Health and Social Care Act 2012

Lord Hunt of Kings Heath Excerpts

Thursday 5th July 2018 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government, in the light of the Prime Minister’s criticism of the regulatory framework established under the Health and Social Care Act 2012, what plans they have, if any, to bring forward measures to amend or repeal that Act.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, the Government have announced a five-year funding settlement, and we have asked the NHS to develop a 10-year plan to transform health and care. As my right honourable friend the Prime Minister said, as it develops its plan we will listen to the NHS about whether there are any barriers created by legislation. We will consider, after that, what changes may be needed.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in her speech on 18 June the Prime Minister referred to chief executives of NHS organisations having to make so many reports to different regulators that they have no time to improve their own organisation, and to a typical clinical commissioning group having to agree 200 contracts with other parts of the NHS. Is not the answer to the first question from the noble Lord, Lord Hamilton, that the NHS, employing 1.3 million, is not hard to manage, but the fact is that the Government have bequeathed to it an organisational structure that is dysfunctional and costs billions of pounds? If he really wants to help the NHS, will the Minister not come forward with a Bill to repeal the Health and Care Act 2012?

[Lord O'Shaughnessy]

My Lords, since the 2012 Act was passed, there have been some significant improvements in NHS performance, not least in cancer outcomes, for example. There are also around 42,000 more staff since 2010. So improvements have clearly been able to happen within the legal framework set by Parliament in 2012. Nevertheless, we recognise that as the service is required to become more integrated and people across different care functions are required to work together, we need to look at the structure. There is already joint working, for example, between NHS England and NHS Improvement at the regional level. But if the NHS identifies any barriers, we will look at those.

Branded Health Service Medicines (Costs) Regulations 2018

Lord Hunt of Kings Heath Excerpts

Wednesday 20th June 2018 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the Branded Health Service Medicines (Costs) Regulations 2018 do not propose any action to be taken in respect of the high cost charged by Concordia and other companies for the drug Liothyronine for the treatment of hypothyroidism, thereby depriving patients of the use of that essential drug, and further do not put an end to the practice of a growing number of Clinical Commissioning Groups refusing to follow the latest guidance from NHS England on making that drug available to NHS patients via referral to thyroid specialists (SI 2018/345).

[Lord Hunt of Kings Heath (Lab)]

My Lords, ensuring that patients get quick access to the most effective drugs ought to be one of the essential aims of any Government in relation to the NHS, yet we know that NHS patients are at a serious disadvantage when compared to patients in, as an immediate example, Germany and France. This of course was a major subject in our debate on the Health Service Medical Supplies (Costs) Bill, from which these regulations emanate. While the eventual Act came about because of concern about certain companies abusing their position in relation to the prices of drugs, we also kept our focus on the overriding need to ensure that patients had access to effective medicines. This becomes ever more important at a time when clinical commissioning groups are being seen to ration services more and more widely. I want to bring to the House’s attention a clear example of clinical commissioning groups ignoring guidelines in relation to this area—an extremely common condition—with many patients suffering as a result.

The regulations before us permit the Secretary of State to control the costs of branded health service medicines for companies that do not belong to the voluntary 2014 Pharmaceutical Price Regulation Scheme, belovedly known as PPRS. The regulations set out details of the new scheme. They do not identify specific companies or branded medicines. No doubt the Minister will point out that they apply only to branded medicines, while the medicine that I am dealing with tonight is a generic medicine. It is a device to enable us to debate this important point. However, the fact that the Government brought the legislation to Parliament and are bringing the regulations here shows that they understand that there was a need to deal with abuse in the case of branded medicines. One of the questions I want to put the Minister is: what about generic medicines? How do we ensure effective early action when it becomes likely, or obvious in fact, that some companies are taking the NHS for a ride?

Liothyronine—or T3, as I will call it, because it is a lot easier to pronounce—is the subject of my Motion. As many as one in 20 people in the UK is affected by thyroid disease. The symptoms of an underactive thyroid, which is the most common condition, are serious and require daily medication. Most patients resolve their symptoms with the standard medication, levothyroxine, otherwise known as T4, but there is a subgroup of patients for whom T3 can be an effective option.

T3 was de-branded in 2007, at which point its cost started to increase. Normally, after de-branding, the cost comes down. By July 2017, the cost had increased by a massive 6,000%. The price per pack had risen from £4.46 to a massive £258 in 10 years. Whereas prices on continental Europe range from 2p to 26p, the NHS pays more than £9 per tablet—this is a tablet that needs to be taken daily.

Concordia was the only manufacturer with UK marketing authorisation until very recently. Throughout the price increases, I understand that there was no intervention by the Department of Health until it referred the matter to the Competition and Markets Authority in 2016. In November 2017, the authority provisionally found that Concordia had abused its dominant position to overcharge the NHS by millions for this essential thyroid drug.

A final decision is still awaited. My understanding—I should be grateful if the Minister could confirm this—is that no intervention will be taken by the Department of Health until the final decision is made. Pace our previous debate about why Governments sometimes hold up making decisions while inquiries are ongoing, that reflects some of the problems in Gosport, which we are now seeing in a totally different area.

The trouble with the delay is that patients are suffering. Because of the high cost, in 2017 NHS England ran a consultation under the title Items which should not Routinely be Prescribed in Primary Care: A Consultation on Guidance for CCGs. T3 was included in the list to be considered as an effective product subject to “excessive price inflation”. The issue was not the effectiveness of the drug; it was the fact that it was costing so much money.

