National Health Service

Lord Hunt of Kings Heath Excerpts

Tuesday 10th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord makes an excellent point. It is true to say that in this country we are very good at creativity and innovation but not always very good at spreading it round. In a way, that is one of the biggest challenges the NHS faces. I would merely highlight a couple of areas where the NHS is working well. The first is the test beds programme, which is working with industry, taking new innovations and spreading them round. Secondly, we have committed to publishing our response to the accelerated access review by the end of the month on how to make sure the most transformative drugs, devices and therapies are taken up throughout the system.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can I ask the Minister about the sustainability and transformation programmes? Has he seen the report issued by the King’s Fund last week that said we have fewer acute beds in this country than almost any comparable country? It also pointed out that the plan of many STPs is to reduce acute care numbers even further. I fully accept that we could use our beds and discharge patients more effectively, but the King’s Fund warns that STP plans to further cut acute beds are unsustainable. Will the Government consider that?

[Lord O'Shaughnessy]

Simon Stevens, the head of the NHS, made an important point several months ago about reconfigurations. Any reconfiguration has to meet four criteria: clinical need, popular support and so on. He added a fifth, which was about taking out beds. Those STPs are judged on their ability to meet the changing needs of their population. If there are proposals to take out beds which mean that those needs will not be met, such reconfigurations will not be accepted.

Health: Sepsis

Lord Hunt of Kings Heath Excerpts

Thursday 14th September 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right. Trusts are now incentivised to report incidences of sepsis and their performance against these quality standards. That is happening. Unfortunately there is still variation within the system. That is why the documents that came out yesterday are so important. For the first time, we have an operational definition of adult sepsis. Clearly, that is critical to making sure that it is spotted in time.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the action plan is very welcome. It seems apparent that when patients come through, particularly from A&E, they are not recognised as having sepsis. Clearly, there is an issue about health service staff not recognising the symptoms or understanding the scale of the problem with sepsis. The Minister will be aware of a 2015 report by the national confidential inquiry which criticised the way coding is designed so that, in fact, sepsis does not appear as the prime responsibility for a death. The Government have been asked to look at coding. If it is not in the action plan, will the Minister look at this?

[Lord O'Shaughnessy]

That is absolutely right: there was an issue with coding. The noble Lord will be pleased to hear that from April this year NHS Digital published new guidance on coding for sepsis to deliver exactly the kind of improved reporting he wants.

Care: Older People

Lord Hunt of Kings Heath Excerpts

Thursday 7th September 2017 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, this has been a short but very interesting debate, and I am grateful to my noble friend and to the noble Baroness, Lady Greengross, for the way in which they have addressed the dilemma that undoubtedly faces us, not just in relation to deferred payments but more generally in relation to funding appropriate social care.

It was interesting that my noble friend Lord Lipsey took us back to the royal commission. Over nearly 20 years we have seen a continuing debate, any number of reports and some measures on the statute book, yet we still seem no nearer to solving the conundrum of how to fund social or long-term care. I have to agree with my noble friend: there are those who argue that social care should be free at the point of use but I regard that as a fantasy. It is very unlikely that over the next 20 years any Government will in reality be able to afford it.

The problem is that, even though Governments have accepted some proposals in principle, when those proposals are costed, in reality they step back from them, and we are left in a hiatus of a completely arbitrary and unfair system. The noble Baroness, Lady Greengross, referred to this problem, which is, if you like, a boundary dispute between such care being free at the point of use in the NHS and means-tested personal social care. Understandably, tensions often arise within NHS hospitals as families try to resist an individual who is receiving care which is free at the point of use in the NHS ending up in the care system, where a means test takes place. I do not think that anyone can say that we have a fair system. In my view, it is equally unfair that self-funders in care homes effectively subsidise local authority-funded residents. Speaking from where I am, I suppose you could regard that as a kind of regressive taxation. It is so arbitrary and so unfair that I believe it is very difficult to justify.

It seems to me that either we try to solve this problem or millions of people over the next 30 years will carry on living in what is sometimes abject misery, uncertainty and fear about their financial future and about their families, to whom they would like to pass on some income where they are in a position to do so. If one were putting odds on it, one would say that at the moment one sees very little likelihood of anyone coming forward with a cohesive package of things which can be funded, which is thought to be fair and which would get public support, although clearly that is what we seek to do.

The deferred payment arrangement is very disappointing. Clearly, David Cameron’s pledge was widely welcomed and was seen to be progressive. My noble friend talked about the increased estimate that the department gave, going from £4,000 to £12,300, but in any case £12,300 seems a pathetic amount. We seem to have a complete failure in the marketplace. There is no easy way for people to translate a housing asset into care home support while retaining the ability to leave some of their resources to their loved ones when they die.

A number of organisations have commented on what has happened to the deferred payment scheme. Clearly, bringing in such a tight means test undermined what we thought Mr Cameron had been offering. The point was well made by the noble Baroness, Lady Greengross, that we need, at the very least, to see how the scheme is working. I know that the Minister, in an answer to my noble friend in March, said that the department is continuing to monitor the success of this scheme and that an update of these deferred payment schemes across all local authorities will be available later in the year. I hope that he may be about to give us a progress report on that.

