector, but there is a restriction on private health services where patients are not NHS patients. The noble Baroness says that the Government want to await the Ian Paterson report, and I can see why, but I think it would be perfectly possible to provide in the Bill for the right of the Secretary of State, by order, to extend the provisions to the private sector in the light of the Paterson report. This may well be the only stage of the Bill we will take, and we may have another Bill fairly soon, so there might be time to reflect on that. I think it is very odd that the Bill as it is being brought at the moment does not encompass private healthcare. I think it should.

I am very supportive of the safe space concept, particularly as Clause 2(2) makes it clear that the purpose of the HSSIB is to focus on system issues and not to determine individual blame. It is clear though, from the briefs we have received the last few days, that many organisations do not agree with that. I have had briefs from the ombudsman, from the Association of Personal Injury Lawyers, from the Campaign for Freedom of Information and from the News Media Association on behalf of media outlets. All have sent submissions arguing that the restrictions on access to information held by the board are too strong and ought to be modified. Obviously, we will test this in Committee, but I think there is a clear tension between an approach that looks at systems safety, which tries to learn from errors and mistakes to say how we can put this right by a redesign of equipment or practice, and the absolute right of individuals to pursue cases against the health service and the right of regulators to regulate professionals appropriately.

Clearly, the Bill seeks to get the balance right. Clause 15 enables the Chief Investigator to disclose protected information,

“to address a serious and continuing risk”,

to safety. Clause 17 allows for a person to go to the High Court for an order of disclosure. In my view, that is the right balance: the safe space concept is set out in legislation, but there are circumstances where information can be disclosed. Where I question it, I must say, is in relation to Clause 19, which makes specific provision for a senior coroner to require disclosure. The noble Baroness has given some explanation of that. My understanding is that there are 95 coroners’ areas in England and Wales, employing 87 senior coroners. That seems rather a lot of people to be given special provision. Again, I think that in Committee we need to test whether coroners should be given this special provision. I remain dubious at this stage.

On maternity investigations, the Joint Select Committee was concerned that the board was being given a different remit in relation to these local investigations. The noble Baroness says that the Government need more time to consider what is to be done with those investigations, but I hope that during the passage of this legislation—however long that takes—there will be some kind of conclusion. Given that we are asking the board to do a specific job in relation to system safety, I wonder whether this is the right place for local investigations into maternity services.

The fundamental question of course is: what happens as a result of the work of the board? One of the NPSA’s problems was that it produced lots of reports, but nobody in the system actually took responsibility for implementing them. Here, there is clearly a mechanism whereby the board sends its reports to relevant organisations, and the Bill also makes provision for those organisations to respond to the board. I think that is a very useful suggestion, as is the requirement for a review of the board to be undertaken after four years’ work. I welcome that. However, we have heard it said that the board might produce up to 30 reports a year. Looking at the first two or three—on piped air, oxygen and mental health in emergency departments—the responses from the organisations that received them were very positive. However, in the report on electronic prescribing, the recommendations are extensive. They would be costly in money, human resources and managerial effort. I begin to worry that if over, say, four years it really produced 30 reports a year, which would be 120 overall, the risk is that they would tend to lie on the shelf. It would be a tick-box exercise, and the impact would be far less. I wonder whether the board ought to be less ambitious in the number of reports it produces, in order to get a bigger impact.

However, the fundamental question I put to the Minister is this: whose feet will be held to the fire if the board produces a report and it is clear after two or three years, when new safety incidents have emerged, that the health service has not actually responded? It is not at all clear to me who has responsibility for making sure that these reports have bite. In the airline industry, where this has come from, the experience is that when safety reports such as these are produced, they are acted upon. The big risk here is that, knowing the health service as we do, the number and range of adverse incidents is so wide that in the end the reports will become simply good practice guidance which people can take or leave. In the end, at heart this is the most fundamental question.

I will talk briefly about governance issues. I note that there are non-execs to be appointed, and I strongly urge the Government to make sure that NHS commissioners are appointed as non-execs to the board. We know that a lot of the expertise on this board has come from other sectors, and it is vital that there are people around the top table who understand the NHS. The best way to do this might be to appoint top clinicians to the board as non-executives. Secondly, the provision in Schedule 1 is for the Secretary of State to approve the appointment of the Chief Investigator, which is made by the board itself. I do not understand why the Secretary of State has to give his or her consent. This is not normal in the way that we generally do public bodies; I fully understand that the Secretary of State appoints the non-executives, but it should then be just for the non-executives to appoint the Chief Investigator.