There was a lot of consultation, including submissions by the British Thyroid Association and Thyroid UK that T3 should continue to be prescribed in primary care. However, NHS England’s recommendation was:

“The Joint Clinical Working Group therefore recommended the prescribing of liothyronine for any new patient should be initiated by a consultant endocrinologist in the NHS, and that de-prescribing in ‘all’ patients”—


in other words, patients who were already on T3—should not automatically occur,

“as there are recognised exceptions. The recommendation would therefore be changed to advise prescribers to de-prescribe in all appropriate patients”.

So the consultation led to a change in the guidance.

But you have to read the guidance very carefully to understand what it is saying, and it is clear that, to put it at its kindest, clinical commissioning groups have perhaps misunderstood what the guidance stated. That has led to many of them informing clinicians in both primary and secondary care to withdraw T3 from all patients, some of whom have been prescribed it for years, and not allowing them to initiate a prescription, or to offer to refer it to an endocrinologist, as the latest guidance states that they should.

This is causing many patients a great deal of distress. It is making them ill again and impacting on their social and mental welfare. As the Thyroid Trust has pointed out, that is compounded because many GPs are not following treatment guidelines to fine-tune the dose of the standard medication for these conditions or to refer patients to see a specialist if well-being cannot be restored in primary care.

Where T4 is not working, it is important that T3, in combination or in its own, can be prescribed. Some patients are appealing against the decision of their CCGs, but this is daunting for an individual patient to do. I have had one description today, who said: “Applying for T3 is like wading through treacle with your legs tied together”. What is particularly difficult for them is that the criteria for being an appropriate patient have not been listed. If you are appealing against a decision by a CCG, what chance do you have?

We know that at a meeting with NHS England fairly recently, it was admitted to patient groups—Thyroid UK and the Improve Thyroid Treatment Campaign—that what happened was not its intention; its intention was to reduce regional prescribing variations. Both organisations have asked for further guidance for CCGs whereby CCGs understand what they should be doing.

In a debate in the other place and in the noble Lord’s Answer to me, Ministers have said that the South Regional Medicines Optimisation Committee has been considering the issue further and that it will issue a statement in due course. Has this august body issued such a statement? You can find this organisation on the web. It is not very transparent. At its January meeting, the matter was discussed and the minutes of that meeting are on the web. The papers have not been made available. There was a further meeting in May when this matter was on the agenda, but the minutes have not been made available, so the latest we have is what happened in January.

The list of members who attended the January meeting is there, and it is noticeable that 21 professionals attended the meeting with one lay member. Yet the terms of reference of these committees is to look at the outcome of medications for the benefit of patients. It is clear to me that it is a rationing body. Let me take one example. We already have guidance, but the committee was most taken by the fact that a sub-part of the south- west had produced its own guidance. Why is a subgroup of the NHS producing its own guidance when guidance is nationally based?

Patients are left in a hopeless position. It is clear that T3 should be initiated by an endocrinologist, but not what happens afterwards. That is being left for CCGs to work out for themselves, often to the detriment of the patient. Some endocrinologists are saying that they cannot prescribe because the CCG has said no. Some are prescribing, but patients have to visit them for their prescriptions thereafter. Some are trying unsuccessfully to pass care on to GPs, but GPs are saying that they cannot take over care without CCG permission. It is a Catch-22 position.

Some clinicians are helping patients by giving them private prescriptions, but these are expensive. The Brighton and Sussex University Hospitals NHS Trust is informing patients that their only option is to obtain the drug privately. For an NHS body to advise patients as such goes against the whole ethos of the NHS. I must say that I am very surprised at the trust doing so.

I received details yesterday through Thyroid UK of a patient who is looking for a price to purchase T3 privately. She contacted Pharmacy2U and asked for a price for 56 T3 tablets. From four suppliers, only one could supply and that price was £774. That was for 56 tablets, one a day.

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[Lord Hunt of Kings Heath]

My Lords, I am very grateful to the Minister and to other noble Lords who have taken part in this interesting debate. The noble Lord, Lord Borwick, really put his finger on it when he said that the key point is the misinterpretation of guidance. As my noble friend Lord Turnberg said, essentially, the system has gone the wrong way about this. Instead of trying to deal with the prices, guidance has been produced that is pretty restrictive and then CCGs have reinterpreted the guidance to make it even more restrictive. As the noble Baroness, Lady Jolly, said, the problem is that if you cannot drive down the cost of T3, the emphasis is almost bound to be on clinical restrictions, which are hard to start with and are then misinterpreted.

On the point raised by my noble friend Lady Wheeler, who asked a number of questions about the regulations before us, I just say to the Minister that I hope that the review, to be published in April 2019, could be shared with noble Lords in one way or another, because I think that there will be general interest in it. I am grateful to the Minister, because he said that the Government are committed to pursuing further with NHS England the way that the guidance has been interpreted. He has also promised me a progress report on the delightful workings of the south regional medicines optimisation committee, which I am sure all noble Lords will be very anxious to see. He has also invited us to send to him details of cases where there is clear evidence that the guidance is not being pursued. We will pursue that; it is all very helpful.

