Young Women: Self-Harm

Lord O'Shaughnessy Excerpts

Thursday 16th November 2017 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, on behalf of my noble friend Lord Storey, and at his request, I beg leave to ask the Question standing in his name on the Order Paper.

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

My Lords, in recent years there has been an increase in self-harming among young women. This is a worrying trend that the Government are committed to addressing. That is why we updated the cross-government suicide prevention strategy and expanded its key areas for action to include self-harm. We are also committed to implementing a community-based care pathway for self-harm by 2019 and to making sure that every acute hospital has mental health liaison services in place by 2020-21.

[Baroness Walmsley]

My Lords, I thank the Minister for acknowledging the shocking 68% increase in the number of young girls being admitted to hospital for self-harm over the last decade. Does he agree that school counsellors can be a very valuable resource in helping to tackle this terrible epidemic of emotional distress among young people, because they are non-stigmatising and easily accessible? However, I visited an area yesterday where I was told that all the school counsellors have had to be sacked because the schools cannot afford to pay them. Will the Minister work with the Department for Education to ensure that by the end of this Parliament every secondary state school in this country has a school counsellor, so that we can tackle the welfare requirements of young people as well as their academic requirements?

[Lord O'Shaughnessy]

The noble Baroness is absolutely right to highlight the importance of schools in dealing with this. It is not just a health issue. Indeed it is not just about education either, but involves a cross-government approach. I would be very keen for her to write to me with the specific details of what she is describing—it does not sound like a positive development. Much more positively, more than 1,000 secondary schools have now had mental health first aid training for at least one teacher in the school, and the ambition is to extend that to all secondary schools. She will also know that there will very shortly be a children and young people mental health Green Paper, which I think will have quite ambitious actions for both schools and the health service to support young people with mental health problems.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, building on the Question from the noble Baroness, Lady Walmsley, does the noble Lord agree with me that bullying in schools can start very early, well before secondary school, and can give rise to very severe mental health issues among those who are bullied? Does he also agree with me that schools struggle to deal with this issue, partly because they are unclear about how to balance their duties of care to victims and to perpetrators, who often have issues of their own? Can he say in what way he is working with his colleagues in the Department for Education to make sure that primary schools have access to good resources to meet this, including programmes such as Place2Be?

--- Later in debate ---

[Lord O'Shaughnessy]

The noble Baroness picks up on a particular interest of mine. She may know that I was involved in setting up three primary schools. It is important to start these lessons early. In the end it comes down to behaviour policies and what is expected from children. Schools with fair and robust behaviour policies do not tend to see bullying. Those which are more lax do. First, it is about making sure that teachers have training and resources and the support they need from the leadership, governors and parents to crack down on it. Bullying now has moved into different domains, particularly online. I think it is very encouraging today—the noble Baroness may have seen it—that His Royal Highness the Duke of Cambridge is launching some actions on cyberbullying. Dealing with bullying is a big part of that and I agree with the noble Baroness about the importance of starting early.

[Lord Farmer (Con)]

My Lords, the Government’s own research, most notably that commissioned by the DWP from Professor Gordon Harold, conclusively showed a causal link between young people internalising problems, such as self-harm, and conflict and breakdown in their parents’ relationships. Will this evidence be acted on in the forthcoming Green Paper on children and young people’s mental health?

[Lord O'Shaughnessy]

I know this area is of great interest to my noble friend and he has done very good research on it. He is quite right to highlight the impact that, unfortunately, parental conflict and breakdown has on children. The Department for Work and Pensions, in a cross-government approach, is doing particular work on supporting parents. I also know that the best schools and community health services work to provide that kind of parenting support. There are a number of parenting programmes out there. I assure my noble friend that that evidence takes a proper place in the mental health strategy that we will be publishing for children and young people.

[The Earl of Listowel (CB)]

My Lords, I declare my interest as a trustee of the Brent Centre for Young People—a mental health service for adolescents which celebrates its 50th anniversary this year. Does the Minister agree that adolescence is a hugely challenging part of human development and that we put far too much pressure, far too often, on adolescents and interfere with their successful development, with the outcomes described in this Question? Will he look at Lucy Crehan’s work Cleverlands, an international comparison of the best performing schools, and her criticisms of the British and American systems? She finds that we put far too much pressure on head teachers through Ofsted inspections. It is a punitive, rather than a supportive, act and we should review it to see whether we could be more supportive of head teachers and get a better, supportive atmosphere for children in our schools.

[Lord O'Shaughnessy]

I congratulate the centre the noble Earl works for on its anniversary. He is absolutely right about the pressures of adolescence. Unfortunately, the causes of self-harm are not well understood. One of the hypotheses is that the motivation appears to be stress relief, which is an incredibly disturbing idea. I am aware of Lucy Crehan’s work from my previous work in schools. I do not think you can link school accountability with the kind of pressures we are describing today and how they manifest in self-harm. We want schools to be successful. It is vital that children are well educated. It is also true that that can be done in a number of ways. The best schools, including ones that I have been involved with in the past, practise something called positive education which emphasises not only the academic aspect but also character and well-being. I think that is the approach that we need to follow.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, if I may bring the Minister back to his area of responsibility, is he aware of recent research indicating that at primary level, references by doctors to mental health services are least in the deprived areas in the country and those are the areas where the self-harming is rising most of all? Can he tell the House what steps he is taking to halt that and move it in the other direction?

[Lord O'Shaughnessy]

I would be interested to see that evidence. It is not something that I have seen. All I can say is that mental health funding has increased by more than 8% in the last couple of years so there is more money going into it but clearly it is vital that it is properly spread.

Older Persons: Human Rights and Care

Lord O'Shaughnessy Excerpts

Thursday 16th November 2017 Lords Chamber

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

I congratulate the noble Lord, Lord Foulkes, on securing the debate and I pay tribute to all noble Lords who have contributed to what has been a very interesting and challenging debate at times. The Government were pleased to see the publication of the Council of Europe report on this important issue in May this year; as the noble Lord pointed out, we have had a chance to discuss it before. He is to be commended for leading such a high-quality piece of work; we would expect nothing less. I also welcome the noble Baroness, Lady Thornton, back to her role on the Front Bench. I look forward to many more of these exchanges in the months ahead; she is clearly going to keep me on my toes.

The human rights of older people are what are in question here and, of course, they are no different from those of other citizens. What differs are the means needed to uphold those rights because of the specific needs of older people themselves including, critically, the care available to them later in life. As all noble Lords have pointed out, an ageing population presents the UK, in common with the developed world, with one of our most profound challenges. It raises critical questions as to how, as a society, we enable all adults to live well into later life and how we deliver sustainable public services that support them to do so. But it presents huge opportunities, too—socially, economically and dare I say it, morally. The care and respect that we provide to older people is the litmus test of the values that we hold as a society.

I believe that the Government recognise the scale of this challenge and are responding to it. I hope that the noble Lord—indeed all noble Lords, though I have a sense that they may not have—will have seen that, at 2 pm today, my right honourable friends the First Secretary of State and the Secretary of State for Health published our plans to produce a Green Paper on social reform by summer next year. The announcement makes it clear that, to achieve reform where previous attempts have failed, we must take a broad view. The Green Paper will cover: social care funding and, of course, issues of means testing; social care services, including continuity of care, as the noble Baroness, Lady Cavendish, mentioned; wider networks of support, such as the role of carers; the role of housing; and interaction with other public services. It will consider how technology, innovation and new workforce models can deliver better quality and value. It will be underpinned by the 2014 Care Act, which introduced national eligibility criteria for access to adult care for the first time, and by £2 billion in additional funding over the next three years to support social care. Part of the purpose of that funding is of course to reduce delayed transfers of care—what the noble Baroness, Lady Thomas, quite rightly described as, in the pejorative term, bed-blocking. I completely agree with her that that is not a term that we want to use or endorse.

To take forward the work towards the Green Paper, a group of independent experts, including Sir Andrew Dilnot and Dame Kate Barker—who have both led reviews into social care in the past—and, from our own House, the noble Baroness, Lady Lane-Fox, will support government engagement with a range of stakeholders including, first and foremost, care users, their families and those providing care in whatever setting, to debate the issues and build consensus. Noble Lords are a treasure trove of expertise on this issue and it is critical that their voices are heard. That is why the First Secretary of State has written to invite the chairs of all relevant all-party parliamentary groups to meet him, so that he can to listen to their views.

An interministerial group has already been established to oversee the policy development process. Our aim is to build consensus around reforms which can last. Once the Green Paper is published there will of course be a full public consultation to provide further opportunities for all interested parties to add their perspective. The Government’s plan is bold in intent and ambitious in scope. I hope that everyone who has an interest in social care sees this as a fantastic opportunity to achieve the lasting and sustainable change that has so far eluded us.

Reform of this vital sector has been a controversial issue for many years but the realities of an ageing society—as noble Lords have pointed out—mean that we must reach a sustainable settlement for the long term. It will no doubt require difficult choices about what that system should provide and how it is paid for. But getting this right promises a better system that everyone can have confidence in, where people understand their responsibilities, can—critically—prepare for the future and know that the care they receive will be to a high standard and will help them maintain their independence and well-being.

