Health: Electronic Patient Records

Lord O'Shaughnessy Excerpts

Thursday 27th April 2017 Lords Chamber

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

My Lords, the Government are committed to making patient and care records digital, real-time and interoperable by 2020. Ahead of that, summary care records, which provide essential information about a patient, such as their medication, allergies and adverse reactions, are now available in many parts of the country in key areas of the NHS, such as ambulance and A&E services. Healthcare professionals can view these, with patient consent, to inform decisions about care.

[Baroness Manzoor]

I thank my noble friend for that comprehensive Answer. I am rather concerned that the National Data Guardian’s third report, which was out last year, does not fully address the issue of who those electronic patient data belong to. Do they belong to the GPs? Do they belong to NHS England? Do they belong to NHS Digital? This is particularly important because some GPs are moving towards only localised electronic patient record-sharing, which will have an adverse effect on the efficiency of the NHS. Can my noble friend the Minister assure the House and me that electronic patient data records will be kept nationally and that it is the patient’s choice over who has access to those records?

[Lord O'Shaughnessy]

My noble friend makes an important point about the use of data. There is a balance to be struck. The first point to be made about the use of data is that patients need to be part of any decision about sharing them. In 2012, the NHS Future Forum published an independent report on this issue and used the phrase,

“No decision about me without me”,


to describe the role of patients. There is of course a need to share data among clinicians, particularly when they treat a patient themselves. There can also be wider concerns: for example, in a public health pandemic or some such incident data would need to be shared more widely. But that can be done only with patients being informed and offering their consent.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is there not a problem here? If all the focus is at national level, that usually takes a long time and it inhibits local progress. Does the Minister agree that one of the great challenges is being able to share information between the health service and social care if integrated care, particularly for older people who are discharged from hospital, is to be delivered? Is any progress being made in getting full integration at local level, which is clearly a challenging area?

[Lord O'Shaughnessy]

The truth is that there is patchy use of data within the health service. Practically all GPs now offer electronic patient records and something like 9 million people have registered to make appointments online. But it is not at the same level in acute trusts, mental health trusts and so on; there is still paper usage. The intention has been to have a paperless NHS by 2020. This means that with patient consent based around clinical need we would have the ability to share data around the patient pathway, whatever part of the health service they were in.

[Baroness Walmsley (LD)]

My Lords, given the continued revelations of data security breaches, along with the absence of a response to last year’s report from Dame Fiona Caldicott, how do the Government intend to avoid a repeat of the fiasco several years ago over care.data? Does the Minister agree that it is vital that patients are given confidence in the security of their data so that they do not withdraw from allowing their data to be used for vital medical research?

[Lord O'Shaughnessy]

The noble Baroness is quite right that the National Data Guardian produced her report last summer. There has been the intention to reply to that report but purdah has had an inevitable impact, unfortunately. She made points in that report about the simplified process for opting out but was also clear that vital uses can be made of suitably anonymised data which benefit patients directly, particularly through medical and clinical research, and about making sure that patients know about that so that they can choose to have their data shared. It is encouraging that at the moment, only around 2% of all patients have opted to have their summary care records not shared. This suggests that when it is explained properly and there are suitable safeguards, people are happy to share their data.

[Lord Marlesford (Con)]

My Lords, on the subject of records, my noble friend on the Front Bench will have studied the February House of Commons Public Accounts Committee report, NHS Treatment for Overseas Patients. The PAC is chaired by the Labour Party at present. It identified a leakage of up to £2 billion a year in the treatment of patients who are either not entitled to NHS treatment free in Britain or whose treatment should be reimbursed by the countries from which they come. The target which the Government have for this leakage is only £500 million a year, or 25%. Will the Minister undertake that in the event of the Government being successful in the election they will make a real effort to stem this leakage, which is diluting the impact of the health service on the British people?

[Lord O'Shaughnessy]

I am obviously not going to make any commitments for any future Government but I can tell my noble friend about the work that the Government have been doing on this issue. We are making sure that there are identity checks for overseas patients in hospitals to ensure that those people who are not entitled to free care, either through reciprocal arrangements or by some other means, pay for the care that is provided for them, while making sure that at all times anybody who is in need of urgent care has that care given to them, even if they then have to pay later.

[Lord Maxton (Lab)]

My Lords, will the Minister make it clear to the House that there are four health services in the United Kingdom, not one? What negotiations are taking place with his equivalent colleagues in the other Administrations in the United Kingdom to ensure that there is one common computer system across the whole of the United Kingdom? Electronic patient records depend upon there being one computer system not a variety of computer systems across the whole of the country.

--- Later in debate ---

[Lord O'Shaughnessy]

The noble Lord is quite right that the UK Government speak only for the English health system. There is a difference between having a single ICT system—we have been down that road and billions have been wasted—and having systems that can speak to one another and a common code of usage around data security, robustness, sharing patient opt-outs and so on to make sure that there is the ongoing access to information that the noble Lord is talking about, particularly for people who live in border areas who move between the different health systems.

[Baroness Greengross (CB)]

My Lords, while of course patient confidentiality must always be respected, in the recent Next Steps on the NHS Five Year Forward View there was a very concerning item on urgent treatment centres. I find it worrying that personalised care plans for patients in mental health crisis or at the end of life would be available in only 40% of emergency care settings, assuming that the target of the report is met. Are the Government prepared to look at these figures and consider them carefully?

[Lord O'Shaughnessy]

The picture that the noble Baroness paints starts from a position of not a great amount of sharing, particularly outside primary healthcare. That is what the Government have been trying to address. The primary route for doing that has been through the global digital exemplars which are enabling data sharing with all the appropriate safeguards in acute trusts and mental health trusts. The intention has been to continue to increase that over time.

Education (Student Fees, Awards and Support)(Amendment) Regulations 2017

Lord O'Shaughnessy Excerpts

Thursday 27th April 2017 Lords Chamber

[Lord Watson of Invergowrie (Lab)]

My Lords, when, in February, I was granted a topical Question on this subject—which, incidentally, I very much appreciate my noble friend Lord Clark raising—the Minister, the noble Lord, Lord O’Shaughnessy, chose to characterise my opposition to the Government’s damaging proposal as a sign that I did not support the policy of student loans. He was being disingenuous because, when student loans were first introduced by a Labour Government in 1988, those studying for nursing, midwifery and allied health professions were specifically excluded.

As tuition fees rose and student loans followed, successive Governments—Labour, coalition and, until now, Conservative—maintained that exclusion. We do not need to ask why. My noble friend Lord Clark and other speakers in this debate have made it quite clear that students building a career in those professions are quite unlike the wider student population. Perhaps the most revealing statistic on that—I will not repeat the others—is that 41% in those categories are over the age of 25, compared with 18% of the total student population. That sets them apart. As the noble Baroness, Lady Walmsley, has just said, they are unable to support themselves as other students can do, and often need to do, during their studies because of the hours required of students in nursing, midwifery and allied health professions.

However, none of that was taken into account by the Government—a Government anxious to make only “savings”. Worse, despite having those facts set out before them, they have declined to alter the course on which they are so dogmatically set. As my noble friend Lord Clark said, the nursing workforce already has severe shortages—up to 25,000 and rising—and already we know that fewer nurses from the EU are coming to work here and that by 2020 nearly half the workforce will be eligible for retirement.

So what do the Government do? They end the established practice of providing nursing students with bursaries and tell them to take out loans that will leave them with debts of at least £50,000 by the time they qualify. I heard what the noble Lord, Lord Willetts, said about loans—it is an argument that he repeated during the passage of the Higher Education and Research Bill. None the less, it is a fact that for those seeking to study for nursing, midwifery and allied health professions on the basis that they would have a bursary, it is quite a shock to find that that is not the case. Those going through school and going to university for what one might term more mainstream courses have known all along that that would be the situation. This is a sudden shock brought about by the Government, and it will have a detrimental effect on those wanting to study.

We like to think that, whenever we need the NHS, it is there for us and our families, but we are naturally anxious when we or our loved ones need to spend time in hospital, and we require an adequate number of nurses for that treatment. The Government are failing the NHS. A further example was provided just today when, in response to my noble friend Lord Hunt, counsel’s opinion was that the Government are acting illegally by not compelling NHS England to treat the required 92% of patients within 18 weeks. My noble friend Lord Hunt has submitted a Motion—for those noble Lords who are interested, it appears on page 4 of House of Lords Business—and I think that that highlights the fact that the Government are cavalier in the way they are allowing patients to be treated.

As we heard in February, the applications for nursing courses starting in September last year were down by some 23%, and the latest data available for March show that that decline is continuing. Although the ratio of applicants to training places is still 2:1, the fall in the number of applications could compromise the quality of candidates applying, as well as geographical provision, which of course is important in the long term. Moreover, it could deter prospective students once they understand fully the implications of the student loan system.

Janet Davies, the general secretary of the Royal College of Nursing, said:

“The nursing workforce is in crisis and if fewer nurses graduate in 2020 it will exacerbate what is already an unsustainable situation. … The outlook is bleak”.


Those are her words. She is the general secretary of the Royal College of Nursing—she should know. The National Health Service Pay Review Body in its 29th report said that,

“The removal of bursaries for student nurses could also have a disruptive impact on supply or the quality of supply”,


and that,

“the removal of the incentive of the bursary could have an unsettling effect on the number and quality of applications for nursing training places”.

They, too, should know. Why are the Government certain that, as always, they have a monopoly on wisdom? Why do they think they know better than the professionals in the NHS?

We should also ask why the Government are doing it. They have given two reasons. The first is the claim that it will add an extra 10,000 nurses up to 2020. But as I have said, far from encouraging additional training places by that time, cutting NHS bursaries will discourage many from becoming a nurse, midwife or allied health professional because of the fear of debt. The House of Commons Public Accounts Committee said in its report entitled Managing the Supply of NHS Clinical Staff in England that,

“the changes could have a negative impact on both the overall number of applicants and on certain groups, such as mature students or those with children”.

If the student numbers are not there, higher education institutions will be worse off because of the decline and the need to finance access bursaries under the Office for Fair Access guidance.

The Government’s proposal also stated that it will ensure sustainable funding for universities, but as yet there has been no indication of an increase in funding that the Government provide for clinical placements. Yet a study by London Economics, a leading policy and economics consultancy used by the Department for Education, found that higher education institutions would be worse off by around £50 million per cohort. Approximately half of that decline will be as a result of the decline in student numbers to which I referred. As a result, there is a real danger that some universities may decide to stop running some health-related courses altogether if they are deemed to be unsustainable. That is related to another government objective—to widen access to nursing training. I want to make clear that we are not opposed to that, but not at the expense of the traditional route through university.

The Government have also said that scrapping NHS bursaries will save the Treasury money. But there will in fact be no cost savings to the Exchequer because most nurses will not earn enough to repay the entire loan and the decline in numbers entering nursing will increase agency nursing staffing costs to cover shortfalls. London Economics also estimated that, with those increased agency costs to cover staffing shortfalls, there will be more than an additional £100 million cost by trusts per cohort wiping out any potential cost savings.