On the issue of pricing and competition, I very much take the Minister’s point about the unbranded generic market generally working well; I agree with him. Clearly there is an issue when it is not working well. One question I will put is whether the department should have intervened earlier; I think it might have done. Hopefully, in the future, it will be able to do so. On PPRS, the noble Lord, Lord Lucas, made a very interesting intervention—but, from my point of view, the PPRS agreement was a good one, as it basically stabilised the costs of branded drugs to the NHS because of the rebate scheme, which meant that, if the costs went above a certain limited level, the extra cost was paid back into the NHS. The problem is that it was not paid back to the NHS—it was paid to the Treasury, because it discounted in advance the likely rebate. The tragedy—and why this is very important in terms of future negotiations on PPRS—is that, if that rebate money had then been routed towards investing in new medicines, we would have had a win-win situation where, essentially, the pharmaceutical industry would have paid for its investment in new medicines. The noble Lord will know that one of the issues facing the branded pharma industry is that the NHS is a lousy customer when it comes to the uptake of new medicines. This is a separate issue, but one that is really important for the future.

Overall, I am very grateful to noble Lords who have taken part in this excellent debate. Considerable progress has been made and the commitments given by the Minister are very welcome indeed. I beg leave to withdraw the Motion.

Motion withdrawn.

Gosport Independent Panel: Publication of Report

Lord Hunt of Kings Heath Excerpts

Wednesday 20th June 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord makes two excellent suggestions. His suggestion about whether cover-ups should count as serious professional misconduct will be something the regulators will want to consider, as is better training on the use and prescription of opioids. We have made some progress in recent years. The freedom to speak up guardians are in place, and we talked about the learning from deaths programme. There is also the duty of candour. They are clearly steps forward but the panel has exposed that we are still not there yet. The suggestions the noble Lord makes are good and serious and we will want to consider them.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I had ministerial responsibility for this area in 2002 and the beginning of 2003, which is reported in the report. First, I associate myself with the Minister’s remarks, his commendation of Bishop James and his panel and the apology that has been given. Reading this report, the question I think about is whether, if those circumstances arose now, the response would be very much different. I am not at all sure it would. First, the report shows the reluctance at local level to have what it saw as interference from the centre in causing inquiries to take place. Secondly, while the police investigations were going on the other inquiries felt they could do nothing, as the noble Baroness, Lady Jolly, said. Thirdly, once the police investigation had been completed and the decision that no prosecutions would take place had been taken, there was an agonised debate within the coronial system about whether inquests would be appropriate. The real issue seemed to be resources. The local coroner’s office did not feel that it had the resources to conduct the inquests and if it did so it would undermine the rest of its important work. In the work now being undertaken, will a real effort be made to grip the issue of the deadening impact of police investigations in stopping us learning lessons immediately? Is the Minister confident that the changes in the coronial system will prevent the kind of unseemly debate that prevented inquests taking place for some time occurring in future?

[Lord O’Shaughnessy]

I thank the noble Lord for associating himself with that apology. He asked the right question. It was very well put. If the circumstances arose now, would the response be different? I think there is reason to believe it would be, for the reason I have set out—the improvements that successive Governments have made on patient safety—but we should not be complacent. We cannot assume that those things are enough. I hope they are an improvement. We believe they are an improvement, but we need to ask ourselves that very difficult question about whether they would be enough. That is what we will be doing through this process.

Resources are one of the issues. We need to make sure not only that there is clarity about the circumstances under which the different bodies can carry out inquiries without impinging upon inquiries by other bodies, but that they feel that they are capable of doing so. That is one of the things we are going to need to investigate.

Education (Student Support) (Amendment) (No. 2) Regulations 2018

Lord Hunt of Kings Heath Excerpts

Monday 21st May 2018 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the Education (Student Support) (Amendment) (No. 2) Regulations 2018 extend the normal student maintenance regime to more categories of nursing students as a replacement for the NHS Bursary Scheme; and calls on Her Majesty’s Government to postpone the introduction of the Regulations until the current review of post-18 education and funding has been completed (SI 2018/443).

Relevant documents: 21st and 25th Reports from the Secondary Legislation Scrutiny Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, the huge pressure which the NHS is under is taking a massive toll on our nursing, midwifery and other health professionals. It has been estimated that the NHS in England has approximately 40,000 nursing vacancies, with a vacancy rate of over 10%. A similar rate applies to midwives, although the RCM estimates it to be higher, to reflect the number of babies being born. The other health professions covered by this regulation are similarly affected. More nurses and midwives are leaving the profession before retirement; one in three nurses is due to retire in the next 10 years. For various reasons, including Brexit, work pressures and the age profile of the nursing profession, the number of nurses and midwives on the NMC register at the end of March 2018 was less than that in March 2017 and significantly less than at the peak in March 2016.

The House of Commons Health and Social Care Committee inquiry found that the nursing workforce in England must be,

“expanded at scale and pace”,

and that,

“future projections of demand for nurses should be based on demographics and other demand factors, rather than on affordability”.

Given this, one would have thought that the Government would do all they could to support and encourage entry to these professions. Instead, they are doing the opposite, reflected in these regulations, by ploughing ahead with their plan to scrap bursaries for yet more students, despite knowing full well the disastrous consequences that will follow.

Two years ago, the Government scrapped the undergraduate bursary. The results were predictable. In 2016, before the abolition, there were more than 47,000 nursing applicants in England. In 2018, the figure fell to about 31,000—a fall of over 15,000. It is clear that this is the reason why we have seen the sharpest ever decline in nursing applications. I have no doubt that the Minister will say that the number of applications is less important than the number of acceptances. I disagree: I want nursing to be seen as a profession where there is hot competition for places because it is such an attractive profession to be in.

