Medicines and Medical Devices Safety Review

Lord Hunt of Kings Heath Excerpts

Thursday 22nd February 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for repeating the Statement. I should also like to thank him personally for meeting representatives from the mesh campaign group two weeks ago, which is much appreciated.

Today’s announcement is an acknowledgement that there are major issues which go back decades in areas that concern safety and a lack of proper scrutiny and research. We have heard how mesh implants have left women in permanent pain, unable to walk and unable to work. Welcome as the Statement is, the Government need to do much more to support those affected. Mesh has been suspended in Scotland and banned in other countries. The most recent interventional procedure advice from NICE on prolapses states that it should be used only for research purposes and not as a front-line treatment, but I ask the Minister whether he thinks we need to go further and suspend the use of mesh until NICE has completed its review into the safety and efficacy of the product. If the Government are not prepared to go as far as suspension, will he at least write to all trusts and indeed private hospitals to remind them that the Health and Social Care Act 2015 requires them not to cause avoidable harm? The review in itself signals that mesh is now acknowledged to cause harm.

I refer the Minister to Owen Smith’s comments in the other place; he chairs the All-Party Group on Surgical Mesh Implants. He said that:

“Lessons must be learned from the awful complications many women have experienced since undergoing mesh surgery and proper processes must be put in place to stop this happening in the future … The mesh scandal shows what can go wrong when devices are aggressively marketed to doctors and then used in patients for whom they were unsuited or unnecessary”.


Will the review chaired by the noble Baroness, Lady Cumberlege, look into that particular aspect?

The Minister mentioned in the Statement the investment of £1.1 million, part of which will go to improving clinical practice. Clearly, one should always seek to improve clinical practice, but mesh campaigners would say that the real issue is not the clinical practice but the product itself, which is not fit for purpose.

The retrospective audit is very welcome indeed, but there is a real question about whether it will capture all the women affected. I have certainly received evidence to suggest that some women suffering greatly from mesh implants are not aware of the reasons and therefore do not approach the health service. Will the Minister also say whether the mesh audit concerns only hospital statistics and records or whether it will cover GPs and primary care as well? Also, will the review extend to when men and women are affected by hernia mesh?

The Secretary of State has said that the review will not go into the science of mesh. But most studies do not use quality-of-life questionnaires, so they do not pick up the devastation of pain, lost sex lives or constant urinary infections. Studies concentrate on whether the mesh has cured the problem of prolapse or incontinence. Many studies are short-term or compare mesh to mesh. Trials should compare mesh to the old-fashioned natural tissue repair to get a proper evaluation of whether the use of these products should be continued in the future. Many trials have low numbers and any woman who has had a mesh implant can feel like a ticking time bomb, as the product can shrink or twist years down the line. No amount of surgeon training can counteract that.

Will the review extend to those with mesh bowel prolapses? Will it also look at what help the NHS needs to give to people currently affected as mesh sufferers? Obviously each country in the UK is taking a slightly different approach but, in his role as the Minister responsible, will he work with Scotland, Wales and Northern Ireland to pull together research and co-ordinated action, which would make great sense?

I hope that the noble Baroness, Lady Cumberlege, will be asked to look at whether device regulation needs to be tightened up. As the Minister knows, it is much less stringent than medicines regulation and there has been an ongoing debate about that. I hope that that will be included within her review.

On Primodos, the Minister indicated that the department would drive forward and accept the recommendations of the expert working group. But in the other place when the report was published in October, it was met with concern from all sides of the House. I hope that he will take that into account.

I am grateful that the Secretary of State has included sodium valproate in this work. The Minister will know that last year a charity found that almost one-fifth of women taking the drug still did not know the risks that this medicine could pose during pregnancy. I therefore welcome government efforts to raise awareness of the dangers of valproate. I also hope that the House can be offered an assurance that the review will gain access to medicine regulation files held in national archives, access to any valuable evidence cited in unsuccessful legal actions and access to documents and information held by pharmaceutical companies, and that all such material will be made public.

I ask the Minister to invite the noble Baroness, Lady Cumberlege, to meet victims to see whether consensus can be agreed on the terms of reference, to maintain trust and confidence in it. That would be a very valuable first step to gaining the confidence of campaigners who have worked so hard and have been gratefully acknowledged by the Secretary of State in his Statement.

[Baroness Brinton (LD)]

From the Liberal Democrat Benches, I am very grateful and thank the Minister for the Statement. I am particularly pleased about its tone, which moves on the Government’s debate with campaigners, families and clinicians about these very serious issues. It makes a break with the past.

