Health Inequality: Autism and Learning Disabilities

Lord O'Shaughnessy Excerpts

Thursday 10th May 2018 Grand Committee

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

My Lords, I congratulate the noble Lord, Lord Touhig, on calling for this debate and on his good grace in agreeing to meet ahead of it so that we were able to discuss some of the issues that have been raised today. I hope to answer as many questions as I possibly can. I also congratulate all noble Lords on their contributions, some of which were very personal. Whether it is a family experience or the experience of people we know, have met or have communicated with, it brings gravitas to a debate. I congratulate Mencap and the National Autistic Society on the quality of their briefings and, if nothing else, on making sure that government is kept honest in its attempts to address the needs of this group.

Noble Lords have set out the many challenges that people with learning disabilities and autism face in leading healthy and productive lives. We have talked about inequalities in health and well-being compared to those without learning disabilities or autism; comorbidities, and particularly mental health needs; great difficulties in accessing health and social care support, as the noble Lord, Lord Touhig, and the noble Baroness, Lady Thornton, and others brought to life through their experiences and the stories they told; difficulties in fulfilling educational potential; and difficulties in securing employment.

The sad fact is that people with a learning disability are more likely to experience major illnesses, to develop them younger and to die sooner. Those are the bald facts. Autistic people are also at increased risk of dying younger and have a higher risk of developing mental health problems and conditions such as epilepsy, diabetes and heart disease. They are less likely to get the screening, checks and treatment they need. They continue to face barriers to accessing services and information. My noble friend Lord Sterling talked about the impact on families: it affects not just the individual concerned but everyone around them. Such inequalities are deep rooted and we have not only a moral obligation to tackle them but, as the noble Baroness, Lady Meacher, pointed out, an economic rationale as well. I agree with the noble Baroness, Lady Jolly, that we need to start from the position of rights: the right of these individuals to enjoy the same standard of health and care as everyone else.

I will set out a few of the things that the Government are doing to try to improve outcomes for this group and then will address questions posed by noble Lords. My noble friend Lord Astor of Hever mentioned the NHS mandate, which is an important place to start. It sets out our ambition and expectation to reduce the health gap between people with mental health problems—who are not the direct focus of today’s debate—learning disabilities and autism and the population as a whole, and support them to live full, healthy and independent lives. The learning disability annual health check is a big part of meeting this aim, in looking for undiagnosed health conditions early and promoting the uptake of preventive care. As the noble Lord, Lord Addington, pointed out, as a group, they are not necessarily that good at coming forward to seek support or to express their needs. NHS England has increased the funding available for GPs for these health checks and there is an ambition to significantly raise the number of people benefiting from them.

We did unfortunately have cause yesterday to discuss the first annual report from the learning disabilities mortality review. I say unfortunately, because, as many noble Lords have pointed out, it sets out the scale of the challenge that still exists to reduce early deaths and health inequalities for this group. The fact of the programme is in itself progress, but the number of deaths reported, and indeed those which have been reviewed and are of concern, is still very high. This demonstrates how much more work there is to do. I did commit in the House yesterday to NHS England and the department working together to try to take forward all the recommendations in that report, as far as we can. It has been noted by the noble Baroness, Lady Hollins, that this is not the first time these recommendations have been made.

Some of the action taking place includes publishing data for the first time on avoidable deaths, including those of people with learning disabilities. Trusts will be inspected against their learning and the changes they have made from studying these avoidable deaths. In answer to the question from the noble Baroness, Lady Hollins, NHS England has provided additional funding for this year. I should say at this point that it has not ruled out funding for future years. The point here is that we need to get up to speed on the backlog of reviews that are taking place and make sure that that is fully embedded in the NHS.

NHS England and the RightCare programme are also producing guidance on pathways of care tailored to the needs of people with learning disabilities, including for diabetes. There are further pathways coming soon on epilepsy, sepsis and respiratory conditions.

The noble Lord, Lord Addington, and the noble Baronesses, Lady Hollins and Lady Meacher, all mentioned training. That is a critical point. There is a training and education framework for people with learning disabilities for use by health and care staff, and there is one to follow for autism training. That builds on the tiered approach that has proved successful in training all staff for dementia and is being rolled out at the moment.

I would like to address the particular issue raised by the noble Lords, Lord Touhig and Lord Crisp, the noble Baronesses, Lady Thornton and Lady Meacher, and my noble friends Lord Astor and Lady Browning—by pretty much everybody: the autism pathways that were mentioned in the five-year forward view for mental health. These pathways are being developed for both adults and children. Specifically, they are for those with a mental health diagnosis with neural developmental comorbidities such as autism. They are about the two things happening together, rather than simply for people with autism alone. That makes sense, because this is about access to mental health services. We have been pressing NHS England for a timeline in the run-up to this debate. I regret that I do not yet have that, but I will continue to press for it and will share news on our progress with noble Lords as soon as I get it.

Some of the other ways in which we are acting to try to reduce that health gap include the wonderfully named STOMP programme—stopping overmedication of people with a learning disability, autism, or both with psychotropic medicines. A pledge to stop overmedication has been signed by 24 professional royal colleges and societies, which have all developed clear plans to deliver on this, and by over 150 social care providers supporting 50,000 people with learning disabilities, autism or both. That is good progress. It is fair to say also that the Improving Access to Psychological Therapies programme has adapted its standard intervention for people with learning disabilities and autism. NHS England is working to update its framework for community mental health services for this particular group.

Many noble Lords have talked about the issues around delayed diagnosis. It was touched on by the noble Lord, Lord Touhig, and my noble friend Lady Chisholm. There is an ongoing review of the quality and outcomes framework by NHS England, which is looking at implementing the NICE recommendation about putting a flag effectively on the record. I do not have a publication date for that but I reassure noble Lords that I will write to them once I do. We also have for the first time autism indicators in the Mental Health Services Data Set, collected from 1 April this year, which is bringing more transparency to the process and helping us improve performance locally.

My noble friend Lady Browning mentioned the Autism Act, which remains the only condition-specific legislation in England. I hope that the consequent adult autism strategy represents to her a clear commitment by the Government to change the way that we support and provide services for adults on the autism spectrum to address those inequalities. I reassure her about the seriousness with which the Government undertake those actions.

While we are talking about schooling, it is worth touching on special educational needs, although it is not necessarily a topic for today. My noble friend Lord Sterling talked about getting the right support at an early age. The introduction of education, health and care plans as a consequence of the Children and Families Act 2014 was a major step forward. Ofsted and the Care Quality Commission are inspecting the arrangements that CCGs and local authorities have for those to make sure that we can improve performance and drive out variation. I am aware that there is huge variation across the country in both the availability and quality of such plans.

While we are talking about education, several noble Lords—the noble Baroness, Lady Scott of Needham Market, the noble Lords, Lord Crisp and Lord Addington, and my noble friend Lady Browning—talked about the issue of advocacy. I absolutely applaud the work that Ace Anglia is doing and the production of easy-read materials. The noble Baroness asked what government can do to support that process. Training, which we have touched on, is one thing, but there is also clearly a role for government funding—I know that the Government have supported the Autism Education Trust to support the development of training for school staff. I think that will provide some reassurance to my noble friend Lady Chisholm, who also asked about the training of school staff.

The noble Baroness, Lady Meacher, also talked about education. I do not know about the work of June Felton but it sounds interesting. My first ever role in education was as a governor of a special school in Wandsworth called Garratt Park School, which has an autism base, and I eventually became chair of governors there. The quality of a good intervention and what it can do for children’s lives is truly dramatic. Indeed, another school in that area is the former Rainbow School, which supports very autistic children with behavioural approaches and which has changed their lives. That school lodged with us for some time at one of the free schools I set up, so I had the opportunity to see that in action, and it does amazing stuff. The links between health and education are absolutely there, which is what the EHC plans are meant to be bringing together.

I will finish with a few more points that I have not touched on yet. On delayed diagnosis, which was raised by the noble Lord, Lord Touhig, from April NHS Digital has been collecting autism diagnosis waiting time data, so that that is now visible, and the autism strategy task and finish group is exploring how to use that data as part of a local accountability regime. So that is in progress, and I hope that we will see something positive emerge from that.

The noble Lord, Lord Crisp, and the noble Baroness, Lady Thornton, mentioned the Mental Health Act, which is an important issue. Professor Simon Wessely is chairing his independent review and has published an interim report—if noble Lords have not seen it, I encourage them to look at it; I will send them a copy of the report. It sets out some of the specific issues that need to be explored under that review for people with learning disabilities and autism, so I can reassure them that that is an explicit part of the work of that review.

The noble Lord, Lord Crisp, and the noble Baronesses, Lady Jolly and Lady Thornton, also mentioned eye care. If you think about the process of having your eyes tested and think about what that must be like for someone with sensory issues, with autism or learning disabilities, it is not a pleasant thought. An NHS working group is looking at this, and I am reassured to see that SeeAbility is part of that. They are looking at that, but if they feel that that is not going as it should, I would be grateful if they could write to me. The noble Lord, Lord Crisp, also mentioned the key issue of staffing, which is critical. We are trying to get more nurses into the NHS; having this golden hello for shortage areas, including learning disabilities, is a good step forward. There is a desire—my noble friend Lady Browning raised this—to increase the number of mental health staff so that we can start to meet some of the standards which we have set ourselves.

I hope that I have managed to answer all questions noble Lords have posed. Again I thank the noble Lord, Lord Touhig, for instigating this debate. The noble Baroness, Lady Jolly, said yesterday that we should judge ourselves as a society on how we look after some of the most vulnerable people. This debate has brought the needs, challenges but also the opportunities and rights of this group to the fore. I reassure noble Lords that it is a major part of the Government’s policy and attention. We know that there is more work to be done; there are some good signs of progress, but there is clearly a lot more work to do together to make sure that people with learning disabilities and autism have the opportunity to lead a healthy, productive and independent life.

Committee adjourned at 6 pm.

Learning Disabilities Mortality Review

Lord O'Shaughnessy Excerpts

Wednesday 9th May 2018 Lords Chamber

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

My Lords, with the leave of the House, I will repeat the Answer to an Urgent Question given yesterday by my honourable friend the Minister for Care on the Learning Disabilities Mortality Review Programme annual report.

“The Government are absolutely committed to reducing the number of people with learning disabilities whose deaths may have been preventable, and have pledged to do so with different health and care interventions. The Learning Disabilities Mortality Review Programme was established in June 2015. It was commissioned by NHS England to support local areas in England to review the deaths of people with a learning disability. Its aims were to identify common themes and learning points, and to provide support to local areas in their development of action plans to take forward the lessons learned.

On 4 May, the University of Bristol published its first annual report of the LeDeR programme, as it is known, covering the period from July 2016 to November 2017. The report included 1,311 deaths that were notified to the programme and set out nine recommendations based on the 103 reviews completed in this period.

The Government welcome the report’s recommendations and support NHS England’s funding of the programme for a further year at £1.4m. We are already taking steps to address the concerns raised, but the early lessons from the programme will continue to feed into our work, and that of our partners, to reduce premature mortality and improve the quality of services for people with learning disabilities”.