Finally, the Joint Select Committee suggested that, because of the importance of these roles, both the chair and the Chief Investigator ought to be subject to pre-appointment scrutiny by the Health Select Committee. That is an excellent suggestion. Have the Government given this further consideration? When they responded to the Joint Select Committee, they said that they would discuss it with the chair of the Health Select Committee. It would be very good to know the outcome of those discussions.

Overall, this Bill is enormously welcome. I wish the board very good luck in the future, but I also look forward to some of the scrutiny that needs to take place.

Queen’s Speech

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare my membership of the GMC, trusteeship of the Royal College of Ophthalmologists and presidency of GS1, the barcoding association. I too pay tribute to the noble Baroness, Lady Emerton; she was an undoubted tour de force over decades of leading the nursing profession. I particular remember her kindness in attending the badge-giving honours at the Heart of England NHS Foundation Trust, which I chaired; she came and spent about three or four hours with the nurses before travelling on to a meeting in Leeds. She is an extraordinary woman who gave so much to our health service.

The Queen’s Speech promised a Bill on the long-term plan, which I suppose is really a cover for getting rid of the calamitous Health and Social Care Act 2012. Any of us should welcome that, but the problem is that it does not answer the much more substantive question of how we will fund and develop a sustainable health and social care system over the next three decades.

The NHS has done wonderfully well in meeting many of the challenges it has faced over the last nearly 70 years or so, but no one can be in any doubt that, with the growing number of older people with comorbidities and the kind of good pressure that new technology and invention bring, the health service is struggling hugely. The CQC’s annual State of Care report, published only last week, shows that there is huge pressure on all health and care services. Waiting times for treatments are going up, and I fear that we will return to the bad old pre-1997 days unless we take decisive action. We have the wholly unstable adult social care market, which noble Lords have already referred to, and there seems to be general agreement that about 1.4 million people who ought to be receiving care at the moment are not.

The question is how we will respond to this issue. The Government’s immediate response is their own long-term plan, a new five-year settlement of around 3.4% growth per annum. That is of course welcome, in contrast to the years of austerity; when the demand was going up, adult social care was being reduced in real terms and for five years the health service received its lowest ever funding level since its foundation. Obviously, 3.4% real-terms growth is a great improvement on that. The problem, as anyone reading the IFS report on public finance going ahead will know, is that this is a temporary blip—we will return to austerity.

The report of the Long-Term Sustainability of the NHS Committee, excellently chaired by the noble Lord, Lord Patel, was very clear that we cannot go on having this short-term upfunding followed by reductions without any serious attempt to solve the real problem of funding health and social care over the next 20 or 30 years. There are no easy answers: it is pretty clear that the public and the political class as a whole will not see any change in the basic premise of a publicly funded service free at the point of use as far the NHS is concerned; it is also clear that public opinion does not favour any increase in charges. One way or another we have to persuade the public to pay more money through taxes to get us back to a sustainable growth figure.

The only possible way that we can do this is through some kind of hypothecated health and social care tax. It is probably not popular with the Treasury, or with many noble Lords. National insurance is the obvious way to do it; the UK take for national insurance roughly equals the amount we spend on health and social care in England, so it is probably the easiest way to do it. There would have to be changes—as my noble friend reminded me just now, the fact that many of us do not pay national insurance any more while still earning is clearly unacceptable. However, we have to think radically about whether we seriously want to go on funding our health service and whether we want a sustainable, excellent health service.

The committee of the noble Lord, Lord Patel, did not quite recommend a hypothecated tax, although I think that perhaps it was trying to get there. However, it recommended that we set up an OBR for health and social care as well. That is an excellent idea: an independent body giving advice on the long-term funding needs of the health and social care system, alongside workforce projections and demographic challenges. If you put the two together, that would be about the only hope we have of maintaining an excellent health and social care system in the future. The alternative is a long period of austerity with a little bit of growth, no certainty and a continuation of some of the pressures we see at the moment.