As these plans for social care reform show, this Government’s ambition is to make the country a good place for everyone to grow old. The noble Lord, Lord Foulkes, accused me—somewhat unfairly, I thought—of lacking specifics in previous answers, so I am going to give some very concrete examples of what we are doing to support older people. We as a country are proud to lead the world in tackling age discrimination. The Equality Act provides robust protection against both indirect and direct discrimination in employment, and in February the Government published a strategy called Fuller Working Lives, which aims to increase the retention, retraining and recruitment of older workers by bringing about a change in the perception and attitudes of employers.

Many older people want to carry on working, and of course the coalition Government abolished the default retirement age and extended the right to request flexible working to all. It is therefore hugely encouraging that the number of older workers is at a record high—and not just because of the growing size of the House of Lords. I should add that I am doing my bit. Just yesterday, as happens every Wednesday, I had my parents looking after all three of my children—so I am keeping them active in their retirement, too.

Huge progress has been made under successive Governments. The noble Lord, Lord Lipsey, mentioned pensioner poverty. It is still too high, at 16%, but that is compared with 40% in the 1980s. The pension credit provides a guaranteed minimum income to help tackle pensioner poverty in Great Britain, and over time the new state pension will reduce the need for means testing.

Beyond social care, we are taking action in a number of areas to support the comprehensive care of older people. One of these is the inclusion, by 2020, of training in geriatrics and prescribing for older people within all medical curricula, so that there will be additional support throughout every part of the NHS. The 2017-18 GP contract set out a requirement for the identification and management of patients aged 65 and over with frailty, to ensure that they receive an annual medication review. Where clinically appropriate, the GP will discuss whether the patient has fallen in the past 12 months, and provide any other clinically relevant interventions.

Of course people want to be at the centre of their own care, making sure that it responds to their own needs—which is why the Government have simultaneously extended both personal health budgets and integrated personal commissioning, as well as promoting the integration of health and care services through the sustainability and transformation programme that is the centrepiece of the NHS’s five-year forward view.

The noble Lord, Lord Haskel, and the noble Baronesses, Lady Thomas and Lady Thornton, raised the issue of integration of care. All parties are aiming towards that. There are different versions of this, but bringing together care for people who experience it, and who do not want to have to distinguish between primary, secondary, community, social and so on, is essential as the health needs of our population change around ageing and comorbidity.

Personalisation is therefore behind these ambitious plans, as well as our plans to digitise health services—a passion of the Secretary of State’s. The potential for mobile technologies to support an ageing society, to combat loneliness—which, as the noble Lord, Lord Sawyer, pointed out, has such a pernicious effect in old age—and to provide real-time diagnostics is a rich seam that has only just started to be explored. New services, such as the GP at Hand pilots, hold huge opportunities for older people who need to see a GP but may be too frail to leave home.

Home is at the centre of providing for good care and for the human rights of older people. At heart, growing old safely and happily needs a good home. We know that most older people would prefer to live at home in their later years, which is why we have seen an increase in domiciliary care and sheltered housing. Others will want or need to be in a residential or nursing home, so the quality of that home and the care provided within it are everything. As the noble Lord, Lord Cashman, pointed out, the Care Quality Commission’s October State of Care report said that about four-fifths of residential homes achieve good or outstanding ratings—although I accept that only 2% or 3% are outstanding, and that could be better. For domiciliary care services the figure was 83%, and for community social care 88%.

The noble Baroness, Lady Greengross, talked about the work she did, when only 50% of care was judged to be good enough. I am not sure what year that was, but I hope that we have seen an improvement. The fact that those inspections are happening is helping to drive quality. The State of Care report highlights variation, and points to some evidence of deterioration. The CQC is looking at this quality, including the deterioration of good and outstanding providers, but it is reassuring to see that 82% of providers that had been rated inadequate had improved by their next inspection.

Providing good care in the home means supporting carers as well as care workers. That is why it is so positive that the role of carers has been wrapped into the overall social care reform programme that I described earlier. I pay tribute to all those, paid and unpaid, who look after older people and provide the dignity and respect that they deserve. Adults with dementia are particularly vulnerable, so I am sure all noble Lords will welcome the fact that over 2 million people have been trained to be dementia friends to support sufferers of this horrible disease.

As several noble Lords have pointed out, making sure that there is good care also means rooting out and, where necessary, taking professional or legal action against the despicable minority who abuse vulnerable older people. That is one reason that we introduced a new crime of wilful neglect, which came into force in April 2015. Looking ahead, the draft Domestic Violence and Abuse Bill will strengthen the Government’s powers to respond to physical, psychological and economic abuse in domestic settings, and we will launch a consultation on proposals soon. However, it is important to emphasise that this is only a minority and that the vast majority of people looking after older people work with great dedication and compassion.

Before concluding, I take the opportunity to respond to some specific questions that I have not yet had a chance to answer. I hope that I have given some specific examples to the noble Lord, Lord Foulkes, and done so politely. I say to him that there is no need to wait for a Labour Government to act on these things. Indeed, as the noble Baroness, Lady Cavendish, pointed out, we want to avoid the political toxicity that can accompany such issues.

My noble friend Lord Balfe and the noble Lord, Lord Sawyer, suggested that collective bargaining was the way forward. Perhaps that was a reminder of the past involvement of my noble friend Lord Balfe in unions and the Labour Party. However, I am not convinced that that is the right way forward. I do not think that it matters whether a provider is in the private sector, the public sector or the voluntary sector. As Tony Blair once said, what matters is what works. It is quality that counts and that is why we need to have the staff and the training to make sure that happens.

The noble Lord, Lord Cashman, talked about discrimination in medical care. That is, of course, absolutely wrong when it is done for unjustified reasons. There can be reasons why decisions are made not to operate on older people but those must always be clinical decisions based on clinical judgments and not because of any kind of prejudice. It is important to emphasise that there are routes such as HealthWatch and the health ombudsman through which people can report instances of discrimination.

At the heart of the proposals of the noble Lord, Lord Foulkes, is the idea of a charter of older people’s rights, which was endorsed by the noble Baroness, Lady Massey. It is quite right, of course, that there is such a charter for children, and, indeed, a Children’s Commissioner has come from that. I hate to disappoint them, but that is not currently part of our plans. However, we will continue to watch the UN’s work in this area, as was highlighted by the noble Lord, Lord Rea, with interest.

The noble Baroness, Lady Massey, also asked about the difference between hospice and care home funding. They are funded very differently. The periods of time that one would expect to spend in one versus the other is also different. However, I shall certainly write to her with more detail of how those could be aligned.

The noble Baroness, Lady Cavendish, asked about merging the health and care professions. That was an incredibly wise point. There are huge benefits from integration, not least because care is increasingly delivered in an integrated way, because of the complexities involved and because of the progression that integration offers. One of the criticisms of social care as a profession concerns the glass ceilings that exist within it; the opportunities for seniority are not there, whereas integration with the medical professions would provide that.

The noble Lord, Lord Jordan, asked about preventive action. I completely agree with him on that. He will be pleased to know that there are big increases in capital spending on the disabled facilities grants, which is going up year on year precisely to combat some of the very avoidable issues of the usability and safety of homes, for example, to provide the kind of preventive action that he is looking for and that ought to reduce the instances to which he referred.

The noble Baroness, Lady Thornton, asked about raising the pension age. The Government have taken action to limit the maximum change to the state pension age to 18 months, building on the 1995 Act at a cost of, I believe, over £1 billion, so the Government are taking, and have taken, action to address that issue.

In conclusion, I again thank the noble Lord for producing his report and instigating this debate. I thank all noble Lords for their wise and thoughtful contributions.

I would like to end where I started. The way we care for older people reflects our values as a society. As a country, we have a fantastic record of supporting and cherishing older people, but the challenge of making sure they can live their lives with independence and dignity is getting harder. We can meet this challenge only by working together, with imagination and compassion, to tackle the difficult decisions and choices that are needed, not least in the reform of social care services and funding. Noble Lords have a huge amount to contribute to this process and—as others have pointed out—because of the mean age quite a keen personal interest in it too. I look forward to working with noble Lords in that endeavour.

Hormone Pregnancy Tests

Lord O'Shaughnessy Excerpts

Thursday 16th November 2017 Lords Chamber

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

My Lords, with the permission of the House, I shall repeat as a Statement the response to an Urgent Question given by my honourable friend the Parliamentary Under-Secretary of State in the other place on hormone pregnancy tests. The Statement is as follows:

“Yesterday, the Commission on Human Medicines published the report of its expert working group on hormone pregnancy tests. As I said at Health Orals on Tuesday, Mr Speaker, this subject demands the utmost sensitivity and I will do my best.

Based on its extensive and thorough review, the expert working group’s overall finding, endorsed by the Commission on Human Medicines, is that the available scientific evidence, taking all aspects into consideration, does not support a causal association between the use of hormone pregnancy tests such as Primodos during early pregnancy, and adverse outcomes of pregnancy with regard to miscarriage, stillbirth or congenital abnormalities. Ministers have accepted the advice of the Commission on Human Medicines and a Written Ministerial Statement was published yesterday, along with a copy of the report.