[Baroness Thornton (Lab)]

I thank the Minister for repeating that briefing. He may find that the decision about the date of the publication was actually that of NHS England and, frankly, publishing it on the Friday before a bank holiday is either incompetent or shameful. However, seven years after the Winterbourne View scandal and five years since the avoidable death of Connor Sparrowhawk, the findings of this review show a much worse picture than previous reports about the early deaths of people with learning difficulties. One in eight of the deaths reviewed so far show there to have been abuse, neglect and delay in treatment and gaps in care. Women with a learning disability are dying 29 years younger, and men 23 years younger, than the general population; 28% of the deaths reviewed had occurred before the age of 50, compared with just 5% in the general population. This is a terrible situation.

I would like to ask the Minister two questions. First, almost one in 10 of the people who have died have been in out-of-area placements, without the support of family, friends, or any local, familiar community support. The Government have repeatedly said that such placements must be avoided, so will the Minister tell the House what action is being taken to ensure that government statements and guidance on this matter are being followed? Secondly, will the Minister expand on the last part of the Statement, and tell us what action the Government are taking to address the alarming gap in life expectancy of people with learning difficulties?

[Lord O'Shaughnessy]

I thank the noble Baroness for her questions and agree with her that it is a troubling report; it paints a troubling picture of the shockingly poor outcomes that people with learning disabilities have in terms of their mortality and morbidity. I would not disagree with her about that picture and I will come to the actions we are taking to try and address it.

On the publication, I agree with her that the timing was less than ideal. The department did not have sight of it; it was an independent report commissioned by NHS England. We are investigating that, but I agree it was not done as it should have been and we will endeavour to ensure that this does not happen again. On the areas of policy that she referred to, on out-of-area placements there is a programme called Building the Right Support, which is trying to increase the amount of care delivered in community settings, bringing people with learning difficulties, disabilities and autism out of in-patient care to more suitable care in the community. The intention is to reduce the use of in-patient beds for people in mental health hospitals by 35% to 50% between March 2015 and March 2019. It is an attempt to locate much more of that care in the community.

The noble Baroness also asked about other actions we are taking to improve outcomes. I want to focus on the annual health checks that are now available for adults and young people from 14-plus years. That is happening every year. We know the use of these checks is increasing; it has increased by 17% year on year up to 2017-18. There is a real ambition to raise that further by 64% in 2018-19 compared to 2016-17. We know this group does not always feel equipped to come forward and bring health issues to the notice of the health system. It needs extra support; it needs people to be on their side, checking in with them to make sure their issues are addressed. I think this is one way in which we will make some difference.

[Baroness Jolly (LD)]

My Lords, I declare my interest as chairman of a learning disability charity that provides services for 2,500 adults in England. This report makes for uncomfortable reading for anyone involved in the sector and it should shock the general public. We are judged by how well we as a society care for those who are weak and vulnerable. On this count, we have failed. Each year, the deaths of 1,200 people with learning disabilities are avoidable. The standard of their care is not fit for purpose. There are not enough learning disability specialist nurses in the NHS and support staff are no longer being funded to support people with a learning disability in a healthcare setting.

I have three questions for the Minister. Do either the Department of Health and Social Care or Health Education England collect figures on how many health professionals attend training in dealing with people with a learning disability? What guidance is given to staff about the provision of written material in an accessible format? Finally, once admitted, learning disabled patients lose their funding from the local authority so they have no one who knows or understands them and they are left frightened and alone. Does the Minister believe this should be the case?

[Lord O'Shaughnessy]

I thank the noble Baroness for raising excellent questions. We know that there is a need for more specialist nurses, and indeed that is one reason for the expansion of the number of nurse training places. The education and training of staff is a focus of the recommendations of this report and, equally, of the Mencap report. If noble Lords have not read that, I commend it too. Because it is a very good point, I will look into whether we are tracking the number of people who access training. Certainly there is now, and has been since 2016, an education and training framework for the care of people with learning disabilities. I believe that there is also one to follow for adults with autism, and that is welcome. However, as the noble Baroness says, it is about making sure that the staff use that training.

On the noble Baroness’s point about advocacy, I did not realise the funding issue that she raised existed. I will take that back and investigate it. I know that NHS England, the LGA and the Association of Directors of Adult Social Services have put out joint guidance on advocacy for this group of people, but I will investigate the funding point and write to her.

[Baroness Hollins (CB)]

My Lords, I declare my interest as the chair of a social enterprise that creates communication resources for people with learning disabilities. My own research more than 25 years ago uncovered very similar shocking inequalities. The noble Lord has responded to a question about education but is it not now time for there to be mandatory education for all healthcare professionals? This is not a specialist matter. Does he agree that such training should be co-delivered by people with learning disabilities in order to reduce the fear and lack of understanding among health professionals when it comes to making reasonable adjustments? What action will be taken now?

[Lord O'Shaughnessy]

The point that the noble Baroness makes about the involvement of people with learning disabilities in this process is critical. I did not respond to a question from the noble Baroness, Lady Jolly, about communications with people with learning disabilities. Having written a manifesto in the past and having had it translated into the Easy Read format, I know that this is critical. I know that there are attempts to make sure that communications are made in that format where it is helpful to do so.

On the noble Baroness’s question about training, we have a really good template which my honourable friend Caroline Dinenage mentioned in the other place yesterday, and that is dementia training. It is tiered, with tiers 1 and 2, and it has been rolled out very broadly across the health and care sectors with great success. Therefore, I think that we have a template for doing this, and I know that my honourable friend is taking that forward. It was a specific recommendation in the report by the University of Bristol. My honourable friend committed to take forward with NHS England all those recommendations, and that is what we will endeavour to do.

[Baroness Finlay of Llandaff (CB)]

My Lords, given that the report recommends that there should be a named healthcare co-ordinator, yet there is a serious shortage of experienced learning disability medical and nursing staff and it will take some time for trainees to feed through the system, have the Government considered discussing with the GMC and the Nursing and Midwifery Council ways of attracting back into the service older, currently retired professionals who might have a great deal of wisdom and might be motivated to work in a specific area, act as a person’s advocate and provide on-site teaching in conjunction with the person? They could take on the role of communicator and navigator to develop a strategic pathway for the person with learning difficulties or disabilities, and they could also have a role in teaching people about the signs of sepsis, pneumonia and so on, so that there are early alerts.

[Lord O'Shaughnessy]

The noble Baroness makes an excellent point. Clearly there is a need to recruit healthcare co-ordinators. One positive thing that I would highlight is a recommendation in the report from the University of Bristol regarding the sharing of health action plans between health and care agencies. That is already happening and is one positive step. Her idea about bringing back into the profession more experienced professionals to act as advocates is a very good one. A concerted effort is being made to do that through the Return to Practice programme. I do not know whether there is a specific strand relating to people with learning disabilities but I will take that away and investigate it.

On her point about signs of sepsis, pneumonia and other diseases, which are among the causes of this early mortality, some good progress is being made. NHS England is creating new pathways in those areas specifically designed for people with learning disabilities, and I believe that it will be publishing some of them this year.

Breast Cancer Screening

Lord O'Shaughnessy Excerpts

Thursday 3rd May 2018 Lords Chamber

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

My Lords, with the permission of the House, I will repeat the Statement made yesterday by my right honourable friend the Secretary of State for Health and Social Care on breast cancer screening. The Statement is as follows:

“I wish to inform the House of a serious failure that has come to light in the national breast screening programme in England. The NHS breast screening programme is overseen by Public Health England and is one of the most comprehensive in the world. It screens 2 million people every year, with women between the ages of 50 and 70 receiving a screen every three years up to their 71st birthday. However, earlier this year PHE analysis of trial data from the service found that there was a computer algorithm failure dating back to 2009. The latest estimate I have received from PHE is that as a result of this between 2009 and the start of 2018 an estimated 450,000 women aged between 68 and 71 were not invited to their final breast screening.

At this stage it is unclear whether any delay in diagnosis will have resulted in any avoidable harm or death, and that is one of the reasons I am ordering an independent review to establish the clinical impact. Our current best estimate—which comes with caveats as it is based on statistical modelling rather than patient reviews and because there is currently no clinical consensus about the benefits of screening for this age group—is that there may be between 135 and 270 women who have had their lives shortened as a result. I am advised that it is unlikely to be more than this range and may be considerably less. However, tragically, there are likely to be some people in this group who would be alive today if the failure had not happened.

The issue came to light because an upgrade to the breast screening invitation IT system provided improved data to local services on the actual ages of the women receiving screening invitations. This highlighted that some women on the AgeX trial, set up to examine whether women up to the age of 73 could benefit from screening, were not receiving an invitation to their final screen as a 70 year-old. Further analysis of the data quantified the problem and found a number of linked causes, including issues with the system’s IT and how age parameters are programmed into it. The investigation also found variations in how local services send out invitations to women in different parts of the country.

The existence of a potential issue was brought to the attention of the Department of Health and Social Care by Public Health England in January, although at that stage its advice was that the risk to patients was limited. Following that, an urgent clinical evaluation took place to determine the extent of harm and the remedial measures necessary. Public Health England escalated the matter to Ministers in March, with clear clinical advice that the matter should not be made public. This was to ensure that a plan could be put in place that ensured any remedies did not overwhelm the existing screening programme and was able to offer proper support for affected patients.

I am now taking the earliest opportunity to update the House on all the remedial measures that have been put in place, which are as follows. First, urgent remedial work to stop the failure continuing has now been completed according to the chief executive of Public Health England. This was finished by 1 April and PHE is clear that the issue is not now affecting any women going forward. Of the estimated 450,000 women who missed invitations to a scan, 309,000 are estimated to be still alive. Our intention is to contact all those living within the United Kingdom who are registered with a GP before the end of May, with the first 65,000 letters going out this week. Following independent expert clinical advice, the letters will inform all those under 72 years old that they will automatically be sent an invitation to a catch-up screening. Those aged 72 and over will be given access to a helpline through which they can get clinical advice to help them decide whether or not a screening is appropriate for their particular situation. This is because, for older women, there is significant risk that screening will pick up non-threatening cancers that may lead to unnecessary and harmful tests and treatment. However, this is an individual choice and, in all cases, the wishes of the patients affected will be followed. By sending all the letters to UK residents registered with a GP by the end of May, we hope to reassure anyone who does not receive a letter this month that they are not likely to have been affected.

It is a major priority to do our very best to make sure that the additional scans do not cause any delays in the regular breast screening programme for those under 71, so NHS England has taken major steps to expand the capacity of screening services, and has today confirmed that all women affected who wish to be screened will receive an appointment within the next six months. Of course, we intend the vast majority to be much sooner than that.

We have held helpful discussions with the devolved Administrations to alert them to the issue. Scotland uses a different IT system, and while the systems in Wales and Northern Ireland are similar, neither believes that they are affected. However, we are discussing with them the best way to reach women who have moved to another part of the UK during this period. This is, obviously, more complicated, but we are confident that all those affected will be contacted by the end of May.

In addition, and as soon as possible, we will make our best endeavours to contact the appropriate next of kin of those whom we believe missed a scan and have subsequently died of breast cancer. As well as apologising to the families affected, we would wish to offer any further advice that they might find helpful, including the process by which we can establish whether the missed scan is a likely cause of death and compensation is therefore payable. We recognise that this will be incredibly distressing for some families and we will approach the issue as sensitively as possible.

