Health: Stroke

Lord O'Shaughnessy Excerpts

Wednesday 14th November 2018 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what progress they have made in developing a national plan for stroke.

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

My Lords, a stroke programme board was established in March 2018, co-chaired by NHS England’s national medical director, Professor Stephen Powis, and the CEO of the Stroke Association, Juliet Bouverie. Following this, the NHS long-term plan will include a focus on cardiovascular disease and stroke, and is set to be published before the end of this year.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. While the promise of including the national stroke plan in the full NHS long-term plan is welcome, nevertheless publishing it in its own entity after the national strategy ran out last year would surely have helped to sustain the progress and momentum since 2010, particularly in the reconfiguration of stroke services. Instead, thousands of stroke survivors say that they feel abandoned after they come out of hospital: 70% of patients are not offered a personalised care plan for their ongoing treatment, care and support; only 30% of CCGs are commissioning the vital six-month reviews of their progress and problems; one in four hospitals does not have access to stroke specialist early supported discharge at home; and, on average, stroke survivors wait 10 weeks for urgent psychological support. What action are the Government taking to ensure that CCGs tackle these problems now?

[Lord O'Shaughnessy]

I understand the noble Baroness’s frustration about the gap between the strategy and the plan but it was right to include the work undertaken on the stroke plan within a long-term plan, because clearly that covers every aspect of how the NHS is working. In the meantime, I point out to her that the NHS RightCare programme for cardiovascular disease has been set up. It is aimed specifically at dealing with some of the variation in service that she talked about. But there is good news in stroke care: not only is there less incidence than 10 years ago but 30-day mortality rates have more than halved, so there is progress which we need to build on.

If the noble Baroness and the House will allow me, I would like to use this opportunity to pay tribute to my noble friend Lord Skelmersdale, who died very recently. He was a predecessor in this role and a great champion of stroke care, both as a Minister and as chair of the Stroke Association for 10 years. I am sure that everyone in the House would offer their sincere condolences to his family and friends.

[Baroness Finlay of Llandaff (CB)]

My Lords, will the Government outline the plans to roll out thrombectomy, which is sucking out the blood clot and is done under remote X-ray control? It has massively improved outcomes, even on thrombolysis, which tries to dissolve the clot. Such services need to be available across the UK on a 24/7 basis because stroke does not respect the clock or the calendar.

[Lord O’Shaughnessy]

The noble Baroness is absolutely right. In 2017, NHS England announced a rollout of the mechanical thrombectomy procedure to 24 centres across England. It is expected that 10% of stroke patients will be eligible. It leads to big reductions in disability after stroke, is now approved by NICE, and will be a significant part of the long-term plan which we will publish by the end of the year.

[Baroness Gardner of Parkes (Con)]

My Lords, my husband had a stroke and it was not recognised. It was a clot. He got to the hospital rather late and his arm was definitely damaged for ever more. He died 10 years ago; the stroke did not affect his continuing to live. The hospital in Newcastle was so far ahead in clot-busting that it was three years ahead of London. I remind the House of how much effort Lady Rendell, who is no longer with us, put into Act FAST, a campaign to let people know pretty quickly what the symptoms are and not to delay so that they have more hope of being successfully treated. We have made great progress, but there is a clearly a lot more to make.

[Lord O’Shaughnessy]

I did not know that my noble friend’s husband had had a stroke; I am grateful to her for sharing that with the House. She is right that the examples of Newcastle and Northumbria have shown that hyperacute stroke units—the centralisation of services—save lives. Closing hospitals or changing services can be controversial, but in stroke we know that it makes a big difference. It is a focus of what we need to do, and we need to take courage on that. The Act FAST campaign, which my noble friend mentioned, has been incredibly successful in making sure that we get fast action when people have a stroke. More than 5,000 fewer people have been disabled by stroke since that campaign started.

[Baroness Jolly (LD)]

My Lords, when the national stroke plan is finally published, we should expect clinical elements. I hope that we will see some lifestyle elements around protection from stroke and stroke prevention. What actions are being discussed with Public Health England on the prevention part of the plan? Can he guarantee sufficient funding for local authorities to deliver it?

[Lord O’Shaughnessy]

The noble Baroness is right about prevention. There are lots of ways that we can prevent stroke, including by reducing hypertension, obesity and other things. Of course that will be a big part of it. She will know that decisions about funding for Public Health England will be taken at the spending review.

[Lord Mackenzie of Framwellgate (Non-Afl)]

My Lords, the Minister will be aware that one of the medical conditions that can lead to stroke is atrial fibrillation. The important thing is to treat the patient once it is discovered. Some time ago, I attended a demonstration in the Palace of Westminster where patients put their hand on to a machine which detected whether they had that problem so that they could be treated. The idea was that the machine would be rolled out into doctors’ surgeries so that people could use it while they were waiting. How is that scheme progressing?

[Lord O’Shaughnessy]

The noble Lord is quite right that patients with atrial fibrillation have a five times greater risk of stroke. Most patients are diagnosed but about 300,000 are not yet, so finding them is critical. The tests are available now not just in GPs’ surgeries but increasingly in pharmacies. I will write to him with specific details about the rollout.

[Baroness McIntosh of Hudnall (Lab)]

Of course the prevention and treatment of stroke is very important, but unfortunately some people have strokes and are incapacitated by them, sometimes physically but sometimes mentally as well. What work are the Government doing to ensure that as many people as possible register a lasting power of attorney so that, when that bad thing happens to them, a proper care plan is available?

[Lord O’Shaughnessy]

I will need to write to the noble Baroness with specific details on promoting lasting power of attorney. There has been an improvement in the availability of occupational therapy for those who suffer disabilities from stroke, but I do not know whether there is support in terms of planning ahead.

NHS: Staff

Lord O'Shaughnessy Excerpts

Tuesday 13th November 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty's Government what plans they have to ensure that British citizens are recruited and trained to staff the National Health Service.

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

My Lords, the Department of Health and Social Care is working with a range of partners to improve the recruitment and retention of staff required to deliver safe and effective NHS services. In England, we are increasing domestic doctor training places by 25%, there are now more than 52,000 nurses in training, and we have made more funding available to universities. Furthermore, we are increasing midwifery training places by 3,000 over the next four years.

[Lord Clark of Windermere (Lab)]

My Lords, I thank the Minister for his Answer, which is a little disappointing. I remind him that there are currently 100,000 vacancies in the National Health Service. There is a shortage of doctors, nurses, physiotherapists and radiographers, and I could go on. There is a shortage throughout the service, and it is no good the Government telling us what their aspirations are. In the light of the Chancellor’s Budget Statement, in which he concealed that there is to be a £1 billion cut for the NHS in the year beginning in 2019, will the Minister explain how the cut in funding for the training of nurses, doctors and other members of staff coincides with the aspirations he has told us about? And please, do not give any excuses whatever about the pension miscalculation.

[Lord O'Shaughnessy]

We agree that there is a need for more staff, and indeed there are more NHS staff than ever. I can tell the noble Lord that we are increasing doctor, nurse and midwife training places, and more GPs than ever started training in the NHS this year. With an ageing and growing population, we absolutely recognise the need for more doctors, nurses, midwives and many other professions. The Budget made no changes to health spending.

[Lord Forsyth of Drumlean (Con)]

My Lords, will my noble friend acknowledge that, as nurses are not paid highly, they will not repay the loan for their maintenance grant or tuition fees? Therefore, would it not make sense to allow them to go back to bursaries? In the long run, this would save the taxpayer money and mean that 30 years from now we would not have to write off a substantial loan—or, rather, the nurses who have not benefited from that support would not have to pay to write off that loan. Is it not time that the Government looked at the fiscal illusion that has led to this state of affairs and moved instead to a system that would help in the recruitment of more nurses?

[Lord O'Shaughnessy]

I greatly respect my noble friend on this topic, which we have gone around several times. As he knows, I defend the current system as being the most progressive. Nevertheless, I am grateful for his report, which he sent me and which I am reading with interest. However, at this point, we are confident that we have the right policy.

[Baroness Emerton (CB)]

My Lords, how are the Government determining the safe level of staffing? In the Health and Social Care Act, one of the requirements was to look for safe levels. Could the Minister tell us how the Government will assure us that they are safe levels?

[Lord O'Shaughnessy]

I am grateful to the noble Baroness for that question. First, we have safe levels by recruiting more staff. We recognise that there is a need for it, and we are recruiting more staff in every category. The actual safe level of staffing is a trust-level issue that needs to be determined in response to the case load they have at any moment.

[Baroness Jolly (LD)]

My Lords, I understand that medical students in England could soon be fast-tracked through their studies, advancing registration by a year. This would put them on wards one year earlier, with a year’s less training than their predecessors. What is the Government’s current thinking on this? Who are they consulting? What risk analysis will be done in making this decision?

[Lord O'Shaughnessy]

The noble Baroness will understand that the safety of NHS patients, and the NHS as a whole, is paramount when considering workforce. We are looking at whether additional flexibilities can be explored, but that will only be done if we can assure ourselves and others of that safety. These issues are being considered in the workforce plan.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the Government have placed great emphasis on mental health recently. Could the Minister tell the House what is the current shortfall of mental health professionals—particularly psychiatrists, and particularly child psychiatrists—in the National Health Service, and how the Government intend to address that shortfall?