These proposals should not be proceeded with, at least until the Government have published the results of the second stage of their consultation on these measures—a point made and expanded on by the noble Baroness, Lady Walmsley. That consultation has been delayed and of course we will not see it now until the other side of the election, if we see it at all. That is entirely unsatisfactory. It is confirmation of what is no more than a leap into the dark. That is no way to treat the career development of some of our most valuable public servants. These changes are high risk at a time when the NHS is ill-equipped to manage such risk. We support the Motion in the name of my noble friend Lord Clark because it is a risk that should not be taken.

I end by responding to the rather dismissive jibe by the noble Lord, Lord Forsyth. Yes, we are keen to get on with campaigning for the leader of the Opposition. That is what we will do to encourage the people of the UK to elect a Government who will properly fund the NHS and properly value its dedicated staff. Bring it on.

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

My Lords, I thank all noble Lords who have contributed to this debate and congratulate the noble Lord, Lord Clark of Windermere, on his prescience in scheduling this debate several weeks ago. He clearly has admirers in the Leader of the Opposition’s office if they have taken his proposal and put it in their manifesto. I leave it to others to judge whether having a policy adopted by Jeremy Corbyn is a good thing or not.

[Noble Lords]

Oh!

[Lord O'Shaughnessy]

While the noble Lord may have been prescient and influential, I fear that on this issue he, the Labour Party and the Liberal Democrat party are wrong. They are wrong because the system that we are introducing for student nurses matches that experienced by other undergraduate students—a system that has been the primary driver of the big expansion of higher education and improved participation among disadvantaged young people—and wrong because of the fears of the impact of Brexit that he has evoked. I thought that the Labour Party was in favour of leaving the European Union, although having heard the tortured exposition of Labour’s policy earlier this week that is anyone’s guess. But I reassure the House that this Government not only understand the difficult choices that need to be made to ensure that our NHS has the resources and personnel that it needs to thrive, but, if we are fortunate enough to be re-elected, intend to make a success of Brexit and, as immigration is reduced, to bring more of our domestic workers into the NHS to meet the challenges ahead.

I join other noble Lords in paying tribute to the amazing work that more than 2.5 million people working in the NHS and care systems do every day, often in challenging conditions. They represent values to which we all aspire—service, hard work, compassion—and are an inspiration to us all. There can be no person in this country who does not have cause to give them thanks for their expertise and commitment.

The Government are taking action on several fronts to support that workforce so that it can deliver excellent patient care through flexible working, good leadership, expanded routes into practice and new career structures. As part of these changes, from August 2017 new full-time students studying pre-registration nursing, midwifery or one of the allied health subjects will have access to the standard student support system for tuition fee loans and maintenance loans.

These reforms will enable more money to go into front-line services—around £1 billion a year to be reinvested in the NHS. Additionally, they will help to secure the future supply of nurses and other health professionals in several ways, such as by removing the cap, identified by my noble friend Lord Willetts as being a feature of the current system, so that more applicants can gain a place. Universities will be able to deliver up to 10,000 additional training places. The changes also enable a typical provision of a 25% increase in living-cost support for healthcare students and put universities in a stronger financial and competitive position so they can invest sustainably for the long term. The noble Baroness, Lady Watkins, in her excellent and of course, expert and well-informed speech, also pointed out that they remove a perverse incentive of the current system where it is the sole degree that is subsidised in that way. That brings with it a number of benefits, including addressing the issue identified by the noble Baroness, Lady Walmsley, of the retention on courses of people who are fully committed to taking part in a nursing career.

Successive Governments’ reforms to student finance have put a system in place that is designed to make higher education accessible to all, as my noble friend Lord Willetts pointed out in his excellent intervention. This has allowed more people than ever to benefit from a university education and has spread more fairly the burden of costs between society at large via the taxpayer and the individuals who benefit financially from the degree course. As a consequence, disadvantaged people are now 43% more likely to go to university than in 2009, and for the last application cycle the entry rate for 18 year-olds from disadvantaged backgrounds is at a record high: 19.5% in 2016, compared with 13.6% in the last year of the Labour Government in 2009. That is what we mean by a country that works for everyone. It is precisely because of these positive effects that moves towards a loan-based system have been supported by political parties across the House. They were introduced by a Labour Government, extended by a Conservative and Liberal Democrat Government and taken on by this Conservative Government.

Turning to the applications for nursing and midwifery courses, the latest data published by UCAS on 6 April show around a 22% fall in the number of applicants to nursing and midwifery courses in England compared with the same point in the 2016 application cycle. However, as my noble friend Lord Willetts pointed out, in previous cases when fees have been introduced application numbers have gone down but rebounded in future years. The same UCAS data also show that since January there have been more than 3,000 additional applicants for nursing and midwifery places, taking the current total to more than 40,000 applicants for around 23,000 places in England. The chair of the Council of Deans of Health, Dame Jessica Corner, has commented on the situation, saying:

“It is to be expected that there would be fewer applications in the first year following the changes to the funding system, but we would expect this to pick up in future years”.


The Chief Nursing Officer, Jane Cummings, said:

“Despite the drop, the level of applications received suggest that at a national level, we are still on track to meet this target in England although we need to monitor this very carefully. We are also introducing a number of opportunities to support future applicants including additional routes to become a graduate nurse”.


Based on all of the information available, Health Education England is confident that it will still fill the required number of training places for the NHS in England.

On the issues raised around Brexit, future arrangements for student support after the UK leaves the EU will need to be considered as part of wider discussions about the UK’s relationship with the EU. However, the Government have confirmed that EU students starting their courses in 2017-18 or before will continue to be eligible for student loans and home fee status for the duration of their course.

On numbers of non-UK nurses, it is correct that the Nursing and Midwifery Council has seen a reduction in the number of registration applications from nurses in the European Union. At the moment, it is unclear whether the drop is attributable to the introduction of more robust language testing by the NMC, rather than as a result of the decision for the UK to leave the EU. The drop in the number of applications is balanced by a reduction in outflows from the profession, meaning that, while monthly fluctuations continue, the number of EU-born nurses is broadly the same. Indeed, slightly more nurses from the EU are working in NHS trusts and CCGs than in June 2016, the time of the referendum.

[Lord Watson of Invergowrie]

Will not the figure that the Minister has just cited be significantly skewed by the immigration skills charge, where, for every overseas person coming in on a type 2 visa, the NHS will have to pay £1,000? Will that not have an effect on nursing figures?

[Lord O'Shaughnessy]

I am not going to speculate on the impact of that. What I can tell the noble Lord is that, despite the scare stories that numbers will have been affected, there have been more EU-based nurses in the past year. That is the point that I wish to get across.

The real issue at stake is whether the number of staff in the NHS is increasing to meet the growing demands on it, and here the Government have a strong record. Over the past year, the NHS has seen record numbers of staff working in it. The most recent monthly workforce statistics show that, since May 2010, there are now over 33,000 more professionally qualified full-time equivalent staff in NHS trusts and clinical commissioning groups, including over 4,000 more nurses.

Health Education England’s Return to Practice campaign has resulted in 2,000 nurses ready to enter employment and more than 900 nurses back on the front line since 2014. There has been a 15% increase in the number of nurse training places since 2013, plus the introduction of up to 1,000 new nursing apprenticeships and the creation of nursing associate roles—the kind of non-graduate nursing roles that my noble friend Lord Forsyth pointed out as being such a crucial part of the mix. These all form part of our plan to provide an additional 40,000 domestically trained nurses for the NHS. These new and additional routes into the nursing profession will allow thousands of people from all backgrounds to pursue careers in the health and care sectors and, critically, allow NHS employers to grow their own workforce.

I will end as I began. I believe that this regret Motion is misguided. The extension of the loan-based system to nursing and midwifery training is a natural development of reforms that have received cross-party support, successfully expanded higher education, dramatically improved the participation of disadvantaged groups and provided a fairer distribution of the costs of funding higher education.

Despite the pessimism of some, the decision by the British people to leave the European Union, which this party respects, has not had a material impact on the workforce. Furthermore, and paid for in part by the resources freed up by our changes to student finance, this Government have put in place a series of programmes that have successfully increased the number of staff in the NHS and provided more training places than ever, allowing us better to grow our own workforce among UK residents.

The true source of regret is that the Opposition have used this opportunity to run scare stories about both the impact of sensible funding changes we have made and the impact of leaving the European Union on the NHS workforce. I urge all Members of this House to vote against the Motion.

[Lord Clark of Windermere]

My Lords, I have listened very carefully to the Minister. I wanted to be persuaded; I am not persuaded. I believe that the Government are taking a big risk. They have gambled before. It may not be known, but in 2011, 2012 and 2013, they reduced the number of nurses in training because they thought we had sufficient. As a result, several thousand nurses were short-trained in those three years, because the Government got the figures wrong. I believe that they have got the figures wrong again. It is a big risk that we do not need to take. It is unfair on the nurse’s career, but, most of all, it is unfair to potential patients in the National Health Service. I want to test the opinion of the House.

Health Service Medical Supplies (Costs) Bill

Lord O'Shaughnessy Excerpts

Ping Pong (Hansard): House of Lords
Wednesday 26th April 2017 Lords Chamber

Moved by

[Lord O'Shaughnessy]

That this House do not insist on its Amendment 3B and do agree with the Commons in their Amendments 3C and 3D in lieu.

Commons Amendments in lieu

3C: Page 2, line 19, at end insert—
“( ) after “body” insert “and any other person the Secretary of State thinks appropriate”,”

3D: Page 2, line 27, at end insert—
“( ) After subsection (1) insert—
“(1A) Consultation about the proposed exercise of a power under subsection (1) must include consultation about the following—
(a) the economic consequences for the life sciences industry in the United Kingdom;
(b) the consequences for the economy of the United Kingdom;
(c) the consequences for patients to whom any health service medicines are to be supplied and for other health service patients.””

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

My Lords, I beg to move Motion A. In doing so, I apologise to the House for the late change to the running order. Noble Lords who were expecting—or indeed hoping—that my noble friend Lord Nash would be taking the Bill through will have to make do with me.

We are here again to consider whether and how the Government can take into account the impact that exercising the powers in the Bill will have on the life sciences industry and on access to new medicines for patients who may benefit from them.

When we last debated these issues, I set out clearly the Government’s reasons for disagreeing with Amendment 3B. As I explained at the time, it would undermine one of the core purposes of the Bill by undermining the Government’s ability to put effective cost controls in place. This could encourage companies to bring legal challenges where cost controls have not in themselves promoted growth in the life sciences industry, seriously hindering the Government’s ability to exercise their powers effectively to control costs. This would have a detrimental effect if the Government were to take action to control the price of an unbranded generic medicine where it is clear that the company is exploiting the NHS, because the Government might be challenged on the basis that the action does not promote the life sciences sector. Nevertheless, as I am sure that all noble Lords agree, in such an instance it would of course be the right thing to do for the NHS, for patients and for taxpayers. The powers in the Bill that enable such action have received universal support in both Houses throughout the Bill’s passage.