I have had evidence from Royal London and some of the charities. Royal London, for example, looked at the inconsistency between local authorities. It said that despite access to deferred payment agreement being a legal right—I am not sure that that is quite how I read the Act, but we know what it is getting at, because it is in the Act—10 local authorities told Royal London they had not entered into a single agreement since the scheme was introduced in April 2015. That is a pretty poor show. I ask the Minister: in light of the work that we hope will be published later in the year, what are we going to do about local authorities which simply refuse to operate the scheme at all?

My final point comes back to the Government’s manifesto proposal, their retreat and the intention set out in the Queen’s Speech to consult on how we improve the social care system. I refer the Minister to the Care Act 2014, a marvellous piece of work. It was consensual, it came from Dilnot and we spent weeks in your Lordships’ House in a consensual approach, yet it is dead and gone. There are some bits in it that are good, still, and which I very much applaud. It is a puzzle that the Government have never explicitly said whether they regard the whole thing as dead and gone and that is why they put the new proposals in their manifesto.

What is the consultation going to be about? Will it be about making the scheme that the Government put in their manifesto slightly more generous—raise the level, reduce the floor—or are they prepared to actually look again at Dilnot, which everyone said was a sensible approach, even if the figures may not be the right figures? Of course, the Government’s rate was much less generous than the original Dilnot proposal, but at the end of the day, whatever information the Minister can give us about the consultation, which we hope can be comprehensive, would be very welcome.

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

I thank the noble Lord, Lord Lipsey, for bringing forward this debate. I know that he has been a tenacious proponent of deferred payments and of reform of the care system. I pay credit to him for that—it is very rare that we have a debate where I can thank everyone individually, so I also thank the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. Unfortunately, I did not have the opportunity to know Lord Joffe, but I know how much the House has mourned his passing and have noted the contribution he made. I want to acknowledge that as we talk about this issue.

We have had a bit of a trip down memory lane today, although others might call it Groundhog Day. We seem to be going over this issue repeatedly without properly resolving it. Of course it is not easy; the ageing population is probably the greatest social challenge, at least the greatest domestic social challenge, that we face. It is not one that we have grappled well with in the past, and that is true of Governments of all hues. That is for a number of reasons, including obviously the money and the changing nature of society, particularly working patterns. What has been highlighted by all noble Lords is the interplay between the taxpayer funded, free at the point of use National Health Service and a social care system that works on a different basis. It means that any attempt, whether it is a Labour-proposed national health and care service or through integration at STP level, is made very hard, particularly as things move. So I do not underplay the importance of this issue, and, of course, as we think about the narrower issue of DPAs, it has to be set in a context of what is happening elsewhere.

In the short run, more money is going into local authorities to try to provide the social care that is required. It is particularly focused on delayed transfers of care. That has some interplay with this issue precisely because of the concerns about moving from one part of the health system into another, something mentioned by the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. It is about the difference between continuing healthcare and social care and the quite radical consequences of the different funding situations for families that are necessarily trying to navigate through it at a time of stress. It is a challenge, but we are trying to address it through this additional funding.

In the long run, as noble Lords have pointed out, the intention is to bring forward proposals on social care reform for consultation. The objective in the consultation—I am glad the noble Lord mentioned the Care Act—is to achieve the widest possible consensus. It should not be a completely open-ended “what shall we do” process, but it should try to put forward some proposals that, inevitably in the process of consultation, will change but will try to achieve some kind of consensus. The noble Lord, Lord Hunt, specifically asked about Dilnot. There was a lot of agreement around Dilnot, but I still come across people who think that Dilnot was the worst thing that could ever have happened. There is a more nuanced picture. If anything, that just underlines the importance of taking care as we try to build a consensus.

Moving forward to the specific issue of the debate, which is deferred payment agreements, as has been outlined, they are a means by which individuals can access equity in their home to pay for care without having to sell it, meaning that they do not have to sell their home in their lifetimes. As the noble Lord, Lord Lipsey, pointed out, DPAs have been in existence for a number of years and the issue was addressed in the Care Act precisely to attempt to create a more thoroughgoing national system to replace what had obviously been quite a patchy one. Even though some elements of the Care Act have not been taken forward, in particular the social care reform agenda, as has been pointed out, the Government took the decision to move ahead with the implementation of DPAs in order to fulfil the pledge of the previous Prime Minister—to whom both he and my noble friend Lady Sugg owe their position in this House—that people should not have to sell their homes in order to go into care during their lifetime.