[Lord O'Shaughnessy]

The noble Baroness is right to highlight that issue. Only around 30% of those who should be seen for treatable mental health illnesses currently are, which means that we have an important and urgent task to expand mental health places. There simply are not enough mental health staff in any category. This affects all developed countries. A big expenditure is being made, and around 21,000 new posts are being created across all specialties.

[Lord Lansley (Con)]

Does my noble friend agree that the production of a workforce plan by Health Education England for the first time is a significant step forward for the health service and for healthcare in this country? Will he assure the House that providing Health Education England with the resources to deliver that plan is a priority in the forthcoming spending review?

[Lord O'Shaughnessy]

I am grateful to my noble friend, who set the foundation for this long-term workforce plan—indeed, the long-term plan for the NHS. He is right. It is not just a workforce plan for health workers but also looks at care workers. We need more staff, and that decision will be taken at the spending review, but it does have the highest priority.

[Lord Laming (CB)]

My Lords, does the Minister agree that the concerns expressed in this Question apply equally or even more to social care services? Unless social care is adequately staffed, the rebound on the health service will be enormous. I hope that, in future, social care will be given priority along with the health service.

[Lord O'Shaughnessy]

I agree. Indeed, my Secretary of State has made workforce one of his top priorities. We are responsible for health and social care, and the Green Paper we will publish this autumn will contain more detail on the social care workforce plan.

[Baroness Thornton (Lab)]

My Lords, 63,000 NHS staff in England are EU nationals; that is 5.6% of all staff. London in particular relies on staff from EU countries, with one-third of all EU NHS staff working in London. We seem to be facing a Brexit emergency here. How will the Government manage both the transition and the long-term recruitment and staffing of the NHS under these circumstances?

[Lord O'Shaughnessy]

EU nationals and staff from across the world play a vital role in delivering our NHS and social care and we absolutely want them to stay. I can tell the noble Baroness that there are 4,300 more EU 27 nationals in the NHS now than in June 2016. I hope that is a reflection of the fact that they know they are wanted and welcome. We are making sure that the settlement scheme is open to them. Health and care staff will be the first cohort of staff to use the scheme, so that we can give them the opportunity to remain where they are very much wanted.

Vaping

Lord O'Shaughnessy Excerpts

Tuesday 13th November 2018 Lords Chamber

[Lord Vaux of Harrowden (CB)]

I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I declare that I hold shares in British American Tobacco, which are below the threshold for registration.

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

My Lords, strong controls are already in place. Vaping fluids containing nicotine are regulated through the Tobacco and Related Products Regulations 2016, which include measures to restrict their use by children. The nicotine inhaling products regulations 2015 make it illegal to sell such liquids to anyone under the age of 18. The Advertising Standards Authority includes a provision in its codes to ensure that advertisers do not target or feature children.

[Lord Vaux of Harrowden]

I thank the Minister for his Answer. However, the regulations do not seem to be working. Flavours include bubblegum, sherbet lemon, unicorn blood and strawberry delight, and come in colourful packaging with cartoon characters and pictures of sweets, for use with high-tech shiny gadgets. It would be hard to design something that was more appealing to children. According to recent tests, four in 10 retailers are willing to sell without age restrictions. In the US, the FDA says that underage use has surged recently and reached epidemic proportions. Does the Minister agree with the commissioner of the FDA, who said:

“I believe certain flavors are one of the principal drivers of the youth appeal of these products”?


Will he please look again at the rules and how they are enforced, just as the US is now doing aggressively, before we too have an epidemic of childhood nicotine addiction?

[Lord O'Shaughnessy]

The FDA has certainly said that it is facing an epidemic of childhood use, but the numbers are quite stark in their difference. In America, many more young people use e-cigarettes compared to in this country, where only 2% of 11 to 18 year-olds are using once a week. Generally, those are young people who smoke already—around 7% of 15 year-olds smoke. America did not restrict tank sizes until recently, but we did; it did not restrict bottle sizes, but we did; it did not ban advertising, but we did; and it does not have restrictions on nicotine, but we do. We have a very sensible system. I am not complacent about the need to make sure that young people do not use, which we are not seeing yet, and there are severe restrictions and punishments for any retailer who sells such products to children.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is it not clear from the evidence that, while we have to be very careful about use by young people, this is the most successful tobacco prevention or stopping measure we have ever had? It is important that we keep a measure of balance in our approach to this.

[Lord O'Shaughnessy]

I completely agree with the noble Lord, and I think that we have the right balance: 57,000 people a year quit smoking through e-cigarette use and that is just about the most important thing you can do to improve your health.

[Lord Brabazon of Tara (Con)]

Is my noble friend aware that the majority of people who use e-cigarettes—an enormous majority—are those, like myself, who have given up smoking cigarettes, and those who are trying to give up smoking cigarettes? All health professionals now recognise that e-cigarettes are the way forward and the best way to give up smoking. To introduce a ban on the sale of vaping liquids would be a complete catastrophe. Not only would people go back to smoking but those who wanted to give up would have no incentive to do so.

[Lord O'Shaughnessy]

I completely agree with my noble friend. Interestingly, ONS data shows that 48% of people said that the main reason for using an e-cigarette was as an aid to stop smoking, and just 1.5% cited the range of flavours available as their main reason.

[Baroness Jolly (LD)]

My Lords, the European tobacco products directive bans all broadcast media in the EU from advertising e-cigarettes. Will the Minister tell the House what the Government’s post-Brexit plans are?

[Lord O'Shaughnessy]

Our post-Brexit plans are the same as our pre-Brexit plans—to have a sensible policy which provides e-cigarettes to stop smoking and to make sure that they are not abused by people who should not be using them.

[Baroness Thornton (Lab)]

The noble Lord, Lord Vaux, asked a legitimate Question about the flavoured nicotine substitutes that are on sale. If the Minister believes that we might see the emergence of vape flavours such as unicorn milk and rocket popsicles—which can only be designed to appeal to young people—can he confirm that the Government have plans for dealing with that?

[Lord O'Shaughnessy]

I am not sure who unicorn milk would appeal to—maybe my five year-old, but she is not smoking yet. Seriously, the point here is about advertising. It is quite right that they cannot be advertised to promote them but they can be advertised for public health reasons. They are incredibly effective at stopping people smoking. As I have said, we are not seeing the kind of abuse and the epidemic of youth usage that we have seen in the States, but we are alert to any signs that that may be the case.

[The Lord Bishop of Chelmsford]

My Lords, the Minister’s joke makes the point. Does he agree that such flavours appeal to children and one needs to be careful about that?

[Lord O'Shaughnessy]

The right reverend Prelate is right. However, as I say, we do not see evidence of what is going on in the States happening in this country. The reason for that is that we have many more restrictions, and the US is now playing catch-up by introducing them.

[Lord Foulkes of Cumnock (Lab)]

My Lords, is the Minister aware that one of the consequences of the welcome ban on smoking in public places is that when you go out of a hospital or an airport you face a curtain of smoke and a carpet of fag ends? Will the noble Lord, as Health Minister, with his colleagues, do something about ensuring that that does not take place and that there are secluded places for people to smoke where the rest of us do not have to go?

[Lord O'Shaughnessy]

I agree with the noble Lord from personal experience. Organisations are encouraged to make sure that there are outside places for people to smoke which are in discreet areas and do not interrupt others.

[Earl Cathcart (Con)]

My Lords, vaping has been a phenomenal success in helping millions of people like myself to stop smoking or to cut down. What plans does the Minister’s department has after Brexit to remove the restrictions imposed by the EU’s tobacco products directive?

[Lord O'Shaughnessy]

I am sorry to disappoint my noble friend but at this point we do not have any specific plans. We have a sensible policy which allows the promotion of e-cigarettes to help people stop smoking but does not encourage people to take them up in the first place, which may lead to smoking. We have struck the right balance at the moment.

Government Vision on Prevention

Lord O'Shaughnessy Excerpts

Tuesday 6th November 2018 Lords Chamber

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

My Lords, with the permission of the House, I will repeat a Statement made in another place by my right honourable friend the Secretary of State for Health and Social Care on the publication of the Government’s prevention vision document. The Statement is as follows:

“Last week, the Chancellor confirmed that the NHS budget would rise by £20.5 billion over the next five years, because we care about the NHS being there for everyone. As well as money, however, reform is crucial. Before Christmas, we will bring forward a long-term plan for the NHS. We know that so much of what contributes to good health comes not just from what happens when someone is in hospital but from what we do to stay out of hospital. Prevention is better than cure. Today, I have laid before the House our vision for the prevention of ill health. It covers what the NHS needs to do, including more funding for community and primary care and the better use of technology. The plan also outlines what we need to see more broadly; everyone has a part to play.

As well as the rights we have as citizens to access NHS services, free at the point of use, we all have responsibilities too. Individuals have responsibilities, and we want to empower people to make the right choices. For instance, smoking costs the NHS £2.5 billion each year and contributes to 4% of hospital admissions. That is despite the massive reduction in smoking over the past 30 years. The next step to a smoke-free society is targeted anti-smoking interventions, especially in hospitals.

As well as stopping smoking, we must tackle excess salt. Salt intake has fallen 11% in just under a decade, but if it fell by a third, that would prevent 8,000 premature deaths and save the NHS over £500 million annually. We are working on new solutions to tackle salt, and we will set out more details by Easter and deliver on chapter 2 of our obesity plan too.