Through our previous debates on this issue, we clarified that there was no intention to undermine the core purposes of the Bill; rather, the intention is to ensure that a mechanism is laid out in the Bill to ensure that the Government pause to reflect on the impact of any proposed statutory price control scheme on the life sciences industry, and on access to cost-effective medicines. With this clarity, the Government have now put forward their own amendment in lieu which will achieve just that, without undermining the Bill’s core purpose.

Consultation requirements are already set out in Section 263 of the NHS Act, prior to the implementation of any statutory price control scheme for medicines. Our amendment, which received support from all parties in the other place, would mean that the Bill would amend the NHS Act to include particular additional factors that must be consulted on. These are: first, the economic consequences for the life sciences industry in the United Kingdom; secondly, the consequences for the economy of the United Kingdom; and, thirdly, the consequences for patients to whom any health service medicines are to be supplied and for other health service patients.

The requirements are framed in this way in order not only to consider the economic consequences for the life sciences industry and for patients who may benefit from new medicines but to balance these factors against wider considerations. I am sure that we can all agree that, although a thriving life sciences industry and access to new medicines are highly desirable, it must not come at any cost and it is the Government’s responsibility to achieve the right balance and to be held to account for it. As with all consultations, the Government must give all responses due consideration before finalising policy. Setting these requirements out in the Bill does not limit the scope of any consultation on a statutory pricing scheme, offering both the Government and consultees the opportunity to give all relevant issues proper consideration.

The amendment is specific to Section 263 of the NHS Act—that is to say, the powers to put a statutory scheme in place for medicines. Where action is being taken against a specific instance of high prices, it would not be appropriate for it to be subject to such a wide-ranging consultation. In such cases, the NHS Act requires consultation with the appropriate industry body or bodies prior to the exercise of the powers.

With this amendment, the Government have therefore addressed the real intent behind Peers’ concerns, giving assurance of proper, balanced consideration of the effects of any statutory pricing scheme on the life sciences industry and patient access to medicine without undermining the Government’s ability to operate such a scheme. I hope that it will meet with the approval of the House.

Before closing, I thank the many noble Lords who have contributed not only to the development of the amendment but to the Bill as a whole. I thank the noble Lords, Lord Warner and Lord Hunt, and the noble Baroness, Lady Walmsley, as well as my noble friend Lord Lansley and the noble Baroness, Lady Finlay, for their contributions to improving the Bill. Finally, I also thank other noble Lords who have made important contributions to the debate, including the noble Lord, Lord Patel, and the noble Baronesses, Lady Masham and Lady Wheeler. I believe that we have worked in a constructive and open spirit and, as a result, the Bill is better and stronger than when we found it. I beg to move.

[Lord Warner (CB)]

My Lords, I am grateful to the Minister for the further thought that he has given to the amendment that your Lordships passed at an earlier stage. I am also grateful to him for his courtesy in showing me the amendments before he went forward with them; I very much appreciate that. I accept the Government’s arguments for the new approach that they have provided on the set of concerns that we had across the House about the adequacy of the provisions in the Bill on the life sciences industry and on speedy access to NICE-approved drugs. I accept their arguments that the original amendment was to some extent too restrictive on their freedom of manoeuvre when they need to act on unreasonable high prices. The Government have skilfully met the concerns of your Lordships’ House and I am very pleased to be able to support the amendment.

While I am on my feet, I will also thank the Minister for the courteous way in which he has listened to concerns throughout this Bill and taken the issues away, considered them with his officials and come back and tried to respond to many of the concerns. Across the Benches of this House, we are grateful for the way in which he has conducted the discussions during the passage of the Bill.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, I look forward to the Minister’s answer to that last question. From the opposition Benches, I very much welcome the agreed amendment that has come forward from the Government today. It is good to see how wash-up can concentrate minds no end, and we have reached a very satisfactory outcome. I am very grateful to the Minister and his officials for their co-operation on this.

The Opposition have been in no doubt whatever that it is absolutely right to take action against those companies that have clearly been abusing the system. We should also pay tribute to the Times newspaper for its campaign, which has opened up some transparency in a pretty murky area.

There are two key issues that need to be taken forward. First, the key message of debates in your Lordships’ House is that, in seeking to deal with this particular problem, we must not underestimate the contribution of the pharmaceutical industry to this country, to the economy and to the life sciences sector. We have a problem in that we are incredibly innovative in the number of new drugs that are developed in this country, but the NHS is finding it increasingly difficult to invest in them and patients are not getting the benefit.

The second is the whole question of balance between the statutory and voluntary schemes—the noble Lord, Lord Lansley, referred to this. I have reached the conclusion that the current arrangements are simply not up to scratch in relation to how government should negotiate with the industry in the future. The patent lack of transparency about the real price paid by the NHS for individual drugs means, in my view, that the arrangements are no longer fit for purpose. I hope that the Government—whichever Government are in power post election—will look afresh at the need for new arrangements in negotiation which get a fair price and also lead to the adoption of innovative new drugs for NHS patients.

Can the Minister say when he thinks the Government will be in a position to implement the key provisions in this Bill in relation to prices?

[Lord O'Shaughnessy]

My Lords, I thank all noble Lords for their warm words and I reciprocate those feelings: it has been a very interesting, challenging and enjoyable experience working with noble Lords on this Bill on what is—as the noble Lord, Lord Hunt, has pointed out—a critical matter. It is critical not just that we get the best possible prices for drugs and that we crack down on those who are trying to rip off the system, but that we make sure we are also supporting the life sciences industry and are improving access for patients.

I am particularly grateful for the work done by the noble Lord, Lord Warner, and I appreciate his support for this amendment. My noble friend Lord Lansley and the noble Lord, Lord Hunt, made the point about the equivalence between the voluntary schemes and statutory schemes. There is equivalence in law and equivalence in spirit. It is in the nature of voluntary schemes that they take into account issues around access and life sciences, because that is, in a way, why they come about. You would not have one if you could not have some agreement on that. By making this amendment today we have provided something that was taken into account by the voluntary schemes by moving it into the statutory schemes and providing that equivalence.

My noble friend is quite right about the need to work in a constructive manner. It is possible to create a system in which the interests of patients, industry and the NHS align. There is no necessary reason for them to be in conflict and, indeed, we all want a system where we have improved access and keen prices that raise the standard of care available on the NHS.

I join the noble Lord, Lord Hunt, in congratulating the Times on its investigations, which continue. Indeed, I think that there was a story at the beginning of the week or the end of last week about that. It has put a turbo boost under this, but clearly there is more to do. This Bill will allow us to get up stream and not have to wait until things get to the Competition and Markets Authority many years down the track; it will allow us to improve things up front.

As to whether the current arrangements are up to scratch and what might happen in the future, noble Lords will understand if I resist making a comment on what might happen in the future, or what a future Government might do. My own observation—this is my way of answering the question from the noble Baroness, Lady Masham, which I will avoid slightly—is that any new system ought to be trying to rebalance spending towards innovative drugs, which can of course be done in any fiscal envelope; it is not necessarily a point about spending per se but about the balance of spending. Any system would probably benefit from being both simpler and quicker. I am sure that is something that Ministers in the Department of Health, whoever they may be after the next election, will want to grapple with.

I thank my officials who have done a fantastic job and have worked very hard with noble Lords across the House on the Bill and on amendments. I am very grateful to them. I think that 24 government amendments have now improved the Bill.

On a personal note, I have very much enjoyed taking my first piece of legislation through your Lordships’ House. Pending the election result, it may be my last, but I hope it will not be. Others may disagree.

[Lord Hunt of Kings Heath]

My Lords, I will not comment on that last remark. The key clause is Clause 5. Can I take it that once the Bill receives Royal Assent the Government can implement that straightaway?

[Lord O'Shaughnessy]

I believe that would be the case. Of course, there is a difference between what officials can do and what Ministers can give instructions to do in a period of purdah. However, as soon as the measure is in law, it is enforceable.

Motion A agreed.

Health Service Medical Supplies (Costs) Bill

Lord O'Shaughnessy Excerpts

Wednesday 5th April 2017 Lords Chamber

Moved by

[Lord O'Shaughnessy]

That this House do not insist on its Amendment 3 to which the Commons have disagreed for their Reason 3A.

Commons Reason

3A: Because it would not always be appropriate to use the powers conferred on the Secretary of State to control the price of medicines and other medical supplies to promote and support the growth of the life sciences sector, and those powers cannot be exercised to ensure that patients have access to medicines and treatments.

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

My Lords, before I address the specifics of the Motion I would like to remind the House of the wider policy context in which this Bill sits. In their approach to medicines and the life sciences industry, the Government have three objectives: to make sure that patients have access to the most effective treatments; to secure value for money for the NHS and for the taxpayer; and to encourage innovations that save lives. That is the overall role of government and, indeed, these are the three objectives that I have to balance in my ministerial portfolio.

We must remember that the Bill is about only that middle objective: securing value for money. It is not the appropriate vehicle for fulfilling the other objectives that government has in this area, as important as they are. That is why we have tabled Motion A and oppose the amendment put forward by the noble Lord, Lord Warner. I do not downplay the importance of patient access to innovative medicines or the importance of a strong life sciences industry in this country—quite the opposite—but achieving these objectives is best done through other means, and I will return to this point a little later.

As noble Lords on all sides of the House have agreed, the Bill plays a vital role in delivering better value for money for the NHS and for taxpayers. NHS spending on medicines is second only to spending on staffing costs, with a spend of over £15 billion during 2015-16. In 2015-16, total spend on medicines grew by 7%, more than twice the growth rate of the overall NHS budget. The Bill helps us to tackle some particular issues which have contributed to this rising spending. It will allow us to align our statutory scheme for the control of prices of branded medicines more closely with our voluntary scheme, it gives us stronger powers to set the prices of unbranded generic medicines if companies charge unwarranted prices in the absence of competition, and it allows us to secure better information with which to operate our pricing schemes, reimburse community pharmacies and make sure that the supply chain is delivering good value for money.

As a result of close and welcome scrutiny by your Lordships, significant improvements have been made to the Bill and 23 government amendments have been proposed. I am grateful to the work of all noble Lords who contributed to those changes. That work has been acknowledged by Members of the other place, who accepted all the amendments put to them, with the exception of Amendment 3, to which we return today.

While the Bill represents an important part of our strategy to deliver value for money, we are engaged in a substantial and transformative programme of work to support the life sciences and improve access to medicines. Following the publication of the industrial strategy Green Paper in January, we are working with industry and the NHS to develop a new strategy for the long-term success of life sciences in the UK. This work is being led by Professor Sir John Bell, and its aim is for the UK to be the global home of clinical research and medical innovation, with huge benefits to the UK economy and NHS patients.

I expect the life sciences industrial strategy to be published by late spring, to be followed by discussions on an ambitious sector deal that we aim to conclude this summer. The emerging strategy is focusing on six pillars: science; growth; skills; regulation; digital and data; and NHS uptake. I want to reflect for a moment on these themes.