No doubt the Government will say that they have committed to create more training places for nurses. They certainly promised an extra 5,000 nursing places and said that nursing bursaries had to be scrapped to make that possible. What has been delivered is a mere 700 fewer students training to be nurses. It is worrying, too, that there has been such a huge drop-off in mature students applying—the extraordinary figure of 42%. The very people we need to apply, who have often brought up a family, are now being denied an opportunity to make a career in nursing or face the consequences of being forced into huge debt.

We know that postgraduate students in particular are more vulnerable to the introduction of fee loans: 64% of postgraduate healthcare students are aged over 25 compared to only 18% of students generally. Women are largely attracted to the healthcare postgraduate route and represent 80% of the course places. There is a higher percentage of ethnic minority students on postgraduate healthcare courses compared to the general population, and the Department for Education equality analysis clearly states that these groups are known to be more debt averse. So introducing loans is likely to undermine recruitment of this cohort and represents yet another missed opportunity to grow the nursing workforce at a time of severe shortage.

The Government claimed in the other place that raising the cap will unlock additional places, but it was the Government themselves who set the cap through their funding of Health Education England. They also say that they can fill some of the gap with nursing apprenticeships. They have promised 1,000 of them, yet only a handful have started the course. This shortfall is not the only problem with overreliance on apprenticeships. A nursing apprentice will take four years to become a registered nurse. Even if there were a miraculous surge in apprenticeships starting this summer, we would not see any qualified nurses on our wards until 2022. Contrast that with an undergraduate nursing course, which can take three years, or postgrad courses referred to in the regulations, which can take two years, which makes them the quickest way to tackle the shortfall in numbers.

Another solution the Government have come up with is nursing associates. But there is clear evidence that using support workers or trainees as replacements for qualified nurses has potentially disastrous consequences for care. I hope that the Minister will confirm that that is not the Government’s intention. The nursing associate is a support role and must not be used as a substitute for registered nurses. Research is clear that diluting and substituting the registered nursing workforce with nursing support workers has ill consequences for many patients.

In pushing ahead with this regulation, Ministers ignore their department’s impact assessment. The DfE’s assessment of the changes to the bursary said that it would disproportionately affect women and ethnic minority students, yet Ministers have pressed ahead. Then the department found that the change could make women, older students and students with lower incomes less likely to participate. Again, Ministers pressed ahead.

This is not just a matter of fairness or even just about the benefit of having a diverse working population. In fact, older nursing graduates, to take the nursing profession in particular, are more likely to stay longer in the NHS and are more likely to choose areas such as mental health or learning disability nursing, which are facing such severe staff shortages. Nearly two-thirds of postgraduate nursing students are over 25, more than a quarter are from minority ethnic groups and 80% are women, so the impact of today’s regulations will surely be even worse than the previous cuts.

I welcome the golden hellos to postgrad students in specific hard-to-recruit disciplines, but the Government need to do much more to financially support postgraduate students.

Even if the Government are determined to make the change, there are good reasons not to make it now. This policy would move postgraduate nursing students over to the main student finance system, which means dealing with the Student Loans Company. There is every reason to believe that that company may not be ready. In recent weeks, the Government have been dealing with an error made by the company that has led to 793 nurses being hit with unexpected demands to repay accidental overpayments they were unaware of. I do not know whether the Minister has seen the recent NAO report on the company, but that also gives great pause for thought about whether it is able to accept this new responsibility. It strikes me that, before embarking on these regulations, we have the flagship review of higher education. The Government could have allowed that review to take account of this matter, rather than going ahead with the change today.

My final point is about student finances in general, and the impact on the Government. How many postgraduate students affected by this policy will repay any or all of their additional loan? How is this financially sustainable? Or is it just another example of what the Treasury Select Committee called a “fiscal illusion”—in this case, a student financial system that allows the Government to pretend that they have made a saving when all they are doing is passing the Bill to the next generation?

It is little wonder that the devolved nations have retained the NHS bursary system. We in England should do the same. I beg to move.

[Baroness Walmsley (LD)]

My Lords, like the noble Lord, Lord Hunt of Kings Heath, we, too, oppose the introduction of these regulations—and for very similar reasons. It always makes sense to make policy based on evidence and on the advice of experts. This is what the Government have failed to do in relation to the funding of student nurses. The removal of the bursaries for undergraduate nurses has already considerably reduced the number of applicants, and the number of those taking up a place was 705 lower last year than the year before. Given the 40,000 nurse vacancies that the noble Lord mentioned, this is a serious matter for patient safety, as pointed out by the Care Quality Commission. I accept that these are only one year’s figures, but I believe that, before upsetting the apple cart even further, the Government should postpone removing bursaries from postgraduate nurse trainees and other important groups until we have clear evidence of the effect on the number of undergraduate student nurses.

If we want to increase the number of registered nurses quickly, which we need to do, it makes more sense to support the two-year postgraduate route, not put it at risk by removing those bursaries, too—because this is the quickest way to get more nurses. Most suppliers of the two-year courses indicate that capacity could be increased by 50% given the right financial support, yet the Government are planning to deter applicants by removing the bursary. This does not make sense. Instead, the Government are focusing on the two four-year routes into nursing, yet the apprenticeship route is not providing the expected 1,000 extra nurses per year. The most recent data tells us that there are only 30 apprentice nurses—hardly a success. Will the Government look into the barriers that are preventing NHS employers taking on apprentices? It could be the 60% cut in funding for further professional development, which has affected the number of those who would like to become training assessors and mentors for student nurses and apprentices.