I am particularly concerned that there should be regular assessments and updates for people with problems from Primodos and sodium valproate, because we know from our experience with thalidomide that everybody thought that everything had been sorted from the initial diagnosis of the children, but as they entered adulthood and more mature years further medical issues appeared. It will be important to recognise that we need to make sure these young people—and adults as they are now—get that protection.

The yellow card system was not available in its current format for these two drugs. One of the things that concerns me most about the Statement is the assumption that the only people involved with the yellow card are clinicians. Speaking as a patient who has been on a drug that has very serious yellow card incidents, I have been trained to recognise that if I get a side-effect I do not just go back to my hospital; I report it to the pharma company. The pharma companies are notable by their absence in this Statement. Will there be specific links back for clinicians and patients on some of the side-effects of drugs? That is easy to say for those who are formally expert patients. I absolutely accept the point made by the noble Lord, Lord Hunt, that some patients are inexpert for all the right reasons.

There needs to be a real focus on all the other health professionals that these patients come into contact with. Reporting a yellow card incident to a GP when it is very difficult to see your own GP these days means that it could quite often be missed. In the case of sodium valproate this certainly needs to include midwives and people involved in the obs and gynae departments as well. What training is to be provided for these non-specialist healthcare people to make sure that they understand, when a patient talks about a problem, that this may need to trigger a yellow card response? To that end, I welcome the proposal for an electronic yellow card. That will be extremely helpful. Printing out a yellow card, filling it in and sending it in is an absolute deterrent to it happening.

On Primodos and sodium valproate, will the longer-term effects also be covered by the Cumberlege review? It is important to have a reference back there. I am also concerned about the vaginal mesh issues, specifically those reported in the Statement. It would be useful to know what percentage of those who have had vaginal mesh implants have faced problems. It is fine to say that many have benefited. I completely accept that, but one needs to understand what the ratio is between those facing problems and those for whom it has benefited them, to understand whether a ban should be in place. What is the date for publishing the retrospective audit? It is fine to say that it will be done. I have no idea how far along the line the process is. Then there is the timescale for creating that computer database for vaginal mesh to improve clinical practice. When will it be not just commissioned, but completed and used in analysis? Will interim reports go to the noble Baroness, Lady Cumberlege, by the people doing this review if evidence emerges that she will need to take account of?

I am concerned about the idea of the creation of a patients’ champion. We already have panels and expert groups. Yet another person that patients may or may not know about, and may or may not be able to turn to, seems problematic. I urge the noble Baroness, Lady Cumberlege, to look at what is available now rather than creating yet another body.

Finally, I echo the concerns expressed by the noble Lord, Lord Hunt, about whether we should move to a public inquiry at this stage. I wonder whether the evidence that the noble Baroness, Lady Cumberlege, will undoubtedly turn up means that she may come back to Ministers and say, “Actually, this is the point at which this needs to go public”. Campaigners have highlighted for years that there are problems.

Health: Pelvic Mesh Implants

Lord Hunt of Kings Heath Excerpts

Tuesday 6th February 2018 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they intend to review the safety of the use of pelvic mesh implants.

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

My Lords, NHS England’s mesh working group report outlined recommendations to optimise care when surgical mesh is used to treat stress urinary incontinence and pelvic organ prolapse. We continue to implement those recommendations. NICE has now published eight pieces of updated interventional procedure guidance related to vaginal mesh. Updated clinical guidance covering urinary incontinence and mesh will be published in February 2019. The MHRA continues to review available evidence to make sure that our regulatory position is up to date, liaising with EU and non-EU partners.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for his personal involvement in the decision to conduct a retrospective audit into vaginal mesh surgery, but will he go a little further? He will be aware that an increasing number of women have reported suffering from complications that include debilitating pain, infection, inflammation, the loss of sex life and mobility issues. A number of countries have now banned the use of mesh implants completely. On the precautionary principle, will he suspend the use of mesh until the audit that he has announced has been completed and new guidelines issued by NICE?