On the science base, the UK is a world leader in this area, and the Government are supporting it by investing more than £1 billion a year in health and care research through the National Institute for Health Research, including 20 new biomedical research centres and 23 clinical research facilities for experimental medicine, to help to speed up the translation of scientific advances for the benefit of patients. The 2016 Autumn Statement announced £4 billion additional investment in R&D, specifically targeting industry-academia collaboration, and we expect the life sciences industry to be a substantial beneficiary.

On growth, this Government continue to support innovative businesses through our highly competitive taxation regime, including measures such as the patent box and R&D tax credits. The recent Budget contained a welcome announcement of investment in a new wave of advanced manufacturing centres to support the development of cell and gene therapies. This determined action is reaping rewards. The UK has one of the strongest life sciences industries in the world, generating turnover of more than £60 billion each year. Indeed, it is our most productive industry.

On skills, we know that attracting the most talented individuals to our life sciences industry is essential. As the Prime Minister has made clear, the UK will always remain open to those with the skills, drive and expertise to support our economic growth. The Budget announced that more than £100 million will be invested in global research talent over the next four years to attract the brightest minds to the UK.

The future of medicine regulation after Brexit is a critical issue. Any future regulatory model will need to ensure that patients have timely access to safe, effective medicines and support a flourishing life sciences sector. I am having extensive discussions with the industry and other stakeholders, and our strong desire is to form a constructive new partnership with the EU on medicine licensing.

On digital and data, technology is already helping to improve patient care, and we are investing £4.2 billion over the spending review period in digital and data transformation, including areas such as electronic patient records, apps and wearable devices, telehealth and assistive technologies. Furthermore, the NHS has a unique opportunity to work with the life sciences industry to use data to patients’ benefit, and we expect the life sciences strategy to provide proposals that will accelerate clinical trials and the uptake of medical innovations.

I reiterate our commitment to improving patient access to new medicines and technologies, a subject that we have spoken about many times in the process of going through the Bill. It is a critical objective of our life sciences strategy. The early access to medicines scheme, introduced in 2014, provides a platform from which to provide patients with innovative medicines prior to licensing. The Cancer Drugs Fund has allowed over 100,000 patients to access innovative, life-saving medicines. NHS England’s test beds programme, launched last year, provides an opportunity to link new technologies with new ways of delivering healthcare, and its commissioning through evaluation programme provides an opportunity for promising but experimental treatments to be brought forward for patient use.

There is clear evidence that those actions are having a positive impact. The latest innovation scorecard, published in January, showed that, of the 77 medicines that are measured, over half saw growth in uptake of over 10% year on year. Still, there is of course more to do. That is why the Government will be responding shortly to the recommendations of the accelerated access review, with the aim of getting transformative products to patients who need them up to four years earlier than we do now.

In discussing patient access, I am aware of concerns about changes that NHS England and the National Institute for Health and Care Excellence are making to the way in which drugs and other treatments are assessed and adopted in the NHS. I must remind noble Lords that these changes have been made in response to the recommendations of the Public Accounts Committee, which stated that NICE should,

“ensure affordability is considered when making decisions”.

I come to the changes themselves. The first is that NICE is introducing a fast-track appraisal process that will bring forward access for NHS patients by around five months to very cost-effective new treatments. In other words, should pharmaceutical companies offer very good value to the NHS in the pricing of their products, we will see faster patient access—a win for patients, a win for the NHS and a win for industry.

Secondly, NICE and NHS England are introducing a budget impact test for new medicines that are expected to cost more than £20 million in any of the first three years after introduction. I want to take this opportunity to address a number of misconceptions about this policy. The budget impact test is not a cap. It does not represent the maximum that the NHS will spend on any individual drug in a given year. The test is simply intended to provide an opportunity for NHS England to enter into commercial negotiations with companies to bring down the price of medicines that have a significant budget impact on the NHS, and in doing so will allow for the kind of flexibilities—for example, commitments around volume—that companies have been asking for. The proposal will affect only around one in five drugs and, while the proposals are intended to improve affordability, they are not intended to create delay. Most negotiations will be concluded quickly and, where agreement is not reached, a managed access scheme will ensure that those whose clinical need is greatest will be prioritised. Patients will continue to have a right to NICE-recommended drugs, as enshrined in the NHS constitution.

Thirdly, the proposals introduce a sliding cost-benefit threshold for very expensive drugs for rare diseases, evaluated through NICE’s highly specialised technologies programme. It will be possible for transformative treatments that offer significant health gains to be approved up to £300,000 per quality adjusted life year, or QALY. That is 10 times greater than NICE’s threshold for treatments considered by its mainstream technology appraisal process. I do not believe, as some have suggested, that the new threshold will prevent medicines being approved via this route. In fact, with increased commercial capacity within NHS England to strike win-win deals, I am very optimistic that patient access will continue for genuinely transformative medicines.

Lastly, let me also be clear that these arrangements apply to new medicines after 1 April. Any suggestion that a patient receiving a medicine approved under the previous arrangements will have their medicine withdrawn due to these changes is wrong.

I turn to the amendments considered in the other place. The Commons rejected the previous amendment proposed by the noble Lord, Lord Warner, a new version of which he has tabled for discussion today. For reasons I have already explained, I do not believe that the Bill is the right vehicle for promoting the life sciences sector or improving patient access: it is only about providing value for money. Furthermore, there are three specific problems with the amendment.

--- Later in debate ---

The Minister says that the Bill is concerned only with value for money and not with patient access and investment in life sciences. However, this is the Bill before us and this is our opportunity to say to the Government that they have got to do something about speeding up access to medicines, not only for patients but in order to strengthen and support a key element in our economy. For that reason, I support the amendment.

[Lord O'Shaughnessy]

My Lords, I am grateful to all noble Lords for the points they have made in the discussion we have just had. I will try to deal with as many of them as I can in my response.

I am afraid that we do not agree with the first point of the noble Lord, Lord Warner, about the change of wording to make it more flexible. Such wording as exists in the current amendment would increase the risk of judicial review. As my noble friend Lord Lansley pointed out, it would impair our ability to crack down on those companies that are abusing the NHS by raising prices in a completely unwarranted way. I cannot believe that this is what noble Lords want.

The noble Lord, Lord Warner, referred to the Bill providing a pausing mechanism. It is important to point out and remind noble Lords that the Bill requires a consultation before the beginning of any new statutory scheme. One of the key amendments that we made—indeed, I accepted proposals from others in Committee and on Report—was to introduce an affirmative resolution on extending price controls into the devices realm. So those consultations and pauses already exist—and they do so in a way that is appropriate to the core purpose of this Bill, which is to control costs.

The noble Baroness, Lady Walmsley, referred to the balance that is being struck. She is quite right that there is a balance to be struck, but that does not mean that the balance needs to be struck in each and every item of government policy. As my noble friend Lord Lansley pointed out, this Bill is not the right vehicle to achieve support for the life sciences and industry and to improve patient access. These aims are achieved through other routes, as I have outlined, and the Government are doing a huge amount of work on them.

I wholeheartedly agree with all noble Lords on the importance of the life sciences sector and of improving patient access. The noble Lord, Lord Hunt, was right to point out that, post Brexit, it will be more important than ever. The noble Baroness, Lady Masham, said that this is not just a macroeconomic point; it is about the lives of humans, often in great suffering, who need to have access to medicines. I thank her for bringing that out. It is precisely why the Government are developing an ambitious strategy and a sector deal; and it is precisely why I have been keen to ensure that the NHS is seen as a partner and beneficiary of that deal. Rather than this being seen as something that is done to it, it has to be a counterparty, as it were. I disagree with the noble Lord, Lord Hunt, because we are seeing improvements in uptake for the reasons that I have outlined.

In the course of dealing with the Bill, while I have had complaints from the life sciences sector about certain things that we have done—I will touch on those in a moment—it is fair to say that I have not received any complaints from the industry that this Bill will affect it negatively. It understands that the Bill is about providing equality between the statutory and voluntary schemes, cracking down on those who seek to abuse the system and making sure that there is proper information to inform the price control schemes that we have.

Looking further ahead, from 2019 onwards we will need to look at the medicine and pricing regulation system in the round—and we will be doing so from a position of being outside the European Union. It is therefore absolutely essential that we have a world-leading price and regulatory environment. I am looking at all aspects of that now and talking to industry and others. As my noble friend Lord Lansley pointed out, it is only right to consider the changes introduced by NICE and NHS England as we look to a comprehensive solution from 2019 onwards.

While we are talking about the outcome of that consultation, I should point out that it was provided in response to the Public Accounts Committee and that there is no threat to the independence of those organisations. I completely agree with the noble Baroness, Lady Finlay, in applauding the reputation that NICE has around the world and the fact that the life sciences industry values getting NICE technology approvals.

The changes being made are consistent with the NHS constitution. I explained in my opening statement how this will work and I have addressed the misconceptions. This is not about delay or reducing uptake, it is about costs, and indeed the changes bring about a variety of positive and welcome benefits to commercial agreements and to a fast-track appraisal process.

The noble Baroness, Lady Finlay, asked what proportion of the growth in the drugs bill has been driven by branded drugs. She will know that that is quite difficult to define because of the issue of what are known as parallel imports. These are branded drugs that are outside the schemes which come in, but of course they make a contribution to the bill. As a country we are one of the best, if not the best, in the OECD in terms of the use of generic drugs, which of course is one way of holding down the bill and creating headroom for innovative drugs. There is a good story to be told about that.

The noble Baroness also mentioned orphan drugs and she is quite right to highlight them. There is the highly specialised technology route. I should also point out that there are routes and specialised commissioning within NHS England, including the commissioning through evaluation programme. These routes have been invented by NHS England to facilitate access to drugs, not to delay it.

To conclude, I want to return to the amendment itself. I should stress to noble Lords that this is not a cost-free amendment and it is not simply a declaratory piece of legislation. It would increase costs to the NHS for drugs for no benefit. No more drugs would be bought and no more people would take them up. Indeed, it would take money away from other care settings. The Government cannot agree with an amendment that would put the NHS at such a disadvantage. I do not believe that it would be in the interests of either patients or the health service. The House of Commons was right to reject the first version of the amendment and this version does not substantively change the intent. I hope and trust that noble Lords will take the same approach in rejecting it, but before that I would like to ask the noble Lord, Lord Warner, on the basis of the arguments that I have made in response to his key points, to withdraw it.

[Lord Warner]

My Lords, this has been an interesting debate and I thank noble Lords for their contributions. I do not interpret this amendment in the same way as the Minister and I am slightly surprised that he thinks there is a happy mood in the industry about all this because that certainly does not square with my contacts. I would also like to draw his attention to a comment made during a pink ribbon conference recently by the oncologist who heads chemotherapy commissioning for NHS England. He was talking about the budget impact test: “That is why we expect the £20 million figure to hit cancer drugs much more than other drugs”. I think that that is quite an interesting revelation which suggests that some of those who are closer to this than perhaps the Minister and me take a different view about how the budget impact test actually works in practice.