In the UK, hormone pregnancy tests first became available for diagnosing pregnancy in the 1950s. Between then and 1978, when Primodos was withdrawn from the market in the UK, a number of studies were published which investigated a possible link between women being given a hormone pregnancy test to diagnose pregnancy and the occurrence of a range of congenital anomalies in their babies. Although there was never any reliable evidence that HPTs were unsafe, concern about this issue, coupled with the development of better pregnancy tests, meant that a number of precautionary actions were taken to restrict the use of HPTs. The tests were voluntarily removed from the market by the manufacturers.

The body of information subsequently accrued by the Association for Children Damaged by Hormone Pregnancy Tests and other campaigners led to a parliamentary debate in Westminster Hall in 2014 during which the then Minister for Life Sciences stated that he would instruct that all relevant documents held by the Department of Health be released. In addition, he determined that an independent review of the papers and all the available evidence was justified.

The purpose of the review was to ascertain whether the totality of the available data, on balance, supported a causal association between use of a hormone pregnancy test by the mother and adverse pregnancy outcomes. It also considered whether, alternatively, the anomalies could have been due to chance alone or to other factors. The final report summarises the scientific evidence that was considered by the expert working group, its conclusions on that evidence, and its recommendations. All the available relevant evidence on a possible association has been extensively and thoroughly reviewed with the benefit of up-to-date knowledge by experts from the relevant specialisms.

The evidence reviewed by the expert group will be published in the new year, once it has rightly been checked in line with the legal duties of data protection and confidentiality. In addition to the overall conclusion, the expert working group has made a number of recommendations to safeguard future generations through strengthening the systems in place for detecting, evaluating, managing and communicating safety concerns with use of medicines in early pregnancy.

While I recognise the conclusion of the report will be a disappointment to some, I hope they will see the recommendations as positive. They are a credit to the efforts of the Association for Children Damaged by Hormone Pregnancy Tests and the All-Party Parliamentary Group on Hormone Pregnancy Tests, which I know the honourable lady chairs, and a lasting legacy”.

[Baroness Thornton (Lab)]

My Lords, I thank the Minister for repeating the Statement. I realise that the House is working him hard today, but he has the comfort of a huge department to provide his brief for him. In some ways, that underlines the dilemma that he and the Government face on this issue. This report has caused such dismay and disbelief among campaigners, and every MP who spoke in the Commons, that it requires the Government to use their critical faculties, listen to what is being said across the piece and look again at the report, its genesis and its lack of transparency.

I have two questions. First, will the Minister explain why Marie Lyon was told:

“I could go to prison if I divulge what was discussed”?


Does he agree that that is about as far away from transparency as it is possible to get?

Secondly, the draft of the report, which was published in October, stated that:

“Limitations of the methodology of the time and the relative scarcity of the evidence means it is not possible to reach a definitive conclusion”.


That sentence was removed from the final version. Why was it removed, why was there a delay of a month and did the Minister speak to the authors of the report about the sentence before its removal?

[Lord O'Shaughnessy]

I thank the noble Baroness for her questions. The most important thing to stress is that this report was the product of an expert working group of scientists and included an independent member in Nick Dobrik, who is a noted thalidomide campaigner and certainly not a government yes man. The chair of the families group, Mrs Lyon, was an observer. We are beholden to take the evidence of those who are best qualified and who have given their view on what link there may or may not have been between these pregnancy tests and the abnormalities. The conclusion they have come to is that, in their view, there is no causal association on the basis of the evidence they were able to consider.

The noble Baroness asked about transparency. Every single member of the expert working group signed a confidentiality agreement. That is common to all such groups in the Commission on Human Medicines. Mrs Lyon was not alone in that. That expires at the point of publication, so she is now absolutely free to say whatever she wants, as indeed is any other member. I can reassure her that there was no particular or unusual treatment for her compared to other members of the panel or to other panels that have operated in similar ways. The minutes of all the meetings will be published. As the Statement pointed out, the full evidence set will also be published, once it has gone through due diligence.

Changes to the draft were suggested by the Commission on Human Medicines and accepted by the expert working group. There was no interference from me or anyone else—it was a discussion between those two bodies. The report was unfortunately delayed. That was in order to make sure that it was as clear and as digestible as possible for non-experts. I think the report is a very thorough and comprehensible piece of work. I recognise that it is not the response that families were looking for. In some cases, they have experienced horrendous events—they have either lost babies or, in some cases, their children have extremely severe deformities—but I come back to the point that the task of the group was to look at whether there was a causal association. The group had scientific expertise. It has given its advice, and we are following it and the recommendations that it made.

[Baroness Thomas of Winchester (LD)]

My Lords, how do the Government intend to restore the trust and confidence of those left feeling betrayed by the lack of transparency and openness surrounding this inquiry that the Minister has just talked about?

[Lord O’Shaughnessy]

As I pointed out in response to the noble Baroness, Lady Thornton, transparency is there in the evidence and minutes that will be published. The report that has come out is big and chunky and contains a huge amount of information. There was an independent member in Nick Dobrik, the thalidomide campaigner, and Mrs Lyon, who chairs the families group, was an observer. We touched on confidentiality agreements. As I said, there is nothing out of the ordinary in that. I think transparency is there. I come back to the point that the working group was set up to examine all the available evidence scientifically. The department provided its scientific and non-scientific papers for that effort. I know the report has not come up with the conclusions that the families wanted, but it is the right group to have made that judgment.

[Baroness Taylor of Bolton (Lab)]

My Lords, I understand that the Minister realises the concerns of those families who have been affected. He put the case and described how the inquiry was conducted very clearly but, as has been said, there is still quite significant concern outside this House among Members of Parliament and the families concerned. If we are talking about getting reassurance, perhaps it would be useful to have a proper debate on the findings of the report so that all these aspects can be laid out in greater detail, including the case from the Minister.

[Lord O’Shaughnessy]

I would certainly welcome such a debate. I know that was discussed in the debate in the other place on the Urgent Question. I want to emphasise the seriousness with which I take this issue. I had the opportunity to meet Yasmin Qureshi MP, who chairs the all-party parliamentary group, and Mr and Mrs Lyon in early August. I will be meeting them again in early December. I utterly sympathise with them in the experience they have had, and I understand that there is a need to reassure them that the process that has been followed is a proper process. I accept that, and I am making all the efforts I can to do it.

National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017

Lord O'Shaughnessy Excerpts

Thursday 16th November 2017 Lords Chamber

[Lord Leigh of Hurley (Con)]

My Lords, the National Health Service is a cherished national institution, historically the envy of the world, and in theory none of us has a problem with overseas visitors using it. However, we currently have a huge issue of capacity. Unfortunately, it is not clear that we have the capacity to treat on the NHS all the overseas visitors that we would like to treat. Already the NHS is in breach of vital targets, such as waiting times for operations and to start treatment for cancer. Consequently, our cancer survival is the worst in western Europe, Canada and Australia. Only a few countries in eastern Europe have worse survival for common cancers.

We all love the National Health Service, so it is only right that anyone using our very valued NHS should make a fair financial contribution to help ensure its sustainability and the continued provision of world-class facilities—just as the British taxpayer does. Although I do not agree with the Motion, I am pleased that the noble Lord, Lord Hunt, tabled it, because it allows this House the opportunity to discuss matters relating to it, and the implementation.

I have no interest to declare, but I have been taking an interest in health tourism since I raised an Oral Question on this subject in March 2014, and we have seen great progress from the Government since then. Indeed, it was mentioned as an objective in my party’s manifesto. Over the past four years the Government have prioritised improved cost recovery, and as a result we have achieved more than ever before, with identified income for the NHS from overseas visitors quadrupling from £89 million to £360 million. All that income is, of course, directed back into front-line services. That sounds good. However, it should be recognised that £200 million of the £360 million comes from the immigration health surcharge, and in return 450,000 IHS visas are issued every year. Therefore, for £200 for immigrants and £150 for students—a subject that has been debated in this House—free NHS treatment is offered, without exclusion of pre-existing conditions, for nearly half a million people.

The regret Motion shows that the noble Lord, Lord Hunt, is concerned about racial profiling but, at the time of registration and to avoid any form of discrimination on arrival for a new hospital appointment, the same baseline question must be asked by an overseas visitor manager of every patient, in every department—using, according to the guidance, these exact words:

“Where have you lived in the last 6 months?”.


If the patient replies “In the UK only”, no further questions are asked regarding residency or immigration status. That is it. If the answer given is yes, there are to be no further questions. I fear that it will soon become common knowledge that, in the NHS, care is free to anyone who answers yes to this single baseline question.

This is spelled out in chapter 11, on page 88, of the Department of Health Guidance on Implementing the Overseas Visitor Charging Regulations. Furthermore, it clearly states at chapter 11.16:

“Administrative staff must avoid discrimination when asking these questions”.


Needless to say, vulnerable groups will be excluded from up-front charging. The guidance issued by the NHS specifically excludes asylum seekers, trafficked people and every other variety of vulnerable grouping. Furthermore, the guidance confirms that up-front charging will apply only to patients presenting for elective treatment. GP services and A&E are, of course, specifically excluded.