Dental Care

Lord Hunt of Kings Heath Excerpts

Thursday 1st February 2018 Lords Chamber

[Lord O'Shaughnessy]

We have talked about fluoridation a lot in this House recently. My noble friend knows the position: it is up for local areas to come forward with proposals. On his particular issue about dentists, they are doing a fantastic job in the NHS. We have more of them than ever. I want to point out that the 1% cap that was applied—we know that was because of the fiscal retrenchment that has had to take place in this country—no longer applies; indeed, we are waiting for dental review bodies to report on it so that we can arrange future payments for dentists.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I remind the House of my presidency of the British Fluoridation Society. The noble Lord says that we have talked a lot. We have not quite talked enough, because the problem is this: fluoridation would deal with a lot of the areas with high numbers of oral health issues. The local authority is responsible for this and for paying the revenue costs, but the benefit falls to the health service. The cost annually for an average local authority is £300,000. Would the noble Lord be prepared to convene a discussion between himself, NHS England and Public Health England to see whether there could be a way to find some resources to help local authorities implement schemes?

[Lord O'Shaughnessy]

I recognise the benefits of fluoridation that the noble Lord has pointed out. There is no question about that. But we know that this is a very difficult and vexed issue locally—there are strong feelings either way. That is why the position was reached in the 2012 Act. The noble Lord’s idea of a discussion is a good one. I should point out that it is not a policy area on which I lead so I will have to speak to my colleague in the department, but if we can get that going and think about ways to encourage more action it would be a very clever thing to do.

NHS: Cancer Treatments

Lord Hunt of Kings Heath Excerpts

Thursday 25th January 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I too thank my noble friend Lady Jowell for an extraordinary speech, full of passion, compassion and hope. I had the great privilege of following her as a Minister at the Department of Health: what a formidable reputation she had as our first Public Health Minister and what a legacy she left. Many of today’s public health programmes which are taken for granted she established in those first two crucial years. I do not know whether she knows that I have not quite forgiven her for her other big decision at Richmond House, which was to get rid of chocolate biscuits and bring in fruit bowls instead. What she does not know is that a certain Minister of State not a million miles from where she is sitting had a secret cache of those biscuits—my noble friend Lord Hutton became very popular for having meetings in his own ministerial room.

My noble friend Lady Jowell has raised a huge question about access for NHS patients to innovative treatments. In a sense, that is the great paradox of health in this country. We have an NHS that we are enormously proud of. It is still very well regarded internationally. We have an incredibly strong life sciences sector, with over £60 billion of turnover and over 200,000 high-quality jobs. We have one of the strongest pharmaceutical industries in the world: 25% of all global medicine is developed in the UK. Then, as the noble Baroness, Lady Dean, and my noble friend Lord Turnberg said, we have the great paradox; it is a British problem too. We have this great development, this great invention, but we are slow to adopt it. The experience of my noble friend Lady Jowell and so many other NHS patients is the same. If we look at other countries, such as Germany and France, we can see that their patients have much more access to innovative treatments than we do in this country.

When my noble friend was a Minister, she had the first discussions about the establishment of NICE, which was set up to deal with this British problem. It was calculated that it took 15 years for a proven new innovative treatment to be adopted generally in the health service. Here we are, nearly 20 years later, still facing the huge problem of innovation adoption. It is true that the Government have established the accelerated access review; they also have a life sciences strategy, post Brexit. However, we have to do much more. Of course finance is important, but the Minister will know that it is not just about finance—it is about attitude. I hope that the one message he will take away from this extraordinary debate and from my noble friend is that we have to do better in the NHS to adopt the huge innovation that so often takes place in our country.

NHS and Social Care: Winter Service Delivery

Lord Hunt of Kings Heath Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Barker (LD)]

My Lords, I thank the noble Baroness, Lady Wheeler, for the opportunity, as the noble Baroness, Lady Pitkeathley, just said, to return again to this subject. I will not make a long speech as I would like to leave as much time as possible for the debate that will follow. On behalf of my colleagues on these Benches, I wish the noble Baroness, Lady Jowell, all the very best and ask her colleagues to convey that to her.

The noble Baroness, Lady Pitkeathley, is right: we have been back to this ground so many times. In preparing for this debate, I thought back to many of the debates that we have had in the past. The origins of the problem we are looking at go back to the National Health Service and Community Care Act 1990. In that Act, for the very first time, welcome things happened: we began to break down procedures within the NHS and to cost and quantify them. But the problem was that we made them into individual units of activity, and to this day, within the NHS, the systems that join up those individual units are failing. They fail completely when they have to be matched up with the social care system, which is completely different.