National Health Service: Bullying

Lord Hunt of Kings Heath Excerpts

Wednesday 3rd July 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Baroness asks an important question. There are structures built into the NHS to enable those people to speak up. There is a “freedom to speak up” champion and a system of champions, so that it is perfectly clear to those experiencing bullying by senior managers who they can speak to.

[Lord Hunt of Kings Heath (Lab)]

Does what the Minister suggests apply to the actions of Ministers? She will recall, from when he was Secretary of State, Mr Jeremy Hunt’s practice of insisting on a weekly Monday morning meeting with the key national regulators, at which the sacking of chief executive officers was often discussed. Bullying starts at the top. If Ministers take a bullying attitude towards the NHS, they can hardly be surprised if that behaviour is followed at local level.

[Baroness Blackwood of North Oxford]

I am afraid I do not recognise the characterisation set out by the noble Lord. One of the key characteristics set out by the former Secretary of State in his leadership was that the NHS should be open and not have a culture of blame, and that people should feel free to speak up, so that when mistakes are made they should be corrected.

Lung Health

Lord Hunt of Kings Heath Excerpts

Monday 1st July 2019 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what steps they will take to implement the recommendations of the Taskforce for Lung Health’s five year plan for improving lung health in England.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, the NHS has worked closely with the Taskforce for Lung Health and the British Lung Foundation to develop a national programme for respiratory and cardiovascular disease. This will improve lung health by piloting a lung health check programme, expanding quality-assured spirometry, undertaking pharmacy medicine reviews in primary care networks and improving self-management support. In addition, access to smoking cessation interventions will be increased and a national workforce group will be established. Finally, the Government have committed to improving choice and ending variation in end-of-life care services.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister for that response. She will be aware that lung disease is often underestimated as a problem; one in five of us is likely to be affected in our lifetime and priority has not really been given to it over the past few decades. Given that outcomes have hardly improved either, will she look again at the response and commit the Government to implementing the task force report in full?

[Baroness Blackwood of North Oxford]

I thank the noble Lord for that question. He is absolutely right that respiratory illness can be extremely serious. The UK has a higher rate of respiratory deaths than any other country in the OECD; this is a clinical priority for the NHS and the Government are committed to driving it forward. We are working with the British Lung Foundation and the NHS to deliver the co-designed lung foundation’s plan and I am happy to give him that commitment now.

Unpaid Carers: Support

Lord Hunt of Kings Heath Excerpts

Thursday 13th June 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

I completely agree with the noble Lord, Lord Patel, who is absolutely right that we must ensure that we sustainably fund social care. The Government have provided £3.9 billion more in dedicated social care funding, but we recognise that there is a need for a sustainable financial footing for social care as a whole, which is what we are working towards with the spending review. Nevertheless, carers will continue to play an important part in our healthcare system, as they do within our society. Many people consider that they are making a rewarding and important contribution within their family and community, and we must be grateful to them for that.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the implication of what the noble Baroness has just said is that the work around the Green Paper on a sustainable mechanism for funding long-term care is focused on the medium and long term. If that is so—and I think the Minister could say something about the actual remit of the work—the question then arises, what about the short term? We know that the money she talked about is a drop in the ocean compared to the money that has been taken away from social care, alongside the increasing demographic pressures. Can she tell me whether, as part of the spending review, which I assume will occur at some point, the immediate pressures are also going to be taken care of?

[Baroness Blackwood of North Oxford]

The noble Lord will know that the spending review has not yet started, so I cannot tell him what is happening in the negotiations. What I can tell him about is the work that has already gone on to improve social care funding: giving local authorities access to around £10 billion more in dedicated funding for social care from 2017-18 to 2019-20; an additional £410 million of new money to improve social care for older people, people with disabilities and children; and £240 million more for winter pressures. However, the noble Lord is absolutely right that it is no good improving the medium to long-term outlook for social care if we do not ensure that we also address the immediate challenges that it faces.