In terms of the actual performance of the scheme, we had a year of voluntary data collecting for 2015-16, although it is now compulsory. A helpful note tells me that the next iteration of the data is 2016-17, and NHS Digital should be publishing them towards the end of October. We will then have a really thorough look at what is happening. The previous year showed that about one-third of local authorities responded, so it was only a partial picture. Nevertheless, it was disappointing that fewer DPAs were agreed than had been anticipated. Indeed, the noble Lord, Lord Lipsey, pointed this out as likely to be the case in the debate on the regulations. I will come to what we can do about it, but these are of course a means to an end in themselves. This is why I am not convinced that having a target is appropriate because it is about enabling a choice and adding to the choices that are available for people by providing a means of deferring payment until after death. There are many reasons why people may not choose a DPA, and of course the private market is evolving all the time. But we need to understand why there were fewer DPAs than anticipated and to ensure that those who are eligible for them can access one. If there are local authorities where not one has been signed, that suggests that something is going wrong at the local level in terms of communication between the local authority, individuals and the social care sector. So we need to know why that happens.

[Lord Hunt of Kings Heath]

In the noble Lord’s very helpful response, he referred to the private market. He mentioned that not everyone thought Dilnot was the right answer, because one of Dilnot’s aims was, by capping costs, for the insurance market to come in when they have been reluctant to. I wondered whether part of the consultation would seek to answer the conundrum of what could make the insurance market come into this area more enthusiastically. Clearly, that would be one way that we could solve some of the problems.

[Lord O’Shaughnessy]

The noble Lord makes a good point. I do not know if that will be laid out explicitly. We have talked a little about the manifesto and how it was a movable feast over the course of a weekend. We ended up with a floor and a cap. At the point at which you have a cap, in theory, you have an insurable product. It depends whether it is insured by the private market or the state, but that was clearly at the core of the Dilnot design. There was lots of disagreement about how you could take forward that principle, but I think it useful so that, in keeping with the nature of the market, you have a mixed economy of funding.

We have been talking to local authorities to understand why people may not be accessing DPAs. There are a number of barriers, such as lack of awareness, interest charges and administrative fees. We are considering what actions can be taken locally and nationally to raise awareness and understanding of the scheme. One example of that is that is the wide variation in administrative fees charged by local authorities. Clearly, it is important that those fees are not set at a prohibitive rate, nor that local authorities are or seem to be profiting from the fees. They are meant to be covering costs. However, I think interest rates provide quite a positive picture, because the interest rate is around a third of that offered by the standard equity release scheme on the market. With wider awareness, that would prove more attractive than it has done.

Regarding the eligibility criteria, £100,000 is a magic fee in this social care debate—even more so after the election. That was the point that the noble Baroness, Lady Greengross, made about the reform proposal and widening eligibility. There are two points I would like to make on this. First, the Government’s aim in establishing the scheme was particularly to ensure that people did not have to sell their homes, rather than run down other capital. I know that that is more limited than noble Lords might like, but that was nevertheless the aim of the scheme.

The second point is that, in expanding the criteria, a local authority should in theory be able to recoup its costs, but there may be some costs in taking on a wider group of qualifying people. There is always a balance to be struck, particularly in cash flow terms, between helping a group who are by definition better-off people, and fairness to local taxpayers. That is one issue that needs to be considered.

The noble Baroness, Lady Greengross, asked in particular about the deep dive that happened. She will be disappointed to hear that departmental protocol is that these are for internal use only, so I am afraid I am not in a position to share that information with her. It sounds like she has the detail on what happened anyway, so I am not sure that that would necessarily reveal anything that she does not know.

To conclude, it remains a departmental priority to make the scheme accessible to all those who are eligible and would benefit from it. We will continue to monitor the scheme and, once the data are published, may look at some of the ideas suggested by noble Lords on how to give this scheme more momentum. Clearly, the intention of it is not to be de minimis, but to reach the original target and more people beyond that. We are open to ideas on how that can be achieved.

Finally, any DPA scheme must in the long run fit into the wider context of social care funding and provision. That point has been well made in this debate. As the proposals come out for consultation, considering the interplay of DPAs and the overall funding environment will be critical in whether reforms are successful. I conclude by thanking the noble Lord, Lord Lipsey, again for tabling this debate and other noble Lords for their contributions. I look forward to working with them on getting consensus on real reform in the sector.

National Health Service (Mandate Requirements) Regulations 2017

Lord Hunt of Kings Heath Excerpts

Wednesday 6th September 2017 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the National Health Service (Mandate Requirements) Regulations 2017, and the associated Mandate to NHS England, do not require that in 2017–18 NHS England meets its obligation to ensure that 92 per cent of patients are treated within 18 weeks of referral; believes that failure to meet this target is a breach of the rights of patients outlined in the NHS Constitution and of the statutory requirement laid out in the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012; and calls on Her Majesty’s Government to publish the advice they have received on the legality of their actions (SI 2017/445).

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am moving this Motion because I believe that NHS England is failing to comply with its statutory requirement to ensure that a minimum of 92% of patients wait no more than 18 weeks for treatment from their day of referral. I believe that the Government are clearly complicit in that failure.