Those problems were identified and partially addressed in 2003 with the Community Care (Delayed Discharges etc.) Act, when the then Minister, the noble Lord, Lord Hunt of Kings Heath, was sitting there trying to answer questions from very talented opposition spokespeople such as me. We asked him a question that he never could answer, which was why the then Government thought that the answer to the problems in the NHS was to fine social services departments. I never understood that. We still have, within the whole system of discharge, a system of penalties.

[Lord Hunt of Kings Heath (Lab)]

Perhaps I can answer the noble Baroness. Surely the point is that both local government and the NHS were being properly funded at that point. Therefore it was entirely appropriate to have a system to encourage local authorities to do the right thing.

[Baroness Barker]

The issue that I think the Government were trying to solve was one for which we have never had any evidence: that of local authorities trying to game the system. It is correct that the overall amount of funding has gone down, but we have not had evidence of people gaming the system.

We have never had a system, or even part of a system, that incentivises GPs and those in charge of social care to prepare for winter pressures, invest in programmes that will see older people through the increased incidence of illness that we know happens in winter, and avoid unnecessary admissions to A&E. What has changed in that time is that we now have better data and better information systems, but in many ways we are still failing to take all that and improve those systems. At the moment we still have ambulance services being rated on completely different systems across the country so we cannot generate data.

The Government have done some things that are very welcome. Everyone agrees that the primary care streaming system, into which they put £100 million, is a worthwhile initiative. Unfortunately, the initial evidence is that it is failing simply because it takes people from another part of the system—GPs—and locates them in hospital. What are the Government going to do to properly monitor that system in its entirety as part of an overall approach to winter pressures, to see whether it is worth more investment or whether it simply takes resources from other parts of the system?

On the question of beds, we have a national system of monitoring general and acute beds and ways of measuring the overall occupancy rate. We do not have a method of assessing the number of beds in relation to need. For example, we can open up a load more beds, as the NHS always does at times of crisis, but if there are no more staff to look after the people in those beds then we are not really addressing the need. We need to refine the measurement of this so that we have a metric along the lines of “nurses per bed per day”. That is the point at which things become really bad. I remember talking to a nurse about a patient—actually my mother—and being told that she was far too good to be in hospital and would be going home. She died two days later, which was not a surprise to any of us. I say that because it is not an uncommon experience for patients.

We have been through this time and again. The one thing that we have failed to do is incentivise GPs to work with community organisations from the summer onwards to predict the people in their area who are going to be most at risk and to put in place very low-level, simple and low-cost packages of care for them that can be there very quickly when they are discharged. The biggest cause of delayed discharge is not the absence of social care but the absence of community nurses and NHS staff available to work in the community to ensure that we do not send people home only to see them return unnecessarily into acute care.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to respond to my noble friend’s debate. As my noble friend Lord Smith mentioned oral health in the north-west, I remind the House that I am president of the British Fluoridation Society, which of course is the answer, at a stroke, to the dreadful oral health issues among children in Greater Manchester and the north-west generally.

My noble friend Lady Wheeler made a persuasive speech about the pressures that the NHS is under and the relationship between that and front-line social care. The latest figures on performance graphically illustrate this: in 2017, 16.5% of patients spent more than four hours waiting for treatment compared to 5.6% in 2012. On delayed transfers of care, there were 1.97 million delayed days in the first 11 months of 2017 compared to 1.26 million in the equivalent 11 months of 2012. The 18-week referral-to-treatment target for consultant-led treatment has not been met since March 2016. The 62 days from referral to treatment target for cancer has been met for only one month since April 2014. The number of cancelled operations is going up, as are ambulance response times—the new target of seven minutes for life-threatening calls was not met in its first month of operation. Occupancy levels in hospitals have become a hugely difficult issue. On 2 January this year, 57 of 137 trusts had bed occupancy above 98%. That means not just pressure but almost certainly unsafe practices in those situations. The Secretary of State, who has made quite a lot of noise about safety, needs to take stock of his own responsibility for the fact that there are now some very critical situations in the NHS where undoubtedly patients are vulnerable.

If the Government were at least open about this, we could have a proper debate, but, as the noble Lord, Lord Kerslake, said in quoting Chris Ham—who knows a thing or two and goes back quite some way—it is the Government’s denial about the scale of the problems faced that makes it so difficult to debate with them and have any meaningful discussion about the way forward. I think all noble Lords agree with my noble friend Lady Pitkeathley that the NHS crisis is also a crisis of social care. The information we received from the Association of Directors of Adult Social Services, saying that 90% of councils are able to respond only to people with critical and substantial needs, is telling, because we know it means that we are storing up even more trouble for the future because we are not intervening at a stage where we could help people. The report that we saw from Age UK and the chair of the Malnutrition Task Force said that only 29,000 people now receive meals on wheels, down from 155,000 a decade ago. No wonder it is said that 1 million older people are starving in their own homes. That is the scale of the problem that we face.