People with Learning Disabilities

Lord Hunt of Kings Heath Excerpts

Thursday 6th June 2019 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, as I shall refer to some workforce issues, I refer noble Lords to my membership of the General Medical Council. I am grateful to my noble friend for instituting this debate. The questions she has posed are very significant. As she said, the “Panorama” programme depicted shocking events. The depressing thing, of course, is that it follows not only Winterbourne View but a series of reports published in the last few years identifying the scale of the problems. My noble friend went through some of them; I will mention three.

One is the Children’s Commissioner for England report of 2019, published only two weeks ago, which found that there are 250 autistic children or children with a learning disability in mental health hospitals in England, who on average had spent six months there. Many, she said, are far away from their homes, friends and families. One in four had not had their care plan reviewed in the last six months. Despite the fact that restraint and seclusion should be only a last resort, many staff in mental health hospitals spoke as if they were routine matters. Last year the CQC was asked to carry out a review into the use of restraint and seclusion in mental health hospitals. It really was a shocking situation: 31 of the 39 people found in long-term segregation whose cases investigators assessed were on the autism spectrum; some were on wards that did not have the appropriate environment for autistic people; many staff lacked training; in the cases of two-thirds of the people the CQC assessed, staff had stopped trying to reintegrate them into the main ward; and a third of the people it assessed were experiencing a delayed discharge because there was not a plan for appropriate care in the community. The National Autistic Society has laid bare many of the problems that these reports have identified.

There was also the very interesting National Audit Office report in 2017, which raised a number of complex challenges that the various partners involved in supporting people with learning disabilities face in making the system work much more effectively and delivering what my noble friend has asked for: appropriate care in the community. It identified that the flow of patients into mental health hospitals was not working effectively and that, shockingly, in December 2016, 28% of such patients had still never had a care and treatment review. Fundamentally to the financing of this, money was not being released from mental health hospitals quickly enough to help pay for the kind of community support we need to see.

We also know, from a report published two days ago by Health Education England, that the learning disability nursing headcount could hit critical levels in the next five years—some would say it has hit those levels already—with vacancies upwards of 30%. In addition to some of the issues we have in recruiting nurses—including bursaries, et cetera—I believe there is a huge crisis in the learning disability field and, so far, no real, tangible means of trying to deal with it.

I know government Ministers are and have been committed to doing something about it, as my noble friend says. We are not short of reassurances that Ministers have given to this House and the other place, and I do not doubt Ministers’ sincerity. It was only on 21 May that the Secretary of State announced a number of initiatives on,

“the model of care for autistic people and people with learning disabilities”,

and the appointment of,

“specialist, independent advocates who will … work with families … join up services … work to move people to the least restrictive care and then out into the community … a new working group for learning disabilities and autism, bringing together experts, clinicians, parents and carers to develop a new model of care … a new awareness campaign, to encourage staff, families and friends to come forward if they have concerns about care”.

I could not disagree with any of that; I am sure it is welcome. The question is: where is the beef? What is going to make this really happen? Is this just a continuation of, frankly, a system of scandals that have been with us for decades?

I could not help going back just over 50 years to Geoffrey Howe’s report into Ely Hospital in Wales, which was the start of a series of inquiries into hospital care for people with learning and mental health disabilities. It led the movement towards more community care. At the time, it caused great shock that our fellow country men and women could be treated so badly in institutions ostensibly established to care for and support them. I make the connection between what was exposed so recently by “Panorama” and what was found by Geoffrey Howe just over 50 years ago in Ely Hospital. I do not think that we, collectively, can be proud of what has happened. Of course improvements have been made, but an awful lot more needs to be done. Ministers often make the glib statement, “We want to make sure this can never happen again”. The Government have been wise not to make that statement in relation to people with learning disabilities. At the moment, I do not believe there is anything to guarantee that it will not happen again.

It is clear, for a start, that there does not seem to be any national leadership. In the end, who is in charge of making a new service work effectively? I cannot see anybody one can identify as being in charge unless it is Ministers, but Ministers do not—or say they do not—have the levers to make the system work effectively. It is clear that commissioners are not up to the task. The lack of interest that many commissioners take in those people, once they have been allocated to these places, is so striking. Given that many of the people in those places come from long distances away, it is almost impossible for their home commissioners to monitor what is going on.