Nursing associates have a role both as assistants to registered nurses and as users of an alternative four-year route into nursing—but, again, it takes a long time and these associates, as the noble Lord, Lord Hunt, said, should not while training ever be seen as substitutes for fully qualified nurses. So why are the Government planning to deter applicants for the rapid postgraduate route, where 64% are over 25, where they are predominantly women and where they are more diverse than the general student population? In a career such as nursing it would be advantageous to attract people with a little more life experience than the average 18 year-old.

Also, we know that older women and ethnic minority students are more debt averse, as well as already having a student debt of up to £50,000 from their first degree. Therefore, it is vital to look at how this fast route into nursing could be supported. The RCN tells us that, if the fees were paid and a modest bursary towards living costs provided, the total would be less than the average annual premium paid by trusts over a single year for a full-time agency nurse. This is short-termism of the worst kind.

While the Government carry out their review of post-18 education, they might benefit from looking at the measures introduced in Wales by Kirsty Williams AM, the Liberal Democrat Minister in the Welsh Government responsible for medical education. Her conversations with students revealed that the main concern and deterrent was not fees but living costs. Therefore, she has introduced the equivalent of the minimum wage for students during their course. This method of student funding should be carefully considered by the Government while carrying out their review, particularly for nursing students, who have more contact time than other students because of their clinical placement and therefore less time to get a part-time job to support themselves. Will the Government please consider this sensible idea?

The House of Commons Select Committee on Health and Social Care stated that the nursing workforce should be expanded at scale and pace to avoid dangerous levels of vacancies. It should be based on need and demand rather than affordability. It is up to the Government to say how the money will be raised, but from these Benches we recommend some sort of hypothecated taxation or a reformed national insurance scheme which is truly progressive and demonstrates intergenerational fairness. The Liberal Democrats are also in favour of restoring the bursaries for undergraduate student nurses and we are against these new regulations, which would remove the bursary from postgraduate nursing students and other important health professional courses.

--- Later in debate ---

[Lord O'Shaughnessy]

That is quite right. That is fully funded clinical placements—just for the sake of clarity. I thank the noble Baroness.

There is understandable concern among noble Lords, which has been expressed previously in this House, about the new system of financial support, but I want to be clear that we are giving the group of postgraduate students that we are discussing access to undergraduate maintenance and tuition fee loans, just as we do with postgraduate teachers. This represents a more generous package of support than the postgraduate master’s loan. We are also making available additional funding for childcare, travel to clinical placements and exceptional hardship funding to ensure that the students are fully supported and are able to complete their studies.

Furthermore, as many noble Lords have mentioned and as the noble Lord, Lord Hunt, and the noble Baroness, Lady Watkins, welcomed, in the debate on the regulations in the other place on 9 May, my honourable friend the Minister of State for Health set out a range of additional support that we are investigating for postgraduate nursing students. This includes specific incentives such as “golden hellos” for postgraduates who go to work in mental health—where the noble Lord, Lord Willis, was quite right that we need to attract more nursing and where there has been a shortfall—the area of learning disability and community nursing. The Government have announced £10 million to support such incentives and we are considering how this should be best delivered.

Many noble Lords have expressed concern about the drop in number of undergraduate applications to nursing courses. We acknowledge that early indications from the latest UCAS data, published in April, show that the number of students applying to study nursing has decreased from this point in the cycle last year. However, that cycle is not yet over, so we need to apply some caution.

It is also worth noting, as noble Lords have pointed out, that there is a distinction between the decline in number of applications and that in the number of students starting their courses. That was exemplified last year, which showed a 23% drop in the number of applications compared to a 3% decline in the number of acceptances. That is regrettable, but it was still the second-highest number of acceptances on record. Several noble Lords have expressed their desire for further information on how this develops. I can confirm that my department has committed to publish an update in autumn 2018 following the close of the 2017-18 application cycle.

As the noble Baroness, Lady Watkins, pointed out, there is a global challenge to recruit more nurses. We are working hard to make nursing as attractive a profession as possible. As a result of constructive dialogue over recent months, NHS Employers and the relevant trade unions began a consultation exercise on a three-year pay deal for NHS staff employed under the Agenda for Change contract. Under the plan, the starting salary of a nurse will rise to £24,907 by 2021, not only rewarding current staff for the incredible work they do but sending a clear signal to the country about how much nurses are valued.

We are boosting the attractiveness of the profession in a number of other ways, too. Nearly 4,500 nurses have started the return to practice programme and 3,000 have completed it. Across the country, NHS trusts are developing arrangements for flexible working and there is a concerted effort to tackle workplace bullying through an NHS-wide call to action. Our homes for staff programme is supporting NHS trusts to dispose of surplus land to help up to 3,000 nurses and other staff access affordable housing. I hope that gives the noble Lord, Lord Clark, some concrete examples to back up the warm words we use about supporting the nursing profession.

Several noble Lords have touched on new routes into nursing, which the Government are prioritising. The most significant innovation in this area was the announcement of a new nursing associate role in November 2016. Health Education England has already trained 2,000 nursing associates in a pilot programme and is planning to train up to 5,000 in 2018, with up to 7,500 nursing associates trained through the apprenticeship route in 2019. As well as creating a much-needed new role in its own right—I emphasise “in its own right”, as it is an augmentation to the nursing and other professions—nursing associate training offers an alternative route to becoming a registered nurse. We expect this “earn and learn” approach to be more attractive to older students, a concern which many noble Lords have raised.