Irrespective of when the incident started, the fact is that for many years oversight of our screening programme has not been good enough. Many families will be deeply disturbed by these revelations, not least because there will be some people who receive a letter having had a recent diagnosis of breast cancer. We must also recognise that there may be some who receive a letter having had a recent terminal diagnosis. For them and others, it is incredibly upsetting to know that you did not receive an invitation for screening at the correct time, and totally devastating to hear you may have lost or be about to lose a loved one because of administrative incompetence. So on behalf of the Government, Public Health England and the NHS, I apologise wholeheartedly and unreservedly for the suffering caused.

But words alone are not enough. We also need to get to the bottom of precisely how many people were affected, why it actually happened and, most importantly, how we can prevent it ever happening again. Many in this House will also have legitimate questions that need answering: why did the algorithm failure occur in the first place and how can we guarantee it does not happen again? Why did quality assurance processes not pick up the problem over a decade or more? Were there any warnings—written or otherwise—that should have been heeded earlier? Was the issue escalated to Ministers at the appropriate time? What are the broader patient safety lessons for screening IT systems?

I am therefore commissioning an independent review of the NHS breast screening programme to look at these and other issues, including its processes, IT systems and further changes and improvements that can be made to the system to minimise the risk of any repetition of this incident. The review will be chaired by Lynda Thomas, chief executive of Macmillan Cancer Support, and Professor Martin Gore, consultant medical oncologist and professor of cancer medicine at the Royal Marsden, and is expected to report in six months.

The NHS has made huge progress under Governments of both sides of this House in improving cancer survival rates, which are now at their highest ever. Some 7,000 people are alive today who would not have been if mortality rates had remained unchanged from 2010. But this progress makes system failures even more heartbreaking when they happen. Today, everyone in this House will be thinking of families up and down the country worried they may have been affected by this failure. We cannot give all the answers today, but we can commit to take all the necessary steps to give people the information they need as quickly as possible. Most of all, we want to be able to promise that this will not happen again. So, today, the whole House will be united in our resolve to be transparent about what went wrong and to take the necessary actions to learn from the mistakes made.

I commend this Statement to the House”.

--- Later in debate ---

[Baroness Maddock (LD)]

My Lords, I am sure that all of us in this House are considerably concerned about those older women who at the moment are suffering acute anxiety because of what happened, and not only them but their families. It would appear that this was a software error. As I understand it, the same situation has not occurred in Wales, although the health service there appears to be on the same system. Can the Minister tell us a little more about that?

The Minister said that past notes will be looked at. How long does it take to get notes from the archive? Not all notes are held with GPs, and hospitals sometimes archive historic records. Are there enough current NHS staff to look at this, or will we need to take on new staff? That leads me on to another point about speed being of the essence. Depending on the uptake, as has already been alluded to, there may be a need to get women in this cohort X-rayed quickly and at scale. I know that we have had a shortage of radiologists; do we have enough to meet this need?

There is a wider issue, already referred to by the noble Baroness, Lady Thornton, of the lowering of the take-up rate. One thing that has come to my notice because of where I live and from talking to other people, is that if you happen to be unable to take up the appointment in the travelling van that comes round, you are often referred to a hospital. Sometimes that works and sometimes it does not—it can be a long way to go. However, when one of my colleagues asked whether she could have it done when she was here in London and have the X-ray emailed to her, she was told that that was not possible. Can the Minister look at that? While on technology, perhaps the problem of not detecting this is connected with the fact that we have become so reliant on technology that we think it is looking after things and so people do not personally ask the questions they need to.

I hope that the Minister will give us a bit more information about other steps that the Government are taking to try to help improve the take-up rate of screening. Unfortunately, this episode will cause some people to lose faith in the system, and we need to do something about that. Can he also say what his department will do to raise awareness, particularly among women over 70, so that they can continue to be checked?

I hope that the House will indulge me if I take this opportunity to thank those in the health service who have served me with my breast cancer. I may or may not have been one of these people; I self-referred when I was 70 because I had been through the screening process and had been looking out for signs that I had been warned of, so that is one very good thing. I had excellent service at the Royal Victoria Infirmary in Newcastle, which has been rated as outstanding after an inspection, and I was fortunate enough to be able to have chemotherapy down the road in my local hospital in Berwick. The two nurses who run that are absolutely fantastic. So I am very fortunate, and I know that that is what happens in my part of the country. I therefore thank the National Health Service for helping me, and I look forward to hearing from the Minister.

[Lord O'Shaughnessy]

First, if I may, I express my thanks to the noble Baronesses, Lady Thornton and Lady Maddock, for their constructive questions and the offer of working together to make sure that we get to the bottom of the situation and put it right. I also thank the noble Baroness, Lady Maddock, for sharing her own experiences with us. I am glad that she got good care, as, of course, the vast majority of people do, and we are indebted to the NHS staff who provide it. She made an incredibly important point about self-referral. One thing we must emphasise throughout this is that screening is one part of a much broader programme for spotting cancer early, and women’s awareness of their own body is absolutely at the front line of those efforts.

I want to add my own apology to those of my right honourable friend and the Government to the women affected, and to express my personal sympathies to them and to their families.

The noble Baronesses asked excellent questions and I will attempt to answer all of them. Key questions included early warnings, whether public concerns were expressed but not picked up on, and whether technology could have looked for trends in uptake in this age group—an example of technology coming to our help rather than being a problem. These are all very good questions that must be and will be the focus of the review. The review will, I am sure, also look at issues around variation. There are attempts to address falling screening rates, including national information campaigns, but whether or not those are adequate is a reasonable question given what we know about uptake.

The noble Baroness, Lady Thornton, asked specific questions about the analysis from Public Health England on the flaw in the algorithm. Indeed, my right honourable friend the Secretary of State committed to sharing that yesterday, which we will do. Since finding out about this problem, we have been in close conversation with NHS England to make sure that there will be additional resources, such that all women can be seen within six months for an extra screening if they want one. The vast majority would be seen much sooner than that and in a way that does not interrupt the normal screening programme, which is critical. The department and NHS England will provide additional resource to make that happen, including using temporary independent sector resource as necessary.

The noble Baroness, Lady Maddock, asked about case notes taking a long time to be assembled. That can happen, and it is critical for any woman or her family who think that they may have been affected negatively by this, with her cancer not being spotted. We will go through case note reviews for each of the women who may have been affected in that way—and if the NHS is shown to have been at fault, they will be eligible for compensation.

The noble Baroness asked a very good question about the location of screening. Choice is embedded in the system. I believe it was the noble Baroness, Lady Jolly, whom she was talking about and who had that experience. I looked into this: the 2016-17 guidance from NHS England provides flexibility and choice for women to say where they want their screening, which is one of the ways of driving uptake. If that has not happened in this case, and it does not sound like it has, I will be happy to raise that directly with NHS England at the highest levels.

I hope that I have been able to answer the questions from the noble Baronesses. I agree with them that this is a dreadful outcome of administrative incompetence and that we need to make sure, as we are reassured at the moment, that it is not affecting either other screening processes or other countries. One reason for that is that the particular clinical trial—the AgeX trial—applied only in England in its interaction with the screening database. The trial is not taking place in Wales or Northern Ireland, which share the same system—which is why the Welsh case seems to be different.

We will at all times in the process of the review and as we find out more be at great pains to make sure that we are as transparent as possible and to share information with the House.

[Lord Stirrup (CB)]

My Lords, the Minister referred to IT and QA failings, and has recently been answering questions about data security. An independent review into the breast cancer screening programme is clearly important and welcome, but how confident is he that the sorts of failings he has talked about do not exist in other areas of the NHS? Given the fact that the QA process failed in the current instance for eight years to pick this up, how can he have any confidence at all in automated processes elsewhere?

[Lord O'Shaughnessy]

We must be absolutely cautious in our dealings with technology. Of course, technology is part of the health and care service now. It is in everything. Making sure that there is good quality assurance is critical to that. Clearly, we have uncovered a problem but we do not think that the problem is in other screening processes. We have had reassurance from Public Health England that that is the case, but we clearly need to investigate further. We also need to be alive to the fact that these systems are often under attack from other actors, and to provide that cyber resilience. So I am afraid that it is an ongoing process to provide that kind of resilience and quality assurance. It is a job that never ends.

[Baroness Massey of Darwen (Lab)]

My Lords, I declare an interest as vice-chair of the All-Party Parliamentary Group on Breast Cancer. The Minister may be aware—I hope that he is—of a report, Good Enough?, about capacity issues within the breast cancer screening service. The report expresses very forcefully that there is regional variation. What is the answer to this and how can it be improved so that wherever you are you can get excellent service and screening?

[Lord O'Shaughnessy]

The noble Baroness asks an extremely good question. It is important in this instance to distinguish between the very correct questions that she is asking and the particular problem in this case. In this case the problem is not one of resource but of, unfortunately, an IT flaw in the interaction between the national screening programme database and its AgeX trial. I want to make that clear. But in response to her question, we had an opportunity to debate these issues in the House yesterday in an Oral Question from the noble Baroness, Lady Thornton. We are increasing and have increased the number of specialist cancer nurses, for example, by 1,000. Health Education England, in its cancer workforce strategy, has outlined a plan to recruit more radiologists, radiotherapists and so forth. Having more staff and higher-trained staff with the proper competency frameworks is clearly one way in which we can deal with the variations that she rightly highlights.

[Baroness Falkner of Margravine (LD)]

My Lords, the Minister mentioned that the Government will be looking at public information campaigns to ensure that women who may not have captured the periodic screening letter that is sent out would be aware that they need to take the initiative themselves and find out if they should have been screened. But, if I understood him correctly, when the Minister gave the figures in the Statement, 270 was the upper limit of deaths that would have been caused. If that is the case, I am slightly perturbed in terms of frightening people. He would probably accept that, whatever the figure, it is impossible to be precise about the number of deaths that “would” have been caused. Perhaps he meant to say “may” have been caused—because screening of itself does not cure breast cancer. That is an important distinction to make.

[Lord O'Shaughnessy]

The noble Baroness makes an incredibly important point. To refer back to the Statement, I think that the word used was “may” and that an upper range was given. I want to distinguish between two things. The first is the national campaigns that take place—I think there were 14 in the past eight years—to encourage women to check for their own symptoms and take up opportunities for screening programmes. Those will continue; that is part of the overall programme. In terms of writing to the women who are still alive who may have been affected, that is a separate and discrete process. It will start with a letter. It is easy for us to track down those who are registered with a GP in England and we are working with colleagues in the devolved Administrations, as noble Lords would expect, to make sure that we can write to those who have moved to those countries, and to provide resources to those countries so that they can provide screening. A helpline is also included that has been publicised.

On the point about the number of deaths that may have occurred, it is a difficult issue. On the one hand, we have received advice that that may be the case and we felt that it was wrong not to be honest and transparent about it. At the same time, there is not a clinical consensus about the benefits of breast cancer screening for women aged 70 and over—that came as something of a surprise to me—because of the non-malignancy or low malignancy of some tumours that can be spotted and the harms that can follow from treatment.