Health tourism is a huge issue. On 1 February 2016, my noble friend Lord Bates, the then Minister in this department, gave an estimate to the House that the cost to the NHS was some £2 billion. Possibly unlike the noble Lord, Lord Hunt of Kings Heath, I am pleased that the Government are now running 35 pilot schemes in 19 NHS trusts to ask patients for two forms of identification to show ordinary residence. Again, this is just for elective surgery, for which there is plenty of time to plan, not emergencies such as complicated pregnancies, where we have seen real evidence of people coming specifically to the UK and literally being taken to hospital from the airport for free—for them—using extremely expensive medical assistance. Needless to say, in Europe if one is unfortunate enough to have to go to hospital, anecdotal and other evidence says that the first thing the hospital asks is to look at your insurance or E111. Our system of state-funded and provided medicine has for too long been lax in properly obtaining payment where it is due.

The real issue we should be discussing is how inadequate we are in terms of OVMs. In September 2017, Professor Meirion Thomas, who has become the country’s expert in this area purely as a matter of public service, sent freedom of information requests to NHS trusts. He asked eight acute trusts in London, two acute trusts in Birmingham and eight acute trusts in Greater Manchester for details of their OVMs. The trusts in London and Birmingham do have OVMs, but a grossly inadequate number. I will not bore your Lordships’ House with the numbers but the proportions are frightening. However, in Manchester, the results are even worse. Only one trust—the Christie hospital—has an OVM, and I would be pleased to provide my noble friend the Minister with details, should he so wish. This research proves that the NHS is not prepared for new legislation: seven acute trusts in Manchester have no mechanism for up-front charging. Therefore, I am afraid that I cannot support this regret Motion. The question we have to ask at another time is not how up-front charging can work in terms of the Motion, but how we are going to implement this to ensure a fair playing field for those who pay for and deserve proper treatment.

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

My Lords, I thank all noble Lords who have contributed to the debate. While, as ever, I disagree with the Motion in the name of the noble Lord, Lord Hunt, I am grateful to him for raising the topic of cost recovery for the NHS from overseas visitors. It is a very important policy issue and it is crucial that the objectives of these regulations, and the safeguards that we have put in place, are discussed and understood by Members of the House.

In July this year, my department introduced amendment regulations to extend and improve the recovery of NHS costs from overseas visitors who are not ordinarily resident in the UK. This followed a period of public consultation in 2015-16. The Government’s response to that consultation, which set out our intentions, was published in February 2017.

Let me first be clear about the principles that sit behind our policy on cost recovery. As my noble friend Lord Leigh has said, the NHS is a cherished national institution. It is paid for by millions of British taxpayers, who care deeply about it being used fairly, so we must protect it carefully. Our country has always welcomed visitors and the NHS is no different, but I hope noble Lords also agree that it is only right that, when using its services, visitors should also make a fair financial contribution to the NHS’s sustainability. On that basis I welcome the support in principle of the noble Lord, Lord Hunt, and the noble Baroness, Lady Hamwee, for cost recovery. However, it would be wrong not to point out that, when specific proposals come forward, they seem less robust in offering that support.

This principle was not introduced by this Government; regulations and guidance requiring cost recovery from overseas visitors have been in place for over 30 years, as my noble friend Lady Redfern pointed out. As the number of visitors to the UK has grown over the years, the Government have supported the NHS to identify more income than ever before, quadrupling that income over four years to £360 million. The regulations we are discussing today continue this policy of seeking fair payment for NHS services provided and allow the NHS to take further action to support cost recovery in a way that is more efficient, more equitable and more effective.

--- Later in debate ---

[Baroness Taylor of Bolton]

In the list the Minister gave, he did not deal with the point that the noble Baroness, Lady Hamwee, and I raised about failed asylum seekers who are still living in England.

[Lord O’Shaughnessy]

For clarity, they are not covered under the exemptions.

The second change the amendments make is to the requirement that any care not deemed immediately necessary or urgent by a clinician is paid for up front. The published guidance, again, for nearly 30 years, has recommended this. This practice ensures that a chargeable patient can make an informed choice about their care and therefore does not unwittingly incur debts when they could instead, for example, choose to wait for treatment until they have travelled home. Given that our NHS is facing unprecedented levels of demand, I hope noble Lords will agree that mandating this position is a sensible approach and that it will help make sure that all users of the NHS make an equitable contribution to ensure its continued success and viability.

The noble Lord, Lord Hunt, has asked whether this practice will not create barriers between vulnerable patients and treatment and result in racial profiling as the front line seeks to determine eligibility for free care. I have already drawn noble Lords’ attention to the exemptions in place and the fact that all GP and A&E services remain free for all. I am also clear that immediately necessary or urgent treatment—such as all maternity services—will never be withheld, regardless of the patient’s ability or desire to identify themselves or pay. To reassure the noble Baroness, Lady Taylor, and other noble Lords, it is for clinicians, and no one else, to determine whether a treatment is immediately necessary or urgent.

On whether patients may face discrimination, this is always unacceptable and not compliant with anti-discrimination legislation. As my noble friend Lord Leigh pointed out, our guidance is clear that simple, short questions should be asked by trained staff of all patients whose records do not already indicate residency status to assist in identifying those not eligible for free care. That information can then be captured in the patient record for the future.

To support the implementation of these regulations, we have developed with front-line staff a “cost recovery toolbox” containing extensive guidance and template letters to patients and clinicians, as well as patient and staff-facing leaflets and posters and a web-based forum for peer support. As my noble friend Lady Redfern pointed out, working with NHS England and NHS Improvement, the department has published operational guidance to support the introduction of the regulations. This includes an average price list to provide consistency in up-front charging. The department has recruited a senior, experienced cost recovery team of NHS professionals who have led improvement visits to over 20 NHS trusts over the last six months. Action plans are in place for each trust and the team will support improvement and the sharing of best practice across the wider NHS.

I would like to end on an issue which has been raised by many noble Lords in this debate: the assessment carried out before we introduced these changes. As I have explained, up-front charging did not represent a change in policy, but instead has existed for many years before the consultation on other amendments. Over the course of the consultation and decision-making process, the Government carefully considered the impact the charges may have and published a full impact assessment alongside the regulations. This concluded that the package of changes would identify up to £40 million a year for the NHS. This is additional income and takes into account any administrative costs associated with the changes. I will also place in the Library copies of the equality assessments carried out by my department to inform the regulations, so that Members of the House will be able to review how the impact on vulnerable and protected groups was very carefully considered prior to the introduction of these changes.

All noble Lords have asked about the implementation of these changes and it is right, of course, that we proceed cautiously and sensibly and that we review how we are doing. So I am very aware of the need to keep the impact of these regulations under careful review in order to make sure they are implemented as planned and with no unintended consequences. My department will therefore undertake a full, formal review of how these amendment regulations are implemented, and monitor delivery closely, particularly where healthcare is provided to the most vulnerable. If further action is needed I will commit to update the House accordingly.

I hope I have been able to reassure all Members of this House about the long-standing principles that underpin our approach to cost recovery, the care that has been taken to protect vulnerable groups, and the reflective approach we will take during the implementation of these policy changes. I believe that they provide an equitable and reasonable step forward in making sure that all the NHS’s users, wherever they come from, make a fair contribution to the sustainability of the NHS, which is what British citizens expect. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to all noble Lords who have taken part in this debate. The fact we spent nearly an hour on it as last business on a Thursday is testimony to the importance of the matter, which is why I welcome so many noble Lords having stayed to take part. I will not push this to a vote, and I will withdraw the Motion, but I do think it is an opportunity to raise some very important points with the Government.

First, the noble Baroness, Lady Hamwee, made some very important points about the analysis of the impact assessment, the doubtful financial benefits set against the bureaucratic costs, and the impact this may well have on some of the most vulnerable people—the very people who, not just from their point of view but the public health point of view, need to access these services.

Secondly, from the evidence that I have received—and I have received many such examples—there is a real concern that people who are legitimately entitled to NHS services may get turned away. The noble Baroness, Lady Hollins, rightly asked what the safeguards were to prevent this.

I think it right that we talk about racial profiling because again there is some evidence that, in spite of what the Minister said and what is promised in guidance, this is taking place in some parts of the country. The NHS has many organisations—we have a lot of community organisations—but it turns out that staff who are given such responsibility may not be aware of the importance of this issue and its sensitivity. The obvious case here is British people with foreign-sounding names being challenged in a way which I think is inappropriate.

The Minister did not respond to the point from the noble Baroness, Lady Hamwee, about the Home Office requiring medical records. I do not know whether he will be prepared to respond to her in writing; I understand that the question goes much wider than his brief today, but I am concerned about the ethics of the Home Office requiring people to open their medical records.

The noble Baroness, Lady Hollins, was of course right to point out the barrier to people with mental health and other disabilities. This is not just about who is eligible: having to produce evidence to legitimise a right to treatment could prove difficult for vulnerable people who find everyday living hard and challenging.

Like my noble friend Lady Taylor, I say to the Minister—the noble Baroness, Lady Redfern, and the noble Lord, Lord Leigh, both spoke about this—that I have no problem with the principle of cost recovery. I accept that it is right that the NHS seek to recover costs from the people who are not eligible for NHS treatment. My problem, particularly with these regulations, is that I have a feeling they will be counterproductive and I doubt they will raise very much in the way of resources. My noble friend also teased out the point about the position of failed asylum seekers, who seem to be particularly vulnerable. I welcome what the Minister said about unintended consequences; that is a very important point.

