Brexit: Reciprocal Healthcare (European Union Committee Report)

Lord O'Shaughnessy Excerpts

Tuesday 3rd July 2018 Lords Chamber

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

My Lords, I begin by saying that I will try to be concise, as all Lords have been, but I want also to cover the many interesting and important points that have been made. I congratulate the committee and the noble Lord, Lord Jay of Ewelme, for his chairmanship and for clearly putting together a very good-quality piece of work, and congratulate all noble Lords who contributed through that committee and, indeed, in this debate.

We have discussed tonight how reciprocal healthcare arrangements help people to live, work and travel across Europe in the knowledge that healthcare access is not a barrier. They are especially important for elderly people and those with long-term conditions. They enable people to access treatments or give birth abroad, promoting choice and healthcare collaboration. They have other economic benefits as well, such as tourism and helping the NHS to manage demand.

That is why we believe as a Government that a reciprocal healthcare agreement between the UK and EU is in the best interests of all. It is worth stating that good progress has been made in negotiations so far, and that is one reason why we are confident that we will secure good reciprocal healthcare arrangements as part of our future relationship discussions. Many noble Lords have asked why we have not done more, or been able to promise more, so far. It has to be said that the rate-limiting step has been the Commission’s mandate in what we were allowed to discuss and, indeed, in its insistence that nothing is agreed until it is all agreed. That was not our position, but the mandate the Commission gave to the Article 50 negotiating team. We have achieved as much as we possibly could within that mandate.

It is important to note—and many noble Lords have done so—that there is history in this area. The UK has a long-standing tradition of reciprocal healthcare agreements. My noble friend Lord Ribeiro pointed out that, for the last century, UK and Irish citizens have been able to access healthcare in one another’s countries. Noble Lords have talked about the many powerful ways in which that co-operation brings benefits to the peoples of both countries.

Since the 1950s, the UK and its European neighbours have had reciprocal healthcare and social security agreements too. I will deal quickly with the point my noble friend Lord Kirkhope made about whether, during negotiations, we are always as good as we could be at securing the moneys that are owed to us; I think it is fair to say that historically, we have not been. It is something we are starting to do better. One example is that we are now able to flag immigration and entitlement status on electronic health records, so that doctors do not constantly have to ask for that kind of information; it can be logged and secured through these agreements.

The UK also has agreements with the rest of the world, including Greenland, the Faroes, the Balkans, Australia, New Zealand and many of our overseas territories; there are precedents, current and historical, for the kind of deal we are aiming to strike.

The Select Committee report rightly recognises the importance of reciprocal healthcare. It has been pointed out in the debate that the NHS currently provides healthcare to over 3 million EU nationals living in the UK and that there are about 1 million UK nationals who live, work and use healthcare in the EU.

The noble Lord, Lord Ricketts, rightly pointed out that about 190,000 UK state pensioners have chosen to retire in Europe, notably Ireland, France, Spain and Cyprus. I am not sure that Ireland is where you would go on holiday if you were after sunshine in the winter but you would certainly choose the other three. It is worth mentioning that this is not just about the number of people who carry EHIC cards; 250,000 medical incidents affecting UK tourists are resolved via an EHIC, and a further 1,500 UK residents travel for planned treatment via the S2 scheme. That is what is at stake.

Several noble Lords referred to the achievements to date. The first of those was the joint report agreed in December 2017, which covered the entitlements of those exercising their reciprocal healthcare rights on exit day. I shall go into more detail on that shortly.

Following the agreement in December, there was further agreement in March 2018 on the implementation period. That means that the rights secured through the negotiations so far will, once the implementation period is agreed, continue until 31 December 2020, providing more reassurance. It includes healthcare for pensioners and workers, as well as the EHIC and S2 schemes, and nothing will change over that period.

Before turning to the impact on British citizens of the withdrawal agreement and implementation period, it is worth talking about the status of EU citizens living in the UK. That was raised by the noble Baroness, Lady Janke, my noble friends Lord Balfe and Lord Kirkhope, the noble Baroness, Lady Thornton, and others. The Prime Minister has been very clear that EU citizens who have made their lives in the UK should be able to continue with their lives here. We have that agreement and, indeed, we now have a route for that. As noble Lords have commented, we have opened the settled status route, which provides a specific legal mechanism by which people can secure their status to live in this country.