So we need to be cautious. What we have projected as a range is based on statistical modelling and not based on scrutiny of actual case note reviews. Of course, we deeply hope that the number will come down as we carry out that inquiry.

[Baroness Masham of Ilton (CB)]

My Lords, why is there the magical cut-off point of 72? In the paper the Minister just read, what are the non-threatening cancers in older people and what are the harmful tests and treatment? If they are harmful for older people, what about younger people?

[Lord O’Shaughnessy]

The noble Baroness asks an excellent question. The clinical advice that we received, which is the reason for the extension of screening from up to the age of 70 to up to the age of 73, is part of a clinical trial. There is no evidence that screening necessarily benefits women in general; of course, it will benefit some women in particular. There are breast cancers—I cannot claim to be able to describe them because that is well beyond my clinical knowledge—that women can have at that age and live with, and, indeed, they can die of something else at a later age. The treatment process, whether it is chemotherapy, radiotherapy or surgery, can be very debilitating, harmful and in some cases unnecessary, although, having found a tumour, a woman may well want to progress with that treatment. We have been driven by that age range, with 72 as the cut-off, and the wider description of this lack of clinical consensus. I assure the noble Baroness that we have been informed by a clinical advisory group throughout the process to make sure that we are as accurate and effective as possible.

[Baroness Masham of Ilton]

I am glad it is not the case that older people are not worth treating.

[Lord O'Shaughnessy]

Certainly not.

[Lord Hunt of Chesterton (Lab)]

My Lords, a broadcast on the BBC news last night commented that people should not contact their GPs but use some number instead. A lot of people will want to go to their GP to be reassured about this. Visits to GPs were not mentioned in the Minister’s Statement, nor in the Oral Statement, so it is important to explain this.

[Lord O’Shaughnessy]

The noble Lord makes a good point. We are encouraging people to use the helpline. Indeed, the number will be written in the letter that is sent to women, whether they are offered a screening because they are aged 72 or under or want to refer themselves for a screening. At the same time, many women will be anxious and will want to see their GP, or are seeing them anyway. We recognise that. We have liaised with the Royal College to make sure that GPs are properly briefed on a potential increase in the number of women referring themselves so that they are able to cope with that and provide the necessary signalling.

It is also important to highlight that we are working very closely with the key cancer charities, such as Macmillan, Breast Cancer Care and Breast Cancer Now, and others to make sure that there is a proper, broad approach so that women, whatever their anxieties—mental health issues may have been triggered as well as physical ones—get the support that they need and deserve.

[Baroness Morris of Yardley (Lab)]

My Lords, I obviously share in the concern about what has happened. I want to emphasise a point that has already been made and make sure that it will be part of the review. It is unimaginable that some women realise that they have not got the recall for their regular breast screening appointment. As a woman, you are sort of aware when it is about to come around; if the letter had not come, some people—though not everybody—would have either contacted the helpline or gone to their GP. I am worried that the response was, “Well, the computer says you’re not ready for a screening yet”, so the person was not listened to. I am seeking some assurance that the inquiry will come back with an answer on what happened when women said, “I think my breast screening appointment is late”.

Secondly, I am not sure about the scope of the inquiry, which I of course welcome. Will it look at all the circumstances surrounding this incident or will it go further, for example by looking at other causes of the drop in the percentage of people taking up such opportunities, as well as the regional disparities, which have already been mentioned?

[Lord O’Shaughnessy]

As always, the noble Baroness makes a very incisive point. The inquiry must look at whether there were signals and whether they were missed. That may be at the macro level or the micro level, with individual women saying to their GP, “Hang on, this is odd, I haven’t got this”. The problem has arisen because of the interaction between the screening process, which is due to run until a woman’s 71st birthday, and the extension, which was meant to run from a woman’s 71st birthday to the end of her 73rd year but was taking women into this clinical trial prematurely and randomising them. Hence, women in their 70th year did not get anything. It was the interaction of the two. It is technically quite devilish. A 70 year-old woman might or might not have known that she was due to have another one. This is one of things we have to get to the bottom of because, as the noble Baroness said, although this is about technology and computers, ultimately humans are at the centre of this problem.

The inquiry is primarily focused on the incident itself, but I imagine that if, during the course of its work, it finds out or establishes that other issues need to be pursued, such as increasing screening rates variation and so on, it will have the freedom to make those recommendations.

[Baroness Donaghy (Lab)]

My Lords, this is very close to home for me—I am probably not the only one in the Chamber. It was probably the breast screening programme that saved my life. I had no symptoms and if it had not been for regular mammograms, I would not have known. I am grateful to the health service, just as the noble Baroness, Lady Maddock, is.

The worry I have is that although I had a regular mammogram directly resulting from treatment every year for eight years, I was then told last summer at the age of 73 that the following year I would not be able to have a mammogram unless I went private. This seems to rely too much on people taking individual responsibility for their own health, which I support, but does not provide sufficient back-up for those who are perhaps fearful of having a mammogram. It is extremely painful for some women. The fear of it is still there. That explains why some of the take-up is quite poor. We have a duty of care for those in that position. Those of us who are vocal will do our best to look after ourselves.

My final point is that the cut-off is arbitrary and has a sniff of age discrimination about it. I agree with the noble Baroness, Lady Masham: there is sometimes an element in hospitals whereby perhaps you are not worth it any more. I feel obliged to say that I am still very active and working, just to make sure people think I am worth saving. That should not be the case and it ought to be reviewed. There is age discrimination. It might be just a clinical thing, but I cannot help thinking that there is some self-limitation when some of these clinical groups get together and decide what is appropriate for a woman, without consulting them as individuals.

[Lord O'Shaughnessy]

I know that the whole House will join me in saying that the noble Baroness is definitely worth it. Indeed, I am pleased to hear that her care was successful and that she is with us today. It is a very interesting question about age discrimination. We have again to separate it from the clinical advice, which I am reassured, having spent time with those involved in putting it together, is based on a proper weighing of costs and benefits—of course, that is inevitably in aggregate because we are talking about whole populations. Clinicians have autonomy to do things differently. Indeed, the offer we have given to women aged over 72 is that they can refer themselves and they will have an appointment if they want one. I can provide that reassurance to the noble Baroness.

There is perhaps a separate issue. There are sometimes problems of age discrimination in society and in the national health system itself. Could that be an issue regarding why signs were missed? We know that in some instances, the National Health Service has not been very good at listening to women on some of the issues we have debated in this House and that my noble friend Baroness Cumberlege is looking at in her review. This is a very good point that needs to be investigated properly: are there cultural reasons why signs that might otherwise have been picked up during these nine years were not? I can reassure her that the inquiry will look at this.

[Lord Judd (Lab)]

My Lords, reverting to the point about the role of the GP, does the Minister agree that it raises wider questions about the operation of the health service? Surely, if we are taking a holistic approach to the well-being of patients and people, the GP has a vital role which increases in importance the more technology comes into play. There should be a proactive role for the GP in helping people to meet the challenges that arise from the inevitably rather more impersonal operation of more technological services. There is a significant issue. Frankly, I sometimes wonder what the role of the GP really is. In a lot of surgeries, it is a pretty meaningless term, because one goes not to a general practitioner but to a surgery. This issue needs attention as we consider the future of the health service.

[Lord O'Shaughnessy]

The noble Lord makes a good point, in the sense that technology is an enabler and supporter of clinical practice done by highly skilled professionals, not a replacement for it. That interaction between reliance on technology and the human face of the service is an issue that the inquiry should investigate.

House adjourned at 1.50 pm.

NHS: Cybersecurity

Lord O'Shaughnessy Excerpts

Wednesday 2nd May 2018 Lords Chamber

[Lord Hunt of Kings Heath]

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

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

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord O'Shaughnessy]

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

[Baroness Brinton (LD)]

My Lords, in Scotland it is possible for your records to be transferred from one hospital to another or from your GP to your hospital without any consequences at all. One of the concerning things about the Public Accounts Committee report is the systemic failures in IT overall in NHS England. One example is where regional hospital A cannot receive data from district hospital B, even if it is a simple blood test, because they use different systems; the consultant I spoke to said that he actually advises people to use faxes. This is our NHS in the 21st century.

[Lord O'Shaughnessy]

The noble Baroness is highlighting a historic problem about interoperability between different bits of the NHS in England. That is absolutely fair enough. I would highlight two things that we are doing. First, the National Data Guardian for Health and Care has defined 10 data standards that should apply to both security and interoperability between different systems, and those now apply in all key NHS contracts, including the standard NHS contract. Secondly, we have launched a programme to appoint up to five local health and care record exemplars, which will provide interactive and interoperable data for patients for their direct care—so that the issue we have at the moment of data sometimes falling between different institutions will not happen any more.

[Baroness Chisholm of Owlpen (Con)]

My Lords, obviously data security is absolutely vital, but so is the collection of data. If we are going to move forward it is so important that we collect that data for research and treatment. Can my noble friend the Minister give us some kind of indication of how we can make sure that the general public feel happy to give their data to the health service?

[Lord O'Shaughnessy]

My noble friend makes an excellent point. Not only is it critical that data is joined up for direct care—quite rightly, patients are amazed when that does not happen—it is an absolutely essential resource for research into new treatments. One thing we are doing to try to provide that reassurance to the public, which has not always been there, is introducing a new data opt-out at the end of this month to provide that reassurance for patients who do not want to be part of it. We are focused on providing that resilience and security so that they can be confident that, when the NHS holds their data, it uses it securely, safely and legally.

[Lord Patel (CB)]

My Lords, one of the lessons learned following the WannaCry attack was that the weakest links in the NHS had to be identified. The Minister has already referred to the upgrading of software that was found to be weak. What work is being done to identify other areas in the NHS that would be open to cyberattacks?

[Lord O'Shaughnessy]

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

[Lord Hunt of Kings Heath]

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

[Lord O'Shaughnessy]

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

Health: Cancer Nurses

Lord O'Shaughnessy Excerpts

Wednesday 2nd May 2018 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government what assessment they have made of the impact of the shortage of more than 400 specialist cancer nurses reported by Macmillan Cancer Support.

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

My Lords, we welcome Macmillan Cancer Support’s report, which acknowledges the fact that the number of specialist cancer nurses has increased by nearly 1,000 full-time equivalent posts, or by 30%, since 2014. There is more to do, however, and Health Education England is working closely with Macmillan and the cancer alliances, so that we can achieve our aim that every cancer patient has access to a specialist cancer nurse by 2021.

[Baroness Thornton (Lab)]

I thank the Minister for that Answer. The census also pointed to the facts that there are vacancy rates as high as 15% for chemotherapy nurses in some areas, that the proportion of specialist cancer nurses who are over 50 years old continues to climb, and that almost one in 10 specialist cancer nurses comes from the European Union. We know that there has been a cliff edge for recruitment from the European Union. I want to ask two questions. First, will the Minister assure the House that this census will be used by the Department of Health and Social Care, Health Education England and the cancer alliances to inform their strategic workforce planning? Secondly, will he explain what steps the department has taken to assess the level of funding required to deliver the recommendations contained in the Cancer Workforce Plan, including the long-term strategy?