Next, prevention can save money and eliminate waste. At the moment, it takes too long, with too many invasive tests, to diagnose some illnesses. Doctors often have to try several different treatments before they alight on what is right for a patient. However, two new technologies—artificial intelligence and genomics—have the potential to change that. I want predictive prevention to help prevent people becoming patients and to deliver more targeted interventions with better results when people do fall ill. Instead of simply broadcasting messages to the nation, technology allows us to support much more targeted advice, messages and interventions for those most at risk.

Turning to environmental factors, our health is not determined only by what happens in hospitals. In fact, only a minority of the impact on anyone’s healthy lifespan is delivered by what hospitals do. The other factors include the air we breathe, whether someone has a job and the quality of our housing. That means our GP surgeries, our hospitals and our care homes all working more closely with local authorities, schools, businesses, charities and other parts of our communities.

Of course, the record number of people in work is good news on that front, and employers have a big role in helping their staff to stay healthy and to return to health after illness. That is where we can learn from the excellent record of our brave armed services, which have an 85% return-to-work rate after serious injury, while the equivalent rate for civilians is only 35%. Building on all that, the Government will next year publish a Green Paper on prevention, which will set out the plans in greater detail. This is all part of our long-term plan for the future of the NHS.

If I may, I will now address two separate issues that I know are of interest across the House today: the treatment of those with learning difficulties and autism, and the medical use of cannabis. Since becoming Health and Social Care Secretary, I have been shocked by some of the care received by those with autism and learning difficulties. Where people deserve compassion and dignity, they have been treated like criminals, and that must stop. Like everyone across the House, I have been moved by the cases of Bethany, Stephen and so many others, whose stories have laid bare what is wrong with our system and what needs to change. I have instituted a serious incident review, but this is not just about individual cases; it is about the system.

Three years ago, the Government committed to reducing the number of people with learning disabilities or autism in secure mental health hospitals by at least a third. Currently, it is down by a fifth, but that still leaves 2,315 people with learning disabilities or autism in mental health hospitals. I want to see that number drastically reduce. I have asked the NHS to address that in the long-term plan, and I know that its leadership shares my determination to get this right. I have also instigated a Care Quality Commission review into the inappropriate use of prolonged seclusion and segregation. The long-term use of seclusion is unacceptable both medically and ethically. It must stop. The review will recommend how to protect vulnerable people better and how to ensure that everyone is cared for with the compassion, respect and dignity they deserve.

On the prescription of medicinal cannabis, I pay tribute to my right honourable friend the Member for Hemel Hempstead, my honourable friend the Member for Dover and the honourable Member for Inverclyde for their campaigning on this issue. We have changed the law to make it possible to prescribe medicinal cannabis where clinically appropriate. Urgent cases have been brought to my attention, including concerns that those who have received treatment on an exceptional basis are now being denied that treatment. There is no reason for that to happen. The treatment of each individual patient is, and must be, down to the decision of the specialist doctor, working with patients and their family to determine the best course of treatment for them.

I met the head of the NHS on that this morning, and I have immediately instigated a system of second opinions. We have put out a call for research to develop the evidence, and we have also commissioned the National Institute for Health and Care Excellence to produce further clinical guidance on this issue. No one who currently gets medicinal cannabis should be denied it, and there is a system in place now for those who need to get it in future.

We want to deliver the best possible care to the most vulnerable, and we want to help build a more sustainable health and care system for all. Today’s announcements will help to do that, and I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, at last we have a Secretary of State who has been listening to my speeches over the years, or perhaps, more realistically, he has come to the same conclusion all by himself that the NHS is unsustainable with the changing demographics and higher demand unless we do something to prevent the 40% of illnesses that are preventable. I am therefore delighted to welcome the Secretary of State’s new focus on prevention.

However, he said in his speech yesterday that it is difficult to divert money into prevention unless funding is rising, because otherwise you will be taking money from treatment. Well, funding is rising. The Minister spoke about diverting part of the extra £20 billion for the NHS into prevention, but that is only part of the answer. This a whole-government problem. People do not live in hospitals or GP surgeries. They live in cities with polluted air, often in overcrowded and damp homes, in areas with too many fast-food outlets and too few fruit and vegetable shops where the local sports centre or swimming pool has closed. They are stressed about paying the bills on low wages or benefits.

Then there are lifestyle decisions. Often when people are in their own homes or the local pub, they smoke or send out for a high-fat and high-salt takeaway or drink too much alcohol. Many do not take enough exercise. They are subjected to large amounts of TV advertising for the wrong kind of food and drink, and far too many ads encourage them to gamble. None of this is good for their physical or mental health.

My point is that the organisations that can help them with this are often not the NHS or wider national government, although both can do a lot. I am speaking about local authorities, whose overall funding, particularly for public health services, has been cut since July 2015 and is projected to carry on being cut. Does the Minister think that this is in line with the Secretary of State’s vision? There is evidence that sexual health services, sports centres and weight management services have closed. Smoking, alcohol and drugs prevention and treatment services have been discontinued. Does the Minister not agree that some of the new funding should be diverted from the NHS into local authorities and ring-fenced to allow them to reinstate and widen these services? Of course, NHS professionals must be involved, but this should come under the public health responsibility of local authorities, where it correctly lies.

Councils run as many of these good services as they can but they cannot afford as many as are needed to stall the national epidemic of obesity and other preventable health problems. According to a systematic review of the available evidence, published online in the Journal of Epidemiology and Community Health, every £1 spent on public health saves £14 on average, as referred to by the noble Baroness, Lady Thornton. In some cases, significantly more than that is saved. We should listen to such a meaty piece of research. Local directors of public health claim that they can spend money more efficiently than the NHS to prevent ill health. Why not fund them to do so?

Turning to two other matters, I applaud the Secretary of State’s initiatives for people with learning difficulties; I strongly wish them well. However, the Minister will understand from my background in cannabis-based medicines that I am still very concerned about the too-restrictive guidance that has been published on prescribing pharmaceutical-grade cannabis-based medicines. It seems that there is still a bureaucratic nightmare for patients who thought that the Government’s recent relaxation of regulations meant that their troubles were over. I fear we do not have time now to go into this in detail, but I welcome the intention expressed in the Statement to get it right. What further reassurance can the Minister give me that clinicians will be given the information from patients and other countries to enable them to make sensible prescribing decisions—not just for Sativex and Epidiolex? Can he assure me that it will not have to be done as a last resort when a lot of licensed drugs with nasty side-effects have already been tried unsuccessfully?

[Lord O’Shaughnessy]

I am very grateful to the noble Baronesses, Lady Walmsley and Lady Thornton, for their questions. I concur completely with their point that the NHS is not sustainable if it is a national hospital service, which the Secretary of State was trying to get across yesterday. He used the stark figures of £97 billion being spent each year on treating illness and only £8 billion on preventing it. Clearly, we need a shift there. Investing more money makes that shift easier; I am glad that the House recognises that we are doing that.

Before I get on to the specifics of responsibility for health, I concur with the idea that this is a whole-government challenge. It is also a societal challenge; it is not just for government to make this happen. It is about people as well, as the Secretary of State said in his point about personal and family responsibilities. We all have a role to play in making it easier for people to do the right thing. That is quite different from a finger-wagging approach; it is about making sure that it is easy to make healthy rather than difficult choices. When you talk to people about that, they feel it is a sensible approach.

On the funding question that both noble Baronesses asked about, it is worth pointing out that local authorities received £16 billion over this SR period. That obviously involves a reduction, as they pointed out. The recent Budget did not change the funding. It has been suggested that it reduced it, which it did not. Clearly, any new budget for public health specifically and for the role of local authorities will be decided at the spending review next year. I hope the noble Baronesses will forgive me if I cannot say more about that, other than that I absolutely concur that local authorities have a critical role working with the third sector, industry and others. So does technology. Noble Lords will know that we have a real technophile in the Secretary of State. He is absolutely right that, while technology will not necessarily change everything, it gives us the possibility to change behaviours much more cheaply and more cost-effectively than in the past, which I hope means that we can do more with our money. That is the promise of new technology if we get it right.

On the specific questions on the prevention strategy, the noble Baroness, Lady Thornton, asked about junk food advertising. The consultation on that is due to be published before Christmas. We are trying to train more staff on children’s health. We are working with Health Education England on a health and care workforce plan as part of the long-term plan. She also mentioned health inequalities. The Prime Minister had been very clear that she wants people to enjoy five more years of healthy life. At the moment, on average, children being born today will live to the age of 81 but might have 18 years of unhealthy life and there is a great discrepancy in that depending on one’s demographic. The greatest gains from that will therefore be for the least advantaged. That is something we are focused on. It is part of the NHS mandate today and it will be part of the plan.

We have debated GP numbers in this House. There are record numbers of GPs in training and that flow will continue over the coming years. We are also determined to make sure that there is much better treatment for mental health, not only because people with mental illness die earlier—sometimes dramatically earlier—but because, as we have discussed and as is being discussed now in the other place, there is too much unacceptable use of in-patient facilities for people with mental illness, learning disabilities and autism. I am glad that the Secretary of State’s strong words on this have been well received. He is absolutely determined, as we all are, to ensure that we deal with this. We have made some progress but we have not got as far as we needed.

As to whether such facilities will be needed in the future, I think that they will. I visited Springfield University Hospital in south London recently. It is being redeveloped from a classic Victorian institution to something being designed with patients to be much more suitable for their needs, with better access to light and to communal areas where appropriate. These facilities have a role to play when properly modernised, but they ought to be used for only a short time. They ought to be close to home and there ought to be a discharge plan in place before they are used. Clearly, in some cases none of those things is happening and unacceptable care takes place, which we need to stop.