The Minister would have had plenty of time, if he had accepted the principle behind the amendment, to negotiate with us a form of wording that would deliver its intent. He has spent his time trying to get us to take it out of the Bill. He has more access to draftspeople than I do. If he had accepted the principle, we could have come up with wording that is more to his taste. Neither he nor his officials have co-operated with that kind of approach. I believe that this amendment as it stands would be of benefit to patients, to UK plc and to the industry. I wish to test the opinion of the House.

NHS and Adult Social Care

Lord O'Shaughnessy Excerpts

Wednesday 5th April 2017 Lords Chamber

[Lord Patel]

To ask Her Majesty’s Government what is their assessment of the long-term sustainability of the National Health Service and adult social care.

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

My Lords, the NHS and adult social care systems face unprecedented challenges due to an ageing, growing population and rising expectations. Making these systems sustainable for the long term depends on changing the way that services are delivered, with much greater emphasis on integration and keeping people well and independent for longer, as set out in the NHS Five Year Forward View and delivery plan.

[Lord Patel (CB)]

I was hoping that the Minister might thank us for the brilliant and well-written report published today. It is, following a great deal of difficulty, a consensus report from all sides of this House, including the Spiritual Benches, and I hope that it will be met with political consensus when the politicians have had time to digest it. It has identified some key threats to the long-term sustainability of health and social care, and I shall allude to just one of them: if we do not get a long-term settlement for social care funding, healthcare will continue to suffer. The report makes some good suggestions, including how individuals who can afford it can make a contribution to funding the long-term sustainability of social care. I hope that the Minister will take that on board when he devises the Green Paper on social care.

[Lord O'Shaughnessy]

I thank the noble Lord for that. I did not want to get ahead of myself but I thank him and all members of the committee for their work in putting together this document. I appreciate that it is an incredibly thorough and important piece of work, and I am also grateful to have received an embargoed copy of it yesterday. I will of course look carefully at all the recommendations and respond properly in due course. I am sure that we will also have an opportunity for a longer debate.

The noble Lord specifically asked about social care, and I completely agree with the priority attached to it in the report. He will know that the Government have committed more money in the short term to support social care, with £2 billion more having been announced at the Budget. But I know that his emphasis and the emphasis of his committee was on long-term reform. He is quite right to point out that the Green Paper is a very important opportunity to take a broad perspective and to put the system on a sustainable long-term footing.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I too commend the noble Lord and his committee for a thorough report, which I endorse and on which I hope we can have a full debate in due course. On the future of long-term care, the noble Lord will know that before the 2010 election Andy Burnham, as Secretary of State for Health, made some very striking proposals for its funding. I wonder whether the Minister regrets that David Cameron and other Conservative leaders at the time condemned this as a “death tax” and put back the search for consensus on the funding of social care for many, many years.

[Lord O'Shaughnessy]

The so-called “death tax”, to use the noble Lord’s words—

[Noble Lords]

Oh!

[Lord O'Shaughnessy]

Those were the words just repeated by the noble Lord. The so-called “death tax” was a percentage levy on all estates, regardless of the use of social care systems. The proposals that the coalition Government came forward with—the Dilnot proposals—were about capping amounts and therefore were much more responsive to the amounts being spent. The Chancellor has recently recommitted us to not looking at that proposal but we will, through the Green Paper, seek to put the social care system on a sustainable basis and, of course, seek consensus wherever we can.

[Baroness Walmsley (LD)]

My Lords, does the Minister recognise the logic of the committee’s criticism of the cuts to public health funding? Will he go back and commit himself to promoting the prevention agenda and good health agenda, not just in his own department but across government, because so many other departments have an effect on the health of the nation?

[Lord O'Shaughnessy]

The noble Baroness is quite right about the importance of public health. It is worth pointing out that it is not just an issue of money. This country was the first in Europe to act on cigarette packaging, to introduce a soft drinks industry levy and to develop a childhood obesity plan. As we have talked about previously, if you look at the risky behaviours displayed by young people, you will see good evidence that this approach is working.

[Baroness Redfern (Con)]

My Lords, as the population ages and the financial pressures on the health and care system increase, evidence tells us of the need to be better at providing proactive, preventive care to ensure that people can live independent, fulfilling lives for longer. Will the Minister do all he can in expressing these concerns and look at ways to address, as a priority, the uptake of innovation and technology, together with data sharing across the NHS, to emphasise the need to develop a credible strategy?

[Lord O'Shaughnessy]

I thank my noble friend for that and for her contribution to the work of the committee. She speaks with great experience and authority from her role in running a local authority. She is quite right that technology offers huge opportunities. The key is to make sure that the NHS and social care systems see technology as an opportunity to improve productivity rather than as providing an additional cost. That is why we are taking a variety of actions through the life sciences industrial strategy, the accelerated access review and other routes to make sure that technology is improving outcomes.

[Baroness Campbell of Surbiton (CB)]

My Lords, the current social care narrative is dominated by the lack of residential homes and home care services for older people. Given that working-age disabled adults make up one-third of those reliant on social care, is it not time that we had a more comprehensive government social care strategy that reflects the diverse needs of all service users, and to work with disabled people to produce it?

[Lord O'Shaughnessy]

The noble Baroness makes an incredibly important point. Despite the ageing population, the fastest-growing part of the adult social care budget is, I think, for adults with learning difficulties. She is quite right that there needs to be a comprehensive approach. That is why additional funding is going in to support not just older people but working-age adults too.

[Baroness Blackstone (Lab)]

My Lords, I declare an interest as the chair of the board of Great Ormond Street Hospital. I was also a member of the Select Committee. I want to pick up on what the Minister said just now about public health—which, if I may say so, I thought was rather complacent. The public health budget has been cut year after year over the past decade. Will he give the House an assurance that this budget will not only be protected but enhanced? Unless that is done, the terrible crisis we have in obesity will not be prevented, and many other areas of public health such as smoking, drugs and alcohol will not be addressed properly.

[Lord O'Shaughnessy]

The budget for all health services has been set out now for the spending review period until 2021. I completely agree with the noble Baroness about the importance of these kinds of activities. We are, of course, moving to a system where local authorities are able to retain their business rates. They have primary responsibility for the delivery of much of the public health services and we are trying to put them on a long-term financial basis so that they will be able to continue with the kind of work she has highlighted.

Healthcare: Spending

Lord O'Shaughnessy Excerpts

Tuesday 4th April 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government whether they will increase spending on healthcare as a percentage of gross domestic product to be in line with the G7 average.

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

My Lords, since 2010 health spend has increased in real terms and is broadly in line with the EU average. This Government are giving the NHS an additional £10 billion above-inflation increase in its annual funding by 2021. We have now gone beyond that, with £425 million of new capital spending for the NHS announced at the spring Budget, and we have pledged to provide further capital at the autumn Budget.

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for his Answer, which goes a long way towards explaining why the NHS is at breaking point. Our hospitals and GPs’ surgeries are full, social care is on its knees and staff are working in impossible conditions. Those are not my words; they are the words of the BMC, which knows what it is talking about. My Question is not about Europe; it is about the G7. First, will the Minister confirm that as a country we are next to the bottom of the G7 nations in health spend? Secondly, why will the Government not commit us to meeting the average of the G7 countries, which would go a long way towards reviving our wonderful National Health Service?

[Lord O'Shaughnessy]

The noble Lord makes the point that the NHS is operating in challenging conditions, not least because of rising demand and expectations. Notwithstanding that, there is a huge improvement in performance. More operations are being performed, there are more diagnostic tests, more people are starting cancer treatment, and people say that they have never been more satisfied with the quality and dignity of care that they are receiving. Those are the points that we need to bear in mind when we talk about the fantastic work that NHS staff do.

[Baroness Brinton (LD)]

My Lords, perhaps we can push the Minister for a clear answer on this. The average spend of G7 economies is 10.4% of their GDP in comparison with the UK’s 9.8%—a gap of £10.3 billion. The Government are proudly saying that they are putting in just under £0.5 billion this spring, with a bit more capital to follow, but what are they going to do to address that shortage, given that £10 billion could provide 10,000 extra GPs and other help in primary care?

[Lord O'Shaughnessy]

As I referred to in my previous answer, the Government have provided additional funding to the NHS—£10 billion more by 2020. It is also worth noting that since the 2015 election over £9 billion of additional funding has been found for social care, which of course has huge strains upon it, and that makes a big difference.

[Lord Bird (CB)]

Does the noble Lord agree with Brian Ferguson, the chief economist of Public Health England, when he says that prevention is much more cost effective than other forms of intervention and that we have to push up the amount of spending on that, which is in the region of 4% to 5%? Is the Minister prepared to talk to MPs and Lords who want to push up the amount spent by this Government on prevention methodology in this country?

[Lord O'Shaughnessy]

The noble Lord is quite right: we need to move from an NHS that deals with illness to one that promotes healthcare, and preventive healthcare is a huge part of that. We are providing over £16 billion of public health funding for local authorities to do that over the period of the spending review. Of course, I shall be delighted to meet any Peers and MPs who want to talk about that further.

[Lord Davies of Oldham (Lab)]

What is the Minister’s response to the fact that we have seen the largest sustained reduction in spending as a percentage of GDP in the history of the NHS? Does not that explain why the NHS system is in crisis?

--- Later in debate ---

[Lord O'Shaughnessy]

The noble Lord might be interested to know that health funding as a proportion of public spending has increased since 2010, from just over 18% to almost 20%. He talks about a challenging position, but that is not just because of rising demand or an ageing population. It is worth remembering that when the coalition Government came into office, we were borrowing £150 billion a year. It is a fantastic testament that we have managed to increase spending on healthcare in real terms while dealing with the problems that Labour left us.

[Lord Lamont of Lerwick (Con)]

Does my noble friend not agree that in making comparisons between the proportion of GDP spent on health by ourselves and other G7 countries, one reason there is a difference is because most other countries in the G7 have a variety of funding sources and are not all providing tax-funded services? Some of them have larger voluntary sectors and some have a larger contribution from the private sector. Although this is a very real problem, is not one avenue for changing things that ought to be considered looking to expand the private and voluntary sectors as well?

[Lord O'Shaughnessy]

My noble friend is quite right to point out that there are different funding systems in different countries. We, of course, have a taxpayer-funded system that is free at the point of use, which this Government are fully committed to. There are different ways of funding healthcare. However, it is worth reflecting on polling carried out by Ipsos MORI which showed that 69% of the public said they get good healthcare in the UK, contrasted to just 57% in France and 59% in Germany. That is a huge testament to the work that everyone in the NHS does.

[Lord Crisp (CB)]

My Lords, does the Minister accept that there is a real problem here? On prevention and the work that NHS England is trying to do to change the system, does he further accept that there is a need for transitional funding, not least for running services in parallel? Additional funding is needed to make the changes that need to happen.

[Lord O'Shaughnessy]

The noble Lord is quite right and he speaks with great authority on this issue. The sustainability and transformation plans are providing the changes that we are looking for. That is precisely why additional capital funding was announced in the Budget: to provide and seed that kind of change so that we can run in parallel services that we need to reduce and upscale those that we need to increase, particularly community care.