Governments often drop inconvenient targets when they are not being met but it is a little more unusual to see them airbrush one out of existence without any public acknowledgement, let alone report to Parliament, as has happened with the 18-week wait. This is one of the key targets for the NHS. It is important for patients to be treated promptly, and the target is also important as an overall barometer of the National Health Service, which is reeling from underfunding, rationing and a Government who are intent on wilfully letting standards slip.

Why have the Government allowed this to happen? Surely it rests with their lamentable failure to deliver on the key standards set out in the NHS constitution. We should look at their record. The current four-hour maximum A&E standard has been missed for the past three years, with performance deteriorating every year. The 62-day maximum treatment wait for cancer has been missed every year since 2013-14. As for elective care, the 18-week standard has not been met now for 16 months. Therefore, the Government are so lacking in confidence that they have just decided that they will drop one of the targets. This first came to light in March when, in unveiling his progress report on the five-year plan for the NHS, Simon Stevens, NHS chief executive, admitted that patients can expect to face,

“longer waits for operations such as knee and hip replacements in a ‘trade-off’ for improved care in other areas”.

The Government have been rather coy about this but the reality is that, behind closed doors, they agreed with Simon Stevens effectively to downgrade the 18-week standard. However, they forget to tell Parliament and the public that they had done so. Remarkably, there is no reference to that in the regulations we are debating tonight. The mandate for 2017-18 is equally silent on it. It is true that on page 19 of that mandate there is reference to the 18-week wait as a goal for 2020. But when you look at the list of deliverables for this financial year, it is completely missing. All we have, on page 20, is a vague reference asking NHS England to “meet agreed standards”. We should compare that with the 2016 mandate which says that NHS England is “required” to meet the 18-week referral for treatment standard.

Let us go back to the NHS England document of 31 March this year, Next Steps on the NHS Five Year Forward View. Chapter 7, on page 47, states that,

“over the next couple of years, elective volumes are likely to expand at a slower rate than implied by a 92% … incomplete pathway target”.

Those are wonderful words, which basically say that NHS England has dropped the 18-week target. Everyone in the NHS knows that to be the case. Not only is that letting NHS patients down, I believe that NHS England and the Government are in breach of their statutory responsibilities. The key standards are pledged in the NHS constitution and are backed up by legislation imposing a duty on NHS England to meet maximum waiting time standards. I refer noble Lords to Regulation 45 of the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012, which is headed, “Duty to meet the maximum waiting times standards”.

In July 2015, the Government explicitly stated that the NHS constitution,

“reflects a series of fundamental standards, below which care must never fall”.

Part 3 of the handbook to the constitution states a number of rights, including the right to start consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions. Therefore, it is my view that NHS England and the Government are required in statute to seek to achieve the objects that have been laid down, including the 18-week standard. The 2017 mandate that we are debating tonight does not include the 18-week target as a list of deliverables or requirements in 2017-18. The question to the Minister is why? I put it to him that the Government essentially agreed with NHS England to fail in its statutory duty to uphold the 92% referral for treatment target.

--- Later in debate ---

[Lord O'Shaughnessy]

That is the truth.

Next year the NHS turns 70. As my noble friend Lady Redfern said, it has a unique place in our society. The mandate to NHS England for 2017-18 goes further than ever before to ensure that we not only continue to deliver the best care and support for today’s NHS patients but also deliver the reform and renewal needed to sustain the NHS for the future. We know there is more to do, which is why we have put our commitment to support NHS England and the NHS in delivering the five-year forward view at the heart of the mandate. We will continue to do so. I hope that I have persuaded all noble Lords, including the noble Lord opposite, that their fears are unfounded, and that the noble Lord now feels in a position to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, that is one of the most remarkable speeches I have heard in your Lordships’ House. I have to say that if the Government really think that the NHS is in the healthy position that the Minister says it is, I feel very sorry for them and sorry for NHS patients. Talk to anyone on the front line and they will tell you of the pressures, of the hopelessness of the changes the Government made and of the Brexit impact on staff. The NHS is facing a critical time and to have this litany, this list of so-called achievements, does no good at all to the health service or to the credibility of the Government.

I shall make only two points. The Minister said at the beginning that the Government are still committed to the 18-week target, but towards the end of his speech he quoted the same words as I quoted, which made it clear, as Simon Stevens has made clear and as is made clear in Next Steps on the Five Year Forward View, that actually the Government have given up on the 18-week target this year. They have said that,

“elective volumes are likely to expand at a slower rate than implied”

by the 92% target. That was an open admission that the target is no longer set in stone. Talk to any chair or chief exec in the NHS and ask them whether the 18-week target is a firm target in this financial year and they will say no. Of course the NHS faces pressures. In the days of my noble friend Lord Reid the demographic changes were taking place just as fiercely as they are now, but he made a dramatic impact in reducing waiting times.

My point is this: if the Government believe it is so difficult to manage the health service in such a challenging time, they should be open and honest and say that the target has been taken away; but they have not been honest, they have not been open and patients will suffer. My Lords, I beg to move.