To support this career path, Health Education England is developing a shortened nurse degree apprenticeship to facilitate transition from nurse associate to registered nurse, which will also automatically recognise the prior learning and experience gained in the nursing associate role. For the first time, apprentices will be able to work their way up from entry-level health work through to advanced clinical practice in nursing.

Several noble Lords expressed their concern about the apprenticeship route and the figure of only 30 nurses. The official data has been delayed and we believe that the figure is more like 250. We will be able to confirm that. It is a better start but, clearly, not yet the target that we want to reach. However, we believe that this stepped approach through the nursing associate role, giving the opportunities for a pause after two years and then to go on for two years, ought to be more attractive to employers than the current four-year commitment. This development of the nursing associate route therefore provides for a better use of the apprenticeship route.

I want to address a couple of what are perhaps misconceptions. The figure of 40,000 vacancies is used often in this House. I might be pedantic and disagree with that number—the quantum is just about right—but it is important to say that these are not empty places. They are being filled by agency and bank staff. Part of the reason for that is that people want flexibility and more pay, two of the things that we are trying to address so that we can provide more permanent contracts for those people who currently work flexibly.

The noble Lord, Lord Clark, and the noble Baroness, Lady Garden, talked about EU staff. I hope your Lordships will agree that I miss no opportunity to say from this Dispatch Box how much we value those staff and that they have just as much right to apply for settled status as anyone else in this country, provided they fit the criteria. However, it is worth pointing out that there are more EEA staff in the NHS than there were in June 2016. The one category where the figure is lower is in nursing and midwifery but the reason for that was the introduction of a more stringent language test. We are dealing with that issue, which I hope will mean that we continue to see an increase in EEA staff working in our NHS.

The noble Lord, Lord Willis, asked specific questions about the apprenticeship levy. I will need to write to him on that issue having consulted my colleagues in the Department for Education.

Turning quickly to the second point of the Motion, several noble Lords, including the noble Lord, Lord Hunt, the noble Baronesses, Lady Walmsley, Lady Watkins and Lady Garden, and others said that we should postpone the introduction of the reforms until the post-18 education and funding review has been completed. As noble Lords know, the Prime Minister launched the review earlier this year to ensure that we have a better system of higher education support that works for everyone. Many aspects of the current system work well and, as was set out in the terms of reference for the review, there are important principles that the Government believe should remain in future. One of those is that sharing the cost between taxpayers and graduates is the right approach, as I rehearsed earlier in my speech.

I take the point made by the noble Baroness, Lady Walmsley, about looking at the Welsh example. I have looked at it myself and I am sure it is something that the review would want to consider. However, it is important that we do not prejudice the work of the expert panel established to support the review or prejudge its outcomes. The fact of the review should not delay these healthcare education reforms, not least because they predate the launch of the review by some distance and already apply to the vast majority of nursing students. We believe it would do more harm than good to further delay these reforms, although it is worth underlining that any relevant reforms stemming from the review will apply equally to this group of student nurses.

In conclusion, I recognise the well-motivated concerns expressed by noble Lords during this debate. However, I hope I have been able to demonstrate that the student finance reforms that this Government have introduced have allowed both the removal of the artificial cap on nurse training places and the largest expansion of student nursing places in a single year ever seen. These two facts are not coincidental; they are inextricably linked. The latter is possible only because of the former and they form part of a wider set of workforce reforms designed to expand, train and reward our nursing profession better so that we can continue to deliver the high standards of NHS care that patients demand. On that basis, I hope the noble Lord, Lord Hunt, will feel able to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to all noble Lords who have spoken in this debate, particularly the noble Baroness, Lady Watkins, who returned early from the WHO to take part in it.

I am left, though, with huge concerns and a real puzzlement as to the Government’s approach. As the noble Lord, Lord Willis, said, faced with this huge crisis in nursing in particular but also among the other professions covered by the regulation, the Government, without any evidence base, seem to be setting out a plan to discourage older women and people from black and minority ethnic groups from entering nursing, midwifery and other professions. In the breakdown of postgraduate healthcare students, the statistics show clearly that 64% are over the age of 25, women are largely attracted to this route and there is a higher percentage of minority ethnic students. We also know from the Department for Education’s own analysis that those groups are known to be more debt-averse. So the consequence is bound to be a negative impact on the very group of people we probably most need to come into the nursing profession.

--- Later in debate ---

[Baroness Walmsley]

I would add that the Browne recommendations had no cap at all.

[Lord Hunt of Kings Heath]

My Lords, I would pray in aid my noble friend Lord Adonis, who sadly is not here tonight, and take the Minister back to the original intent of the loans that we introduced.

The Minister does not seem to have responded at all to the issue that, essentially, we are transferring this debt to future generations. At some point, the fact that so little of the loans is being paid back will have to be confronted. The Minister justifies increasing the number of places now on the basis that at some time in the future some Government are going to be faced with a massive problem. So not only are we discouraging some of the most important people that we want from coming into the profession, but we are also engaging in the most extraordinary financial trickery to justify current expenditure.

The Minister mentioned apprenticeships and associates. Of course we should welcome apprenticeships, and I welcome the associate profession, which is a good thing. However, the problem is that we know what the health service gets up to. We know that directors of nurses do not have as much influence on boards as they need, and that NHS trusts up and down the country will substitute associates for qualified general nurses whenever they can. Given the debacle of the whole apprenticeship approach, in putting all our eggs into that basket we are very much risking the future of this profession.