I reassure noble Lords that the department was one of the first to act on this new route. We have written to all NHS trusts to make sure that the many staff whom they employ and whose work we value so much are able to access that route as quickly as possible so that we can secure their future in the NHS and social care system. We want to allay their anxiety and I hope that that goes some way to doing so. It is worth pointing out, as always, that there are more EU staff working in the NHS today than there were two years ago, and of course we hope that they will stay.

What does the withdrawal agreement mean for UK nationals in the EU? The noble Lord, Lord Ricketts, and the noble Baroness, Lady Thornton, talked about the state pensioners living in the EU. We have agreed that the S1 scheme will continue for that group so that they continue to be able to access reciprocal healthcare in the same way as they do now. To answer the question from the noble Baroness, Lady Thornton, we will of course look at data on whether there are returners, although we have not seen any evidence of them yet. It is also worth pointing out that this group of S1 beneficiaries will also be able to use an EHIC to obtain healthcare if they visit other member states—the so-called onward rights.

More broadly, UK nationals living and working in the EU at the end of 2020 will be able to access healthcare on terms similar to those in place now under the implementation agreement, in line with the rights that we have agreed for EU nationals living in the UK.

Turning to the EHIC and the S2 scheme, during the withdrawal agreement and implementation period discussions so far, we have not agreed long-term continuation of the EHIC and S2 schemes for the reason that I gave. However, we have agreed that a transitional arrangement will ensure that people visiting the UK or the EU on holiday or for study will be able to continue to use their EHIC while in that state of travel. People receiving planned treatment via the S2 route will be able to complete their course of treatment abroad, however long the treatment lasts, so that there will be no disruption to their care. We will also continue to press for the right of people covered by the withdrawal agreement to move to other member states—a right that we have been able to secure for pensioners under the S1 scheme.

Inevitably, the debate has focused on what the future relationship will look like. The Government have been clear about what we are seeking to achieve: the right of UK state pensioners who retire to the EU to access healthcare in those states; full ongoing UK participation in the EHIC scheme; and the right of UK residents to receive planned treatment in the EU, when the NHS authorises it.

The noble Lord, Lord Jay, asked: why S1 rights? I think that he has in mind, for example, frontier and posted workers. It will inevitably depend on wider agreements about mobility and security rights. There is a co-dependency between those citizens’ rights and the more extensive application of the S1 right to healthcare. However, the other elements of the reciprocal healthcare rights do not have the same co-dependency with the wider citizen rights.

The noble Baroness, Lady Janke, my noble friend Lord Balfe, the noble Baroness, Lady Thornton, and the noble Lord, Lord Ricketts, also asked about the no-deal arrangement. Indeed, if noble Lords did not mention it, it is certainly on everyone’s mind. The committee obviously heard about and described the anxiety that there would be if people could not easily access healthcare abroad, and it suggested solutions that we could adopt, such as bilateral agreements. I reassure noble Lords that it is our intention to secure a deal, given the commitment to protect the interests of citizens from both sides in the negotiations. I should also reassure noble Lords that the department is doing everything it can and everything necessary to avoid any kind of cliff edge. There is a programme of work that aligns with the ideas already posed by the committee in the unlikely event of a no deal.

We are of course planning for all scenarios. I think that British citizens would find it bizarre if we did not prepare for all eventualities, not just on reciprocal healthcare but on other health issues and across the piece. I am afraid that noble Lords will have to forgive me: this is not the time for me to go into further details about what those no-deal preparations look like, although of course at some point in the future we will have more to say. I shall resist the entreaty from the noble Baroness, Lady Thornton, to give her probabilities—I am terrible at betting, so she would not want to trust me anyway.

Ireland has obviously been a heavy feature of the debate and the report. My noble friend Lord Ribeiro spent much time highlighting the benefits of that relationship, and the noble Baronesses, Lady Pinnock and Lady Janke, talked about it as well. As somebody who has an Irish connection, it is something that features heavily in my, as well as the Government’s, thinking. I reassure noble Lords that the UK and Ireland have agreed that we will protect healthcare access and co-operation for our populations whatever the outcome of the EU exit. That would take place under the common travel area and other agreements that we have made together.