On the various Green Papers and so on, the Secretary of State has set out vision documents in areas he has identified as early priorities. A lot of this stuff will be wrapped up in the long-term plan that we will publish before Christmas. As we move ahead there will be Green Papers on key areas. Social care will be one, for not just older adults but working-age adults; there will be a prevention Green Paper on that in the new year. There will be many more for us to discuss, to the great delight of the House, I am sure.

The noble Baroness, Lady Walmsley, asked about cannabis medicine. We are treading a fine line in difficult territory. We know the great benefits that these medicines can bring and are bringing, particularly to children with some horrendous epilepsies and other illnesses. At the same time, we know that there are risks associated with the active ingredient THC. It is about trying to move forward in a way that is compassionate to patients but does not put them at undue risk while evidence is still being gathered.

I will say three things. First, we are trying to fund more research so we understand the real world impact of these kinds of medicines. Secondly, by rescheduling them to Schedule 2, THC-based medicines can be procured through an unlicensed medicines route, which was not something that was there before. That goes beyond the Sativex and Epidiolex question, in terms of licensed drugs at the moment, although again that will be done with care and caution by specialist doctors. NICE is working on a clinical guideline to supersede those currently in place, which are temporary guidelines. It will be gathering evidence as broadly as possible internationally from patient groups, clinicians, families, industry and elsewhere. I am confident that, while we have clearly not perfected the system yet, there is a genuine attempt to get a much better, more compassionate system that ensures that drugs such as this can get to people who will benefit from them when they need them. I am confident that we will get to the right position eventually.

[Lord Ribeiro (Con)]

My Lords, the Statement makes reference to the use of predictive prevention to deliver more targeted interventions. At the recent meeting of the American College of Surgeons in Boston two weeks ago, the director of the National Institutes of Health—he likes to call them the national institutes of hope—said on targeted interventions that they are taking a new approach to disease prevention through the All of Us research programme and that, by taking account of individual differences in lifestyle, environment and biology, researchers will uncover paths towards delivering precision medicine. To date, since May this year, 100,000 people have signed up. What plans does the department have in the UK for a similar programme, and to use genomics for the benefit of all?

[Lord O’Shaughnessy]

I am very grateful to my noble friend for that question: he speaks with great wisdom and insight on this. The great promise of technology is to take all the information we hold about people—their health and care records, their genomic data, their lifestyle data—and use artificial intelligence to tailor health advice to them. There will be not just broadcast public health messages that everyone sees, but specific messages that will change my behaviour or your behaviour, to make sure that we live the kind of lifestyles we actually aspire to live, even if we do not always fulfil that.

I highlight three things we are doing. The first is our commitment to sequence up to 5 million genomes over the next five years. Secondly, we will try to make sure that AI is used in the right way to support healthcare and that relationships are entered into by the NHS and tech companies on a proper basis to bring the maximum possible benefit to the NHS and patients. Thirdly, we will try to take advantage of the enormous opportunity we have with the data that is available in a single-payer comprehensive health system by reassuring people that it is being kept and used safely and legally, but then utilising it so that it is joined up as a single integrated health and care data record, available for direct care and—critically—for research. Then we can start to tailor the medicine we deliver and move to a truly personalised NHS.

--- Later in debate ---

[Baroness Uddin]

With respect, my Lords, I state my objection at being shouted at to move on; many Members would simply carry on.

[Lord O'Shaughnessy]

I am grateful to the noble Baroness for the question. On learning disabilities and autism, I know that the Secretary of State has been very moved by some of the cases that he has become aware of since taking the job in the summer. He has instigated not only serious incident reviews into individual cases but a thematic review by the CQC, with contributions from NHS England, on how to improve the system and ensure that we move more services out of in-patient facilities and into the community. I am absolutely confident—I will confirm this to the noble Baroness—that the best providers, from wherever they are, will be able to contribute to that review.

[Lord Kakkar (CB)]

My Lords, I declare my interests as chairman of UCLPartners and business ambassador for healthcare and life sciences. In repeating the Statement, the Minister focused on the important opportunities provided by genomics and the application of artificial intelligence to transform the landscape for prevention. In answer to a previous question, he identified the importance of trust for the ability to marshal this vast amount of deeply personal data and ensure that it can be appropriately applied for individual benefit and, more broadly, population benefit. In that regard, I make two points to the Minister.

First, what progress has been made towards achieving that social licence which will ensure broad trust with regard to the mechanisms available and the security of the structures, not only for data collected in hospital but now in the community and the prevention setting, so that it may be shared and applied for individual as well as population benefit? Secondly, there will need to be a substantial investment in skills to ensure that not only professionals who work in healthcare for the delivery of health services but those who will have to engage more broadly in the prevention agenda are able to respond to this vast amount of data, and help individual citizens and patients apply it for maximum benefit.

[Lord O'Shaughnessy]

On the question of trust and social licence, which is a very good expression, KPMG published a report in September which found that the NHS was the most trusted organisation in the country when it came to looking after people’s data. That is a very precious thing and we must not lose it, so a number of steps are being taken to try to reinforce that degree of trust. We have introduced a national data opt-out and very recently had the national data guardian Bill, which puts the National Data Guardian on a statutory footing to provide that security and statutory guidance to government, so that we can ensure we build on that trust. On investment in skills, we have commissioned Eric Topol to carry out a review of the skills needed in the workforce to adopt new technology, which will report soon. We also have to recruit new professions: it turns out that bioinformatics is one of the most important things to have in taking advantage of that. We do not currently train enough people in that field but we need to ensure that we do, so that every patient and every clinician can take advantage.

[Lord Robathan (Con)]

My Lords, in commending this Statement may I pick up on what the noble Baroness, Lady Walmsley, said about the obesity epidemic? I think that she used that word. Does my noble friend agree that all of us, be it in Parliament or as health professionals or teachers, have a role in setting examples to others? Does he also agree that young people and others look to us to see what we do? If we eat or drink too much, or if we smoke, they may follow. Does he also think that health professionals should perhaps be less understanding when people are grossly obese and tell them that, if they do not lose weight, they will die early and cost the NHS a huge amount through diabetes and other diseases?

[Lord O'Shaughnessy]

My noble friend brings to mind the quote—I forget who it was by—saying that children never listen to their parents but have never failed to imitate them. There is a point about setting an example, which I agree with. I do not quite agree with the force of his opinion about how health professionals should speak to people suffering weight problems of that kind. These things can be genetic or epigenetic; there can be all sorts of causes. The most important thing is to get people on board with losing weight and motivate them to do so. We have lots of good understanding about how to do that, which is at the heart of the obesity strategy.

[Lord Sherbourne of Didsbury (Con)]

My Lords, on the question of obesity, will the Minister look carefully at the two successful public health campaigns which helped to change behaviour? One was the campaign on AIDS many years ago and the other was the campaign over many years against smoking. Both had beneficial effects on behaviour.

[Lord O’Shaughnessy]

My noble friend is quite right. The campaigns took quite different approaches. One used tax and regulation and the other used destigmatisation and the provision of services, but they were highly successful and I reassure him that the knowledge and learning from those campaigns influence our current prevention strategy.

[Lord Framlingham (Con)]

Given how unhelpful much of the advertising is nowadays, how brave are the Government prepared to be in curtailing it?

[Lord O’Shaughnessy]

We have said that we will clamp down on junk food advertising. Clearly we have cut down on the advertising of alcohol, smoking and many other things over successive Governments. This country has led the way in dealing with this sort of issue, so I am confident that we will have the necessary approach.

[Baroness Masham of Ilton (CB)]

My Lords, will the Minister assure us that some of the most important things that are not in the Statement are not downgraded? They are antibiotic resistance, vaccination and immunisation, drug misuse, the prevention of hepatitis C in prisons and sexually transmitted diseases which are becoming resistant.

[Lord O’Shaughnessy]

I can provide the noble Baroness with that reassurance. This is a vision document, not a plan. It does not go into detail in every area, but merely tries to set out an ambition for the kind of health service that we want. All the issues that the noble Baroness raises are incredibly important, and I promise her that they form a big part of the department’s agenda.

[Baroness Barran (Con)]

My Lords, I join other noble Lords in welcoming the focus on prevention. A key point in prevention is early childhood, the so-called first 1,000 days of a child’s life. I looked at the paper from the department and found several references to this, but they were nearly all in relation to the impact on adult mental health as opposed to physical health. The evidence on the impact on physical health, including obesity, cardiovascular disease, diabetes and cancer is overwhelming from the research done by some of the big health insurers in the States and from the Harvard Center on the Developing Child. Will my noble friend reassure me and other noble Lords that greater prominence will be given to the prevention of the so-called adverse childhood experience, the toxic stress that very young children experience, which impacts on their mental and, crucially, physical health as adults?

[Lord O’Shaughnessy]

I agree with my noble friend. There is a strong desire for the Green Paper to be cross-government and therefore, like the vision document, take us into areas that go well beyond the remit of the Department of Health and Social Care. My noble friend Lord Farmer has published an interesting paper on the impact of family stress, marriage breakdown and other things on childhood outcomes. It is quite disturbing. Clearly making sure that we support families in all their forms is a critical part of giving children the best chance in life.