Operational guidance, which the Minister referred to, is one thing. I would have preferred to see some of the points he has made and reassurances he has given in the regulations, rather than operational guidance. I also noted with great interest what he had to say about accident and emergency and GP services. From the confidence with which he said it, can I take it that the Government intend that they will remain free for all in future? Perhaps I can ask him quite what he meant by that, because in the briefings that I have had people have emphasised that it is the Government’s intention to extend the charges to accident and emergency services and GP services.

[Lord O’Shaughnessy]

We are talking about the regulations that we are implementing, and they do not introduce that. That is the point I was making.

[Lord Hunt of Kings Heath]

Noble Lords will interpret that response in the way they wish to. That is a bit disappointing.

The Minister has promised a review. I very much welcome that. He said it would be a full, formal review; let us hope it will also be an independent one. Asylum Matters has reminded me, in the most efficient way that that organisation works, that of course in 2016, a review was promised. I hope this time, we will actually get such a formal review.

Having said that, this has been an important debate. A lot of people are looking with great interest at what your Lordships have discussed tonight. We knew we were not going to be able to stop these regulations but I hope we have expressed those legitimate concerns. I am grateful to noble Lords for taking part and beg leave to withdraw the Motion.

Veterans: Mental Health

Lord O'Shaughnessy Excerpts

Tuesday 7th November 2017 Lords Chamber

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

My Lords, the majority of those serving in the Armed Forces have a positive experience, but it is our duty to make sure that veterans with physical or mental injuries continue to receive the best possible care. The Good Psychiatric Practice report from the Royal College of Psychiatrists states that clinicians must,

“be competent in obtaining a full and relevant history that incorporates developmental, psychological, social, cultural and physical factors”.

Veterans, like all other patients, should be diagnosed in that way.

[The Countess of Mar (CB)]

My Lords, I am grateful to the Minister for that reply, but there is a very serious problem. I think particularly of the antimalarial Lariam, which is issued to members of the military without the normal warnings you get when given a drug. In some cases there are recognised psychotic results. Unfortunately, when these men become veterans they are referred to their GPs, who often have very little knowledge about the drug or its effects and who may well treat the patient for PTSD. Does the Minister recognise that there is a severe danger of these men being given drugs that will increase their psychosis and cause them to end up in prison?

[Lord O'Shaughnessy]

I reiterate the point I made in my Answer: NICE guidance on the treatment of post-traumatic stress disorder is clear that clinicians should take into account a range of factors when seeking to make a diagnosis. That should include the patient’s detailed case history, including medicines taken and under what circumstances. Regardless of whether the person is treated while serving or afterwards, that should be on their patient record, be accessible for anyone giving them direct care, and influence any prescriptions of treatments given. I also point out to the noble Countess that veterans’ issues are now in the training curriculum for all GPs. That came out of the Armed Forces covenant.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the treatment of veterans is clearly important, but so is prevention. Will the noble Lord confirm that for the drug the noble Countess referred to, whatever geographical area you are in in the world, there is always an alternative? Will he also confirm that the Surgeon-General told the Defence Select Committee last year that he could not guarantee that every member of the Armed Forces had a face-to-face risk assessment before the drug was given to them? Have the Government now ensured that face-to-face risk assessments take place?

[Lord O'Shaughnessy]

For the drug in question, Lariam is the brand name and mefloquine is the generic name. There are indeed alternatives available, and only 1% of antimalarial drugs prescribed to the Armed Forces are of mefloquine. There are instances when alternatives are not available, which may be because of a particular response to individual drugs or because the prescribing details are different—mefloquine is given on a weekly basis, for example—but the proportion is only 1%. The Defence Committee set out several recommendations, one of which was that there should be face-to-face risk assessments before prescribing. That figure is now up to 89% of the total; for the remaining 11%, the problem may be about recording rather than their not happening. The rate is much higher than it has been historically.

[Lord Robathan (Con)]

My Lords, I was prescribed Lariam in 1985. When I came back from Kenya in 1986, I was specifically told that it was linked to suicide. When I became a Minister, I asked for this to be investigated, but unfortunately I was pushed off elsewhere before the results came in—it happens the whole time. Can my noble friend look again at this, because the threats from taking Lariam are often worse than the threat of getting malaria?

[Lord O'Shaughnessy]

I am glad to see that my noble friend is still in very good shape. It is important for me to point out that a link between mefloquine and severe and persistent psychiatric symptoms has not been established. What I can talk about is what the NHS is doing to make sure that there is proper treatment of and care for veterans and those serving in the Armed Forces. The MoD is now giving on a six-monthly basis a report to the House of Commons Defence Committee on its actions. As I said, that includes increased risk assessments and so on. This is constantly under review, not just in the government department but in the MHRA, which is the licensing authority with responsibility for drug safety.

[Lord Stirrup (CB)]

My Lords, the Lariam case is a severe one, and I understand that the manufacturers acknowledge the link on the packaging of the drug. More broadly, the Armed Forces covenant is an acknowledgment of the debt and duty that society owes to its veterans, but one challenge for those providing public services such as within the medical profession is to identify those who fall within the ambit of the covenant. Those who most need some of those resources and some of that help from public services are the least able to identify themselves. What are the Government doing to ensure that those who provide such services are fully aware of the status of those veterans?

[Lord O'Shaughnessy]

On the first point, there have been reviews at European level to improve the packaging and the patient information leaflets about any risk that might attend taking this drug or indeed any others. Status as a veteran is now recorded in the NHS and goes into the patient record.

[Baroness Brinton (LD)]

My Lords, the mefloquine help page for veterans and current serving officers is very good at explaining the signposting, but there is no mention in Meeting the Healthcare Needs of Veterans, which has not been updated since 2011. Only 2,000 GPs out of more than 50,000 have attended the day training course on working with veterans. Can the Minister ensure that at least one GP from every surgery has training, so that he or she can advise other GPs when they are helping to serve our veterans once they are back in the civilian workforce?

[Lord O'Shaughnessy]

The noble Baroness makes a good point. As I mentioned, that training is now in the curriculum, but of course that deals with the flow of new GPs as opposed to the stock of existing GPs. I shall certainly look at that and see what more can be done to make sure that GPs have up-to-date training.

Greater Manchester Combined Authority (Public Health Functions) Order 2017

Lord O'Shaughnessy Excerpts

Tuesday 7th November 2017 Lords Chamber

Moved by

[Lord O’Shaughnessy]

That the draft Order laid before the House on 20 July be approved.

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

I beg to move that the draft Greater Manchester Combined Authority (Public Health Functions) Order 2017, which was laid before this House on 20 July 2017, be approved.

The draft order we are considering today, if approved and made, will confer local authority public health functions on the Greater Manchester Combined Authority as agreed in the devolution deals, and support Greater Manchester’s programme of public sector reform.

The Government have, of course, already made good progress in delivering their commitment to implement the historic devolution deal with Greater Manchester. Since agreeing the first deal with Greater Manchester in November 2014, we have passed the Cities and Local Government Devolution Act 2016, followed by a considerable amount of secondary legislation for Greater Manchester, including: establishing the position of an elected mayor; new powers on housing, planning, transport, education and skills; transferring fire and rescue functions and assets; and setting out the operation of the police and crime commissioner function, which transferred to the mayor on 8 May.

The draft order we are considering today provides a further significant step for Greater Manchester. Greater Manchester has identified public sector reform and population health improvement as priorities. This draft order provides for the conferral of certain local authority public health functions on the combined authority. Once the order is made, the combined authority will be able to exercise those public health functions concurrently with the 10 metropolitan district councils in its area.

The main new function is conferral of a local authority’s duty to take such steps as it considers appropriate for improving the health of the people in its area. The effect of the order will be to treat the combined authority as if it were a local authority, with the same duty to improve population health and the same consequential requirements to comply with guidance and the NHS constitution, and with the ability to enter into partnership arrangements with local authorities and NHS bodies.

Conferral of local authority public health functions will enable a Greater Manchester-wide strategic leadership approach to the delivery of agreed public health functions and commissioning responsibilities—for example, public health intelligence, health needs assessment and health protection. It will support a Greater Manchester-wide approach to tackling health inequalities, variation in quality and service improvement to promote fair and equitable access and to achieve an upgrade in health outcomes for the population of the wider city. It will also support strengthened collaborative decision-making for population health through the identification of city- wide commissioning priorities and intentions, underpinned by shared principles and common commissioning standards —for example, commissioning for whole-system sexual health and substance misuse services. Finally, it will enable population health to be embedded across the city’s health, social care and wider public services through the Greater Manchester strategy and the population health plan.

Noble Lords will want to know that the statutory origin of the draft order before us today is in the governance review and scheme prepared by the combined authority in accordance with the requirement in the Local Democracy, Economic Development and Construction Act 2009. Greater Manchester published this scheme in March 2016 and, as provided for by the 2009 Act, the combined authority consulted on the proposals in the scheme.

The consultation ran from March 2016 to May 2016, in conjunction with the 10 local authorities in its area. The consultation was primarily conducted digitally, including promotion through social media. In addition, of course, respondents were able to provide responses on paper, and posters and consultation leaflets were available in prime locations across Greater Manchester. As statute also requires, the combined authority provided to the Secretary of State in June a summary of the responses to the consultation, and the Secretary of State concluded that no further consultation was necessary.