End of Life Care

Lord Hunt of Kings Heath Excerpts

Tuesday 5th September 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the right reverend Prelate for making that point. In Scotland there are different funding environments. I am aware of the 50% funding commitment from the Scottish Government. We are trying to make sure that CCGs in England not only have the funding they need by increasing NHS funding in real terms but that they understand how to spend it well for end-of-life care, and topping that up where necessary with central funds. So there is a big spending commitment there and with the new accountability framework we have a way of holding those CCGs to account for their performance.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister has talked about a new accountability framework but the fact is that the work that has been done so far shows that CCGs are simply not implementing the guidelines. What is the point of NICE guidelines if we cannot be assured that they are going to be implemented? I refer him to the NHS England mandate for 2017-18, which talks about developing a set of measures on end-of-life care against which CCGs will be judged. Can he assure me that the NICE guidelines will be fully part of those measures?

[Lord O'Shaughnessy]

It is important to point out that the NICE guidelines are not mandatory in and of themselves. What matters is that there is high-quality end-of-life care provided at the local level and indeed that CCGs are judged on that care. They can of course do things differently and that is the point of the system: to trust that clinical judgment. The noble Lord is quite right that end-of-life care is in the mandate—that in itself is a relatively new development. I will come back to him on the specifics that he asked for about the extent to which those metrics will be included in the mandate.

Health: Obstetrics and Gynaecology

Lord Hunt of Kings Heath Excerpts

Monday 17th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I agree that parents should be involved in such reviews—as those who are ultimately most affected by these tragedies, they absolutely should be involved. It is fair to reflect that issues around maternity deaths, brain injuries and so on have been going on for a very long time, and in certain trusts there have been acute instances of tragedy. That is why, as I said, the Secretary of State is determined to halve the number of deaths and incidents. We have had a number of reports, not only the one we are discussing today but also that of my noble friend Lady Cumberlege, Better Births, in an attempt to improve the way that services are delivered.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I want to follow on from the question about reviews. The royal college that looked at the way in which the local reviews were undertaken found wide inconsistencies between different hospitals. Not only did a majority of reviews not involve parents at all, but my understanding is that, in its initial report, it found that only 9% of the reviews involved external experts. I know that the Government are very reluctant to intervene, but surely it would be possible to issue very straight guidance to the NHS to say how reviews should be undertaken and that in all circumstances both parents and external reviewers should be involved. Will the Minister give that some consideration?

[Lord O'Shaughnessy]

I shall certainly give that consideration. There may be specific reasons why, in particular instances, that might not be possible or even desirable, but I shall certainly look into it. Take one of the instances: the tragedies at Morecambe Bay. It was found that there was a lack of objectivity in investigations and that that—along with other problems such as a lack of good data—led to the kinds of tragedies we saw, not happening once but over and over again. I completely take the noble Lord’s point, and I will look into it.

Brexit: Risks to NHS Sustainability

Lord Hunt of Kings Heath Excerpts

Wednesday 12th July 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure for me to congratulate the noble Lord, Lord Warner, on this debate, which I think has been very good and wide ranging. He linked the long-term sustainability of the NHS with the UK’s departure from the EU and demonstrated amply that, even without Brexit, the NHS faces a very difficult challenge in terms of its long-term sustainability. The report of the Select Committee chaired by the noble Lord, Lord Patel, demonstrates very comprehensively some of the questions that we need to consider.

It is abundantly clear that the NHS does not have the required funding. The question we need to put to the Government is: what is their plan for the NHS? Essentially, are they engaged in a wind-down of the NHS’s activities? We know that CCGs are rationing increasingly. We know that the key targets are being missed and I do not know anyone in the health service who thinks that the health service will ever get back to meeting those targets under current circumstances.

A similar question has to be asked of the Government in relation to social care, following the débâcle over the dementia tax. I put it to the Minister that we are still waiting on an answer as to why Dilnot is not being implemented. There has not been a straight answer. We had the report; we had legislation—we spent months taking the Bill through this House. The Government announced the cap at £72,000. They then announced a postponement, but we have yet to hear one reason as to why Dilnot is not being proceeded with. I think we are owed some explanation of why we are in the position we are in.

No doubt the Minister will talk about STPs and the transformation process that is being undertaken in the health service—but there are two things to ask him about that. First, it was the Government’s intention to introduce legislation to amend the 2012 Act to allow the STP process to proceed in a legal way, because clearly it drives a coach and horses through the 2012 legislation. My question for the Minister is: what is now going to happen? I cannot see that the kinds of things that NHS is seeking to do at local level are at all legal in terms of the 2012 Act.

Secondly, the right reverend Prelate put the point very well when he asked: how can it be that in his diocese, in a hospital which is under huge demand, you can justify closing two wards without seeing the commensurate investment in the community, when we are told that if you do that, you will reduce demand on acute hospitals? By the way, I have to say to the Minister that there is no evidence that that will actually happen. No respectable institute has produced any hard evidence that suggests that investing in primary community care reduces demands on acute care. It is much more likely, as Nye Bevan found in 1948, that it deals with unmet demand, but that demand within acute care is likely to continue.