[Lord Robathan]

Since my noble friend thinks I am a bit harsh, does he not agree that the ghastly photographs on cigarette packets of people suffering from diseases caused by smoking have contributed to the reduction in disease from smoking and that therefore we should perhaps be a little bit harsher in explaining to people that they will die early if they do not take control of their own lives?

[Lord O’Shaughnessy]

I do not disagree with the content, in a sense, of what my noble friend said, but I think it is important that we communicate it in a way that will motivate people rather than terrify them into inaction. The difference with smoking is that there is no good or safe amount that you can smoke whereas there is clearly a good and safe amount that we can eat and drink and for sugar and salt intake and so on. It is about striking the right balance.

[Lord Scriven (LD)]

My Lords, while I welcome the Statement, particularly around prevention, and the use of AI, technology and data, there are two issues that come to mind. My first question is this: what regime will there be on issues related to the ethics of AI and data use? This is quite important, and there needs to be some form of regime and regulation about what the health service does there.

The second issue is on prevention. As a former health service manager, I know that hospitals are huge sunk costs, and the issue of prevention has been around for many generations. The key is how you move resources from the sunk costs in hospitals into prevention. What work and ideas do the Government have on that? It has always been the Achilles heel of prevention and dealing with hospitals.

[Lord O'Shaughnessy]

I absolutely agree with the noble Lord about ethics. In a sense, everything that we do in this area has to pass the basic fairness test that people apply to it: is this a fair use of resources and a fair distribution of benefit? A number of programmes have been set up to support our work in this area. There is the Centre for Data Ethics and Innovation set up within DCMS. I also point the noble Lord to the code of conduct for data-driven technologies in health and care that I published at the NHS Expo in September. This is our first attempt to provide some rules of engagement on how NHS trusts or other bodies can enter into relationships with technology companies in a way which brings the maximum possible benefits to the NHS. We will do more on this in due course.

[Lord Patel (CB)]

My Lords, I support what the Minister said about the importance of the national data guardian legislation. That will give the public the confidence they need that their health data will be properly used and protected. I hope that legislation will not be held back.

On the Statement, one of the factions of our society that is at higher risk of diabetes and obesity is the south Asian population. I declare my interest as a patron of the South Asian Health Foundation. Any health education programme needs to target that population in order to reduce the incidence of diabetes, which probably runs at around 40% of the population. If we are to benefit from the information that genomics will provide, we need not just bioinformatics but data scientists, with the ability to mine genomics data. My question for the Minister is: what is the plan for further education for both bioinformatics and data science?

[Lord O'Shaughnessy]

I am very grateful to the noble Lord for welcoming the NDG legislation, as he did when we dealt with it in this House. I hope that that can progress at full speed.

On the noble Lord’s point about diabetes, he is absolutely right that prevalence differs from population to population. I will send him details of the NHS Test Beds programme, which includes quite a few diabetes programmes aimed at different parts of the country, which obviously have different ethnic make-ups. We are conscious of the need to tailor messages to particular groups.

The noble Lord is also absolutely right about the workforce. That is why I mentioned the Topol review. It is critical to making sure that people who are in the service are retrained properly, and that we have enough data scientists, bioinformaticians and others.

I apologise to the noble Lord, Lord Scriven; I did not answer his second question about the sunk costs of hospitals. We are in the process of moving to a system of integrated care services, which is an attempt to integrate primary, secondary and tertiary care—we know what the goal is. These things are up and running and are showing some great benefits through the new models of care programme in moving care out of hospital, improving outcomes and reducing costs. That is clearly something that we need to take nationwide.

Cannabis: Medicinal Uses

Lord O'Shaughnessy Excerpts

Thursday 1st November 2018 Lords Chamber

[Lord Farmer]

To ask Her Majesty’s Government whether they intend to respond to the concerns raised by the Faculty of Pain Medicine in their Faculty Position Statement on the Medicinal use of Cannabinoids in Pain Medicine, and their call for further research into the potential benefits of cannabis for medicinal uses.

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

My Lords, the Government acknowledge the valid concerns raised by the Faculty of Pain Medicine. Under the new regime, only specialist doctors will be able to prescribe cannabis products. Clinical guidance published yesterday is clear that these products will be considered only in a small number of conditions and where alternative treatments have not helped or have been discounted. The National Institute for Health Research has issued a call for proposals in order to enhance knowledge in this area.

[Lord Farmer (Con)]

I thank the Minister for that Answer. Bearing in mind the faculty’s overarching cautionary position, and the fact that according to the National Health Service website,

“Regular cannabis use increases your risk of developing a psychotic illness”,


what assurances can the Minister give us that Her Majesty’s Government will not allow the changes in prescribing cannabis for medicinal use to be a Trojan horse for the legalisation of cannabis for recreational use?

[Lord O’Shaughnessy]

I can absolutely reassure my noble friend by reiterating the position outlined by my right honourable friend the Home Secretary. He has been crystal clear that the Government have no plans whatever to legalise cannabis for recreational use. Indeed, the penalties for unauthorised supply, possession and production remain unchanged.

[Baroness Walmsley (LD)]

My Lords, while it is true that the faculty warns against the use of dried cannabis plant of unknown composition, it accepts that there may be benefits to pain management from pharmaceutical products. Fortunately, that is exactly what patients are demanding and what the Government have just legalised. However, the faculty is also demanding that, while we wait for clinical trials, a database—which is essential to better understand these medicines—should be set up. Will the Minister support the setting up of this database and ensure that it contains the massive amount of lived evidence and experience available from patients?

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for her question. I believe that the position we have reached now is the right one, not least driven by the heart-rending stories of children who had been benefiting from these kinds of medicines but were then not able to access them. It is a very good thing that we have got to this position. However, we also have to acknowledge—as the Chief Medical Officer did—that there is a lack of evidence, particularly beyond specific conditions such as paediatric epilepsy. It is precisely to provide that evidence that we are going to do two things: first, we will fund clinical trials through the NIHR, and, secondly, we will start collecting evidence and data on usage so that we can gain the evidence base to understand whether there are other applications where these medicines could be helpful.

[Baroness Thornton (Lab)]

My Lords, it is to be welcomed that the Government have today issued guidance on the use and access of cannabis for medical use. Having spoken to several GPs about this matter in the last day or so, to a person they are experiencing an increase in the number of patients requesting access to cannabis medicine in their surgeries for pain management. Some of those requests will probably be justified. My question is: will GPs refer those patients to specialist doctors who are allowed to prescribe this medicine? Will this create additional cost and demand? Who will pay for it? Could the Minister explain and say when this will be reviewed?

[Lord O’Shaughnessy]

It is important to state that GPs will not be able to prescribe it; that is part of the new regime. On the specific issue of pain management, the interim guidance from the Royal College of Physicians says there is no evidence to support its use for treating chronic pain. In the meantime, NICE will be providing clinical guidance in about a year’s time, which will take a broader view. So it should not be the case that specialists are providing it in this area—the evidence does not exist and therefore the costs will not occur.

[Baroness Meacher (CB)]

My Lords, I applaud the Home Secretary for finally recognising the therapeutic value of medical cannabis. We know that about 1 million patients up and down the country will be queueing up for these medicines. I very much understand the Government’s narrow approach, but can the noble Lord assure me that Ministers will make available to doctors the comprehensive review of medical cannabis research from the National Academies of Science, Engineering, and Medicine in America? This showed conclusively that there is substantial evidence that medicinal cannabis is valuable for the alleviation of pain—in particular neuropathic pain—and that it does not cause psychotic illness.

[Lord O’Shaughnessy]

We are, thankfully, now taking an evidence-based approach. The Chief Medical Officer said in her statement that there is evidence of therapeutic benefit from cannabis-based products, and that is why they have been rescheduled. However, we need to move cautiously. We know that the active ingredient, THC, is linked to psychotic illness and other things, so we need to make sure that, as we move ahead, its use is properly controlled and that the benefits always outweigh the risks for any patient who takes it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I think that the noble Lord, Lord Farmer, referred to prescribed medicine addiction in his question. The Minister will be aware that this is a growing problem, with very little support locally for patients who have terrible outcomes. PHE is undertaking a review of the evidence at the moment. Can the Minister assure me that, when that review is published, the Government will publish an action plan to try to deal with what is a terrible issue for many people?

[Lord O’Shaughnessy]

I absolutely acknowledge the scale of the issue. I think that the point my noble friend was getting across was that we do not want to create the next opioid addiction crisis, and I completely concur with that position. Public Health England is conducting that review and I will write to the noble Lord with specific details of what we as a Government intend to say after it has concluded.

[Baroness Hussein-Ece (LD)]

My Lords, I declare an interest, as my grandson has intractable epilepsy. He has just been assessed for medicinal cannabis and we very much welcome that. However, I am very concerned about the comments that this will be used as a last resort. My grandson has been subjected to many, many drugs and the side-effects from many of them have been horrific, so to say that those drugs are fine but that somehow medicinal cannabis oil is a problem is looking at this in the wrong way. I am worried about the restriction that has been put in place, and that many children who might benefit from this medicine will not be able to access it because of the very strict guidelines. Can the Minister give an assurance that each person will be looked at on a case-by-case basis?

[Lord O’Shaughnessy]

I absolutely acknowledge the case that the noble Baroness mentioned. She has shared it with me before and my sympathies go to her and to her family—it must be very difficult. Generally speaking, medicines in this country are licensed on the basis that they have gone through randomised control trials to make sure that they are safe and efficacious. A lot of these cannabis-based drugs have not been through that. We want to see more trials and, until we do, it is important that clinicians are able to access licensed drugs first, but with the ability to use unlicensed drugs if necessary.