The discussions are progressing well. I recently met my counterpart, the Irish Health Minister, Simon Harris. We are both satisfied by the progress in this area. I reassure noble Lords—particularly the noble Baroness, Lady Pinnock, who was very interested in this matter—that it is a priority for us and that we are making good progress.

My noble friend Lord Balfe asked about the devolved Administrations. We are of course engaging with them all the time and making sure that they are involved in the decision-making. As we go forward, we will be seeking a deal that works for all parts of the UK, and it therefore needs to work for and be agreed by the devolved Administrations too.

The noble Baroness, Lady Janke, made some important points about insurance, as did the noble Baroness, Lady Pinnock. We are continuing to engage with the Association of British Insurers. Clearly, the exact outcome and its implications for travel insurance will depend on the future relationship, we agree. But for the reasons that I have said, I will not go into the detail now of preparations for no-deal scenarios. I can tell the noble Baronesses that we have that open relationship and are having discussions, and we understand exactly what is at stake here.

Finally, my noble friend Lord Ribeiro raised the issue of radioisotopes. It is a topic that we have discussed several times. He will know that we are investigating not only domestic production but making sure that there are customs arrangements and other arrangements such as trading arrangements to make sure that the supply of radioisotopes is not impacted in any way by the circumstances under which we leave the European Union. I am reassured from the work that has gone on in this House through our debates on the withdrawal agreement and the Nuclear Safeguards Bill that we have a proper understanding of how we achieve that. Noble Lords made a fantastic contribution to that work. Of course, as the noble Lord will know, regarding the proton beam, there is a centre open at the Christie and another one to follow, so we will be able to provide more of that therapy at home for UK citizens.

I thank the committee again for its fantastic work, the noble Lord, Lord Jay, for his expert chairmanship and all speakers. I think we are all agreed on what we want to achieve from these negotiations and why we want to achieve it. It is inevitably a complex task. The input of the committee is highly welcome and has been very productive and influential on our thinking as a department. I want to make sure that that is reflected as much as possible in the work we do and the proposals we make, whether in a White Paper or other routes. I hope that we will continue that dialogue so that we can make sure that concerns are raised and properly dealt with and we end up with an outcome that protects citizens’ and patients’ rights after we leave the European Union.

Health: Endoscopy and Bowel Cancer

Lord O'Shaughnessy Excerpts

Monday 2nd July 2018 Lords Chamber

[Baroness Benjamin (LD)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare an interest as patron of Beating Bowel Cancer.

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

My Lords, the Health Education England Cancer Workforce Plan includes a commitment to invest in a further 200 clinical endoscopists by 2021 to support an increase in capacity for earlier diagnosis. This builds on the existing commitment to train 200 clinical endoscopists by the end of 2018. The Health Education England training programme has already recruited 130 trainee endoscopists against this target, with two further cohorts planned this year.

[Baroness Benjamin]

I thank the noble Lord for that Answer. Around 16,000 people die from bowel cancer each year—my mother was one of them—so early diagnosis is vital. I congratulate the Government on introducing FIT, a test which will save lives, but endoscopy units are already struggling to cope with the increase in referrals because of inadequate funding and a lack of highly trained NHS staff to carry out the procedures. What plans do the Government have to provide training for the staff needed, and when will details of the planned phased rollout of the FIT be published?

[Lord O'Shaughnessy]

I thank the noble Baroness for raising that question and am sorry to hear about her mother. As she will know, bowel cancer is unfortunately the third-most prevalent cancer and the second-biggest killer, and we need to go a long way to improve treatment. I have already mentioned the increase in the number of endoscopists, and that will help. There are also plans to make sure that existing staff within the cancer workforce have the necessary specialist skills. The size of the cancer workforce has increased over the last few years but there is a goal to dramatically increase it further. We know that the test that the noble Baroness mentioned is much more effective and can be administered much more easily. The rollout will take place from December this year.

[Lord Winston (Lab)]

My Lords, there is an increasing interest in capsule endoscopy, which of course is less invasive as it does not require an instrument to be put down into the abdomen. However, it requires training, which the medical literature clearly shows is insufficient. Can the Minister indicate whether the NHS is planning to provide more training for the provision of capsule endoscopies? Also, what is the risk of a large number of false positive results with all these endoscopies?