Before laying this draft order before Parliament, the Secretary of State has also considered the other statutory requirements in the 2009 Act. He considers that conferring these functions on the Greater Manchester Combined Authority is likely to improve the exercise of statutory functions in the area, and he has had regard to the impact on local government and communities, as he is required to do. Also, as required by statute, the 10 constituent local authorities and the combined authority have consented to the making of this order.

In conclusion, the draft order we are considering today, if approved and made, will confer local authority public health functions on Greater Manchester Combined Authority, enabling it to play a key role in improving the health of the population in Greater Manchester. I commend the draft order to the House.

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I thank the noble Lord for his explanation of the order. As I am going to touch on oral health in Greater Manchester, I declare an interest as president of the British Fluoridation Society.

The order is unexceptional and we support it. It takes a sensible approach, enabling the combined authorities in Greater Manchester to undertake public health duties which at present fall just to individual local authorities. The Greater Manchester Health and Social Care Partnership has published a very interesting population health plan, which has a lot of very good things in it, and I commend the local authorities and the combined authority for what they are doing.

I mentioned my interest in oral health. It is well known that Greater Manchester has very poor oral health. It is also well known that, at a stroke, this could be dealt with by the introduction of fluoridation in the water supply in the north-west. All I would ask is that when the order has gone through, Greater Manchester be gently urged, through the Minister’s good offices, that an improvement in oral health be one priority that the combined authority—and indeed the mayor, who I know is a passionate believe in fluoridation—might take on. I hope the Government will encourage them in the right direction.

The order proposes that for some interventions, there can be reductions in visits to urgent care, a reduction in the number of people with chronic conditions, and that 700,000 people will be able to manage their chronic conditions more effectively. But of course, this takes place in the context of a very rocky position for the NHS and social care. The funding gap and the demographic pressures on the health service are severe. Inevitably, this is going to impact on the effectiveness of what Greater Manchester can do on health and social care as well as public health.

--- Later in debate ---

[Lord Turnberg (Lab)]

My Lords, perhaps I may ask the Minister about infectious diseases and express my interest as a past chairman of what was the Public Health Laboratory Service and as a Mancunian. Infectious diseases know no boundaries, and it is important with any infectious disease outbreak, which may occur anywhere in the UK, that information is spread very easily to epidemiological centres and central laboratories, so that such outbreaks can be traced and checked. Is there anything in this agreement that will ensure that there is association, collaboration and co-operation with the central laboratory services?

[Lord O’Shaughnessy]

I thank noble Lords for their contributions and for their broad support for the order before the House today. As I outlined, it represents another significant milestone in the Government’s devolution agenda and I am glad that that has been welcomed across the House. I will try to respond to the various points that noble Lords have made.

Like the noble Lord, Lord Hunt, we support the idea of the population plan, which will clearly differ from place to place where there is this kind of devolution. I stress that an important and distinctive part of this plan is that it confers on the combined authority the same powers and responsibilities as a local authority. It is therefore about them acting concurrently, rather than in an overbearing way, or seeking to override.

I have been in your Lordships’ House long enough to know that fluoridation is an area of particular interest. I wonder only why it has taken so long for me to have to answer a question on it. This is a devolution deal, and it is therefore about those powers being taken locally and acting in concert. I do not think it is consistent with the idea of devolution for me to urge any combined authority to point in one direction or another, and it sounds like my noble friend Lady Gardner has been doing plenty of urging already. Any such move would have to be made in concert by all 10 of the local authorities and the combined authorities and be done through the usual processes of consultation and so on, with regard to all the responsibilities that attend on those public health powers. I hope that provides some reassurance to my noble friend Lady McIntosh.

[Lord Hunt of Kings Heath]

After the Strathclyde case and the ruling from Lord Jauncey, the then Conservative Government took legislation through both Houses of Parliament to make sure that fluoridation was legal and above board. That was based on evidence that has not been undermined since.

[Lord O’Shaughnessy]

I am trying to make the point that there is an established regulatory framework around such proposals. As noble Lords can tell, I am trying to avoid coming down on one side of the argument or the other. In the end, this is an issue both for local areas and for clinical opinion and research. On the broader position of public health, difficult decisions had to be made about local authority budgets as a consequence of the financial crisis and the deficit which it brought about. It is still the case that local authorities are getting £16 billion to spend on public health over the five years from 2015 to 2020. Alongside that, power and decision-making have been devolved to local authorities on using that money and combining it with other functions that have an impact on public health. One of these would be housing, the quality and condition of which has a huge impact on the public health of local people. You cannot both welcome devolution and say that local authorities should not have the power to act in different ways, so long as they comply with their statutory obligations. From that point of view, local authorities should not act outwith those obligations, whether in the case of contraception clinics or any other public health responsibility.

The noble Lord, Lord Beecham, asked about integration: I stress the point about pooling of budgets. As he will know, a chief officer for health and social care has been appointed in Greater Manchester. That person is an NHS England employee, because the NHS is a national health service and NHS functions have not been devolved. We are clearly trying to achieve greater integration of services, through the sustainability and transformation programme. We hope that doing this at a level where there is a degree of integration by the relevant local authorities will be fertile ground, and that it will provide evidence for and leadership in the move towards accountable care systems, which NHS England is now leading through its five-year forward view.

On the final point about information being spread to epidemiological centres, I again stress that this measure confers the powers of a local authority on to a combined authority, so it will absolutely have the responsibility to share data. Indeed, it will not be able to assume responsibility for any functions if the 10 local authorities do not want it to do so. Obviously, we hope that they will. Indeed, by committing to support this order, they have signalled their intention to do so. I reassure the noble Lord that there is absolutely no risk that these kinds of responsibilities will be watered down as a consequence of this order.

In conclusion, I hope that I have answered noble Lords’ questions and inquiries about the impact of this order on fluoridation and many other issues. It is an important order and I hope that all—

[Lord Hunt of Kings Heath]

I am sorry to intervene again but I have just reflected on what the noble Lord said about fluoridation. He seemed to say that he was not prepared to come down on either side. That sounds to me like a new statement of government policy, as traditionally government has been in favour of fluoridation.

--- Later in debate ---

[Lord O’Shaughnessy]

That is not what I am saying. I am saying that it is for Greater Manchester to decide if that is the course it wants to pursue. That is the topic we are discussing. I hope that I have answered all noble Lords’ questions.

Motion agreed.

South East Coast Ambulance Service

Lord O'Shaughnessy Excerpts

Wednesday 1st November 2017 Lords Chamber

[Baroness Smith of Basildon]

To ask Her Majesty’s Government how many 999 calls were made to the South East Coast Ambulance Service on 23 September to which no ambulance was sent; and what was the average waiting time for ambulance attendance on that day in that area.

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

My Lords, we do not centrally collect that level of information on ambulance trust activity. However, the latest available data published by NHS England shows that in August 2017 the South East Coast Ambulance Service received 68,855 emergency calls, 52,832 of which received a face-to-face response from the service. The median response time for emergency category A calls—that is, the most serious— during that month was 8.7 minutes.

[Baroness Smith of Basildon (Lab)]

My Lords, that does not really answer my Question. I could have picked any day to ask about but I specifically chose 23 September because on that day Bognor Regis Town Football Club called 999 six times and eventually, after almost three hours, had to take an injured player in considerable pain to hospital by car. That is not an isolated incident. This service is in special measures. A recent report exposed a toxic atmosphere, a culture of bullying and a fear of speaking out. The CQC confirmed that the service is inadequate. The noble Lord quoted figures at me but what is really important is that the response rate for 999 calls is getting worse. Only 50.8% of Red 1 calls and 39% of Red 2 calls—both of them codes for life-threatening situations—attended within the Government’s eight-minute time limit. This is the worst performance ever in the UK since these records have been kept. Will the Government now accept their responsibilities to the public and to National Health Service staff and step in to ensure both proper funding and decent and effective management?

[Lord O'Shaughnessy]

I would have liked to have given data at the level that the noble Baroness asked for but it is not available in a way that has been centrally assured by NHS England. I have a responsibility to provide good-quality, verified data, and I hope she will understand that. However, the bigger point, with which I do not disagree, is that this is the worst-performing ambulance trust in the country, and that is the case whether you look at calls data or performance standards for call-outs. The question, as she rightly points out, is what you do about it. The CQC rated the service as inadequate about a year ago and has just followed up. Unfortunately, it is still inadequate, although the CQC says that some progress has been made. About half a million pounds of special measures funding has gone in. A new CEO has been in place since spring this year, and the local sustainability and transformation partnership has asked the ambulance trust for a business-case bid for transformatory funding. Therefore, I realise that this is playing catch-up, because clearly the level of service is not good enough. I understand that the latest data month on month—that is, September compared with July—shows some improvement since bottoming out in July, but I agree with the noble Baroness that it has a long way to go.