The current system is simply not capable of stopping this. Ministers must appoint someone centrally with the powers to dictate what will happen. Unless we do that we will simply come back here year after year with yet another scandal. The measures taken so far are sensible, but will not cut the cake.

National Institute for Health and Care Excellence (Miscellaneous Amendments) Regulations 2018

Lord Hunt of Kings Heath Excerpts

Wednesday 1st May 2019 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House takes note of the National Institute for Health and Care Excellence (Miscellaneous Amendments) Regulations 2018 (SI 2018/1322).

Relevant document: 12th Report from the Secondary Legislation Scrutiny Committee (Sub-Committee B)

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am glad to lead a short debate about NICE and the introduction of charges. I was NICE’s first Minister and have long taken an interest in the work of the national institute. Overall, it has done a fantastic job; its methodology has been followed by many other countries and, clearly, it has had an impact on judgments about clinical and cost effectiveness.

However, its role has changed over the years. It was brought into being to encourage and speed up adoption of proven, innovative new medicines and treatments because of a concern at the time that the NHS was slow to adopt new treatments and innovations that had been shown to be better than existing treatments and drugs.

To start with, that worked. However, despite the legal requirement on the NHS to implement the technology appraisal decisions of NICE, right from the start it proved remarkably reluctant to do so. As time has gone on and money has been squeezed, NICE has become more a rationer of treatments than a pusher of the introduction of new, innovative products. My concern about charges is frankly not so much to do with the principle of charging, because it follows a well-known model and principle used throughout government endeavours, as with some specific issues, particularly in relation to small companies and the current or future review of NICE’s methodology, which I wanted to raise.

We know from the helpful paper produced by your Lordships’ Secondary Legislation Scrutiny Committee that the government grant to NICE has fallen from £66.4 million in 2013-14 to £51.2 million in 2018-19 and that the Government have argued that NICE needs to identify other sources of funding to enable it to continue its full programme of work.

Obviously, there was consultation. One issue raised in it was the impact of charging on the relationship between NICE and the pharmaceutical industry—but it is important that we recognise that NICE is concerned not just with medicines and the pharmaceutical industry. In the consultation, the potential for conflicts of interest and the public perception of such conflicts were identified as risks. In other words, because the pharmaceutical industry will now be paying for the work being done by NICE, will it have undue influence on the work of NICE? Looking at the robust approach of NICE, I think we can dismiss that fear, but it would be good if the Minister could say something on the record about how we can avoid any perceived conflict of interest.

The second issue I want to raise is the mechanism for reducing the impact on small companies. The original proposal was for a 25% discount but, as a result of concerns raised, the Government decided to provide a subsidy of 75% for small companies. That is welcome and I accept that the Government moved a long way, but the Ethical Medicines Industry Group, which represents a number of small pharmaceutical companies, says that despite that, there is concern among those companies about the impact on them when they have a number of other issues and challenges at the moment, including Brexit and the rebates associated with statutory and voluntary medicines pricing schemes. It thinks that the NICE charges still present a significant cost for small companies and asks the Government to consider whether further measures could be introduced to help mitigate the impact of this on SMEs. One of its suggestions is a fee exemption for companies bringing their first product to market. I think that is an interesting suggestion in terms of encouraging new entrants into the market, which I believe is government policy.

More generally, it is important that, with the extra resources that will be going to NICE, we take the opportunity to ensure that NICE modernises its approach to medicines assessment. When the Government introduced the concept of cost recovery they said the charging would provide a more sustainable model, enabling NICE to flex its capacity in response to the pipeline of technologies that require assessment by NICE. That is welcome, but I want to refer to a briefing I received from a company called AbbVie, which says that it is imperative that NICE fulfils this commitment to adapt and update its methodology and modernise its approach to assessing new technologies.

One example it gives is that we know that medicines are increasingly targeted at smaller patient populations developed through clinical trials. Inevitably, these will embrace patients in smaller numbers. The problem is that regulatory agencies tend to approach this with some caveats. Inevitably, the clinical trials result in smaller datasets and regulatory agencies are certainly demonstrating significant flexibility to approve such medicines, often conditional on that data. However, the approach of health technology assessment bodies such as NICE is often challenged by such datasets, resulting in delays and highlighting a disconnect in the medicines approval pathway. AbbVie-commissioned research shows that medicines, such as those specifically expedited through the regulatory approvals system, due to their addressing areas of high unmet medical need, take longer, on average, to receive subsequent approval from NICE than those medicines that have not been expedited, thereby making the whole process very difficult. The upcoming NICE methodology review, due to commence through 2019-20, provides an opportunity to look at this again and I would be grateful if the Minister would say one or two words about that.