[Lord O'Shaughnessy]

I will have to write to the noble Lord with an answer to his question about the type of endoscopy he mentions, as I do not have the details of it. The risk of false positives is one reason that we have to be extremely careful with screening programmes of all kinds, whether it is the faecal immunochemical test or an endoscopy. As he knows, whatever screening programmes are implemented, the National Screening Committee tries to reduce the number of false positives wherever possible.

[Lord Patel (CB)]

My Lords, given that we have one of the poorest outcomes compared with other health services in the developed world and that the demographic changes that will occur in the population may well mean that one in two people will develop cancer, are the Government aware of what determinants there are for poor outcomes? What plans do they have to improve them for cancer patients?

[Lord O'Shaughnessy]

The noble Lord is quite right to point that out. While outcomes have improved, they lag behind those of other countries, which we need to correct. The independent cancer taskforce set the goal of saving 30,000 extra lives a year by a number of different routes. The one that I pick out in particular is early diagnosis. We know that too many cancers are diagnosed at a late stage, so this year the NHS has committed to increasing the proportion of cancers diagnosed at stage 1 or stage 2, and we are spending £200 million in cancer alliances to support early diagnosis in the community.

[Baroness Neville-Rolfe (Con)]

My noble friend has done much to bring the benefits of the digital revolution to the NHS. Are there digital solutions that might help to prevent bowel cancer and other cancers in the fight against this dreadful disease in the coming months and years?

[Lord O'Shaughnessy]

My noble friend is quite right to point out the potential of digital, particularly the analytical capability of artificial intelligence to look at samples. That was one reason why the Prime Minister recently pledged to have 50,000 more early cancer diagnoses by 2033—a long-term goal—precisely because the NHS is such a good place to use artificial intelligence to improve care.

[Baroness Jolly (LD)]

My Lords, after a cancer diagnosis, English patients have poorer outcomes than all but one of our European comparators. We welcome the announcement that the Minister has just made about new clinicians, but in some areas there are delays in referral, testing diagnosis and then treatment. The longest wait for treatment reported this year was 541 days. That is not good enough. How long does the Minister think we will have to wait for there to be sufficient clinicians and facilities to deliver a service that moves us significantly up the table?

[Lord O'Shaughnessy]

The noble Baroness is right to highlight the importance of waiting times. The 62-day standard is unfortunately not being hit at the moment. The NHS has pledged to get back on that standard this year. We are also piloting a faster, 28-day diagnosis standard in five areas at the moment with the idea of rolling that out so that there is a higher standard of care and fewer people have to wait longer.

[Baroness Thornton (Lab)]

We should probably be grateful that the Minister did not choose to bring a FIT as a visual aid, as his honourable friend did on the “Andrew Marr Show” yesterday. I welcome the Government’s announcement that that test will be in introduced in England in the autumn, but will the Minister confirm that all eligible people will receive the FIT kit in the autumn rather than through a phased introduction across England? How long will that take?

[Lord O’Shaughnessy]

I will not be rummaging around in my pocket to reveal something; nobody wants to see that. My understanding is that FIT will be introduced from the autumn and the intention is to get national coverage. I do not believe that it will be achieved immediately, but I will write to the noble Baroness with the specific timeframe.

[The Earl of Listowel (CB)]

My Lords, will the Minister look at access to mental health services, so that referrals can be made early on for patients who are identified with bowel cancer where that is helpful? Does he not agree that patients will make better recoveries if assessments are made of their mental health and emotional well-being, along with support groups and other services to help them with these aspects of their recovery?

--- Later in debate ---

[Lord O’Shaughnessy]

The noble Earl makes a good point. A cancer diagnosis can be a devastating piece of news. One way of ameliorating that is through the support of charities like Macmillan Cancer Support, as well as through clinical nurse specialists who can provide such support. Some 90% of people are seeing those nurses when they are diagnosed and our ambition is to see that percentage rise to 100% next year.