Hospitals: Patient Transport

Lord O'Shaughnessy Excerpts

Tuesday 4th April 2017 Lords Chamber

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

My Lords, it is the responsibility of local NHS commissioners to decide how best to deliver patient transport services. We do not centrally monitor these waiting times. The eligibility criteria for patient transport services stipulate that patients should reach appointments in a reasonable time, in reasonable comfort and without detriment to their medical condition. Where local issues arise in the delivery of these services, we expect commissioners to take swift action.

[Lord Harries of Pentregarth (CB)]

I thank the Minister for his reply. Recently, I had to take my wife, who is extremely disabled, to hospital using hospital patient transport. After a satisfactory medical appointment we then had to wait three and a half hours for hospital transport to take us home. The following day I took her to another hospital and there we had to wait one and three-quarter hours. In the light of this experience, I asked around and discovered that some people are having to wait as long as six hours—and these are people who are extremely disabled, and some of them are without escorts to take them to the loo. Does the Minister agree that this is totally unsatisfactory and that there needs to be a proper system of monitoring and, if necessary, sanctioning the private companies that are now operating this service?

[Lord O'Shaughnessy]

I am sorry to hear of the wait faced by the noble and right reverend Lord’s wife, and indeed others. Those delays do not sound acceptable. There are clear guidelines in the standard contract for commissioners to outline the quality of patient services, and they are inspected by the CQC. I would certainly be happy to meet him to talk about this in more detail and find out exactly what is going on.

[Baroness Walmsley (LD)]

My Lords, according to the NHS website, there are some areas in which patient transport services are not available. I want to ask the Minister two things about that. First, what should patients in those areas do if they need transport? Secondly, are the Government going to hold to account the CCGs that are not commissioning these services?

[Lord O'Shaughnessy]

There are challenges in patient transport, particularly in rural areas. That was one of the reasons for the Department for Transport creating the Total Transport pilots in an attempt to deal with the problem. In Devon, the local authority and CCG are now working together to provide better transport. As I said, it is in the clinical commissioning standard contract to provide that kind of transport and NHS England is responsible for making sure that it is provided.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister said that there are no national targets in relation to patient transport services, but there are targets in relation to ambulance services. Can he tell the House when those targets were last met by the ambulance services in England? Can he also tell me why, in the mandate for 2017-18 to NHS England, no guarantee is given that the NHS will come back to meeting those ambulance targets? Can I take it that, just as the Government have now decided to drop the 18-week target for surgery, they are also dropping the idea of a target for ambulance services to be met?

[Lord O'Shaughnessy]

I am afraid the noble Lord is wrong on the 18-week target—it has not been dropped. It is within the mandate. The 18-week target is being fulfilled in the vast majority of cases. Performance is much better than it was 10 years ago in terms of both median waits and the number of people who are waiting. I do not have the precise figure for ambulance services. However, they are in the mandate and local trusts are expected to deliver against the targets in the mandate.

[Lord Polak (Con)]

My Lords, some patients cannot use patient transport. Your Lordships will be aware of the story in the press over the past 24 hours about the desperately ill young man and father of two. If he lives past midnight tomorrow, when the changes to the widowed parent’s allowance take effect, it will mean a substantial financial loss to his family. This is not a story—it is real. His wife and mother of his two children is a close friend of my wife. Other families will be in the same situation. Will the Minister talk to his ministerial colleagues so that the Government can display understanding and humanity and allow this brave young man to pass peacefully from this world with dignity, in the knowledge that the financial future of his children is taken care of?

[Lord O'Shaughnessy]

I am sorry to hear about the case of this young man and offer my sympathies to both him and his family. I appreciate the urgency and I understand that this person may not have long to live. I shall certainly speak to colleagues as soon as humanly possible and come back to the noble Lord with information on the situation.

[Lord Hunt of Kings Heath]

My Lords, the noble Lord said the Government have not dropped the 18-week target. What on earth, then, did the chief executive of the NHS mean when he said on Friday that the NHS would not achieve that target and that it would take less priority than other targets?

[Lord O'Shaughnessy]

The chief executive of the NHS was talking about the relative priority and importance of achieving A&E waiting times in particular to the targets that it is not hitting at the moment. The five-year forward view delivery plan refers to the fact that elective operations will continue to increase and that the median wait may move marginally. However, it is worth pointing out that 10 years ago the median wait for an in-patient for an elective procedure was 15.6 weeks—under a Labour Government, of course—and in January this year it was 10.6 weeks. The median may increase but it is still within the 18-week target.

[Baroness Royall of Blaisdon (Lab)]

My Lords, the statement from Simon Stevens was very honest and welcome but it means some profound changes in the National Health Service. Will the Government come forward with a statement as to how these changes will be implemented and when?

--- Later in debate ---

[Lord O’Shaughnessy]

The five-year forward view delivery plan is a publication by NHS England. We continue to back it to deliver its ambitious plans, which include further increases in diagnostic tests and making sure that even more people survive cancer. We are focused on ensuring that the system is as efficient as possible in order to do this.

[The Archbishop of York]

My Lords, the Minister speaks with such clear diction that we can hear every word he says. He is not producing a drama, but although I have been listening to him carefully, I do not think that he has answered the Question put to him by the noble and right reverend Lord, Lord Harries. He asked what steps were being taken,

“to reduce waiting times for patients using hospital patient transport”.

I did not hear the answer. All I heard was that the Minister was willing to have a word with him, but it is not just about the noble and right reverend Lord and his wife. A lot of other people are in the same predicament. We want to know what those steps are. That is the nature of the Question and, if I did not hear the response, I apologise.

[Lord O’Shaughnessy]

I thank the most reverend Primate for giving me the opportunity to come back on this. First, NHS England is working with clinical commissioning groups to make sure that the kind of delays outlined by the noble and right reverend Lord, Lord Harries, do not happen. Also, a series of 39 pilots are being conducted in rural areas which are particularly badly affected by patient transport delays to put in place the kind of transport necessary to make sure that people who cannot get to hospitals and may miss appointments are able to do so.

Alcohol: Children’s Health

Lord O'Shaughnessy Excerpts

Monday 3rd April 2017 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what assessment they have made of whether the way in which supermarkets and convenience stores display and promote alcohol can endanger the well-being and health of children.

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

My Lords, Public Health England’s evidence review identified the negative impact that the advertising and marketing of alcohol can have on children and young adults. The Government are committed to working with industry to address concerns over any irresponsible alcohol promotions, advertising or marketing to make sure that children and young people are protected.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I take it from that reply that no research has been undertaken on this. In those circumstances, I wonder whether the Minister is prepared to commit himself to the Government undertaking such research. If they are not willing to do so on their own, will they enter into discussions with the drinks industry—probably the Portman Group, which represents the drinks industry—to see whether such research can be undertaken jointly?

[Lord O’Shaughnessy]

The noble Lord is not quite right on that. Public Health England’s evidence review identified a negative impact, and that constitutes research. It looked at the evidence, which is that advertising and marketing to young people has a negative impact on their drinking behaviours. There are stringent rules, particularly around advertising, which is policed by the Advertising Standards Authority, to make sure that that does not happen.

[Lord Robathan (Con)]

My Lords, while we all wish to see responsible supermarket advertising, is it not the case that law already exists to prevent the sale of alcohol to children? Surely this law should be enforced and parents held responsible if their children are drinking illegally.

[Lord O’Shaughnessy]

As my noble friend points out, there are very strict rules around the sale of alcohol to children under the age of 18, and tough punishments exist for anyone who is doing so.

[Lord Rennard (LD)]

My Lords, does the Minister accept that we really need better labelling on alcohol products, particularly to assist those seeking to follow a healthier lifestyle and who might be seeking to purchase low-alcohol or no-alcohol products? We need to improve labels to show more clearly the level of alcohol, the number of calories in the product and the amount of sugar in the product to assist those consumers.

[Lord O’Shaughnessy]

The noble Lord makes a good point. I believe that something like 80% of alcohol for sale is now labelled in some way, whether that is in units or calories and so on. The issue is currently being looked at at a European level—

[Noble Lords]

Oh!

[Lord O’Shaughnessy]

Given what is going to happen in the next couple of years, we might want to look at it ourselves, too.

[Baroness McIntosh of Pickering (Con)]

My Lords, is my noble friend aware that it is currently not an offence to sell alcohol to those under 18 at airports, airside, for the simple reason that the Licensing Act 2003 does not apply? Will my noble friend undertake to review this with a view to making it an offence in future and to bring the whole regime under the Licensing Act 2003 without delay?

[Lord O’Shaughnessy]

I thank my noble friend for that question; I was not aware of that issue. I understand that there is a voluntary code in place, but I shall write to her to outline in much greater detail what the situation is regarding the sale of alcohol to underage young people at airports.

[Lord Hunt of Kings Heath (Lab)]

Now that we can see the end of the light-touch European regulations on alcohol labelling, can I take it that the Minister’s department is looking to 2019 to produce a much tougher labelling regime, for which we have called for many years?

[Lord O’Shaughnessy]

We are obviously looking at all aspects of alcohol control, and this has nothing to do with Brexit per se. It is worth pointing out that successive Governments’ alcohol policies have had a very positive impact on the activities of young people. Fewer young people than ever are drinking—it is fair to say that they set an example to older cohorts. However, there is more to do. Around 400 11 to 15 year-olds drink weekly. That is clearly not acceptable and we need to do more.

[Baroness Royall of Blaisdon (Lab)]

Will the Minister remind the House of what the Government’s attitude now is towards a minimum price for alcohol?

[Lord O’Shaughnessy]

The noble Baroness will know that on minimum unit pricing a court case is ongoing in Scotland, where the proposed introduction of minimum unit pricing has been challenged by the Scotch Whisky Association. We are awaiting the outcome of that court case before we move ahead.

[Baroness Farrington of Ribbleton (Lab)]

Will the Minister give an undertaking that, in looking at this issue in the broad, the Government will have regard to the number of children who grow up in households where there is a severe alcohol problem among the parents or adults? Will he undertake to monitor carefully how much the public health authorities are providing and enhancing alcohol treatment centres, which appear to be diminishing in some parts of the country? Many children grow up suffering because of this sort of family problem.

[Lord O’Shaughnessy]

The noble Baroness highlights a difficult and, indeed, tragic area. The other day, my honourable friend the Public Health Minister met the APPG on Children of Alcoholics. In preparing for a debate last week organised by the noble Lord, Lord Brooke, I discovered that Alcohol Concern estimates that there are 95,000 children under the age of one who live in a family where the parent has an alcohol problem. That is a rather horrifying statistic. One way we are dealing with that is through the family nurse partnerships; indeed, more than 16,000 places are now available and one of the capacities they have is to provide help for families struggling with addiction, whether it is to alcohol, drugs or other things.