Health: Diabetes

Lord O'Shaughnessy Excerpts

Wednesday 31st October 2018 Lords Chamber

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

My Lords, first, I thank the noble and learned Lord, Lord Morris, for instigating this high-quality debate, and the small but select group of Peers who have contributed to it. I will attempt to answer all the questions, as seems only reasonable.

The noble and learned Lord, Lord Morris, mentioned the letter I wrote to him—or perhaps it was a Written Answer—about the principle of universal access. Obviously, that principle is at the foundation of the NHS and is one to which the Government are absolutely committed. Part of that commitment means making sure that when effective technologies come around—whether digital, devices, drugs or diagnostic—people have access to them once their benefit is proven. Diabetes is no different. As the noble and learned Lord, Lord Morris, and the noble Lord, Lord Rennard, brought out, this is a growing public health crisis: 400,000 people alive today in the UK have type 1 diabetes and many more have type 1 and type 2. The cost is not just the £10 billion a year but the lives and the quality of life being lost. It is a major public health crisis, with very individualised consequences, as the noble Lord, Lord Rennard, brought to life from his own family’s experience. That is the challenge.

With regard to the NHS more broadly, it is fair to say that in this country we are very good at coming up with new ideas—innovating—but traditionally poor at the uptake, or adoption, of good ideas. We have been carrying out a review over the past year with NHS England and the Office of Life Sciences, and we have found that the description I just gave is reasonably accurate. A lot of the money that we spend on supporting innovation is at the upstream end—coming up with new ideas—so that we are doubling down on our strengths while not addressing our weakness, the uptake of new technologies. That is the topic of discussion tonight.

Before turning to flash monitoring, I will give a few examples of how we are trying to address this weakness. The first is through the accelerated access collaborative, now chaired by the noble Lord, Lord Darzi. It recently announced a list of seven high-potential technology areas and 11 rapid-uptake products that are already on the market, and for which an evidence base exists, but are not being taken up. Currently they apply to cancer, heart disease and MS—not, it has to be said, diabetes, but there will be further rounds once the accelerated access pathway is considered, so that new technologies for treating diabetes will be able to apply through that route. That initiative involves all the key players—NHS England, the Department of Health and Social Care, industry, and so on—so that we are sure that we horizon-scan, know what is coming and do not get caught out when new technologies come along that can have a really life-changing effect.

Secondly, we are strengthening the Academic Health Science Networks; they spot these innovations and make sure that they can be spread. One example, which has been adopted through that route, is a free app launched by the Oxford AHSN diabetes clinical network, brilliantly titled Monster Manor. It is a game that encourages children with type 1 diabetes to track their blood glucose readings and become more engaged in their diabetes management. It is very important to ingrain those habits early on.

We have also expanded the NHS test-bed programme, a couple of whose projects are focused on the management of diabetes. One, in Greater Manchester, is called My Diabetes My Way—again a digital platform—and is designed to help people self-manage. In south London the diabetes test-bed is working with Year of Care Partnerships to train GP practices to adopt a more collaborative approach with patients and support self-management using digital technologies. There is, therefore, good technology going on; it is getting into the service and the challenge, as ever, is to make sure that it is spread.

This brings me to flash glucose monitoring, which is clearly an incredibly exciting technology. I was delighted to be able to sign it on to the tariff last year as FreeStyle Libre—that is one brand; there are others. Everyone, from the Prime Minister downwards, can attest to its benefits, but it is worth saying—as the noble Baroness, Lady Thornton, brought out—that it is a new product with quite limited clinical trials data and economic analysis, so it is appropriate that we take a more staged approach. I will explain how we are doing that—there is cause for optimism.

In relation, however, to the role of NICE, I can assure the noble Lord, Lord Rennard, that NICE takes long-term perspectives into account in its economic analysis. The cost per QALY approach tries to take a broad measure of quality—QALY stands for quality-adjusted life years—so that we can make sure that all the benefits, not just health but social and other benefits, are accounted for. The challenge, however, is that because this is a new, exciting technology that we want to get on to the tariff, there is not yet the data to enable us to understand exactly for whom it works and when. That is why it has been up to CCGs to prescribe it and develop their prescribing policies. As the noble Baroness, Lady Thornton, pointed out, it is not for everyone—not least those who are not in a position to carry out the high levels of monitoring and use that it requires.

The noble and learned Lord, Lord Morris, asked what we are doing to encourage its use. I can tell him that a regional medicines optimisation committee was asked to provide advice to support local decision-making. I would be interested to understand, perhaps as a follow-up, whether Camden CCG—where I think the noble Baroness, Lady Thornton, sits on the board—has found that useful. The committee was tasked to provide that advice to deliver much more consistent policy-making and it has produced a set of criteria for use by GPs, CCGs and others. At the start of the year, NHS England wrote to GP groups to remind them of their responsibilities and of the guidance that exists.

We have seen some progress. About 70% of CCGs—144 of them—have now approved FreeStyle Libre for use and are putting together plans to bring it forward. If we look at spend on patches, for example, in November a year ago CCGs provided 421 sensor packs at a cost of £15,000. In August 2018 that figure was 14,412 packs at a total cost of £500,000—so there has been a fairly steady ramp-up. As we go along, we are of course gathering information about which populations this is most suitable for. Ultimately, this is the responsibility of CCGs; I know that that in itself is a cause of discussion, shall we say, and debate about whether that is a proper role. But as evidence grows about for whom it will be most beneficial, we will clearly have a better opportunity to define who should have immediate access to it and who should have access only after other routes have been pursued.

I will not detain the House by talking about the various other things that we are doing to support diabetes, other than to say that obviously a huge amount of work is being done. The noble and learned Lord, Lord Morris, asked about responsibility. We have a national programme for diabetes, and health checks and personalised and tailored support are being provided. It has been incredibly effective: about 250,000 people have been referred to the service and just over 100,000 have taken up the offer of a programme—so we are starting to see that kind of lifestyle support going in.

I was asked what we are doing specifically to support diabetes technology. While it would not be right to have a fund only for diabetes, as we develop the long-term plan—which we are looking to publish very soon—we are intending to explain in it how we have a much more systematic approach to spotting new technologies, getting them into the system, gathering data on them, establishing their efficacy and value for money, and then ramping them up through a much greater national push so that we deal with the issue of postcode variation. That is something I hear about all the time from patient groups, industry and clinicians themselves. We are conscious that it is a long-standing weakness of our service but is also something that we can do something about. I hope that as we move ahead with the long-term plan in the next few weeks, and with the updated sector deal that we are working on, noble Lords will see policies going into place which provide that—for the benefit not just of diabetes sufferers but everyone in this country.

I hope that I have managed to answer all the questions that the noble and learned Lord asked. Obviously I would be delighted to discuss this with him further afterwards, but I thank him again for bringing this very important topic for debate in this House.

House adjourned at 8.03 pm.

Mental Health Units (Use of Force) Bill

Lord O'Shaughnessy Excerpts

3rd reading (Handard): House of Lords
Tuesday 30th October 2018 Lords Chamber

[Baroness Massey of Darwen (Lab)]

My Lords, in moving that the Bill do now pass, I should like to sincerely thank several people, including the Minister and his counterpart in the other place, Jackie Doyle-Price MP, who have been so supportive and helpful on the Bill. I also thank the voluntary sector, which has been incredibly vigorous and thorough in making sure that the Bill is as close to perfect as it can be. Will the Minister confirm that there will be other, informal, meetings on the Bill, which will look at the guidance to the Bill, particularly on statistics, impact and measurements? I wish to say that the Bill should now pass.

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

I am very grateful to the noble Baroness for her question and, more importantly, for her steering the Bill to this point. I offer my thanks to her, her colleague Steve Reed in the other place and everybody who has been involved in this important piece of legislation. As she will know, my honourable friend Jackie Doyle-Price, the Minister for Mental Health, committed to the Government publishing statutory guidance within 12 months of the Bill being passed. I am happy to confirm to the noble Baroness that, in developing this guidance, the department will establish and consult an expert reference group, which will include experts on restrictive intervention as well as people with lived experience and, furthermore, that public consultation will take place before the publication of the final guidance. So I can absolutely reassure the noble Baroness and all noble Lords that we will consult widely with a broad set of stakeholders, as well as reflecting discussions in this House and the other place, to make sure that all those contributions are included in the guidance.

Bill passed.

Health and Social Care (National Data Guardian) Bill

Lord O'Shaughnessy Excerpts

2nd reading (Hansard): House of Lords
Friday 26th October 2018 Lords Chamber

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

My Lords, it has been with great interest and pleasure that I have listened to the discussion on this important Bill, introduced by my noble friend Lady Chisholm, and I speak on behalf of the Government in support of it here today. I join other noble Lords in congratulating my honourable friend Jo Churchill on her efforts in introducing the original Private Member’s Bill and on being a mainstay in keeping attention on it after it fell at the last election; my honourable friend Peter Bone, who has worked closely with Jo and many others in the other place to get the Bill to this point; and my noble friend Lady Chisholm on introducing it so lucidly and bringing to life the importance of its provisions.

I also join other noble Lords in recognising the enormous contribution that Dame Fiona Caldicott has made to the area of data safety and security in the health and care service. As the noble Lord, Lord Patel, pointed out, over many years she has had a profoundly positive impact in this area. The Bill’s purpose, and in some ways its genesis, rests on her work and desire to put the issue even more front and centre than it is today. I thank her profoundly for that.