My other question for the Minister is this. The word in the service is that the Government will not support any controversial change in service locally if it will cause angst to local MPs. If that is the case, it is quite clear that the whole STP process will grind to a stop over the next few months as more and more people recognise that it is not the game in town that the Government thought it was going to be.

These are major questions that the Government need to consider. How much worse does the problem become when we come to Brexit? Noble Lords have eloquently described some of the issues that we face—but I put to the Minister the point made by his noble friend Lord Cormack: why are the Government so reluctant to support a Joint Committee of both Houses to consider these matters? After all, part of the debate on Brexit was about the so-called sovereignty of the UK Parliament. Why are the Government so resistant to the UK Parliament exercising sovereignty over the biggest decision this country has faced in 50 years?

The Prime Minister has talked about bringing the country together. How do you bring the country together when your interpretation of a very narrow majority for Brexit is to take an obdurate view that the red lines are around migration and the European court? How on earth is that bringing the country together? Surely a consensus approach would be to find some kind of middle way through the Brexit negotiations, rather than the cul-de-sac the Prime Minister has got herself into—which, of course, in the end she will have to get herself out of because she does not have a majority in the other place for the proposals that she is putting.

We then come to the issues facing the health service. The noble Baroness, Lady Ludford, has already raised the seemingly simple issue of our rights to health treatment in the EU and vice versa. But we are told by the Brexit Secretary that this is now an aspiration. I ask the Minister: what is our policy on this in the future?

We then come to the workforce. We have reached the ludicrous position where the pay policy and the way that professional staff are treated in the health service mean that we have fewer people from this country coming into nursing in the NHS than are actually leaving. We have completely choked off people coming from the EU because of the atmosphere the Government have created with their wretched approach to Europe. My chief exec contacts in the health service tell me that we have dozens of teams in the developing world—India and the Philippines—recruiting nurses to substitute for the nurses we would have had, happily, from the EU. How can that possibly be a sensible approach to the way the NHS is run? It just beats me; it is bizarre. The end of the line is that the Prime Minister will not get anywhere near her immigration target because she will desperately have to approve the recruitment of thousands of nurses from the developing world. Is there any more nonsensical position than that taken by this Prime Minister?

Then there are the life sciences. There are problems around European research. Already universities are losing out on research bids because other European universities will not go into partnership with them. This can have a devastating effect on our life sciences. Our universities are reeling under the ludicrous position taken by the Prime Minister—both as Home Secretary and as Prime Minister—over students coming from overseas to study in our universities. They are a huge earner. Britain has a fantastic reputation. Why on earth are we trying to prevent these people coming to this country? It again defies all understanding.

We then come to medicine regulation. The risk is that if companies continue to develop drugs in this country, they have to have an assurance that when they get a licence from our regulator, the MHRA, it will be recognised throughout the whole of Europe. If they do not get that, we will lose drug development in this country—that is £4 billion of investment. We have seen the letter that the Minister’s right honourable friend the Secretary of State and Mr Clark wrote to the FT a week ago, which makes the right noises in relation to regulation, safety and the interrelationship between what we do in this country and what happens in the EU, but does the Minister agree that in the end the only way forward is an agreement on mutual recognition, even if that involves the European court, as it may well do?

Finally, my noble friend Lord Clark speaks with great authority on Euratom. Why are we risking our energy supply, in many cases, and the safety of patients? For what? It is for some bizarre view that anything with any relationship to the European court is completely out of court.

I fear for the future of the NHS and for the future of this country if this is the Government’s approach. I am confident that Parliament will assert itself to ensure that the Government will have to change course. I hope the Minister will give us a little bit of movement on this in relation to the NHS.

NHS: Working Conditions

Lord Hunt of Kings Heath Excerpts

Wednesday 5th July 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I just do not understand the Government’s response to this very pressing question. Already, recruitment from other EU countries has ground to a halt because of the anti-EU rhetoric of the party opposite. In this country we now have a net loss in the number of nurses coming into the NHS. Is the Government’s policy to recruit nurses from overseas countries other than the EU, as we have for generations? If it is, and I hear that the NHS is recruiting hugely in those countries, does that not make a mockery of the Prime Minister’s ludicrous target to reduce immigration?

[Lord O'Shaughnessy]

As the noble Lord knows, we have talked about one of the reasons for the drop-off in nurses coming from the European Union; it is because of the stricter language testing. Stricter language testing was brought in for reasons of patient safety and was supported by the noble Lord when the regulations went through in 2015. Indeed, I think there was cross-party support for that. As for anti-EU rhetoric, I do not recognise that in anything that we have said. We absolutely value the contribution of anyone who is living and working here in the UK, and indeed have made a very generous offer to solve this problem as part of the talks for leaving the European Union. As for recruitment, of course we want to recruit as widely as possible. We want the brightest and the best to be here, and that is an absolutely core part of any immigration strategy.