[Baroness Andrews (Lab)]

How many ambulances are there across East Sussex and West Sussex at the moment compared with five and 10 years ago? If it is difficult to collect that information centrally, can the Minister make efforts to make it available to us in some other way? I ask that because I had reason to be involved with the ambulance service earlier this year. There is a terrific amount of stress and pressure on paramedics, although they do the very best they can. I would also like to know how many paramedics there are in the service compared with five and 10 years ago. After two years of special measures, it is really worrying that this trust is failing on basic issues of patient safety and response times.

[Lord O'Shaughnessy]

I do not disagree with the noble Baroness. I do not have the specific data on the number of ambulances in that area but I can tell her that the paramedic workforce in that particular ambulance trust increased from 635 in May 2010 to 992 in July 2017. So there are more people, but there is a huge growth in demand, which they have to meet. However, the truth is that there are other ambulance trusts all over the country that do a much better job with similar resources. Therefore, as much as anything, it is a question of leadership and management, and that is part of the special measures process.

[Lord Selkirk of Douglas (Con)]

My Lords, does the Minister accept that in the case of medical emergencies the wise use of defibrillators can, and sometimes does, make the difference between life and death?

[Lord O'Shaughnessy]

My noble friend is quite right to make that point. There has been a big effort to install defibrillators in a number of public settings—they are throughout the Palace of Westminster and many other workplaces. They make a big difference to that immediate response where it is needed.

[Baroness Jolly (LD)]

My Lords, around a million calls a year are made to the South East Coast Ambulance Service and there have been many reports of technical problems with the service. According to a CQC report, the first reports of these malfunctions, which affected the recording of calls, occurred in June 2016. Does the Minister have any information on how many recordings were lost? Have the specific circumstances around any patient’s arrival to NHS premises been lost?

[Lord O'Shaughnessy]

The noble Baroness is right about the technical problems. I understand that two new systems have been put in to address those; one is a computer-aided dispatch system and the other is the moving of the emergency operating centre to new premises. That is part of the special measures investment that has been taking place to improve the quality of service.

Health: Flu

Lord O'Shaughnessy Excerpts

Monday 30th October 2017 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what preparations are being made to deal with the anticipated rise in flu cases this winter.

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

My Lords, it is too early to predict the impact of flu this winter. As part of the Government’s preparedness, every trust has developed plans for the coming winter season. The seasonal flu vaccination has been offered to those at particular risk of flu, and to all health and social care workers. A nasal spray vaccine will be offered to all children aged two to eight years old to help to protect them and their families.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Last week’s Healthwatch report showed an alarming increase in the number of hospital readmissions, which have risen by nearly a quarter in four years. The survey also showed a rise of 29% of people readmitted to hospital as emergencies within 24 hours. Does not this raise huge concerns about patients being discharged unsafely and before they are medically fit in order to meet the Government’s empty beds targets, not to mention the trauma and upset caused to the patients themselves and their carers and families? Do the targets take account of readmissions? What additional funding and contingency plans are in place across NHS trusts and local authorities, if there just are not enough beds to cope with the winter flu crisis? Is not the Government’s flu preparedness in urgent need of review?

--- Later in debate ---

[Lord O'Shaughnessy]

The NHS has never been better prepared for winter and, indeed, for flu. There are something like 21,000 people eligible for free flu jabs this year, including, for the first time, care workers in the independent and voluntary sector. So that is good progress. Of course, we do not know how exactly it will play out.

On the point about readmission, the head of Healthwatch said that the data raises some big questions—and we would agree with that. Some work needs to be done on the quality of the data, and NHS Digital has been asked to look at it. One issue is having the right care settings for patients to be discharged to, which is why I am sure the noble Baroness will welcome the data published last week showing a £500 million-plus increase in health and social care spending on precisely that kind of provision.

[Baroness Morris of Bolton (Con)]

My Lords, a few weeks ago, I read an excellent letter by a doctor in a newspaper which said that, as well as having the flu jab to protect ourselves, we have a responsibility to those around us who are more vulnerable. I was shocked last year, when I went to the excellent drop-in centre that we have every year, to discover that one of the most vulnerable groups to influenza is pregnant women. Would my noble friend agree that that message of responsibility to others is a very powerful one, and one that should make us all stop, think and then be immunised?

[Lord O'Shaughnessy]

My noble friend is absolutely right. I fear that the Westminster flu clinic had run out of jabs when I went, unsuccessfully, to get mine, but I did have one last week. Her point was about super-spreaders and this is one of the reasons why young children aged two to eight—who are most likely to live in families with pregnant women—are now getting the nasal spray at nursery and in school. This is precisely to protect the families of those who are most vulnerable.

[Lord Clarke of Hampstead (Lab)]

My Lords, I am sure that the possibility of people getting vaccinations in places such as Sainsbury’s and Boots while they are doing the shopping is a very good thing. I talked about this to a doctor friend at the weekend and was told that the pharmacists in those places get paid more for these vaccinations than doctors in their surgeries. Can the Minister confirm whether this is the case? If it is, it is a bit unfair to the NHS people.

[Lord O'Shaughnessy]

I was not aware of that particular fact, but I will look at the issue of the tariffs. Vaccinations are available in a range of settings: nurses, schools, shopping centres, even the Houses of Parliament—and, of course, community pharmacies, which have a critical role to play as one part of the strategy. Something like a million people have already been vaccinated in them so far this year. I will write to the noble Lord with the specifics on the tariff.

[Baroness Jolly (LD)]

My Lords, the Minister has, quite rightly, said that community pharmacies are a really important place to seek one’s flu jab. However, the owner of Lloyds Pharmacy, Celesio UK, has announced that nearly 200 of its local chemist’s shops will cease trading. What assessment have the Government made of the potential clinical impact of this decision? What pressures will follow next winter as a result?

[Lord O'Shaughnessy]

I agree with the noble Baroness about the role of community pharmacy. It is worth bearing in mind that some 88% of people are within a 20-minute walk of a community pharmacy, which is accessible for the vast majority. There are also 20% more pharmacies than there were 12 or 13 years ago. Pharmacies have a critical role to play and are there in the community, but companies come in and out all the time.

[Baroness Meacher (CB)]

My Lords, I talked to a very senior NHS consultant this morning. To my absolute amazement, he said that the latest research showed that compulsory flu jabs for NHS staff provide no significant improvement at all in patient health. This is rather striking and a bit unexpected. Does the Minister have any different research evidence?

[Lord O'Shaughnessy]

That is unexpected and would be worrying if it is true. That is not the information on which we have based our policy. Our information is that, for most people—though not all—flu jabs are effective in mitigating the risk of flu in care settings.

[Baroness Manzoor (Con)]

My Lords, the World Health Organization recommends what strain of vaccine should be developed, nine months to a year ahead. This happened before the Australian epidemic which affected the elderly and killed many people. Will the Minister confirm that the vaccine which has been developed here in the UK is both effective and relevant and that the young and elderly people do need to access it?

[Lord O'Shaughnessy]

My noble friend is absolutely right. Back in September, Simon Stevens, the head of the NHS, warned about the impact of the flu epidemic in Australia and New Zealand. The feedback on that was that the particularly vulnerable groups were the over-80s and five to nine year-olds. We have talked about helping younger children through school-based immunisation. We also have the highest uptake in Europe of over-65s getting flu jabs. There is clearly more to do because around one-third of people still do not.

[Lord Winston (Lab)]

My Lords, will the Minister reconsider his statement, in answer to the Question, that the NHS has never been better ready for a flu outbreak? The problem with viral infections, like pandemics, is that they are completely unpredictable and often hit in a way that we never expect. They remain one of the biggest single threats to humanity. I hope he understands that this unpredictability is a very real issue with all these infections, including influenza, as history has shown us.

[Lord O'Shaughnessy]

The noble Lord is, of course, quite right: we cannot know what will hit us. However, we can prepare in advance as much as possible. That was the sense I meant to convey—namely, that a huge amount of preparedness has gone on for not just flu but the winter. That work started in the summer—earlier this year than ever before. The flu vaccination on offer covers the strains that Public Health England thinks are most likely to come, but, of course, we cannot predict exactly what will happen.

Child and Adolescent Mental Health Services

Lord O'Shaughnessy Excerpts

Monday 30th October 2017 Lords Chamber

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

My Lords, the Government are committed to making sure that 70,000 more children and young people each year will receive evidence-based mental health treatment by 2020-21. Since publishing Future in Mind, the Government have made an additional £1.4 billion available to improve children’s mental health. Key mechanisms for delivery are local transformation plans, which cover the full spectrum of mental health, and the upcoming children and young people’s mental health Green Paper, which will contain proposals for further improving access to services.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that early intervention is essential to prevent escalation into crisis and lifelong problems? Is he aware that the number of CAMHS psychiatrists fell by 6.6% between 2013 and this year, while demand for their services rose? The number of qualified doctors who go into psychiatry is 2.6%, the lowest of any specialism, and some universities do not send any. Will he consult Health Education England to find out what it is doing about this, because the pipeline is drying up?

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight the fact that we need more staff to meet the mental illness burden in society, which is sadly growing. I hope that she will have seen that Health Education England has announced that there will be 21,000 more mental health staff by 2021, of which 13,000 will be qualified clinical staff, including 700 more doctors. The warning she has made has been heard loud and clear and those changes have been made.