My noble friend Lord Puttnam talked about the problem that it takes a long time to recover from a situation of drastic shortage, and my noble friend Lord Clark talked about some of the implications. When you see a car crash about to happen, you usually attempt to stop it. I see this policy as putting the foot on the accelerator, leading to an inevitable crisis.

However, this was debated in the other place. I see no purpose in prolonging the debate. I hope that, under the auspices of the review of student finance, the Government will start to think again. I beg leave to withdraw the Motion.

Motion withdrawn.

NHS: Cybersecurity

Lord Hunt of Kings Heath Excerpts

Wednesday 2nd May 2018 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what assessment they have made of the response of the National Health Service to cyber attacks.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, as the lessons learned review into the WannaCry attack by the Chief Information Officer for Health and Care set out, the NHS responded well to what was an unprecedented incident. However, a number of areas for improvement were also identified. Consequently, several immediate actions were taken to improve the cyber resilience of the NHS. They included updating and testing incident plans and investing more than £60 million to improve security in local IT infrastructure.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome the measures that have been taken, but the noble Lord will know that recently the Public Accounts Committee has identified that his department and the NHS were wholly unprepared for what was a relatively unsophisticated attack, and that many trusts failed to act on warnings that they had been given to patch exposed systems. I understand that the committee said that, extraordinarily, at the time it took evidence some trusts had still not patched up their systems. My understanding is that that is because those systems were linked to the use of medical equipment, and in patching up the systems they could have damaged a lot of the service-giving infrastructure. That suggests that the NHS is in a very poor condition indeed to deal with this kind of threat in the future. Can he reassure me that the recent announcement by the Secretary of State will really do the job?

[Lord O'Shaughnessy]

The PAC review found that the use of Windows XP was at the heart of the problem, as an unsupported and unpatched system. Several things have happened as a consequence. First, XP usage has gone down from 18% in 2015 to 1.7% now. We also have a customer support agreement with Microsoft now and are transitioning to Windows 10, which is of course fully supported and much more secure. We also have a system now called cursor collect. The notifications that go out, called cursor notifications, are due to be acted on within 48 hours. That exposes the fact that we did not have a way of tracking that. We now have a way of tracking that and enforcing action at trust level. So there is a much higher degree of security than there was. Of course, no security is ever perfect and our vigilance carries on.

--- Later in debate ---

[Lord O'Shaughnessy]

The noble Lord makes an excellent point. One thing we are now doing is more intelligence-led penetration testing based on work that the Bank of England does, which is to probe in a safe way any weaknesses and to make sure that they are dealt with. The CQC has also added data security to its well-led criteria for inspections. We have now demanded that a board member of each trust takes responsibility for cybersecurity. Indeed, for a trust to be rated as well led, it has to demonstrate that competence.

[Lord Hunt of Kings Heath]

My Lords, one of the things that happened when this occurred made it clear that NHS trusts did not follow the instructions they were given to patch their systems. Is the Minister assured that, if this were to happen in future, trusts would follow, without exception, the instructions given?

[Lord O'Shaughnessy]

I am absolutely assured that they would perform much better than they did that time. I do not think I can give the assurance that every single one would do it, because there are still capacity issues in some trusts. The investment that we are carrying out is designed to deal with that. It is a much better performance, but we need to make sure that we are always vigilant for weakness in the system.

NHS: Winter 2017-18

Lord Hunt of Kings Heath Excerpts

Wednesday 18th April 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right. That is one of the reasons we have taken some big decisions over the winter, one of which is to reduce the amount of delayed discharges. I think it has been reduced by about 1,500 beds. It was also the reason behind what was undoubtedly an unpopular decision and one that we did not want to take: to suspend and postpone some elective surgeries during January. That freed up a number of beds, which helped us to cope with the emergency admissions. Happily, it has not had to be reinstated since the end of January.

[Lord Hunt of Kings Heath (Lab)]

My Lords, a huge debt is owed to the NHS for the way that it has responded to the pressures this winter. However, can I ask the Minister about elective treatments and the cancellations in January? He will know that the maximum 18-week wait target has not been met for, I think, at least two years. Given that the BMA has said that winter pressures will really never come to an end—they simply continue throughout the year—does he think that we will ever meet the 18-week target again under the current Government?

Prescription Drugs: Dependence

Lord Hunt of Kings Heath Excerpts

Monday 19th March 2018 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they have plans to provide a network of support, nationally and locally, for people affected by dependence on prescribed drugs.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

The Government take seriously the issue of dependence on prescription drugs. The Public Health Minister has commissioned Public Health England to review the evidence on the scale and nature of the problems with some prescription medicines, and how those problems can be prevented and treated. The review is due to report in spring 2019.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I very much welcome the review, but there is a real problem: many, many patients are suffering huge damage as a result of overdependence, often because they have been prescribed a particular medicine for too long a period. There appears to be woeful ignorance among many people in the health service about this impact of dependence. There are no national programmes for supporting people. Instead, people rely on local charities, which are grossly underfunded. Does the Minister not think it is time for a national action plan, a national helpline and support for local charities, and to get the NHS to start taking this seriously?

[Lord O'Shaughnessy]

I agree with the noble Lord that it is a serious issue. A NatCen study found that there has been a doubling of the use of serious painkillers. Indeed, deaths due to opiates of all kinds have risen by about two-thirds in the past five years; of course, that is illegal as well as legally procured drugs. We agree that there is a problem. That is why the review is taking place. It is premature to say what the outcomes of that review will be, but undoubtedly we need a comprehensive approach to dealing with this problem, because it is getting worse.