At the heart of our discussion today is maintaining and strengthening the public’s trust in the appropriate and effective use of health and social care data. The interests of patients and the public are at the heart of this Bill and the reason why it is such an important piece of legislation. As we reflect on it, I think it is important to bear in mind two truths. The first is that the NHS remains the most trusted institution in the country for holding and using data. That was confirmed by recent research by KPMG. The second is that in England, we have a world-class, comprehensive health system offering a unique opportunity to bring together an unrivalled, diverse, longitudinal dataset on the health and care of more than 55 million people. Let me be clear: we need to protect the first truth, otherwise we will not realise the extraordinary benefits provided by the latter. Giving the NDG a statutory footing is an important part of realising the same, because we will underpin the trust we need to deliver the healthcare transformation that we all want to achieve.

As the noble Baroness, Lady Kidron, and the noble Lord, Lord Knight, pointed out, the potential gains in front of us from the digital revolution are enormous: improving outcomes for patients, making the health system safer and more efficient, and improving research so that patients benefit more quickly from medical breakthroughs. To secure these benefits, we need to appreciate and act on people’s concerns about how their data is used, who it is shared with and whether that is lawful. People want to understand, and have more control over, how their data is collected and used, and to see the benefits being realised for themselves, other patients and the health system more widely.

The noble Baroness, Lady Kidron, makes an excellent point about the value of data and points out some of the concerning behaviour that we have seen in recent history. I agree with the noble Baroness, Lady Thornton, that the Bill is not the right place to deal with those issues, but there is a concerted effort—heavily influenced by the NDG—going into what is the proper way to value the NHS data asset and then realise that value in a fair way that maintains the public’s confidence. We had a fantastic debate instigated by the noble Lord, Lord Freyberg, about six weeks ago on that topic. In that time, we have published a new code of conduct on data driven technologies, and there will be much more to come. I look forward to working with the noble Baroness on developing that.

As the noble Baroness, Lady Walmsley, reminded us, the ghost of care.data is always present at this feast. Experience tells us that public confidence in the Government’s ability to hold, share and use data cannot be taken for granted. If data and information are to be used effectively and their great potential unlocked, we need to strengthen the public’s confidence in the safeguards in place to protect it from inappropriate use. Of course, this is a time of great technological change, and new uses of data are transforming the type of care that is possible to deliver. There are exciting government initiatives to make the best of this opportunity: local health and care records, global digital exemplars and digital innovation hubs. Meanwhile, academics, clinicians and life sciences companies of the kind mentioned by the noble Lord, Lord Knight, are developing pioneering digital therapies and algorithms that will utterly transform healthcare in the years ahead.

Last week, the Government published the Secretary of State’s new vision and a standards document on the future of healthcare, describing a more tech-driven NHS so that the health and care system can make the best use of technology to support preventive, predictive and personalised care.

The potential is here today, but to fully enjoy its fruits, we need to put in place a bedrock of reassurance. That means improving cybersecurity, as well as clear rules around privacy and data sharing. The National Data Guardian is an essential stratum in this bedrock. It is one safeguard that we already have in place to ensure that the interests of the patient are front and centre of all our deliberations about the best way for the NHS and the UK economy to make the most of those innovations.

Let me be clear, if I have not been already, that the Government strongly support the Bill. As my noble friend Lady Chisholm pointed out, it was a manifesto commitment of my party at the election. By supporting the Bill and putting the NDG on a statutory footing, we are playing our role in ensuring that it has the powers needed to make an even more positive contribution in future, allowing the office to effectively advise and challenge the healthcare system. As such, it represents a significant moment in our efforts to maintain and strengthen the public’s trust in the proper use of health and care data.

The Government want the Bill to succeed. I am confident that it will achieve the aims that my noble friend Lady Chisholm set out. The NDG will, as it has to date, work in concert with the Information Commissioner. There has consistently been cross-party support for the Bill, which I welcome in our debate today, as well as support from professional organisations within the health and care sector, as the noble Lord, Lord Patel, reminded us. I hope that it will make swift progress through its remaining stages.

Let me just deal with some of the questions raised today and, I hope, provide the reassurance that noble Lords are looking for. The noble Baroness, Lady Thornton, asked about demographic data. I can confirm to her that where issues surrounding demographic data have the potential to impact on or form part of the processing of health and adult social care data, this would fall within the NDG’s statutory remit and it would be able to publish formal statutory guidance on the topic, with organisations having a corresponding legal duty to have regard to that guidance. I hope that that provides the reassurance that she was looking for.

The noble Lord, Lord Knight, and the noble Baroness, Lady Kidron, asked about children’s social care data. Children’s health data is of course covered in the remit. The reason that their social care data is not is that it has its own safeguards and protections which operate within a different legal framework and is governed by its own statutory guidance. However, I can tell noble Lords that my department and the Department for Education have reached a sensible interpretation of the Bill which would not preclude the National Data Guardian engaging constructively with the DfE on adult social care data and its interaction with or effect on children’s social care data. There has been an exchange of letters between the departments to formalise this agreement. I am happy to provide more reassurance on that front, but what I can say now is that this relationship is already being developed and we are finding a sensible way to interpret the powers within existing regulatory frameworks to make sure that there is a much more joined-up system. I should also mention that the Department of Health and Social Care is working closely with the Home Office on its online harms White Paper so, again, we are making sure that there is a cross-government approach to dealing with this issue.

I will just quickly deal with some of the other issues that have been raised. The noble Baroness, Lady Kidron, asked about the duty of health providers. They have a duty to have regard to this statutory guidance, but this is of course the sort of thing that is inspected by the CQC and NHSI. It is worth pointing out that when the National Data Guardian provided her feedback on the WannaCry attack, it directly led to 10 data standards that are now embedded in the NHS contracts, so that gives you a sense of the kind of response that the system has to the high-quality advice that comes from the National Data Guardian when there are problems. I confirm to the noble Baroness that it will be up to the National Data Guardian to decide on her priorities.

The noble Baroness, Lady Walmsley, asked about the national data opt-out. I tell her that we ran an extensive public campaign in May, which has continued from then. It is now much easier to opt out oneself rather than, as she pointed out, having to go through GPs as in the past, which not all GPs were wild about, it has to be said. Nevertheless, the service is in a public beta at the moment, so we are honing and improving it and are always keen to have feedback. One thing that I found reassuring about the introduction of the new single data opt-out is that we have seen people who have previously opted out who are now opting back in. I find that rather encouraging; it is quite a good metric of whether we are doing the right thing. I therefore think that there is some cause for encouragement but I of course take the noble Baroness’s advice seriously.

In terms of how this relates to Wales, it will be up to the Welsh Government to implement with the same statutory force that the NDG will have in England, because health and care are devolved issues. That is something that the noble Baroness may be keen to impress upon the Welsh Government.

On the costs of implementation, all authorities have a responsibility to take standards into account—that is part of their normal, everyday life—but I should point out that there are major investments going into the IT space in health and care. For example, a big investment, which was centrally funded, has gone into replacing unsupported IT systems following the WannaCry attack. So there is central funding support for some of these changes.

Helpful advice and guidance is something that I would need to speak to Dame Fiona about personally. I am sure that she would be willing to provide it; it is certainly within her ability to do so and she is not precluded from that.

To conclude, I hope that I have been able to reassure all noble Lords that the Government take seriously and are dealing with the points that they have raised. This Bill is an essential building block in the foundation of trust that we need to have in this country in order to make sure that the public are with us on this extraordinary technological journey that we are on at the moment, which will transform the way that we deliver health and care and will deliver radically better health outcomes for patients. That is something that I am sure we all want to see. I close by once again thanking my noble friend Lady Chisholm for introducing this Bill. I look forward to its swift passage through this House.

Antimicrobial Resistance

Lord O'Shaughnessy Excerpts

Thursday 25th October 2018 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government what steps they are taking to reduce deaths from antimicrobial-resistant infections.

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

My Lords, antimicrobial resistance, or AMR, is a significant global threat and the Government are committed to tackling it domestically and internationally. Over the past five years, we have worked to deliver our strategy and ambitions as set out in response to my noble friend Lord O’Neill’s review. However, we recognise that no country can tackle AMR in a single five-year strategy. That is why we will shortly be setting out our longer-term vision for tackling AMR and setting challenging ambitions for the next five years.

[Baroness Thornton (Lab)]

I thank the Minister for that Answer. As he rightly said, AMR poses a grave threat to health. Quite simply, if action is not taken to address this growing threat, it is estimated that, by 2050, AMR will kill 10 million people a year, more than cancer and diabetes combined. This week we saw the publication of the Commons Health Select Committee report which outlined the gravity of this issue. It is of concern that the Chief Medical Officer said to that committee that she would like,

“more visible and active Government leadership”,

on AMR. I think I need to press the Minister. When we will see more visible activity and what form will it take to deal with a huge threat to our nation’s health?

[Lord O’Shaughnessy]

I agree with the noble Baroness about the grave long-term threat AMR poses, but it also poses a threat in the short term. Estimates vary, but between 2,500 and 5,000 people a year in England die because of AMR. In relation to the seriousness with which the UK takes it, I mentioned the new strategy which will be published shortly. I should point out two things that have been a success. First, the UK has taken a very important global leadership role in making AMR a priority for the G20. Secondly, as a consequence of our action plan, we have seen reductions in the prescribing of antibiotics at GP level. That means that we are starting to drill down on the overprescribing and inappropriate prescribing which is driving AMR.