[Lord O'Shaughnessy]

The noble Baroness is quite right that the Macmillan report highlights some challenges around vacancy rates and the age profile of cancer nurse specialists. It was explicitly set out in the cancer workforce strategy that it would have a phase 2 of planning once the census had been published. This census has been published, so there is an absolute commitment by Health Education England to work with Macmillan and the cancer alliances to bottom out how many more staff are required to meet the standard that we have set out—for every patient to see a cancer nurse specialist by 2021—and how many extra people we would need to recruit for that, and therefore to deliver the funding that would enable that to happen.

[Baroness Hayman (CB)]

My Lords, I declare my interest as a member of the General Medical Council. What assessment have the Government made of the effect on cancer services of the repeated refusal of visas to overseas doctors qualified to work here, and who have been recruited by the NHS to work here, but not being allowed to enter the country because of Home Office policies? Given the severe shortages of doctors across the board in the NHS, not just in A&E, is it not time that the cap on tier 2 visas for doctors was lifted?

[Lord O'Shaughnessy]

The noble Baroness will know that the NHS benefits from many of those visas issued under tier 2, which obviously has great benefits for our workforce. It is in the long-term interests of this country that we recruit more of our staff, wherever possible, from the domestic workforce. On that basis, Health Education England has committed to increase the number of cancer consultants by more than 20% between 2016 and 2021, as well as increasing the number of radiographers and others.

[Lord Forsyth of Drumlean (Con)]

My Lords, does my noble friend really think it necessary that specialist cancer nurses are educated to degree level? If he does think that, given that because of their levels of remuneration most of the student loan will not be paid back, would it not be a good idea to consider writing off those student loans for those nurses who stay for a period within the health service?

[Lord O'Shaughnessy]

What comes to life in the cancer workforce strategy and the Macmillan report is the complexity of the workload that these nurses carry out, so a very high level of qualification is required. One thing we do not have at the moment is a national competency framework, which is being designed. Funding for nurses is obviously a topic that we come to often in this House and it is worth noting that the income point at which repayment of the loan starts has been increased by this Government, to make sure that lower-paid nurses and other staff are alleviated from that burden.

[Baroness Corston (Lab)]

My Lords, how many nurses from overseas have applied to work in the National Health Service and have been refused permission on the grounds of the arbitrary target set by the Prime Minister, as exemplified by the 100 Indian doctors who wish to work here and have fallen foul of this arbitrary rule?

[Lord O'Shaughnessy]

I do not believe that nurses would have fallen into that category as nursing is named as a shortage profession in the immigration system, but I would have to check those figures and I will write to the noble Baroness.

[Baroness Jolly (LD)]

My Lords, the failure to screen nearly half a million women for breast cancer is a scandal. When it is coupled with the report of Macmillan Cancer Support, it has really been a bad few days for cancer. Immediate action is required on both counts. Is it the Government’s view that this shortage of cancer nurses is due to local budget constraints or to workforce planners’ failure to act on the demographic trend of the ageing workforce?

[Lord O'Shaughnessy]

My Lords, regarding the Statement made by my right honourable friend the Secretary of State earlier today about the errors in the breast cancer screening programme, I take this opportunity to apologise wholeheartedly and unreservedly on behalf of the Government, Public Health England and the NHS for the suffering and distress that has been caused to women by this flaw in the screening service. We will have an opportunity to discuss this at greater length tomorrow, when I will repeat the Statement.

The shortage that has been described is based on an analysis of vacancy rates. The number of cancer nurse specialists has actually increased by 1,000—that is 30%—in the last three years alone. That is a huge increase. Of course we know that we need to do more, but it is worth recognising the great steps forward that we have made in cancer treatment in this country.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, can I take the Minister back to the question from the noble Baroness, Lady Hayman? In his answer, he made the rather odd observation that it was in the long-term interest of the service that we should recruit our workforce domestically, and no doubt that is at least an arguable position. However, we are not talking about the long term here: we are talking about the immediate term. In the interest of joined-up government, could he go back to his colleagues at the Home Office and ask them to look again at whether they have made the right decisions in this case?

[Lord O'Shaughnessy]

I reassure the noble Baroness that we have lots of discussions with the Home Office about the recruitment of international doctors and nurses. I reiterate the point, however, that it is our intention to increase the number of training places for doctors and nurses from this country.

Brexit: Food Standards Agency

Lord O'Shaughnessy Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Jones of Whitchurch]

To ask Her Majesty’s Government what steps they are taking to enhance the role of the Food Standards Agency after Brexit.

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

My Lords, the Government, including the Food Standards Agency, are committed to making sure that the high standards of food safety and consumer protection that we currently enjoy in this country are maintained as the UK leaves the European Union. From day one after Brexit, the FSA is committed to having in place a robust and effective regulatory regime, which will mean that business can continue as normal.

[Baroness Jones of Whitchurch (Lab)]

I thank the Minister for that reply. However, given that a range of EU agencies, including the European Food Safety Authority, protect us from food scares, contaminated products, misleading labelling and so on, can we be sure that the FSA will have the resources, science and skills to fulfil the noble Lord’s guarantee that UK food will be safe as from exit day? When will it receive clarification of its post-Brexit responsibilities? Finally, does he also agree that the 2 Sisters chicken scandal, which noble Lords will know came to light from an undercover investigation and not from an FSA check, illustrates the importance of regular and robust inspection on the ground in the future, rather than just a reliance on data-sharing and self-regulation by food companies?

[Lord O’Shaughnessy]

I can certainly reassure the noble Baroness that the Food Standards Agency is getting the resources it needs, as well as a stable funding settlement across the spending review period. The Chancellor announced £14 million more for it for 2018-19. That money will also beef up—excuse the pun—the National Food Crime Unit to make sure that it can investigate the kinds of cases that she has highlighted. As for the ongoing relationship with the EU, it is important to recognise that during the implementation period we will continue to access food information-sharing systems. We will continue to have food risk assessments carried out on our behalf by the European Food Standards Authority, and the Commission will make risk-management decisions that affect the UK. We will continue to be part of that system until the end of the implementation period. Naturally, what happens after that is a matter for negotiation.

[Baroness McIntosh of Pickering (Con)]

Will my noble friend commit to setting out the timetable for all the implementation regulatory statutory instruments that are required to enhance the powers of the Food Standards Agency, given the role that it will be required to play not just in domestic food production but in relation to all imports from 29 March next year?

--- Later in debate ---

[Lord O’Shaughnessy]

I reassure my noble friend that not only are we taking 95% of legislation that derives from the EU regarding food standards and hygiene into UK law through the withdrawal Bill but we are also undertaking work to ensure that we have the right statutory instruments in place in a timely way so that we are prepared for all circumstances when we leave the European Union on 29 March.

[Lord Rooker (Lab)]

If today is an average day, eight notices will be issued around Europe under the Rapid Alert System for Food and Feed. The only countries that get those notices are members of the EU and the European Economic Area. We will be outside those. This is an integral part of the single market and the customs union; the system did not exist before we joined the Common Market. How can the FSA operate on day one? If this area cannot be transferred over, how will we get those 3,000 notices a year warning of potential hazards? Collectively they provide security and safety for our population.

[Lord O’Shaughnessy]

The noble Lord is quite right to say that we get those alert systems now, and I can reassure him that we will continue to get them during the implementation period up to the end of December 2020. As all noble Lords will know, we are seeking to negotiate a deep and special relationship with the European Union when the implementation period ends—

[Noble Lords]

Oh!

[Lord O’Shaughnessy]

I do not think it is a laughing matter; it is a matter of the utmost seriousness concerning the security and safety of this country. It affects not only food safety but chemicals, medicines and aerospace. We have set out our plans for associate membership and others forms of relationship that will provide that information to our systems. Equally, information that makes a massive contribution to the safety of EU citizens is also fed back to the EU.

[Lord Bird (CB)]

My Lords, is it possible that the Food Standards Agency will become so strong after Brexit that it will actually do something about the appalling poor-quality food that most poor people have to eat, which leads to our hospitals being filled up by people with all sorts of nutritional problems? Will the Food Standards Agency get behind addressing the problem of class-divided food?

[Lord O’Shaughnessy]

The noble Lord raises an important issue. However, it is important to distinguish what the Food Standards Agency is responsible for and what it is not. It is responsible for making sure that food is safe. Nutritional value is a different responsibility that accrues to the department and to Public Health England, and we have taken many significant actions, including reducing sugar content in drinks and food, to make sure that precisely the issues he is talking about are dealt with.

[Baroness Bakewell of Hardington Mandeville (LD)]

My Lords, given the increased monitoring at slaughterhouses, both through CCTV and the presence of meat inspectors, is the Minister confident that the FSA has the capacity to train sufficient inspectors to ensure that the meat which arrives on supermarket and butchers’ shelves is fit for human consumption so that we can avoid the CJD and salmonella outbreaks of the past?

[Lord O’Shaughnessy]

The Food Standards Agency has the resources, the expertise and the powers it needs to make sure that it can guarantee safety, as the noble Baroness has described.

[The Countess of Mar (CB)]

My Lords, the Food Standards Agency is very reliant on local environmental health officers for enforcement. In the light of the poverty of local authorities and the cutting back in the number of environmental health officers, are the Government sure that enforcement can take place as it should?

[Lord O’Shaughnessy]

In preparing for the Question today, I looked at local authority spending on enforcement. It is stable at around £140 million a year and has been for a number of years, so local authorities are continuing to prioritise this, as indeed is their responsibility. We want to make sure that we bring new forms of assessment into the food standards regime so that we have an even more robust picture of the risks that are involved in food production.

The Long-term Sustainability of the NHS and Adult Social Care

Lord O'Shaughnessy Excerpts

Thursday 26th April 2018 Lords Chamber

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

My Lords, I begin by congratulating all noble Lords on a debate that has been truly epic: in subject matter, in content, in form, in the heroic contributions—not just in this debate but also from those whom we laud in the health and care services—and in length. I am conscious of the need to give a fitting denouément to such a debate, and I hope I will do it justice.

Before dealing with the content of the report and the many excellent questions from noble Lords, I will say four things. First, I thank and congratulate the noble Lord, Lord Patel, and the entire committee on an excellent and far-sighted piece of work. My noble friend Lord Ribeiro called it a landmark. The noble Baroness, Lady Hollins, called it game-changing. It is a very far-sighted piece of work. Indeed, some of the very important recommendations in it—the addition of social care policy back into the department, the commitment to a long-term funding settlement, and a workforce strategy—are not small suggestions, but those have all been taken up by the Government since the publication of the report.

Secondly, I apologise yet again for the unacceptable delay in our response. It was not good enough. I apologise, too, to my noble friend Lord Saatchi for the jargon in it. It is a jargon-ridden industry, as he knows, although I do not think that his quote was a direct quote. I hope not. I would say only that he should have seen the first version.

Thirdly, I reaffirm the commitment of this Government to a world-class NHS free at the point of use, with access based on need. My noble friend called the NHS a remarkable institution, which indeed it is. The noble Baroness, Lady Masham, called it our most important insurance policy. We are also committed to a social care system that provides good-quality care and is based on a fair and mixed model of funding. I think that all noble Lords would agree with those commitments; we know that compassion is not the preserve of one political party or another.