I also raise an issue raised with me by Alexion, a company focused on the development of medicines for rare and ultra-rare diseases. It has concerns about the potential unintended consequences of introducing charges for appraisals without action to address the significant challenges these treatments face in NICE assessments.

In conclusion, I do not object to the principle of charges: I think it is quite proper and the Government’s approach is to be supported. I have concerns about the small companies. I know that the 75% rebate is generous on any count, but any additional costs on those companies is something to be concerned about. The core of my question to the Minister is around the methodology review, to ensure that NICE keeps up to date with developments in science and technology. That is very important.

Turning to my final point, I know that the noble Baroness has taken a great interest in this over the years, representing her old constituency, particularly the life science sector. On the one hand, government policy is about encouraging UK life science and biotech companies to develop, to innovate and to invest in the UK. However, the National Health Service is set up to ensure that those innovations are not adopted by it. Despite a number of welcome government initiatives, they are all what I would call upstream, because the downstream is too difficult. This is a real problem so long as we have an NHS dedicated to stopping innovation. I fear that, despite all the warm words from Ministers that we have heard over the years, the NHS response is to dampen down investment in these new technologies and medicines. My argument is that, post Brexit, we cannot afford for this to happen. One way or another, we have to find a way to get the early adoption of new medicines and new techniques, where they can be shown to do better than the existing ones, and NICE has to play a part in that.

This is really my usual rant about innovation and getting patients access to the fantastic things being developed in the UK. I look forward to the Minister’s response and I beg to move.

[Baroness Jolly (LD)]

My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for giving us the opportunity to ask the Minister some questions. As I expected, it was really interesting, starting with NICE from its inception. Those of us who have been involved with the NHS for some while know the standing that NICE has within the NHS community and how it is changing and adapting to changing circumstances, new technologies and the importance of really exciting new pharma, including pharma for specialised conditions. It also gives us the opportunity to better understand the motivations and reasons behind some of the changes.

As I see it, this SI does two things. It enables NICE to recruit experts from across the UK to its appeal panel, as opposed to individuals only in England. This aspect of the SI appears to represent a sensible change. Secondly, it will allow NICE to charge industry for the cost of making technology appraisals—TAs—and highly specialised technology, or HST, recommendations. I see this aspect of the SI as potentially contentious. How will the anticipated savings from the SI be used? To whom will they be allocated? Will they be used to support growth of the life sciences sector in the UK, or will they just become part of the income stream and then go some way towards the possible privatisation of NICE? Is not the reason for this SI that NICE’s government-funded budget is decreasing? The documents with this SI note that in 2013-14 NICE received £66.4 million in government funding, and that by 2018-19 this had dropped to £51.2 million. I wonder how many other NHS-funded organisations have faced cuts of 23% over five years and quite considerable growth in their business.

--- Later in debate ---

I close by stressing that the Government share the view that we have heard today about the vital importance of NICE’s work. These matters are very important to all of us. With the changes we have made in response to the consultation comments, I am confident that the introduction of charges and the charging regime for NICE recommendations will enable it to continue to be sustainable and develop its recommendations with the same authority, transparency and impartiality that have been the backbone of its world-leading reputation, and that the UK life sciences sector will remain as strong as it has ever been, if not stronger.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Baronesses who have taken part in this short debate. I echo what the noble Baroness, Lady Jolly, said about ensuring that NICE continues with a full work programme, which is very important indeed. I want to reinforce my noble friend Lady Thornton’s vital point about the rare diseases strategy and the issue of access across the UK. Twenty years on, NICE can be congratulated on its work. Remarkably, its first chief executive, Sir Andrew Dillon, is still chief executive. I extend my tribute to him. Not only has he done a great job, but he has also always been accessible to parliamentarians and held open debates, which is much appreciated by Members of your Lordships’ House.