If I may, I would like to use this opportunity to say that I made a mistake in my previous answer, when I talked about there being 21,000 people eligible for flu jabs. If that really was true, that would be a poor place to be. It is actually 21 million, which is slightly more reassuring.

[Baroness Pitkeathley (Lab)]

My Lords, I would like to ask the Minister about the 700,000 young carers, who often have severe mental health needs because of the stress of the duties they undertake, as he will know. We had high hopes of specific action for young carers in the refreshed carers strategy, but I understand that this is being rolled up into the consultation on the social care Green Paper. I am concerned and would like to be reassured that the Government have not abandoned the long-awaited carers strategy. If we are waiting for the social care consultation, how will he ensure that the mental health needs of young carers are urgently addressed?

[Lord O'Shaughnessy]

I know that the noble Baroness cares passionately about this group of people. My understanding is that those policy issues are being considered in the round with the social care consultation. I shall write to her to clarify that point. She might like to know that, in the upcoming Green Paper on children and young people’s mental health, there will be an expansion of some of the work that has already gone on around providing mental health first aid and various other things in schools, which will capture some of the young people that she is talking about.

[The Archbishop of Canterbury]

I declare an interest as having members of the family who have used child and adolescent mental health services. Does the Minister not agree that the fundamental principle of the NHS is free treatment at the point of need? Does he also agree that one of the major failures in CAMHS—it has been well evidenced by academic studies over the last two years—has been that, because of the shortage of resources, only those with the most critical needs are treated at all, and the early intervention which would help prevent needs becoming critical has been deeply neglected owing to an absence or lack of specialised therapies, particularly talking therapies? Will he confirm that the work on the most critical side is going to be extended so that children and adolescents can get care earlier and more effectively, saving the state money and fulfilling the purposes of the NHS?

[Lord O'Shaughnessy]

Yes, I wholeheartedly agree with the most reverend Primate. We are making up for lost time, unfortunately, with children and young people’s mental health care and there is a lot to do. He will be pleased that the additional funding being provided is helping with the rollout of the children and young people’s IAPTs—the talking therapies. As I said, the intention of the extra funding is to be able to treat 70,000 more young people, on top of those who have already been treated, by 2021—so more young people are being seen. That will increase the 25% of the potential caseload currently dealt with to 35%. Obviously that is better but it is not the whole way.

[Lord Farmer (Con)]

My Lords, following on from that question, I ask what the Government are doing in relation to preventing children’s mental health problems by addressing parental conflict and family breakdown.

[Lord O'Shaughnessy]

That is an incredibly important point because good relationships are very influential on young people’s mental health, and the Green Paper will look at the role of family conflicts. My noble friend will be pleased to know that the Department for Work and Pensions is launching a programme to reduce parental conflict in conjunction with the Early Intervention Foundation. I hope that it will have some positive benefit in reducing parental conflict, which is, of course, one of the causes of mental illness.

[Lord Brooke of Alverthorpe (Lab)]

Does the Minister accept that there is a wide variation in the offering of services between one geographical location and another? Will the Green Paper which is being prepared address this, and how quickly will it be resolved?

[Lord O'Shaughnessy]

The noble Lord is right about variation, sadly. We had the CQC thematic review on mental health provision at the end of last week, which showed that 80% of specialist in-patient care is good or outstanding but that that is true of only two-thirds of community care provision, with around a third either requiring improvement or inadequate. That is clearly not good enough. Patchy provision is absolutely one of the things that we need to deal with. The best way of doing that is by expanding both the number of children being treated and the size and quality of the workforce, to help us to meet our targets.

[Baroness Jolly (LD)]

According to a Guardian article last month, English CAMHS is struggling to satisfy the rapidly growing demand of referrals. We all know this. Within the past decade, 68% of admissions into hospital because of self-harm were girls under the age of 17. What are the Government doing to decrease the number of young girls inflicting self-harm?

[Lord O'Shaughnessy]

Again, this is one of the most difficult issues. Two hundred thousand people a year are admitted into the health service with self-harming injuries. Twenty per cent of young women under the age of 24 have said that they have self-harmed at some point in their lives—that is one in five. There are now NICE guidelines on self-harm and its treatment and there will be a new care pathway by 2019. However, I do not underestimate how difficult it is to crack this problem.

NHS: Winter Staffing Levels

Lord O'Shaughnessy Excerpts

Thursday 26th October 2017 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government what plans they have to increase staffing levels in the National Health Service to meet anticipated demand during the forthcoming winter period.

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

My Lords, providing appropriate staffing over winter is essential. NHS England and NHS Improvement have worked together to make sure that every major consultant-led emergency department has a robust plan to meet demand. This includes necessary staffing levels. In addition, the department has provided £100 million to relieve pressure on urgent and emergency care specifically to allow primary care streaming and improve patient flow in A&E departments.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his reply. Those are soothing words, but I am afraid not really matched by the reality on the ground. It is clear that we face a dire prospect this winter on account of the Government’s poor labour planning over the years they have been in power. We know that we are 40,000 nurses short, GP numbers are tumbling and adult social care staff numbers have fallen from 70,000 to 48,000 in four years. Last year, 45% of the consultant posts advertised were not able to be filled. We really are in a very difficult position.

I ask the Minister a very specific question: is it true that the Government have given the go-ahead for vulnerable patients who are not fit to be discharged to their home to be discharged to third parties? They will be allocated to homes where the hosts have no medical expertise and for which they will get paid £1,000 a month.

[Lord Clark of Windermere]

This is my final question. Will the Government not listen to medical opinion and drop this preposterous scheme?

[Lord O’Shaughnessy]

The noble Lord knows that winter is always a more difficult time for the NHS. I hope he also knows that there are 11,000 more nurses on wards than there were in 2010. Indeed, I was looking at the data on doctors. There has been a 30% uplift in emergency doctors in that time as well. So there are more staff in the NHS—but, of course, there is much more need for winter preparedness. The NHS feels that it is better prepared than ever for winter.

On the issue that the noble Lord refers to—I assume he is talking about the story in the press today—that is, I stress, a local pilot that is being explored. I do not think it is even under way. It is being proposed by a local doctor—indeed, an emergency registrar. For it to go ahead, it is clear that any such pilot would have to abide by the very strict rules that exist on safety, safeguarding quality and so on for any care setting. The head of Age UK said that any new innovation—I think we want to encourage innovation—needs to pass the mum or grandma test. I think that is a very reasonable test to apply to something such as this.

[Lord Ribeiro (Con)]

My Lords, the only way in which to increase staffing levels in anticipation of the flu epidemic is through agency staff, which is going to cost a huge amount of money. Surely, the better thing to do would be to ensure that all health staff are vaccinated so they are at least healthy when the epidemic hits us—if it does.

[Lord O’Shaughnessy]

My noble friend talks with great authority on this issue and he is quite right. The NHS is offering all front-line health staff free vaccinations. NHS England has confirmed that it will also be paying for care workers in social care settings to get free jabs. Furthermore, we are now, for the first time, inoculating in school children aged between two and eight, who are sometimes known as “superspreaders”. This is to ensure that, if such an epidemic were to happen, we would be as well prepared as ever.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister join me in acknowledging the stance being taken by the NMC in seriously considering changes to the English language test to make it more relevant to nursing practice, while maintaining patient safety? This has the potential to increase significantly the recruitment of overseas nurses in the UK. I also seek assurance that the Government will not cut investment in district nurse training.

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for raising this. We have discussed a number of times the impact of the test on recruitment from countries other than the UK. It is entirely sensible for the NMC to look at this. On nurse training, I hope she will have been reassured by the announcement from my right honourable friend the Secretary of State for Health at the Conservative Party conference that we will deliver a 25% increase in nurse training places from 2018-19 onwards.

[Lord Rennard (LD)]

My Lords, is not part of the problem for the NHS, and for hospitals in particular, during the winter that so many people have difficulty in accessing their GP? The number of GPs has fallen by 3% over the last two years. Is it not, therefore, counterproductive that the Government have been cutting funding for community pharmacies when many more people should be seeing their pharmacist and not seeking to see their GP or even turning up at A&E units?

--- Later in debate ---

[Lord O’Shaughnessy]

We recently debated community pharmacies. Reforms have ensured that most people—more than 80%—are within a 20-minute walk of a community pharmacy. As a consequence of these reforms, there has been no decrease in the number of community pharmacies in England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the case raised by my noble friend relating to Essex goes to the heart of the problem of discharging patients from NHS hospitals because of the lack of support in the community from social care and the reduction in nursing home places during the last four years. Is the Minister as surprised as I am that, despite this, up and down the country the NHS, through its sustainability and transformation plans, is putting forward proposals to cut out community hospitals and community hospital beds? Will Ministers issue an instruction to the NHS so that this will not be allowed to happen?

[Lord O’Shaughnessy]

We have discussed the issue of nursing home beds. We also know that there has been an increase in the provision of domiciliary care packages which reflects people’s changing care needs. Figures published yesterday show that social care spending has risen by £500 million during 2016-17. I am sure this will be warmly welcomed across the House. On community beds, noble Lords should know that, in addition to the usual four tests for reconfigurations, last year Simon Stevens, the head of NHS England, said that there is now a fifth test—the bed test. There must be robust evidence that any proposed reduction in beds is because of a reduction in demand and not the other way round.