The noble Baroness, Lady Wheeler, in talking about the experience of carers, really brought this home to us. As she said, emergency care and hospital admission and then discharge is a make or break time for carers and their families. People like her become carers for the first time when this happens. Despite all the guidelines and good practice, most discharges take place with very little notice, particularly when there is such pressure to free up beds to make way for patients who are waiting in A&E, on trolleys or, indeed, in the ambulance, waiting to be seen in A&E.

My noble friends Lady Pitkeathley and Lord Pendry talked about the impact of carers and the problems they face for their health. I hope the Minister will respond to this question: if we cannot produce a carers’ strategy, can we at least have an interim action plan? Let us not just hide behind a Green Paper, which, frankly, I do not think we will see for many a month, if at all. I suspect the problem is that the Treasury will not agree to any proposal that is not along the lines of that which Mrs May proposed during the last election, which caused such concern.

Capacity is a major issue. The pressure is increasing but NHS capacity is reducing. Could the Minister explain why that is happening? I should also like him to reflect on STPs. There was a time when all the answers to all the problems were to be in the sustainability and transformation plans, which then became programmes. We do not hear so much from Ministers about STPs now, but the health service is trundling on because no one has told it to stop work on them. We debated here a few months ago the west London STP, which is a remarkable document. Because financial balance by 2021 is the imperative, it is essentially taking a great deal of capacity out of west London and then saying that through heroic demand management, which we have never seen before, everything will be all right. Most STPs repeat this because, basically, they have been told by the regulators that they have to come up with a plan that meets financial balance. I do not think Ministers believe in them anymore, but they used to believe in them; they used to say that they were the answer to the problem—but everyone out there knows that they are pieces of fantasy, which will never be delivered. I pray in aid the National Audit Office report, which came out in January and said:

“Local transformation of care is being hampered by a lack of resources and ongoing pressure to make increasingly tighter finances balance each year”.


So they are reducing capacity, but not producing any investment to develop other services, which would then help to reduce demand on acute care. So there is no hope whatever of achieving anything that these STPs say they will do.

We then come briefly to the new role of the Secretary of State. Will the Minister explain what that new role is? He knows that his department has been responsible for social care for decades; he also knows that the Department of Health negotiates the adult social care vote, albeit that then goes through DCLG. So what is changing? Is the Department of Health now to have the money for social care and is that then to be ring-fenced as an allocation to local authorities? If not, has there been any change at all in the Secretary of State’s responsibilities? I think we ought to know.

I accept, and my noble friend Lord Smith and the noble Lord, Lord Kerslake, explained, that it is not simply a matter of having integrated health and social care budgets. First, you have to deal with the gap between free-at-the-point-of-use NHS spend and means-tested social care spend. Until you deal with that, integration is very hard to deliver at local level. Secondly, you cannot look at social care budgets without looking at the overall spend and discretion of local authorities. Adult social care is probably the biggest discretionary spend they have: if you start to intrude on what they can do, it is very difficult to see how local authorities have the flexibility at the moment to be able to manage the rest of the local authority responsibilities. This is not at all easy.

The noble Lord, Lord Macpherson, spoke very articulately about the pressures on government finance in general. He said we could do with better management and I agree: the system needs to be reformed. I also agree with my noble friend Lord Brooke about the way hospitals are run. The hypothecated tax, informed by the OBR and based on national insurance contributions, seems to be a runner. His point about retired people having to pay national insurance was very well made. I have just been re-reading, or glancing at, the book by the noble Lord, Lord Willetts, about intergenerational fairness. Reflecting on my noble friend Lord Desai’s willingness to increase taxes, which I agree with, it is very difficult to say to younger people, “We are going to increase your taxes to be spent largely on a service that provides for older people”, when you have the current benefits for older people. This is a controversial statement to make from this Dispatch Box, but inevitably this has to be confronted. I am hoping to join my noble friend in being sacked at this point.

I come back to the report by the noble Lord, Lord Patel. It is a very good report, published on 5 April 2017. “How long, O Lord, how long” before we get a response from the Government?