[Lord Brooke of Alverthorpe]

My Lords, I want to come back to the Public Health England report that the Minister mentioned, of which I am aware. Would he concede that many issues are raised in that report? For example, it recommends that minimum unit pricing should be introduced, but it is not being introduced. When I am in my local Co-op, I am surrounded by alcohol as I queue for the checkout. I am also surrounded by children. Why are the Government not taking action to stop that?

--- Later in debate ---

[Lord O’Shaughnessy]

Action is being taken. There are clear rules and mandatory guidelines around the promotion of alcohol. It is important to point out that alcohol is different from smoking, where there are extremely strict rules on promotion. Most people enjoy alcohol in moderation as part of their healthy, pleasurable, normal social life, so there is a difference. However, there are clear and strict rules around promoting, advertising or selling to children.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that whereas the commonest cause of cirrhosis of the liver used to be alcohol, it is now the obesity epidemic, which could be cured by eating less?

[Lord O’Shaughnessy]

My noble friend is right. Of all the things we should do in our lives, we should eat less and drink less—as I am sure every Member of this House does.

Alcohol Abuse

Lord O'Shaughnessy Excerpts

Thursday 30th March 2017 Grand Committee

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

My Lords, I congratulate the noble Lord, Lord Brooke, on securing this important debate and on his obvious tenacity in pursuing this issue. I am sure that this will be the first of many occasions we will have to discuss this matter. I also thank all noble Lords for a wide-ranging, well-informed and informative debate.

I think all noble Lords accept that the vast majority of people who consume alcohol—whether in my noble friend Lord Smith’s clubs or elsewhere—do so as a pleasurable and indeed even positive part of their social lives. However, we also know there are very serious harms and health costs associated with alcohol misuse, which is estimated, as the noble Lord, Lord Brooke, and other noble Lords have pointed out, to cost the NHS around £3.5 billion a year. The recent Public Health England evidence review tells us that alcohol is now the leading risk factor for ill-health, early mortality and disability among 15 to 49 year-olds in England, causing 169,000 years of working life lost. That is more than the 10 most frequent cancer types combined—a truly alarming figure. As the noble Lord, Lord Colwyn, pointed out, that is having an effect in specific areas such as increases in oral cancers.

Alcohol misuse is also a significant contributor to some 60 health conditions, including circulatory and digestive diseases, liver disease, a number of cancers, as has been said, and depression. Alcohol-related deaths have increased in recent history, particularly deaths due to liver disease, which saw a 400% increase between 1970 and 2008. As several noble Lords have pointed out, that is in contrast to trends seen across much of western Europe and, as my noble friend Lady Berridge pointed out, it is also in contrast to outcomes in many minorities in the UK. It is not so much a British problem as a problem of certain communities within Britain.

In the UK, there are currently more than 10 million people drinking at levels that increase risk to their health. Those health risks, as the noble Baroness, Lady Walmsley, pointed out, are both mental and physical. They lead to more than 1 million hospital admissions annually, half of which occur in the most deprived communities, so this is also an issue of social justice. My noble friend Lord Smith was right to point out the work that the police, the ambulance service and other public services do to deal with—mopping up, sometimes physically as well as figuratively—the results of alcohol misuse. I take this opportunity to pay tribute to their work; they often have to deal with both physical and verbal violence in doing so.

We also know the tragedies that can occur from mothers drinking alcohol during pregnancy, leading to problems after birth. This is not just a UK but a global issue. To address the challenges of the prevalence of fetal alcohol syndrome disorders, the WHO is starting a global prevalence study. We will consider lessons from this for further work in the UK.

It is also important to recognise the devastating impact that addiction has on individuals and their families. It is unacceptable that children have to bear the brunt of their parents’ conditions. I was shocked to learn that, according to Alcohol Concern, 93,500 babies under the age of one, which I make to be about a sixth or seventh of the cohort, live in a family where a parent is a problem drinker. As the noble Baroness, Lady Walmsley, pointed out, there is a link to domestic violence which affects not just children but also partners. My colleague, the Minister for Public Health and Innovation, recently met with members of the All-Party Parliamentary Group on Children of Alcoholics to set out our plans to work with MPs, health professionals and those affected to reduce the harms of addiction and support those who need it. I am sure that noble Lords will agree that that is an important mission.

However, I am glad to say that we can also observe some promising trends regarding alcohol. As my noble friend Lord Smith pointed out, the figures for alcohol crimes and deaths are down, although there are other problems which we have talked about. People aged under 18 are drinking less, which stands in stark contrast to the data for the over-65s who are drinking more—I am not looking at anyone here—and there has been a huge increase in the number of hospital admissions for the over 65s in recent years of more than 130%. Nevertheless, there has also been a steady reduction in alcohol-related road traffic accidents.

We also have social action campaigns, such as Alcohol Concern’s dry January, in which I have taken part over the past few years, as I am sure other noble Lords have too, which are starting to change attitudes. The point that my noble friend Lady Berridge made about minority and religious groups leading the way was incredibly important. I accept her point about the need for appropriate analysis of how to communicate with those communities. We were unable to get the information, admittedly at short order, that she wanted, but I shall certainly write to her and put a copy of the letter in the Library for noble Lords. She makes an important point and she may have highlighted a weakness in the current strategy.

We have also seen real progress through working in partnership with industry: 1.3 billion units of alcohol have been removed from the market by improving the choice of lower alcohol products; nearly 80% of bottles and cans now display unit content and pregnancy warnings on their labels; and we have published guidance on updating the health information contained on labels better to reflect the latest advice on alcohol published by the UK Chief Medical Officer.

Several noble Lords asked about calories and labelling. This is an area where the European Commission is looking at legislation. It is not always the fastest moving institution in the world, and we have of course just signalled our intention to leave the European Union, but we will certainly look at that legislation as it comes through. It is fair to say—although I am not in a position to make a commitment at this point—that the UK has been a leader in this kind of area, not just on drink but on smoking as well, and I hope that, looking ahead, we would continue that leadership position.

An essential part of our strategy to tackle alcohol harms is the provision of high-quality, evidence-based treatment services. Local government now has the responsibility to improve people’s health, in particular on the public health side. This includes tackling problem drinking and commissioning appropriate prevention and treatment services for the local population’s needs. Several noble Lords asked about addiction and spending on cessation services, which increased from 2014-15 to 2015-16, even within the context of challenging budgets for public health. I see this as a positive move, but it is something to be kept under review.

The NHS remains critical to preventing alcohol harms. There is a new scheme to incentivise investment in alcohol interventions. The national Commissioning for Quality and Innovation indicator has been developed, and in the way beloved of the NHS, it has been given the acronym CQUIN. It links a proportion of service providers’ income to the achievement of national and local quality improvement goals. The practical effect of that is that every in-patient in community, mental health and from 2018-19 to acute hospitals, will be asked about their alcohol consumption and, where appropriate, will receive an evidence-based brief intervention or a referral to specialist services. The noble Baroness, Lady Walmsley, pointed out that the evidence shows that people who receive a brief intervention are twice as likely to have moderated their drinking six to 12 months after the intervention when compared to drinkers receiving no intervention, so it is obviously a low-cost but highly effective action.

In addition, as my noble friend Lady Chisholm mentioned, by 2018, around 60,000 doctors will have been trained to recognise, assess and understand the management of alcohol use and its associated problems. My noble friend Lord Colwyn pointed out that dentists have a vital role in prevention and spotting early problems. The new dental contract means that there has been an increasing number of patient episodes, and Public Health England has developed an alcohol training resource for dental teams. I would be interested, as a follow-up, to find out if that has been successfully adopted within the profession that he represents.

Furthermore, the inclusion of alcohol assessment and advice in the NHS health check, which is offered to all adults in England aged 40 to 74, means that GPs and other healthcare professionals can offer advice to promote a healthier lifestyle. Since we mandated the alcohol assessment and advice component, nearly 5 million people have had a check. Referral to alcohol services following an NHS health check is around three times higher than among those receiving standard care, which is yet another example of how a small nudge in the right direction can make a great impact.

Several noble Lords talked about providing people with the right information so that they can make informed choices. Last year, Public Health England launched the One You campaign to help motivate people to improve their health through action on the main risk factors. This includes a drinks tracker app to help drinkers identify risky behaviour and lower their alcohol consumption and a new “days off” app to encourage people not to drink alcohol for a number of days a week, in line with the CMO’s recommendations.

My noble friend Lady Chisholm and the noble Baroness, Lady Walmsley, asked about education. PSHE is obviously a critical part of making sure that young people are informed about their choices. There has been a review of the PSHE curriculum—we have seen a strengthening of PSHE in recent announcements by the Secretary of State for Education. There must be, at least in part I think, some impact on the positive trends that we are seeing among young people in lower drinking, although it is of course hard to isolate what exactly causes that. We know, however, from the smoking environment that constant public health campaigns do have that impact, particularly for younger people. It is also notable that while the incidence of mental illness has unfortunately and sadly increased among young people, there has not been the same increase in drinking. That is an interesting inverse correlation that is worthy of further investigation.

Several noble Lords asked about the affordability of alcohol. In this context you think of Hogarth’s “Gin Lane” and “Beer Street”, and the important role that taxation has historically played in changing drinking habits. The UK currently has the fourth highest duty on spirits among EU member states, and higher-strength beer and cider are already taxed more than equivalent lower-strength products. In relation to a move in the direction that the noble Lord, Lord Brooke, pointed to, noble Lords may know that it was announced in the Budget that duty rates on beer, cider, wine and spirits will increase by RPI inflation. In addition, a consultation is currently seeking views on the introduction of a new band to target cheap, high-strength white ciders which are a particular problem among young people. It is also seeking views on the impact of a new lower-strength still wine band to encourage production and consumption of lower-strength wine—another point talked about by the noble Lord, Lord Brooke. It is worth touching briefly on minimum pricing. I am afraid that my answers are entirely predictable on this issue. We await the conclusion of the court case. I will, however, look at the IFS report that was mentioned and we will keep a close eye on that issue going forward.

The noble Baroness, Lady Walmsley, asked about advertising, as, I believe, did the noble Lord, Lord Hunt. The Advertising Standards Authority has a vigorous approach to preventing advertising to children and young people, but I am assured that it is kept under review to make sure that it is having an impact. Again, it is worth investigating whether that has had an impact on the lower instances of drinking among young people.

It would be wrong for Ministers to restrict the treatments offered to young people. That is a clinical decision, although I know that clinicians are increasingly trying to change the behaviours of smokers and drinkers before providing significant treatments. There is also a link between drinking and depression, as the noble Lord rightly pointed out.

I close by again congratulating the noble Lord, Lord Brooke, on securing this debate on such an important subject. Alcohol misuse has a significant impact on people’s health, the NHS, the wider care system and society in general. I also believe, however, that progress is being made. The Government remain deeply committed to ensuring that people are given the information and support—and if necessary the treatment—that they need to reduce harms from alcohol. I look forward to working with the noble Lord and all noble Lords to reduce alcohol misuse in the years ahead.

Committee adjourned at 5.58 pm.

Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) (Amendment) Regulations 2017

Lord O'Shaughnessy Excerpts

Thursday 30th March 2017 Lords Chamber

Moved by

[Lord O'Shaughnessy]

That the draft Regulations laid before the House on 1 March be approved.

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

My Lords, I am delighted to speak about these important regulations, which will continue to ensure the provision of five mandatory health and development assessments and reviews as set out in the Healthy Child Programme. It was a policy I first worked on over 10 years ago. Having had three children in that time, whose births and early months were not always straightforward, my wife and I know from personal experience the benefits of the programme.

The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) and Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) (Amendment) Regulations 2015 transferred responsibility for commissioning public health services for children aged zero to five from NHS England to local authorities, allowing local public health services to be shaped to meet local needs. This includes responsibility for delivering the healthy child programme. This programme is the main universal health service for improving the health and well-being of children, providing families with health and development assessments and reviews, health promotion, screening and immunisation. This is supplemented by advice around health, well-being and parenting. The five reviews are offered by health visitors to pregnant women, new mothers and children from birth to age five and include the antenatal visit, the newborn review, the six to eight week check, the one year review and the two to two and a half year review. They are required to be provided by all local authorities in England.

I know that your Lordships will agree that health visitors play a crucial role in ensuring that children have the best possible start in life, and lead the delivery of the elements of the healthy child programme which relate to these children. Health visitors provide valuable advice and support to families and are trained to identify health and well-being concerns. Through the health visitor programme, the Government have supported the profession more than ever before to transform the service and I pay warm tribute to its excellent work. In April 2015, at the end of the health visitor programme, there was an increase of around 4,000 in the number of full-time equivalent health visitors in the workplace since May 2010. Health Education England is now ensuring sustainable development of the health visitor workforce and there are presently more than 800 health visitor student training places commissioned. This, along with service transformation, means that more families now have access to the support they need in those precious early years.

The Government are also committed to supporting school-aged children and young people by promoting their health and well-being through school nursing services. There are currently around 1,100 school nurses in England, supported by other professionals, such as community staff nurses, healthcare support workers and nursery nurses. In January 2016, Public Health England published commissioning guidance for school nursing which makes it clear that school nurses should be accessible and responsive to children’s needs. The current 2015 regulations, which place a duty on local authorities to provide the five universal health visitor reviews, contain a sunset clause and so will lapse on 31 March 2017—tomorrow. The legal obligation on local authorities to provide health visitor services is also set to lapse tomorrow. The draft regulations before the House will prevent this. The current regulations also include provision for a review to be undertaken of the operation of the regulations.

The Department of Health commissioned Public Health England to carry out a review of the operation of the five mandated universal health visitor reviews following the transfer of responsibility to local authorities, as set out in the 2015 regulations. A review was carried out in summer 2016 and Public Health England’s report of the review was published on 1 March 2017. The review found widespread support from local authorities and commissioners for the universal health visitor programme remaining in place, in order to secure the delivery of long-term benefits from the healthy child programme, including improved health and well-being outcomes for children and their families. There was also a strong view held by professional representatives of local government and the nursing profession that the services are essential for prevention and early intervention and a general agreement that they deliver a positive return on investment and contribute to other government priorities such as reducing childhood obesity, controlling tobacco and improving maternal mental health. I thank Public Health England for its important work on the review and for helping to inform these regulations.

Local authorities will continue to be funded to deliver the mandated health visitor reviews. They will receive more than £16 billion between 2015-16 and 2020-21 to spend on public health, which includes children’s services including health visitors. This is in addition to what the NHS will continue to spend on vaccinations, screening and other preventive interventions. The Government announced earlier this month that the ring-fence on the public health grant will be retained for a further year, until 2019, as we move towards implementing 100% local business rate retention. This is a step on the way to a more locally-owned system and will help smooth the transition by providing some certainty for the next two financial years.

It is right that local authorities should have appropriate flexibility to deliver against their local priorities, but it is also appropriate that there are some key requirements set nationally, such as the five universal health visitor reviews. By continuing these mandated elements of the healthy child programme, this Government intend to maintain consistency across all local authorities when ensuring the delivery of these services. The draft regulations before your Lordships today will remove the sunset clause from the current regulations, ensuring that local authorities continue to provide these important visits to families. Removing the sunset clause will ensure that the current duty on local authorities to provide these services does not lapse on 1 April. I am confident that this sends a clear signal to health visitors, family nurses, local authorities and the public of the Government’s ongoing commitment to universal public health support for pregnant women, children, and their families.

This Government are committed to improving the health outcomes of our children and young people, so that they become among the best in the world. What happens in pregnancy and during the early years of life has a huge impact throughout the life course. Therefore, a healthy start for all children is vital for individuals, families, communities and ultimately the nation. I commend these regulations to the House.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, I am delighted to support these regulations because I am an enormous fan of a universal health visitor service, and in particular the healthy child programme. Our economy is never going to keep up with the demand for health services unless we pay more attention to the issue of prevention. That really is the public health agenda. Any doctor will tell you that you really must lay the foundations for a healthy body, lifestyle and habits in the early years or you will get illnesses later on. The review of the programme so far has been very positive. As the noble Lord, Lord Hunt, said, there have been significant improvements in the populations reached. However, we will not see the true benefit of this programme until we are years down the track and find that those young children who have been given a healthy foundation grow up to have fewer of the terrible but preventable chronic diseases that are costing the country so much.

I am very proud of the coalition Government’s vision of improving the health outcomes of children, young people and their families. Transferring the responsibility to local authorities was part of that: it gives them the chance to combine services, right up to the age of 19. However, as the noble Lord, Lord Hunt, said, there are serious questions to be asked. The first, of course, is about resources. Although these services are mandated, and although the Minister may say that the money has been ring-fenced, budgets have been cut and are going to be further cut. Local authority councillor friends of mine tell me that it is getting more and more difficult for local authorities to provide even those services which they are mandated to provide because things are getting so tight financially. I hope the Minister can give us some encouragement on that, although I somehow doubt it.

The other question on resources is about people. We have heard from the Minister about the number of health visitors in training. Are they going to be enough to serve rising demand? We have a rising population and a lot of additional young people and families who require services. A universal service is terribly important because you do not just get health problems among the most deprived. However, there is a great deal of poverty in this country and the need for these services is growing. How confident is the Minister that we will have enough sufficiently trained nurses, given the stresses on all health service staff and given that so many people are leaving and retention is getting more difficult? Are we going to have enough people?

Are there any plans to extend these services a little further up the age range? I am particularly concerned about the large number of children who are starting school between the ages of four and five already overweight, obese or with poor eating habits. So, although the healthy child programme and the reviews that are mandated here in these regulations go up to the final check at two to two and a half years, it is really important that we do it again just before the child goes to school, because at that point they are already at a disadvantage. Many of these children are from a disadvantaged background and sadly these problems occur more frequently in those backgrounds. They get to school and they are already developmentally a good deal behind children from more advantaged backgrounds. I think the proof that we have had over the few years that this programme has been in place is sufficiently convincing to tell us that perhaps we ought to extend it a little bit further.

[Lord O'Shaughnessy]

My Lords, I am grateful to both the noble Lord, Lord Hunt, and the noble Baroness, Lady Walmsley, for their endorsement of the universal health visiting service. The noble Baroness is quite right to emphasise the long-term benefits that derive from a universal health visiting service of high quality and it is true that it is a great coalition achievement that we should be proud of. I am also grateful to the noble Lord, Lord Hunt, for his endorsement of not only the programme but also the mandated reviews and indeed of local authorities taking ownership of the programme.

To deal with the funding issue first, as I set out there is both the £16 billion that is going into local authorities for public health and the extension of the ring fence for another year. I will not gloss over the fact that it is a challenging fiscal environment. We know why that is; it is because the country continues to borrow more than it is bringing in in tax. I do not want to go into the reasons for that for fear of being accused of being too political, but we do operate in a challenging environment. That is why the business rate retention and reform is so important, to give local authorities more sustainability for their own funding base. I should also point out that, whether the issue is smoking or other risky behaviours, we are still making good progress, so it is possible to continue to reduce these kinds of risky behaviours, notwithstanding the pressures that are inevitably placed on budgets. In the round, total health budgets are increasing, not just in the NHS but across all health budgets. So while I do not gloss over the fact that it is a challenging fiscal environment, we are still making very strong progress, not just on health visitors but on a number of important public health issues.

In terms of the point that the noble Lord, Lord Hunt, made about the review by Public Health England of mandated services, obviously there are no plans to review the health visiting service, as I think we are all agreed that this is something we want to happen. Health visitors are popular and desired. I am not in a position to say at this point whether any other services are under review but I shall certainly write to him about that.

Both the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, asked about the numbers of health visitors. They increased by 50% in the last Parliament, which I think is a huge achievement. It has become slightly more difficult to track their numbers because they have a number of employers now that the budget has been devolved, but there are still very high numbers of them as a result of the changes made in the last Parliament. There are over 800 training places for health visitors and there are more nurses in the system as well. So there is investment going into the workforce, and I absolutely recognise that there has got to be a high-quality workforce. It is also the case that other healthcare professionals are able to deliver some of these services. If a family, which of course will more likely be a poorer or more disadvantaged family, is receiving support from a family nurse partnership, then the nurses that are delivering that can also deliver the health visit and some of the early reviews, so it is a mixed picture. The number of family nurse partnership places has increased over the past few years as well.

There are a couple of final issues. Breastfeeding is part of health visitor training and indeed their mandate is to encourage greater breastfeeding. I am not aware of the specifics of the variability. I shall certainly look into that. It is a critical part of maternal and child health and to be encouraged. I know that there are variations from one part of the country to another. Whether they are due to training and workforce or to other cultural or longer-term issues is a different question and it is bound to be more challenging in some areas than others.

The noble Baroness, Lady Walmsley, asked about the age range. It is important for the health visiting service to stick to what it does best. I certainly recognise the picture she is describing, having worked in primary schools. There is an increase in children coming unprepared to school, or increasingly to nurseries, whether in their eating habits or toilet habits or whatever it is. The increase in formal childcare places that has been made available to both three year-olds and disadvantaged two year-olds will go some way to addressing that but I shall certainly keep an eye on that issue.

[Baroness Walmsley]

Sorry to spring this on the noble Lord but there was something that I forgot to ask him. He mentioned the accessibility of school nurses. The fact is that if a school nurse is looking after five schools they are not terribly accessible. I wonder if he might write to me as to whether there are any plans to increase the number of school nurses, because that is part of increasing the child’s health right the way through the age range.

[Lord O'Shaughnessy]

Yes, I shall certainly be happy to do that, probably looking at it in the round in terms of all the local health support that is available for school-age children. I hope, in responding, that I have been able to talk to all the points that have been made by noble Lords in this debate. I am glad that we all agree that health visitor support to families is vital and is about giving children the best possible start in life. It is why the Government have taken this action to continue to ensure the provision of the five mandatory health and development assessments and reviews so that this service continues to be provided for all families with children aged nought to five. I beg to move.

Motion agreed.