[Earl Attlee (Con)]

My Lords, is it correct that last-resort antibiotics are being fed to pigs in order that they can be weaned at an earlier stage?

[Lord O’Shaughnessy]

I do not know specifically about pigs, although in my briefing there was a quote from Pig World, which is not a periodical I read very often. Antibiotic use in the veterinary environment has gone down by 40%. It is one of the big successes of the strategy.

[Baroness Boycott (CB)]

My Lords, today the European Parliament is voting to ban all prophylactic use of antibiotics in farming, which will mean that they can no longer routinely be fed to groups. While British farmers have done magnificently in reducing antibiotics, I gather that the UK’s Veterinary Medicine Directorate is not minded to adopt this ban. Can I have an assurance from the Government that, in any new legislation now and post Brexit, a total ban on prophylactic use will be installed and that food standards will be maintained so that, if we ever start taking American meat imports, we will not accept them because of their unacceptable use of antibiotics?

[Lord O’Shaughnessy]

I join the noble Baroness in congratulating farmers on fantastic action in reducing the use of antibiotics. The specific issue the noble Baroness asked about is in the competence of Defra, so I will have to speak to my colleagues in that department about their opinion on the prophylactic use of antibiotics. On food standards, we have some of the highest food standards and animal welfare standards in the world, as the noble Baroness knows, and we have no intention of lowering them in any trade deal.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the Minister referred earlier to overprescribing. Will he tell the House what is being done to protect the future of scientific research in this area, particularly post Brexit? Although changing the behaviour of GPs and patients is important, long-term certainty will come from research which is yet to be completed.

[Lord O’Shaughnessy]

The noble Baroness is quite right. A key part of the strategy to date has been a £350 million investment in R&D specifically on AMR. On what will happen after Brexit, as she will know, our intention, as set out in the White Paper, is to be part of the successor programme to Horizon 2020, which you do not need to belong to the EU to be part of.

[Baroness Jolly (LD)]

My Lords, in 2016 just under 250,000 people developed multidrug-resistant TB globally, and in 2015 a report found that one-third of London boroughs exceeded the World Health Organization’s high-incidence threshold for TB. This poses a huge threat to public health. What action is being taken to get on top of this by the Department of Health, Public Health England and other agencies?

[Lord O’Shaughnessy]

The noble Baroness is quite right about the risk in London. We actually have a good TB story in this country—a 41% reduction between 2011 and 2016—but London has the highest rates in the UK. I can tell her that Public Health England and the GLA are working closely together to reduce TB. In fact there are innovative new approaches, such as UCLH’s Find & Treat mobile unit, which I myself visited last year, which is going out and finding people at the highest risk, screening them and then taking them for treatment.

[Lord Patel (CB)]

My Lords, accepting that the overprescribing or inappropriate prescribing of any drug is a bad idea, the issue of bacterial infections will remain with us. I hope the new strategy that the Minister mentioned will address the issue of how we might tackle bacterial infections in future. This could be by developing new antibiotics; developing drugs that deal with infections but do not produce resistance; developing therapies such as boosting the immune response to be able to cope with these infections; and even, if I may say so, developing drugs that might deal with so-called zombie cells that cause infections, which would be more appropriate for older people. I therefore hope his new strategy will address the necessary research.

[Lord O’Shaughnessy]

I can reassure the noble Lord on that front. We have made good progress in dealing with hospital-acquired infections such as MRSA and C. difficile, although unfortunately we have had less success with E. coli. Obviously, a big part of this is driving down infections completely. The other part is about drug discovery, and that is a big global action. It is part of the G20 work that we are taking forward with Argentina to ensure that we have new classes of antibiotics to deal with these problems.

Child and Adolescent Mental Health Services

Lord O'Shaughnessy Excerpts

Wednesday 24th October 2018 Lords Chamber

[Baroness Tyler of Enfield]

To ask Her Majesty’s Government what is their most recent assessment of access to treatment in Children and Adolescent Mental Health Services.

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

My Lords, the Government are improving and expanding access to children and young people’s mental health services. Because of the additional £1.4 billion available for these services, we expect that an extra 70,000 children and young people will access NHS specialist mental health services each year by 2021. We are either on track or exceeding waiting time targets for eating disorders and early intervention in psychosis, and the plans published in the Green Paper will further widen access to mental health support.

[Baroness Tyler of Enfield (LD)]

I thank the Minister for his Answer. Last week, Action for Children reported that one in three young people now have mental health issues. It also estimated that only a quarter of those who need help are currently able to access treatment from NHS services; this is quite often because they are not considered “ill enough”. I am particularly concerned by the often non-existent provision of crisis care for young people who are experiencing suicidal thoughts, self-harming, or just desperately needing help, often in the evening or at weekends—certainly outside of nine-to-five office hours. Could the Minister say whether setting up 24/7 crisis care provision for children, young people and their families will be a key priority for the Government in the forthcoming NHS long-term plan?

[Lord O'Shaughnessy]

I certainly think that is an interesting idea which I am very happy to feed into that process. I know the noble Baroness is a great campaigner on this issue, and the numbers of young people who are suffering from mental health problems are, frankly, terrifying. On the point about access, she was right that around one in four children and young people have been able to access these services. Our ambition, which we are on track to meet, is that this should rise to 35%. Clearly, we ought to reach 100%, but that involves recruiting a very large workforce, which we are in the process of doing.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister comment on whether there will be significant investment in trying to take psychology graduates into mental health nursing to enhance the number of people entering the profession?

[Lord O’Shaughnessy]

I do not know the specifics on psychology graduates; I will write to the noble Baroness. If the number of nurses in mental health nurse training at the moment comes through into the profession, there will be 8,000 more mental health nurses by 2020. I am sure we will be keen to recruit them from wherever we can.

[Baroness Wheeler (Lab)]

My Lords, on the issue of 24/7 services, CQC evidence suggests that the number of children visiting A&E departments for mental health treatment has more than doubled since 2010. Earlier this year, a CQC review highlighted growing demand as children, young people, their families and carers find that they have to reach crisis point before they can get help. On top of this, the recent FOI response to the BBC’s “Panorama” programme showed that at least 1.5 million under-18s were estimated to be living in areas where there are no 24/7 child mental health services. What steps are the Government taking to join up services across health, education, local councils and the voluntary sector to ensure that these vital crisis and support services are available and funded?

[Lord O’Shaughnessy]

I recognise that there is variability across the country. Indeed, waiting times vary, which is not acceptable. That is why a new four-week waiting time standard is being trialled as part of the Green Paper I mentioned. I should also point out that new, community-based eating disorder clinics are being set up so that people do not have to go to an A&E environment and can access something that is better for them, frankly, both more easily and locally.

[Baroness Fall (Con)]

My Lords, I start by commending the Government for their important work in this area. It remains true that many people who seek help are often either not helped at all or put on a waiting list. Can the Minister outline the exact thresholds that are used when many people who seek referral are turned away? In the interests of transparency, it would be important for us to know what they are.

[Lord O’Shaughnessy]

I thank my noble friend for her question. The definition is a “diagnosable mental health condition”. That is the performance target, or threshold, we work against. At the moment, unfortunately, only around 30% of children and young people with a diagnosable condition access care and treatment but we are clearly trying to increase that figure.

[Baroness Parminter (LD)]

My Lords, have the Government made an assessment of the number of children and young people referred to community eating disorder services? Given that anorexia has the highest mortality rate of any mental health disease, how many of those referrals do not go on to get treatment?

[Lord O’Shaughnessy]

The noble Baroness makes a very important point. There are 70 new or enhanced community eating disorder services. The intention is that they should serve over 3,300 children and young people every year.

[Lord Roberts of Llandudno (LD)]

My Lords, what consideration is being given to refugee children who come with tremendous trauma from the camps in Dunkirk and Calais? Is any consideration given to them and the threat that when they reach the age of 18, their status changes and they can face deportation? Can we not do something to relieve that anxiety?

[Lord O’Shaughnessy]

As I hope the noble Lord will know, refugee children have as much right to access these services as other children. I should also point out that a new mental health assessment trial is being funded by the Department for Education specifically to design mental health assessments for looked-after children of all kinds, including refugee children.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, can the Minister say what work his department is doing with the Department for Education in making consistent the level of pastoral care available in schools, particularly for young people who have experienced mental health problems and may not be in an acute stage but need ongoing monitoring?

[Lord O’Shaughnessy]

I am pleased to tell the noble Baroness that extensive work is being done. It was summed up in the plans outlined in the Green Paper last December and revolves around two things: every school having a designated senior lead for mental health and the recruitment of mental health support teams that will sit in and around schools. It is precisely about joining up education workers and health workers in the community to provide that kind of support.

[Lord Ramsbotham (CB)]

My Lords, too many people in our young offender institutions are suffering from mental health problems. The Minister mentioned the likely increase in the number of nurses, but one of the problems with the young offender institutions is that there is an acute shortage of child and adolescent psychiatrists. Will he please tell the House what the situation is regarding those vital people?

[Lord O'Shaughnessy]

I hope the noble Lord will forgive me if I do not have the specific number on psychiatrists. The plans to extend the mental health workforce as a whole cover all settings, including the recruitment of a further 1,700 children and young people’s therapists. I will find out whether the young offender institutions are included in that and what the figure is for psychiatrists.