NHS: Nurse Retention

Lord Hunt of Kings Heath Excerpts

Wednesday 17th January 2018 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what steps they are taking to stem the flow of nurses leaving the NHS.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I beg leave to ask a Question of which I have given private notice.

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

My Lords, nursing numbers have increased since 2010, including 11,700 more nurses on hospital wards. To retain more of these hard-working staff and to build a workforce fit for the future, the Government are increasing the number of nurse training places by 25%, supporting new flexible working arrangements in the NHS and delivering a new homes for nurses programme.

[Lord Hunt of Kings Heath]

My Lords, even for the Minister, that is remarkably complacent. The overall number of nurses may be rising, but it has nowhere kept pace with the increasing number of patients. For years, the Government have failed to get new recruits coming through, while failed policy decisions such as the NHS pay cap and the ending of the NHS bursary have contributed to the growing crisis. Last year, 33,000 nurses left the NHS. More than half of those who walked away were under 40, and the number of leavers outnumbered joiners by 3,000. There are now more than 100,000 vacant posts in the NHS. Does the Minister accept the need to lift the pay cap, fund proper rises for nurses, restore bursaries and support this precious profession, which has been so unappreciated by this Government?

[Lord O’Shaughnessy]

The noble Lord is quite wrong to say that it is an unappreciated profession; nurses are deeply appreciated by everybody in this country, and that includes members of the Government.

Of course we want to reduce the number of nurses leaving the profession. It is important to point out that the number is down on two years ago, which was the peak in both number and proportion, and that the number of nurses has risen over that period. The noble Lord mentioned the pay cap. He will know, I hope, that in the Budget the Chancellor announced that he would be funding pay increases above the pay cap for nurses and other professionals on the Agenda for Change contracts, which is extremely welcome. We know that pay matters.

The noble Lord is right to focus on under-40s; that was an area that concerned me. The programme whereby we are promising to deliver 3,000 social homes for nurses is an important part of retaining staff, because we know how important housing costs are, particularly in the south of England.

Finally, we have been around the issue of bursaries a number of times, and there is no evidence that their introduction will make a long-term impact on our ability to recruit the nurses we need. Indeed, we are increasing the number of nurse training places from next year by a further 5,000.

Smoking: Vaping

Lord Hunt of Kings Heath Excerpts

Tuesday 19th December 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Viscount is right to highlight the benefits of vaping: it is considerably safer than smoking and is a very effective quitting aid. There is no particular evidence that it encourages people to take up smoking or to transition into smoking. Government policy has, obviously, been made under the EU regulatory framework—and we think that it is pragmatic and evidence based. Direct advertising is, as he will know, banned, but the department, Ofcom and the Advertising Standards Authority are looking at the current guidelines in this area. I should point out that Public Health England includes in its public health campaigns positive messages about the relative benefits of vaping, so that message is getting out. In the end we must beware of renormalising the act of smoking, even if with a different device, particularly for children, so there is a balance to be struck.

[Lord Hunt of Kings Heath (Lab)]

My Lords, lest Brexiteer noble Lords get too excited, will the Minister confirm that it was the British Government who pressed the EU for draconian regulations, and the EU modified what Britain wanted? We should beware repatriation of those regulations.

[Lord O'Shaughnessy]

I will only talk about what I know, and what I know to be coming up, which is that we want to take a pragmatic and evidence-based approach. Other countries are looking at the balance we strike in this country with allowing smoking and vaping to take place—and indeed, positively encouraging vaping. I think our approach is sensible.

Health: Atrial Fibrillation and Stroke

Lord Hunt of Kings Heath Excerpts

Tuesday 12th December 2017 Lords Chamber

[Lord O’Shaughnessy]

I thank my noble friend for making that point. He is quite right that atrial fibrillation is easily diagnosable and treatable. In the end, it has to be a clinical judgment on what kind of medicine is appropriate for any given patient, but the variation in the prescription of anti-coagulants demonstrates that there is not uniform understanding of the options. There are a number of things I could point my noble friend to, such as the NICE guideline which promotes not only self-monitoring systems, which are typically what we have had, but encourage patient choice for the new types of anti-coagulants which have a lower risk of bleeding and are much more popular with patients.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister say why the national stroke strategy has not been updated or renewed? We had outstanding success in London in concentrating hyperacute services in a small number of centres, which improved outcomes and mortality rates. Why on earth has the NHS been allowed to stop proposals in other parts of the country taking that forward so that outcomes there are higher?