The fourth, and in some ways most important, thing is to express my gratitude and admiration for those who work in the NHS and care services—among the most-loved people in our country, as my noble friend described them. I want to reassure the noble Lord, Lord Kakkar, that these people, who serve us through their lives wherever they were born, will be at the heart of the celebrations for the NHS’s 70th birthday party. I also want to join the noble Baroness, Lady Jolly, and others in paying tribute to the many migrants—150,000, I believe, including the Windrush generation—who make such an important contribution to our national life.

As many noble Lords have pointed out, the NHS and adult social care systems face unprecedented challenges due to the ageing and growing population. These challenges are not unique to this country but common among developed economies. The noble Lord, Lord Warner, described it as tsunami of rising demand. It is worth pointing out, as did the noble Lord, Lord Patel, that the Commonwealth Fund has ranked the NHS as the overall best-performing health system for the second time in a row, but I accept his criticism, which is entirely fair, that we need to do better in achieving world-class outcomes.

I will deal now with the six main chapters in which the report is structured. The first is service transformation. The report says:

“Service transformation is at the heart of securing the long-term future of the health and care systems”—


and we quite agree with that statement. At the heart of the integration of those two systems are, of course, the sustainability and transformation partnerships. I reassure the noble Lord, Lord Willis, and the noble Baroness, Lady Wheeler, that we have not abandoned these plans—quite the opposite. We are investing in them like never before, with more than £2.5 billion of capital. However, I take on board the comment of my noble friend Lord Suri about the importance of engaging with communities in these transformation programmes because, if we do not bring people with us, change will not be supported.

We are also trying to improve integration between the NHS and local authorities in social care through the better care fund, which is now pooling more than £5.5 billion into the provision of integrated care. Bringing those two subjects into departmental policy-making is critical for the future.

Several noble Lords pointed out the panoply of arm’s-length bodies that exist in this space, but I can reassure the noble Lord, Lord Bradley, and others who asked about it that regulatory integration is going on. NHS England and NHS Improvement are working more closely than ever, and our mandate to the NHS and the remit letter to NHS Improvement were published together for the first time ever last month. I also assure noble Lords that we are able to achieve these changes without the need for primary legislation. The noble Baroness, Lady Thornton, the noble Lord, Lord Carter, and my noble friend Lord Prior asked about our commitment to integration. It is absolutely there in our strategy, along with a commitment to more integrated care systems. These are already demonstrating big improvements in the delivery of care in community settings, which is of course not only better for people’s care but more cost-effective.

I also reiterate our commitment to publishing our social care Green Paper by this summer. It will set out our plans to tackle care and support for older people and the challenge of an ageing population, but we are deeply conscious, as the Prime Minister and the Secretary of State have said, that changes to social care and the NHS need to go hand in hand.

The noble Lord, Lord Kakkar, wisely pointed out that consensus is needed not just on funding but on service transformation. It is incumbent on all parties to look to their own political tactics, particularly as we face the local elections next week, and ask honestly whether we are prepared to be part of that consensus. There are clear benefits to be derived from the rationalisation of services. The noble Lord, Lord Rodgers, and the noble Baroness, Lady Wheeler, talked about stroke services, where centralisation has helped. I think that 84% of stroke patients now spend the majority of their hospital stay in a specialist stroke unit, compared to 60% in 2010. There is clearly more to do and I will write to the noble Baroness with more detail on the stroke action panel.

We see fantastic examples of integration happening on the ground. The noble Lord, Lord Turnberg, and the noble Baroness, Lady Walmsley, talked about the work of Sir David Dalton and the Northern Care Alliance, which I have visited in Manchester. I have spent time with David and the alliance truly is a model for integration that we want to push, through the five-year forward view.

Many noble Lords, including the noble Baronesses, Lady Meacher, Lady Finlay, Lady Murphy and Lady Tyler, my noble friend Lady McIntosh, the noble Lord, Lord Rea, and my noble friend Lord Bridgeman all talked about the importance of primary care. The Government completely agree about the importance of good quality and good funding for primary care. Primary care funding is increasing in real terms over the spending review period. There are more nurse training places, as we discuss often in this House, more GP training places and a commitment for 5,000 extra staff in GP surgeries. This Christmas we saw, for the first time, GP services running 8 am till 8 pm seven days a week, to support people during winter. This is all about keeping people out of acute care wherever possible.

My noble friend Lady McIntosh asked in particular about rural coverage. I can tell her that a full review of the Carr-Hill funding formula, which affects allocations for surgeries across the country, will take place shortly. I believe that a review on that will be published next year.

I would like to take a moment to congratulate the noble Lord, Lord Carter, on his exemplary work in improving productivity and reducing variation. He is somewhat of a legend in the service, it has to be said —so much so that he even has a programme named after him. It is impossible to have a meeting without a reference to the Carter programme. I see that the noble Lord is smiling.

There are things such as the getting it right first time and model hospitals programmes, which my noble friend Lord Prior mentioned, and we are now applying some of these technologies to the better use of medicines as well. The noble Lord, Lord Carter, also talked about delayed transfers, as did the noble Lord, Lord Loomba, the noble Baroness, Lady Greengross, and my noble friend Lord Suri. Over what was a difficult winter we saw some improvement in delayed discharge, but we know there are still thousands of people who are medically fit to be discharged and should not be in hospital, and we need to get more of them into a social care setting.

Turning to the workforce, the report states:

“Those who work in the NHS and adult social care are the lifeblood of the organisations they serve”.


We completely agree that these people are the best asset we have. The Secretary of State announced in March a three-year pay deal for those employed under the agenda for change pay contract, which we hope the unions will agree. It will help our plans for retention. We have recently carried out a public consultation on adult social care to gather greater evidence of how we can recruit to that workforce. That has to go hand in glove with recruiting into the NHS.

Following the committee’s report, one of the great achievements has been Health Education England’s draft strategy for a 10-year workforce plan. As the noble Lord, Lord Willis, said, it is probably 25 years overdue, but it is important in that it sets out for the first time the idea, particularly for the lower-skilled workforce, of having a career that spans social care and allied health professions. Bringing together those workforces is surely critical to delivering integrated care.

In order to retain our staff we need to make sure they are treated properly. The statistics about harassment have been mentioned. It is completely unacceptable. The noble Baroness, Lady Watkins, and the noble Lord, Lord Parekh, mentioned it. We are making some changes to try to improve the well-being of staff, including more flexible working, greater support through nursing associates, the new homes for nurses programme and tackling bullying.

As the noble Baroness, Lady Meacher, and my noble friend Lord Sterling pointed out, it is equally important to address the blame culture. We are trying to get away from it through the learning from deaths programme and rapid resolution and redresses processes so that we can create a culture of learning rather than blame from when things go wrong.

There is a chapter in the report on funding. I shall deal with funding in two ways: short-term funding, if you like, and longer-term funding issues. We of course agree with the committee about the need to provide further funding between now and 2020. Noble Lords will know that we have backed the NHS forward view with an extra £10 billion by 2020-21, and the NHS was given additional funds in the Autumn Budget and more in the Spring Budget. We have also announced more than £9.4 billion extra dedicated to social care funding over three years, so we recognise that there has been a short-term need, regardless of what happens in the long term, to put more money into the health service and social care—but I accept the challenge from all noble Lords that a long-term settlement is needed, and I will return to that subject.

The committee’s report says:

“The Government should make it clear that the adoption of innovation and technology, after appropriate appraisal, across the NHS is a priority and it should decide who is ultimately responsible for this overall agenda”.


The noble Lord, Lord Winston, pointed out that many of the most impactful health innovations have come from the United Kingdom, and we agree that the NHS should be investing in and adopting new technologies. As my noble friends Lady Bloomfield, Lady Redfern and Lord Saatchi, said, uptake can be too slow. We are trying to address this through the life sciences industrial strategy and our response to the accelerated access review. We are investing in better digital and data infrastructure through things such as the global digital exemplars as well as providing support directly to SMEs to help them bring their innovations into the system. I now chair a new data strategy board, which is trying to bring our data infrastructure up to date. We plan to launch an NHS app at the end of this year to have more patient-focused digitisation and are creating the first local health and care records, which will provide across every health and care record dataset— believe me, there are a lot—the opportunity to link up data for direct care, which we will then build on through digital innovation hubs to provide that kind of dataset for research purposes. I hear over and over again that this is one of the unique opportunities that the NHS and Britain have because of the way our health and care services are set up.

My noble friend Lord Prior, who knows much more about these issues than I do, asked about the role of the NHS in supporting life sciences. He is quite right to say so. I would choose one example, the world-leading 100,000 Genomes Project. We are genuine world leaders in genomic medicine. It is now moving out of the research realm and this year we are setting up for the first time an NHS genomic medicine service, which is a great example of collaboration between the science base and the NHS. I was glad to hear my noble friend Lady Bloomfield’s personal positive experience of this kind of partnership. However, it is worth saying, possibly in typical fashion, that we have too many programmes in this area that need to be rationalised. I asked my team to have a look at it about six months ago with the Office for Life Sciences, and there are 38 programmes supporting innovation across six agencies, possibly not adding up to the sum of their parts although spending £750 million. I am very focused on making sure that money is spent more rationally and with greater effect.

One of the ways that that will happen, as the noble Lord, Lord Winston, was quite right to highlight, is through the academic health science centres and academic health science networks. We have just recommissioned the academic health science networks. I intend to do the same for the AHSCs as well but I wanted to ensure that they are fully integrated into the innovation review we are carrying out internally. It is deeply important to me that Imperial does well because all my babies were born at the Queen Charlotte’s and Chelsea, which I believe is a stone’s throw away from the noble Lord’s office.

My noble friend Lord Saatchi asked about the commencement of the provisions of his Act. He will know that it is something I am looking into at the moment and am not able to give him the commitments he is looking for. He knows I was not Minister at the time but I can tell him that this is something that is taking my attention, and I will write to him on that topic.

Many noble Lords emphasised, probably more than any topic other than funding, the importance for public health of prevention and patient responsibility. Indeed, the report called for the Government to be clear with the public that access to the NHS involves patient responsibilities as well as patient rights, a point emphasised by the noble Baroness, Lady Walmsley. It is undoubtedly the case that a healthy population is key to the sustainability of the NHS and many noble Lords, including the noble Lords, Lord Ribeiro, Lord Rea and Lord Rennard, have pointed out that tackling obesity is a great challenge. We have launched a childhood obesity plan. One of the major aspects of that, which has been commented on in this House today and on other days, is the impact of reducing sugar in soft drinks as well as a comprehensive sugar reduction programme. I am delighted that we will perhaps be able to relay to the young respondent of the noble Baroness, Lady Walmsley, that this is a preventable disease and we are trying to prevent it. It seems to be working, and there is cause for young people to have hope.

We are going to publish all the data and research that informs our plans, so that it is open for scrutiny. We are committed to considering whether sufficient progress has been made and whether additional policies are needed, whether in the form of advertising bans, statutory regulation or, as my noble friend Lord Ribeiro said, more bariatric surgery. We accept that we need to get a grip on this crisis, and we will take further steps if the ones we have taken so far have not worked.