Antimicrobial Resistance

Lord Hunt of Kings Heath Excerpts

Thursday 8th March 2018 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to wind up for the Opposition and thank the noble Baroness, Lady Greengross, for an excellent contribution, which other noble Lords added to. I want to raise two issues. One is about the use of antibiotics in animals and the other is about incentives for developing new drugs and vaccines. First, I refer to the wide-ranging speech of the noble Baroness, Lady Greengross, in which she referred to immunisation uptake, which is a very worrying issue for health in this country, let alone in other countries. I have seen various reports that there is ever more misinformation out there undermining people’s confidence in vaccines. We saw with the MMR issue the problems arising when this gains ground. Is the Department of Health and Social Care exercised about this and is it developing a strategy?

On the use of antibiotics in animals, I know that the Government made a progress report in 2016, commented on this and particularly referred to compliance with Red Tractor assurance scheme standards and to the work of the task force Responsible Use of Medicines in Agriculture Alliance. My noble friend Lord Grantchester, to whom I have referred on this, has made the point to me that, alongside this and influenced by various suppliers, farm assurance schemes are having a positive impact in reducing the use of antibiotics in animals. Will the Minister comment on this and give a progress report in that area?

On how better incentives can be used to promote investment in new drugs and vaccines, the report by the noble Lord, Lord O’Neill, was very clear that the current pipeline of new antibiotics shows that there is a mismatch between the drugs that the world needs and the number and quality of new antibiotics that are being researched. He recommended,

“a global system of market entry rewards for antibiotics and alternative therapies”.

He suggested that the challenge really is,

“to ‘de-link’ the profitability of an antibiotic from volumes sold, reducing uncertainty and enabling reward without encouraging poor stewardship”.

This arises from the fact that it is very difficult in the current model for the industry to see how it can get any return on the development of new antibiotics, and because of that, we have this very big problem.

I know that the Government have acknowledged the principle of de-linking, particularly in their endorsement of the 26th UN declaration on AMR but, just to reflect on the problem, STOPAIDS, which is a UK network of agencies which have developed a global response to HIV and AIDS, set out the de-linking issue, stating that the incentive to innovate is still tied to the price that pharma companies can charge for the products they create and therefore there is still a risk of continuing this problem of high price. The ABPI, the trade association for the pharma industry, is continuing to work with the noble Lord’s department on this to explore reimbursement and evaluation models, which could perhaps be piloted in the UK, but I wonder whether the noble Minister can say a little bit more about whether progress is being made.

I refer noble Lords to a recent—2018—report by the Access to Medicine Foundation, which is an international NGO based in the Netherlands. Very recently it produced an anti-microbial resistance benchmark. The report states that despite some progress being made by some companies, there are still too few in the pipeline and we need to strengthen that pipeline. I wonder whether there are other actions that now need to be taken to provide the right incentives.

Emergency Hospital Admissions

Lord Hunt of Kings Heath Excerpts

Wednesday 7th March 2018 Lords Chamber

[Lord O’Shaughnessy]

One of the issues the NAO reports is that we do not yet have good enough data on what is happening in the community. The creation of the community services dataset will enable us to track precisely what is available in the community in every area. Concerns have been raised in this House before about the number of district nurses, which unfortunately has fallen over recent years. It has now shown a small increase year on year and we hope we are starting to turn the corner on community nursing numbers, too.

[Lord Hunt of Kings Heath (Lab)]

My Lords, there are two stark facts from the NAO report. First, the real problem has been the reduction in social care funding. Surely the real answer to this problem, above all else, is to restore what has been cut. Secondly, I refer the Minister to the chart in that report which shows that, despite the increase in demand, bed capacity has been cut by 6,000 beds since 2010-11. I understand that in February the occupancy rate reached a dangerously high level of 95%. Does the Minister accept that, while we need to prevent avoidable admissions, it is very unwise to reduce acute care capacity at the moment?

[Lord O’Shaughnessy]

I agree with the noble Lord about funding. The Government have now made £9.4 billion of extra funding available to local authorities over three years, including in the most recent local government funding settlement. The noble Lord makes a good point about bed capacity: it had shown a downward trend for a long time before stabilising in recent years. I point to two successes this winter. The first is the improvement in delayed transfers of care—we have really started to get some traction on that. The second is about £60 million, I believe, of funding that went into providing extra bed capacity over winter. Occupancy levels are too high. The NHS is getting better at managing it more efficiently, but we certainly need to do better.

National Child Obesity Strategy

Lord Hunt of Kings Heath Excerpts

Monday 26th February 2018 Lords Chamber

[Lord O’Shaughnessy]

I reassure the noble Lord that the national curriculum, through PSHE, includes elements around nutrition and healthy eating. Indeed, many schools offer the kind of classes he is talking about.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I refer the noble Lord to your Lordships’ Select Committee on the Long-Term Sustainability of the NHS, which said that the Government,

“should not cite unwillingness to behave as a ‘nanny state’ as an excuse for inaction on the major public health issues, including obesity”.

If the study that is being undertaken at the moment shows that outcomes are poor, will the Government move from their current voluntary approach to take more decisive action?

[Lord O’Shaughnessy]

The point here is that we know that these are difficult decisions and, of course, children have decisions made on their behalf by their parents, people in schools and others, so there needs to be a combined approach of statutory action and voluntary action. We should applaud the voluntary action that many people have taken—supermarkets, food producers and others—but clearly there is a continued role for the Government and I do not think questions of nanny statism come into it.