[Lord O’Shaughnessy]

On the stroke strategy, a follow-on plan is being developed by NHS England and its partners, including the Stroke Association, which will take forward that approach. The noble Lord will also be pleased to know that it is an integrated-service approach including ambulances, community care and secondary care. On the point about reorganisation, he is quite right that London has seen excellent success through the specialisation and concentration of services, and we certainly encourage the rest of the country to do that too.

Children: Oral Health

Lord Hunt of Kings Heath Excerpts

Monday 4th December 2017 Lords Chamber

[Lord O'Shaughnessy]

I am sure that milk does have those benefits. I should also point out that one of the best things one can do for all bone health is to have vitamin D and calcium supplements, which are recommended for young children.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that we are all grateful to the Minister for his wisdom in advising us on such important matters. I declare an interest as president of the British Fluoridation Society. To return to the point that I have raised with many Ministers over the past few years, the Minister says that it is down to local decision-making. The problem is that the hurdles that have been put in place make it almost impossible for local authorities to get fluoride into their water supplies. Will he look again at the rules and the law and agree that this is a strategic decision that needs to be made by government?

[Lord O'Shaughnessy]

I am certainly happy to look again at that issue because we know the benefits of fluoridation. That is one reason why more children are having fluoride varnishes, for example.

NHS: Staff

Lord Hunt of Kings Heath Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to thank my noble friend Lord Clark for allowing us to have this important debate. I also pay tribute to the noble Baroness, Lady Emerton. It was very good to hear her speak today. She threatens retirement, but let us hope that is a little time off yet.

My noble friend spoke in a passionate, informed way of the considerable challenges facing the National Health Service and its workforce, and the link between the workforce challenges and the problem of NHS performance at the moment. As my noble friend Lord Pendry said, the NHS faces its most difficult time since its inception. Not only are targets being missed but the key quango, NHS England, effectively says that it will no longer attempt to meet some of those targets, including the 18-week target.

My noble friend Lord Clark spoke of statements emanating from the leadership of NHS England that it will have to ration treatment. I put it to the Minister that paragraph 16 of the board papers published this morning by NHS England states:

“Our current forecast is that—without offsetting reductions in other areas of care—NHS Constitution waiting-time standards in the round will not be fully funded and met next year”.


I remind the Minister, because we debated this in September, that meeting the core targets, including that of 18 weeks from referral to treatment, is a legal requirement under the NHS constitution. I also remind him of a statement made by the Government on the morning of our debate on 6 September this year. It said that the 18-week standard,

“remains a patient right, embedded in the NHS Constitution and underpinned by legislation. We have no plans to change this”.

Will the Minister today repudiate the action that the NHS commissioning board is being recommended to take, signal to the House that the constitution and associated regulations will be amended to allow NHS England to not meet the standard, or produce the funds so sorely needed to ensure that the NHS can meet it? It is no good for Ministers just to shrug this off; it is a matter for which they must account to Parliament.

That is just one example of why we have such huge workforce pressure. I thought that NHS Providers summarised the situation very well when it talked about mounting pressure:

“Rapidly rising demand and constrained funding is leading to mounting pressure across health and social care”.


My noble friend Lord MacKenzie spelled that out well. It also said that most provider trusts,

“are struggling to recruit and retain the staff they need”,

that the supply of new staff,

“has not kept pace with rising demand for services and a greater focus on quality”,

and that,

“recruiting and retaining staff has become more difficult as the job gets harder, training budgets are cut and prolonged pay restraint bites”.

It also states:

“Even if there were no supply shortages of staff, and provider trusts had no difficulty recruiting and retaining staff to work for them”,


many would,

“be unable to afford to employ the staff they need to deliver high quality services”.

No doubt we will hear the Minister peal out some statistics showing that there have been some increases in staff between now and 2010, but that is not the whole story. First, he must take account of the increase in demand on the health service over those seven years. Secondly, in 2010, the coalition Government made disastrous decisions to cut, in particular, nurse training places. In a panic, they have had to reverse that decision, but we are behind the curve in relating staff numbers, the number of staff training places and the way services are going. The decision to scrap bursaries has proved a disaster—disastrous to the wretched universities that proposed it, because they do not have more nurses coming in, as they thought they would, and a disaster for the Government. It must be reversed.

On pay policy, my noble friends Lady Donaghy and Lord MacKenzie spoke very well about the impact of pay restraint on low-paid workers. The pay review bodies are hardly independent in that it is clear that they have now been told they can go above 1%, but there will be no money to pay for it. Independence? What independence do they have? What prospects are there for so many NHS staff to have decent pay in the future?