It is worth addressing public health spending, which noble Lords have mentioned. We know that it came under pressure—there is no hiding that—as we made difficult decisions on coming into government in 2010. However, the 2015 spending review made £16 billion of funding available for local authorities over five years and, as the noble Baroness, Lady Masham, the noble Lord, Lord Rennard, and others have said, it is important that this public health funding, as well as other social care funding, must increasingly focus on keeping people independent in their own homes.

Many noble Lords—the noble Earl, Lord Sandwich, the noble Lord, Lord Rodgers, Lord Bradley and Lord Cotter, and the noble Baronesses, Lady Tyler, Lady Hollins and Lady Thornton—have talked about mental health and parity of esteem. We have legislated for that, of course, but that is not the only way in which we shall achieve our aim. There is increased funding. The mental health investment standard will be compulsory this year for CCGs. We are recruiting more staff and reducing out-of-area placements. We have the first waiting time standards and are extending those to receiving treatment. Making sure that those services join up around the sufferers of mental illness is critical, and we know that the Prime Minister has a deep commitment to that agenda. I accept that we need to do more and to go faster but, unfortunately and sadly, we are starting from a very low base.

The noble Baroness, Lady Finlay, raised the important issue of screening, diagnostics and staffing in radiology and pathology. This is one area where we can use technology. Indeed, the life sciences industrial strategy and sector deal committed us to use AI—another topic of conversation in the Chamber today—to transform radiology and pathology.

My noble friend Lord Farmer rightly highlighted the importance of family breakdown. He has been an ardent proponent of these issues. There is a focus on the role of families in the mental health Green Paper, but I always accept his pressure to do better. My noble friends Lord Colwyn and Lord Ribeiro talked about the importance of dental care and oral health. Actually, access to NHS dentistry is rising and the number of decay-free five year-olds is at its highest level, but I accept that this is something that we need to do more on, and I hope that our sugar reduction plans will help.

The noble Baroness, Lady Masham, my noble friend Lord Ribeiro and the noble Lord, Lord Brooke, talked about alcohol. I think we can take confidence from the benefits of the action taken to reduce smoking, and we are looking carefully at the minimum unit pricing scheme as it is implemented in Scotland, because we accept that there is powerful evidence in its favour.

I say to the noble Lord, Lord Cotter, that I will investigate the hospital closure he mentioned. My noble friends Lady Redfern and Lord Ribeiro asked about the bowel screening programme. The intention is to roll it out from this autumn.

The final section is headed “Towards a lasting political consensus”—leaving the best till last, perhaps. As the noble Lord, Lord Rodgers, reminded us, attempts at national consensus have eluded many Governments since the 1970s. The noble Baroness, Lady Pitkeathley, rightly encourages us to be bold. The Prime Minister is being bold. She recently announced a plan to come forward with a long-term funding settlement for the NHS, so that we can avoid what my noble friends Lady Redfern and Lord Prior called the feast and famine approach. I congratulate my noble friend Lord Prior on his work and that of the noble Lord, Lord Darzi, on the IPPR report published today. The Government have been working with NHS clinicians and experts, of course, but also with stakeholders—users, patients and carers—and I can tell the noble Baroness, Lady Pitkeathley, that my letter to her will be with her on Monday and we will publish our action plan on carers in the coming weeks.

I think the ultimate purpose of the report of the noble Lord, Lord Patel, is to build a political consensus. If there is one area where I share the concern of the noble Lord, Lord Hunt, and the noble Baroness, Lady Thornton, it is about a royal commission. I am not sure we need another one. As the noble Lord, Lord Hunt, said, what we need is leadership and consensus, but I thought we saw perhaps a glimmer of the future approach that the Labour Front Bench might take—I hope it is not true—of not wanting to be part of that consensus. I think the noble Baroness was keen to dispel that impression, and I hope that the Labour Party will join us in this process, but I accept that it needs political leadership from the Government of the day.

I have to deal with the proposal in the paper for an office of health and care responsibility, strongly pushed by the right reverend Prelate the Bishop of Carlisle, the noble Lords, Lord Taverne and Lord Rea, and the noble Baroness, Lady Thornton. The OBR, on which it is modelled, evolved from the Institute for Fiscal Studies, so perhaps the first stage to getting such an idea off the ground is to establish it as an independent health economic body outside government.

On funding and taxation, the noble Lord, Lord Layard, whom I know and admire, made a compelling argument for the benefits of a sophisticated form of hypothecation and the happiness that would come from such action. The noble Lord, Lord Desai, called for a softer version of such an approach.

Many noble Lords talked about what they felt was the willingness of older people—people over retirement age—to contribute, whether via national insurance or forgoing a winter fuel allowance. Many noble Lords used the phrase “intergenerational fairness”. I tell them without, I think, overstepping my brief and getting into Treasury territory, that to someone in this perhaps younger corner of the House that seems quite appealing, and I shall make a very personal case to the Treasury to consider it. I think it is representative of older generations’ willingness to contribute to the financial sustainability of the NHS. It is also important, as the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Desai, said, to make sure that we prepare people for the costs that will inevitably come their way in the social care system, which will continue to have a mixed-funding model.

To touch on Brexit, my noble friend Lord Prior asked about a research participation visa system for skilled workers and about remaining part of the European regulatory environment. I can say that on all those aspects, we have set out our intentions to be part of the research community and the regulatory environment. That is something that we hope to achieve through the negotiations.

To conclude, I thank the noble Lord, Lord Patel, and his committee again for a truly landmark report, which we continue to study hard. Our homework has been sent back to us by the noble Baroness, Lady Thornton, and I think it fair to say that since it was published I hope we have gone at least from a C+ to a B- with the actions we have taken. The Government have committed extra funding to the NHS since last November, but we are in no doubt about the pressures on the system because of the ageing and growing population, as well as the demands for improvements in areas such as mental health. A major review programme is under way through the five-year review, but there is no getting away from the fact that we need to move away from annual top-ups towards a sustainable long-term plan. The Prime Minister, with the support of the Chancellor, will provide a multi-year funding settlement in support of such a plan. Any such plan must turbocharge, as noble Lords have said, progress in spreading the excellence that exists in some parts of the system across the whole health and care service.

Alongside the development of this plan, we will have a new workforce strategy and a Green Paper and then there is social care. Our department and, indeed, No. 10 are particularly clear that the solutions to social care and the NHS must go hand in hand. As the NHS reaches its 70th birthday, this is what the Government are focused on delivering. We know that we can do that only with a broad consensus for change. This report is an excellent contribution to that process, and one that will stand the test of time.

Domiciliary Home Care Support

Lord O'Shaughnessy Excerpts

Wednesday 25th April 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they are taking to ensure the provision of domiciliary home care support, in the light of the decision by Allied Healthcare to file for a company voluntary arrangement.

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

My Lords, the law is clear that, if services may be disrupted due to business failure, the Care Quality Commission will notify local authorities so that they can put appropriate contingency plans in place. In respect of Allied Healthcare, no such notification has been made to date. The public should be reassured that the Care Quality Commission has been monitoring closely the situation at Allied Healthcare and will continue to do so.

[Baroness Wheeler (Lab)]

My Lords, Allied Healthcare is the latest hedge-fund-owned care provider to have to take drastic action to keep up the huge burden of paying off loans to its creditors. The precarious finances of many domiciliary care companies has already led to large-scale provider closures and to companies handing back contracts in almost half of councils, and we know that residential care is in a similar position. The CVA means that Allied Healthcare has four weeks to come to an arrangement with its creditors. Its closure would have serious consequences for continuity of care and the safety of its 13,500 clients, including many vulnerable older people and people with learning difficulties, and for its 8,700 staff. With local authorities unable to pay fees that cover the actual cost of care or meet the implementation costs of the national minimum wage, let alone address the potential £400 million of deserved back-pay costs for staff sleep-in payments, what reassurances can the Minister give that councils will be able to discharge their statutory duty to deliver care if Allied Healthcare collapses? Does he really think that this is the way to fund the care that people in need of support in their homes deserve?

[Lord O'Shaughnessy]

I thank the noble Baroness for the opportunity to provide that reassurance for people using and benefiting from the care provided by Allied Healthcare. I want to reassure them that the Care Act 2014, passed by the coalition Government, gives local authorities responsibility for continuity of care if a business were to fail. Of course, we are not in that position with Allied Healthcare, because it still has to go through the CVA process. I can reassure people that the LGA has said that councils have “robust”—its word—plans in place to ensure continuity of care if that is required. I put that on record for those who may be worried about it.

We know that extra funding is needed in the sector. Over three years, through a number of means including extra money through the precept and direct funding to local authorities, the Government have increased by about £9 billion the funding available for social care, which we know is required. I also point out that, if you look at domiciliary care provider numbers, you will see that there are 50% more than there were eight years ago. We know that markets have entrants and that providers are exiting, but we have more providers in the market and more packages being delivered than ever before. Ultimately, the backstop is that local authorities have that responsibility to provide continuity of care.

[Lord Laming (CB)]

My Lords, does the Minister understand the importance of this Question? Imagine being a very vulnerable person living in a residential home with no alternative to go to or being dependent on a home help for the basics of daily living. Now imagine living under the shadow that the company that provides that service is going to go out of business at any time. Nothing could be more anxiety-provoking for these residents. The Care Quality Commission telling the local authority that there is a problem here is of no comfort. I hope that he will take this Question rather more seriously.

[Lord O'Shaughnessy]

I have huge respect for the noble Lord and his expertise in this area. I take this issue very seriously, which is why I used the opportunity in answering the noble Baroness to provide the reassurance that is in law. Local authorities need to step in to provide continuity of care with notice from the CQC, which now has a new responsibility to monitor the financial sustainability of providers and to make sure that that care is provided, whether it is delivered in-house or through contracts with other providers. That reassurance did not exist before it was introduced in the 2014 Act. It ought to provide a degree of reassurance among vulnerable people, who I accept will be anxious. That responsibility is in law.

[Baroness Gardner of Parkes (Con)]

The Minister has said that this is a matter of law. There has been a court judgment that fees should be paid to carers for time spent going between clients, which can be nearly half of their day. They may have one hour to spend with many clients. Is he aware that providers of domiciliary care—run as agencies and used by most local authorities —are not honouring that legal decision that this should be paid as part of their employment?

[Lord O'Shaughnessy]

My noble friend is right to bring up that issue. They should of course be paid. If she has any specific examples to share with me, I shall be glad to investigate.

[Baroness Jolly (LD)]

My Lords, everyone knows that the social care sector, particularly in domiciliary and care homes, is under great stress at the moment—I declare my interests as in the register—and we look forward to the Green Paper coming up some time in the summer. I hope it takes into consideration that such homes need to pay not only wages and pensions but, for larger ones, an apprenticeship levy. Normally there would be a market for mergers but at the moment the sector is anxious about inheriting sleep-in liabilities. Can the Minister give any guidance about when these issues within the department and the Treasury will be remedied?

[Lord O'Shaughnessy]

We know that the issue of back-dated pay for sleep-ins has had an impact on this and other sectors. Two aspects of this are, first, that the Government have waived penalties for non-payment prior to July 2017; and, secondly, that there now exists an HMRC scheme that allows providers to work with HMRC and the business department to understand their liabilities and gives them a further year to pay them. That is the support we offer to any organisation affected by the changes to the taxation arrangements of sleep-ins.