First, I am quite clear that I do not think that there will be a conflict of interest. We can rely completely on the integrity of the NICE progress in relation to that point.

Secondly, uptake and access are fundamental issues. The noble Baroness pointed out that the UK’s position in relation to the speed of regulation is very good, which is pleasing. The problem is that the health technology assessment side is not fast. It is particularly clear from some of NHS England’s interactions with NICE that it is keen to slow down the introduction of many of these new products because, I am afraid, it is concerned about the overall financial package. The problem is that NHS England has no responsibility whatever for UK plc, nor for the health of our life sciences sector; indeed, it has often refused to meet that sector. Given who the chair of NHS England is and given how instinctively sympathetic he is to the issues we are discussing, I hope that we will see a change in attitude. If we really are concerned about the quality of patient care, we must be concerned that access to new medicines and drugs in this country is way behind that in France, Germany and other countries. Most decisions are made in North America, although the pharma industry has other global headquarters. Our reputation for being behind other countries in the adoption of such products is a big problem for future investment.

I have one suggestion. It is very disappointing that, under the original voluntary rebate scheme, the rebate money was essentially paid into the Treasury because the amount to be rebated was discounted in advance. In Scotland, some of that rebate has been used for funding that has been fed back into the Scottish health service to fund new medicines and treatments. Thinking about how we might move on, given that we now have a new rebate scheme, that money should be seen as additional money to be used to encourage the health service. I hope that the Government might think about that in future. The debate has been short but really good.

Motion agreed.

Access to Medicinal Cannabis

Lord Hunt of Kings Heath Excerpts

Tuesday 9th April 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question, and I know that she has campaigned on this issue for some time. NHS England has clarified that clinical guidance does not remove or replace the clinical discretion of the prescriber to act. I know that the process review will look at the impact of clinical guidance, which will hopefully be helpful. We will also look at the role of second opinions. I hope that that has answered some of the noble Baroness’s questions; she made a number of points, and I will write to her on the rest.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I want to come back to the point about NICE made by the noble Baroness, Lady Walmsley. My understanding is that, at the moment, the evidence on which doctors can base a decision to prescribe these medicines is very limited. Clearly, relying on the NICE guidance is one way through. My problem is that, if we look at another area such as cataract operations, we see that despite NICE guidance many patients are now being denied treatment that has absolutely proven to be effective. My concern is that the Government seem to be trying to find a way round the evidence relating to these medicines when, up and down the country, patients are being denied interventions that we know will be successful and that can help thousands of people. Can the Minister comment on that?

[Baroness Blackwood of North Oxford]

The noble Lord is right that it is important that guidance is provided. The point of bringing the guidance forward is to look at the most up-to-date evidence available across the country. The challenge with medicinal cannabis is that the evidence base is developing. Currently, more than 100 clinical trials are ongoing worldwide. We are bringing the NICE guidance forward in the autumn to take all that clinical evidence into account in the most up-to-date guidance, so that patients can benefit and clinicians can have more confidence in prescribing. The NIHR call for clinical trials has been brought forward so that the evidence base can be strengthened even further as we go forward because, in the long term, the only way for us to move from an unlicensed prescribing route, which is where we are now, to a licensed route is through clinical trials and a greater evidence base. That is what the Government are keen to encourage.

Child and Adolescent Mental Health Services

Lord Hunt of Kings Heath Excerpts

Monday 25th March 2019 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, on pace, will the Minister acknowledge that this Government and their predecessor, the coalition Government, have made any number of promises about investment in and prioritisation of mental health services, particularly for children and young adults, but that when it comes to the decisions made by clinical commissioning groups, the reality is that they have not brought them to fruition? What guarantees do we have that this time clinical commissioning groups will do what they have been asked?

[Baroness Blackwood of North Oxford]

The noble Lord, Lord Hunt, is very experienced in this area and has been involved with local clinical commissioning groups. The NHS has already opened 117 additional new mental health beds, and we have introduced new waiting standards for psychosis and eating disorders among children. Progress is already being made, but we should not dismiss the frustrations of those trying to access services. That is why we have put in place ambitious new targets with the long-term plan: we want to see 100% of children able to access the care they need.