I also raise something I find very disturbing. First, there is the attack by Jeremy Hunt on NHS staff over compensating for working anti-social shifts. Apparently, he thought he did so well over the junior doctors’ negotiations that he will bring the same great skill and leadership to the other staff groups in the health service. That will certainly improve morale, will it not?

I also raise with the Minister a disturbing trend being forced on NHS foundation trusts by NHS Improvement, which is designed to take thousands of staff out of NHS employment and, as worrying, out of the NHS pension scheme. This is a growing trend to set up wholly owned subsidiary companies to run a lot of non-clinical services within trusts. Clearly, it is a VAT fiddle—it is designed to reduce VAT payments—although the DH has to make up to the Treasury the VAT return, so it is a false economy by the health service. Staff who transfer to the company retain their employment rights, terms and conditions and NHS pension, but new employees have no such guarantee whatever. I gather that NHS staff who are really being forced to transfer to these subsidiary companies are being encouraged to opt out of the NHS pension scheme in return for a bribe of a higher wage rate. I find it deplorable that this can be encouraged by bodies responsible to the Minister. Staff are being encouraged to come out of the NHS pension scheme. That is absolutely disgraceful. I hope the Minister will say today that that will be stopped.

On resources, what can I say? My noble friends Lord Pendry and Lord Clark clearly think that the bung put in by the Chancellor is insufficient. The Institute for Fiscal Studies said that the NHS was in the middle of its toughest decade ever. It said that after accounting for population growth and ageing, real spending had and would remain unchanged for years. Sir Bruce Keogh, medical director of the NHS, said after the Budget that, “longer waits seem unavoidable”.

The King’s Fund, the Nuffield Trust and the Health Foundation, in their post-Budget analysis published two days ago, said that next year the NHS will not be able to meet standards of care and rising demand. Resources are a major issue in relation to the workforce. So, too, as my noble friend Lady Donaghy said, is staff affection for the shambolic system the coalition Government imposed on the NHS in 2012. We knew it would be a disaster; we said so for 15 months in your Lordships’ House. They determined to go on with it and we have ended up with a hugely fragmented leadership, wholly inadequate commissioning and rampant instability in providers. We have reached a point where the Secretary of State himself disowns the 2012 Act. The whole purpose of setting up STPs is basically to circumvent the rules of the market within that Act. No wonder the staff feel unhappy when leadership is so fragmented and hopeless. When will the Government legislate to legitimise what is happening? The 2012 Act is clearly being ignored.

My noble friend Lady Pitkeathley focused very well on social care, of which there was nothing in the Budget. The Green Paper has been put into the long grass and I do not expect to see it for many, many months. For carers there is a whole lack of support and no strategy. No wonder the social care workforce is in such a shambles.

I am sure the Minister will talk about this: we are now promised a workforce strategy. The Secretary of State gave an interview to Health Service Journal recently, in which he said:

“My strong view, having been involved in this job for a while now, is that the big problem with workforce strategies is that both me and predecessors in my role have only thought about workforce in terms of the current spending review and that’s really what has caused us a problem in the past because we only committed to train people for whom the Treasury had given concrete assurance they were prepared to fund. We ended up with very short-termist spending reviews, sometimes they were only a year … My view is, given how long it takes to train a doctor or a nurse, you cannot have a workforce strategy that is anything less than 10 years”.


In 2010 the Government inherited a long-term workforce strategy, and what did they do? They cut it viciously.

The Minister is always fond of sermonising to me, in particular, on the economy, and why the Government did what they did. I remind him that in 2010 the economy was growing at 2% per annum and the Government snapped it off. It took a long time to recover. I also remind him of what the noble Lord, Lord Warner, said: the UK economy is incredibly fragile at the moment. We have low productivity and downward projections on growth. The OBR has revised growth down to 1.5% this year, 1.4% in 2018-19 and 1.3% in 2019-20. The IFS has described this decade of a Conservative Government as the age of austerity and stagnant wages, which it now expects to last for another decade. I say to the Minister that, with the disaster of Brexit to come, the Minister should spare us lectures on the economy.

What are we to do? What is the future? NHS Providers did a very good piece of work, recently setting out a strategy for closing the workforce gap, making the NHS a great place to work and ensuring that we have strong, effective leadership. I commend that report to noble Lords. There is an awful lot to do, and I am afraid I am not confident in the Government’s ability to do it.