NHS: Artificial Intelligence

Lord O'Shaughnessy Excerpts

Tuesday 24th April 2018 Lords Chamber

[Lord Holmes of Richmond]

To ask Her Majesty’s Government what steps they are taking to encourage the adoption of artificial intelligence in the National Health Service.

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

My Lords, the Government believe that artificial intelligence, or AI, has the potential to transform health and care services. Our work to support this includes £4.2 billion of spending to update hospital IT infrastructure as well as the digital health technology catalyst, which provides funding to help small and medium-sized enterprises turn innovative ideas into reality. In addition, the Industrial Strategy Challenge Fund is supporting AI programmes in digital pathology and radiology, with winners of the wave 3 competition announced next month. We will continue to ensure that our regulatory frameworks protect patients while enabling the benefits of AI to transform care.

[Lord Holmes of Richmond (Con)]

My Lords, does my noble friend agree that the potential benefits to the National Health Service from AI go far further than just the clinical setting? For example, DNAs currently cost the service in excess of £1 billion. What more can be done to generate proofs of concept and work, not just in London but across the country, to ensure that AI machine learning, with all its benefits, can be put into making the NHS the greatest health service, not only in patient care but in taking up all the advantages of the fourth industrial revolution?

[Lord O’Shaughnessy]

My Lords, I thank my noble friend for his question and congratulate him and the rest of the committee on the excellent report, AI in the UK: Ready, Willing and Able?, which has a substantial chapter on AI’s application in healthcare. The potential to transform every element of health and care is susceptible to artificial intelligence. A couple of areas outside the clinical setting that I would highlight are workforce planning and triaging patients between different forms of care. As for support, in addition to the items in my first Answer, I highlight the work of the Topol review, which is designed to make sure that staff are fully equipped and trained to take advantage of these technologies as they come through the system, rather than letting them sit with a few early adopters and not becoming more widespread in the NHS.

[Baroness Thornton (Lab)]

My Lords, it is quite clear that the use of big data and AI will have transformative outcomes for patients. There are at least two challenges. The first is investment, which the Minister has already mentioned. What framework of accountability and transparency is in place to deal with that level of investment? How will we know whether it is being sensibly invested? The second is safeguarding and protecting data, and I use my local hospital as an example. A partnership between Google DeepMind and the Royal Free Hospital trust resulted in a breach of the Data Protection Act and the personal data of more than 1.6 million patients was transferred to the Google subsidiary as part of the creation of Streams, an app to diagnose and detect acute kidney injury—which we would, of course, all support. This suggests inexperienced procurement and negotiation skills in the NHS and the potential for the Googles of this world to run rings round them, to all our detriment. What are the Government doing to safeguard patients and their data?

[Lord O’Shaughnessy]

The case the noble Baroness highlighted brings to the fore both the potential benefits and risks. There are tremendous benefits in having personalised healthcare, and we all want to see that delivered. At the same time, if data is not used safely and securely we lose the public’s trust. If we do not have that trust, we will not be able to get the changes that we want. The Government respect the decisions made by the Information Commissioner and National Data Guardian in their judgments about poor practice at the Royal Free. I am pleased to say that the hospital has responded well to these. We are doing a couple of things to make more systematic changes. First is implementing the proper data standards of the GDPR in one month’s time. We will also make sure that National Data Guardian’s 10 data standards are written into every NHS contract so that, when it comes to procurement, there is understanding about the kind of things they should and should not be doing to safeguard data.

[Baroness Grender (LD)]

My Lords, does the Minister agree with the recommendations of the AI Select Committee, regarding NHS data, that a framework for the sharing of data is now urgent or needs to be delivered by the end of 2018? Does he support the need to digitalise, in consistent formats, by 2022? Evidence received by the committee suggests that failure to do so risks our missing out on profound opportunities from AI, because the current approach to data storage—especially among different NHS trusts—is outdated and piecemeal.

--- Later in debate ---

[Lord O’Shaughnessy]

The noble Baroness has highlighted two of the recommendations from the report. I support the proposal for a regulatory framework; it is a piece of work that I have kicked off in the department. I cannot put a timing on that, but I understand the need to provide a safe operating environment so that people who want to get into this field, whether from NHS trusts or businesses, can do so knowing that they are operating on a legal basis. That is something that we are working on.

On digitalisation, she is quite right: the £4 billion programme known as Personalised Health and Care 2020 is trying to deliver before 2020—as the name suggests—the kind of digitalisation that will enable AI to bring those benefits across every corner of the health and care systems.

[Viscount Ridley (Con)]

My Lords, is the Minister aware that many parts of the world envy Britain’s strengths and opportunities in AI, particularly in the health area, and that government procurement could turn this early lead into a golden opportunity for the UK?

[Lord O’Shaughnessy]

Yes, I absolutely agree with that. As the report highlights, we have a unique opportunity because of the nature of the way that the NHS was set up and its potential for realising a comprehensive data set of 65 million people. It is not just about those procurement rules; we have talked about having the right framework. It is about providing reassurance within the system—at a time when the public are beginning to understand just what data can do for good and for bad—that the NHS will use their data safely, securely and legally so that they can trust that it is being used for proper purposes from which they will benefit.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. Does the Minister believe that there is a sufficiently robust mechanism for the diffusion of the innovation associated with digitalisation and artificial intelligence across the NHS? In particular, what role does the Minister think the academic health science networks should play in that process?

[Lord O’Shaughnessy]

Of all the innovations, diffusion is probably one of the greatest challenges that the NHS faces, as the noble Lord knows very well. We are doing a couple of things. First, we are supporting the global digital exemplars, which are providing that digitalisation at trust level, to make sure that they have the infrastructure there. Secondly, he talks about academic health and science networks. They have just been relicensed and are now to have a national remit to promote innovation. AI is absolutely part of the work that we are expecting them to do.

Health: Online Services

Lord O'Shaughnessy Excerpts

Monday 23rd April 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what action they are taking in response to the Care Quality Commission’s report, The state of care in independent online primary health services, published on 23 March.

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

My Lords, the online provision of primary care is a development with the potential to improve patient outcomes. However, it is important that these services are regulated and inspected properly. The CQC will continue to hold online providers to account while sharing good practice. Following its report, we are considering what further action is needed to ensure that the right balance is struck between the provision of safe, effective care and encouraging further innovation.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. We are strongly in favour of technologies and innovations that help to provide the widest possible access to primary health services, particularly when getting a timely GP appointment is so difficult for thousands of patients. The CQC inspection role is crucial but there is no disguising the serious issues to be addressed and resolved. These include checking patients’ identity, sharing information with the NHS GP and the safe prescribing of medicines. Some 43% of companies are failing to meet regulations for keeping patients safe and there are particular concerns about inappropriate prescribing of antibiotics and medicines and about managing long-term conditions. How will the Government ensure that the lessons from the first phase of the CQC inspection are learned, and will they pledge to take swift action on the problems now before the service is further rolled out?

[Lord O'Shaughnessy]

I thank the noble Baroness for raising this important issue. She is right that the CQC report identified some serious issues among this group of online providers, which of course operate in the independent sector. She mentioned safety and safeguarding, and I would add to that. It is worth saying that there were some positive responses, in terms of 97% of the providers being caring and 90% of them responsive, so some strengths were identified as well as weaknesses. Obviously the CQC retains the ability to take regulatory action. As it sets out in the report, it has done so to ensure that standards improve, and in general they improve from one inspection to the next. However, this is of course the independent sector. We are looking at the lessons for the provision of NHS services. The biggest one of those that comes out of the report is around data sharing: to ensure a clear flow of data between an online provider and a GP, if they are different, so that any problems can be spotted early on. That is particularly important for safety.

[Baroness Jolly (LD)]

My Lords, as the Minister has just said, this is a picture of things to come. Could he give an indication of when the Government expect that GP practices would regularly be able to give an online service to the general public and their patients? What support, financially and developmentally, would they be sure to get from NHS England?

[Lord O'Shaughnessy]

On that specific point, NHS England is providing £45 million through the general practice forward view to promote online consultations. That is to ensure that they are available in general practice across the country. The noble Baroness will be aware of the GP at Hand practice, which is one practice in west London offering these services, but we are seeking to expand them, and NHS England, the CQC and others are providing regulatory support during that process.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, can the Minister explain the process? If someone chooses to access an online GP service, what happens to their registration with the GP with whom they are already registered—if they are registered? Is the process clear to each patient?

[Lord O'Shaughnessy]

That is an excellent question. It is important to distinguish between the independent sector and the NHS. The CQC report was about the independent sector, so a patient would continue to be registered with their NHS GP practice and have an augmenting consultation, if you like. With GP at Hand, as it is an NHS practice, they would switch their registration. One issue that has come up is whether people have full enough information about that switching, which is one thing that NHS England is reviewing in the independent review that it has commissioned about the success or otherwise of that service.

[Lord Leigh of Hurley (Con)]

What steps are the Government taking to encourage people—I appreciate that they cannot force them—throughout the UK to use only online medical services which are registered with the CQC?

[Lord O'Shaughnessy]

This is of course the way the economy is going in general and is a great passion of the Secretary of State. Indeed, he made a commitment at the NHS Expo conference last year that, by the end of this year, every patient would have access to an NHS app online which will enable them to do things such as book consultations, see who has viewed their medical record and set their preferences about things such as blood and transplant donations. A huge stream of work is going on to ensure that those services are available to all patients in the NHS.

[Viscount Waverley (CB)]

My Lords, the Minister will be aware that Brussels is introducing the GDPR arrangement for registration of email addresses and the rest. Could he say a word about how that might impact both independent services and the National Health Service, and counsel doctors accordingly so that they do not get it wrong?

[Lord O'Shaughnessy]

That is an excellent point: the entire country is preparing for the advent of the GDPR on 25 May. We are engaged in a large programme of work with the Information Commissioner’s Office and others to ensure that everyone working in the health and care services understands their obligations and informs patients accordingly.

[Lord Winston (Lab)]

My Lords, a large number of reproductive clinics publish their wares by advertising on the London Underground, often at great cost, sometimes making claims about their treatments. If I did that as a doctor, I would be struck off the register. They get round it because they are private clinics. Is that appropriate? Does the Care Quality Commission have any involvement in this process, and should it?

[Lord O’Shaughnessy]

I would have to look at the specific clinics that the noble Lord is talking about. The subject of the report was those providing online services. One of the things it discovered was that certain regulatory issues are unique to the provision of online services, an example of which is when the data is held offshore and what that means for regulation. As the CQC says in its report, it is reviewing its regulations to make sure that it can account for the unique aspects of online provision, so that the critical aspects, whether they are about truthful advertising or other aspects, are dealt with properly.

[Lord Patel (CB)]

My Lords, as the noble Lord is aware, there is an increasing number of independent primary care practitioners. What assessment have the Government made of the impact of that on the medical workforce of the NHS?

[Lord O’Shaughnessy]

I am not specifically aware of such an evaluation, but I know that there is a need for more general practitioners, which we are all aware of, and indeed for a plan to recruit many more to the service to ensure that all patients and citizens of this country can find a GP in the NHS when they need it.