Health: Medically Unexplained Symptoms

Lord Hunt of Kings Heath Excerpts

Tuesday 4th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I congratulate the noble Countess on the important work that she does through Forward-ME on behalf of the illness’s sufferers. On who takes responsibility for the care of those suffering from CFS/ME, it is of course clinicians. They work to evidence of best practice, which is guided by NICE. She alluded to the fact that the NICE guidelines are being reviewed to make sure that we have the best possible understanding of what is effective in the treatment of the illness, but I reiterate to her the point that the Government’s acceptance of the WHO classification of it as a neurological disease has not changed.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the approach taken by the NHS and child protection services to CFS/ME and other unexplained symptoms has had a sorry history. Some clinical commissioning groups state with great authority that graded exercise and CBT are the appropriate response. The point made by the noble Countess is that in many cases they are not, and can cause damage. Unfortunately, where children are involved, patients who resist such therapies often find themselves in problems with child protection agencies—there was an excellent programme about this on Radio 4 over the weekend. Prior to the NICE guidance coming out, will the Minister look with his officials at whether CCGs might be given some rather more authoritative advice, because it is clear that some CCGs have got this wrong?

[Lord O'Shaughnessy]

I am certainly happy to investigate CCG practice and commit to write to the joint panel to make sure it understands both the nature of the classification of the illness and the fact of the NICE guidelines. Of course, those are guidelines for clinicians; they are not mandatory in themselves.

Queen’s Speech

Lord Hunt of Kings Heath Excerpts

Thursday 29th June 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, as we have covered so many subjects, I remind noble Lords of my interests in the register, specifically as a self-employed consultant, president of GS1 and trustee of the Royal College of Ophthalmologists—and my wife is a consultant with the Education and Training Foundation.

We come to an end of a spirited, five-day debate on this Government’s rather threadbare legislative programme. The Brexit election has been followed by the Brexit Queen’s Speech, which, despite the Government’s loss of majority and authority, still, unbelievably, focuses on a crude and unrealisable determination to cut immigration, whatever the consequences to our economy, jobs and public services. Of course, Brexit is hugely important. However, as my noble friend Lord Whitty said, and anyone who campaigned in the recent election will know, many of the matters that really concern the public are to do with the subjects that we have debated this afternoon.

What is so disappointing is the Government’s response to that election. Although they have dropped some of their more contentious proposals, they have not signalled an end to austerity, nor shown any recognition that our young people, schools, hospitals and older people need urgent support. There is no answer whatever to the noble Earl, Lord Kinnoull, my noble friend Lord McKenzie and others, who spoke about the need to improve social mobility.

I turn first to education. The Minister promised more money for education. However, the IFS has confirmed that the supposed extra money this will amount to will still leave schools with a cut in per-pupil spending of around 7% between 2016 and 2022. The Education Select Committee has been abundantly clear what this means: larger class sizes and more reliance on unqualified teachers. That is why parents are so concerned.

The Secretary of State for Education has told us that no school will lose out. But she has not said where the money will come from, given the free school meals debacle. I hope it will not come from technical further education, because the one risk of putting that back into the Department for Education is that it has always been targeted within that department as an area regarded as softer than other areas of education expenditure. Given the fall in further education budgets between 2010 and 2015 of 14% in real terms, this is a legitimate concern. The ambitious target for apprenticeships, with which we all agree, is also a concern; my noble friends Lady Cohen and Lord Young made this point. The risk is that the Government will simply go for the numbers at the expense of high-quality apprenticeships. I hope the Minister can respond on this point.

On grammar schools, it would be good if the Minister would confirm that plans to return to the wretched 11-plus and the reinstatement of secondary modern schools are at an end. Will he also reject back-door proposals through the ability of existing grammar schools to open satellite campuses or annexes miles from their original site, as happened in Kent? Will the Minister put an end to that?

I also want to ask the Ministers about exam results this summer. Ofqual has said that schools should expect more variability in exam results this year. What on earth are parents and children to make of that? The fear is that they have become guinea-pigs on the altar of the ideological experiment to satisfy the bizarre notions of Mr Gove when he was Secretary of State.

I also hope that the Minister will respond to my noble friend Lady Lawrence about the value of overseas students to our universities. When, oh when, will we take student numbers out of the migration statistics? It is causing huge concern in our university sector.

I turn to welfare. What is the Government’s policy on the triple lock? The new Work and Pensions Secretary said this week that it is unlikely to last in the long term. I think that Parliament is entitled to some response from the Government on this. My noble friend pointed out their silence on many other aspects of social services. There is nothing to address the falling value of benefits and tax credits, nothing to restore work allowances in universal credit—which, of course, were put in to make work pay—nothing for WASPI women who find themselves in unexpected financial circumstances after a lifetime of work, and nothing for the noble Earl, Lord Listowel, who spoke so movingly about young people caught in the trap of getting a job and then finding they lose their housing benefit. It is a scandal. Let us hope that the Government have an answer to it.

I turn to health. I do not always agree with the BMA. I certainly have not always done so in the past, but I thought that its chairman, Dr Mark Porter, put it well this week when he said that the NHS was at breaking point. Talk to anyone who knows anything about the health service and they will agree. My noble friend Lord Pendry talked about the situation in the north-west. But Ministers seem to be in total denial. Waiting times increase, staff shortages grow, CCGs ration ever more vital services, yet Ministers carry on as if nothing is happening and it is not their responsibility. They have not met their targets for month after month after month. When is the 18-week elective care target to be met, or the 95% four-hour A&E department target? Do those targets stand? The chief executive of the NHS has said on a number of occasions that he does not expect them to be met. What should we understand the Government’s policy to be?

I want to ask the Minister about the internal document of 25 May. It focused on trusts in London. Trusts with the biggest deficits were officially advised by the system to deny patients treatment, lengthen waiting times and close hospital units in the interests of a capped expenditure process. How does that square with the mandate for this year, which says that those targets are to be met? It simply does not stand up. On funding, the King’s Fund has said that the amount we spend on healthcare as a proportion of GDP has fallen and must now be increased. Will the Government respond?

On mental health, will the new draft Bill be subject to pre-legislative scrutiny? I took through the Mental Health Act 2007 after pre-legislative scrutiny—I shared a little of it with the noble Lord, Lord Warner, who did the Second Reading speech with great eloquence and then quickly disappeared stage left. That legislation gained enormously from pre-legislative scrutiny. I urge the Government to consider the merits of putting a draft Bill into pre-legislative scrutiny. It will certainly ensure the passage of the eventual Bill will go more smoothly, and will certainly be more informed.

The other point to make on mental health was made by the right reverend Prelate the Bishop of Peterborough. It is that over the past few years, Ministers have made very welcome statements about the priority that mental health is to be given. We do not dispute any of that, but it does not happen. We know that clinical commissioning groups are cutting mental health budgets. In the end, Ministers have to take responsibility. They cannot simply say that they have made these edicts and CCGs have been told to do it, and then we have a situation where clearly CCGs cannot do it because they do not have the money, they have conflicting priorities and they are left in an impossible situation. So any further statement by Ministers on mental health will be treated with a touch of scepticism in your Lordships’ House until we get to the point where we see the additional money ring-fenced and guaranteed to be spent on mental health.

My noble friend Lady Donaghy and others talked about the importance of public servants. That applies as much to the defence forces and the police as other public services. NHS pay has been held down for a long time—frozen in 2011-12 and subject to a 1% cap. Why should public-sector workers be treated so badly? Is this not a key reason for current recruitment difficulties? Downing Street yesterday morning briefed that the pay cap was coming to an end, but this incoherent Government then similarly briefed in the afternoon that it was not. What is happening to the pay cap and when will the Government realise that they cannot artificially hold down the pay of public sector workers year after year?

A number of very important points have been made about public health, which I endorse. On social care, we have the immediate issue of funding. We need extra funding now. On the dementia tax, I ask the Minister this. The Government, with their Lib Dem colleagues in coalition, set up the Dilnot commission. They accepted recommendations. They then legislated; we spent months in your Lordships’ House legislating for Dilnot. They even said what the cap would be— it was higher than Dilnot at £72,000, but it was accepted as a reasonable response. Even when they then delayed its implementation, they said it would be implemented in 2020. The question remains of why the Government ran away from the Dilnot commission. Why are we having a consultation? What is there to consult about?

The one thing I say to the Minister is this: he will talk about the need for consensus, but he should look back to 2010, to just before the election, when Andy Burnham put forward proposals on a consensual basis for funding long-term care, and Cameron and Osborne and the rest of the crew attacked it as a death tax. He will find that his Government have no credibility in this area. Frankly, any old person who is concerned for the future has everything to fear from this Government’s approach.

I want to finish on culture. I very much warmed to the speech of the noble Lord, Lord Grade. I am sure the Minister would cause great joy in God’s own city of Birmingham if he were to announce this afternoon that Channel 4 is coming—it is the logical place, and I expect the Government to insist that Channel 4 moves out. Given the loss of broadcasting facilities in our city when compared to the great days of ATV, if I may say so, Birmingham is the right place, and I hope that will happen.

We welcome the data protection Bill, and there will be much discussion on it. However, I end by coming back to the point that I link education to creativity. A number of very important points have been made about our concern that, in many schools, creativity has been sacrificed on the altar of what is now an obsession with exam results. Like my noble friend Lady McIntosh, I was hugely impressed by the sensible comments made recently by the Chief Inspector of Schools. She made it clear that, in her view, the obsession with schools chasing exams at the expense of other activities that would give young people a rounded education has to stop. I hope that the Minister will say that the Government accept that view and support the chief inspector in more rounded inspections to ensure that children get a much wider education, in which these cultural issues are given huge importance.

This has been an excellent debate. We look forward to the response from the Minister, but I hope that over the next year or two, or for as long as this rather chaotic Government carry on in a half-light existence, we will get to debate more of these very crucial subjects.