Health: Stroke Survivors

Lord O'Shaughnessy Excerpts

Thursday 28th June 2018 Grand Committee

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

My Lords, I congratulate my noble friend Lord Lingfield on securing this debate. As the noble Baroness, Lady Wheeler, has just pointed out, it has been short but sweet—rather, we have had a small cast list but a high quality of output. The experience of the noble Baroness and that of her partner has been invaluable, while the noble Baroness, Lady Barker, asked some searching questions, which I shall attempt to answer. The noble Baroness, Lady Coussins, will be amused to learn that in my briefing it states of her, “Does not normally ask health questions”. I am absolutely delighted that she is here, because hers is a perspective that we have not had before. I hope that it is not the last time that we see her taking part in a debate of this kind, and I shall come to the very interesting ideas that she mentioned. Along with other noble Lords, I recognise and applaud the work of charities like ARNI, while my noble friend also referred to the Stroke Association, Canine Partners and others. They make a valid and vital contribution to care in this area.

We have talked about the impact of stroke. In England some 80,000 people a year are being admitted to hospital. We also know about the impact that strokes can have not only on the lives of sufferers themselves, but also on their families, friends and carers. The statistic that stroke leaves half of those affected with a disability is a sobering one. We know also that the difficulties are not just physical. As we have discussed, they include communication difficulties, psychological cognitive fatigue and others. Indeed, stroke is the leading cause of complex disability, as well as the fourth largest cause of death, which is why it has quite rightly been the focus of successive Governments.

It is worth saying that major improvements have been made in stroke prevention, treatment and outcomes since the publication of the 2007 strategy, for which the then Labour Government deserve much credit. I shall highlight one or two of those outcomes, because they highlight some of the questions which have been asked. Over the past 20 years, the 30-day mortality rate has dropped from 30% to 13.5% in 2015-16. There is now better compliance with the occupational therapy standards, from 56% to 83%, while physiotherapy standards have risen, along with speech and language therapy. However, it is notable that even with speech and language therapy, where compliance has doubled, it remains at less than 50%, which goes to the heart of some of the points about variations in provision which noble Lords have pointed out. While improvements have been made, it is clear that a lot more needs to be done.

As several noble Lords mentioned, one way that we can improve rehabilitation is to get the care right in the first place. The noble Baronesses, Lady Barker and Lady Wheeler, mentioned mechanical thrombectomy, which is highly effective at preventing severe disability. The statistics are interesting: for every 100 patients treated, 38 will experience a less disabled outcome than with the best medical management—an extraordinary improvement—with 20 more achieving functional independence. Having national coverage is clearly important, and I will come on to how we try to achieve that.

The noble Baroness, Lady Wheeler, talked about how her partner had benefited from Public Health England’s Act Fast campaign. That is reducing the amount of time between someone having a stroke and arriving at hospital. The campaign has been going for about nine years now, during which 5,365 fewer people have become disabled as a result of a stroke, saving the equivalent of 12,200 quality-adjusted life years. This is quite an achievement for a public health campaign. The third area on the acute side where big improvements have been made, and which noble Lords have spoken about, is the centralisation of services, including hyper-acute stroke services. The noble Baroness mentioned the work which our colleague, the noble Lord, Lord Darzi, did in London. Because of that, a significantly higher proportion of patients are receiving care compliant with the guidelines and processes. That alone has delivered a 5% relative reduction in mortality at 90 days, another significant improvement.

Those things are at the acute end, but the topic for today is rehabilitation. As has been mentioned, there are over 1 million stroke survivors. Not only do half of those have a disability but half are also living with four or more co-morbidities. The question is: how do we get their lives back on track? We know that rehabilitation delivers better outcomes, improves quality of life and reduces health inequality. It also provides good value for money; it is the right thing to do on every level. It is also important to approach this with an optimistic mind set. As noble Lords have pointed out, stroke can be a recoverable condition, with survivors continuing to improve for months after their stroke.

We know from stroke survivors and the charities that represent them, and we have heard today, that they need early and ongoing rehabilitation and support. The testimony of the noble Baroness, Lady Wheeler, and her partner brought this to life. This includes holistic reviews of progress; a personalised care and support plan which is regularly updated; the provision of information; the availability of the right therapies; and so on. This obviously has to happen in the acute setting but, more importantly, it needs to happen in the post-acute setting as well.

My noble friend Lord Lingfield and the noble Baroness, Lady Wheeler, talked about the stroke working party guideline of 45 minutes, but they also said that that is being missed all too often. What are the Government doing about it? The governing document has been the strategy which began in 2007, which has now been replaced with the stroke programme board, established in March this year. It is chaired by the national medical director of NHS England and the CEO of the Stroke Association and is developing a costed stroke plan to address the challenges of prevention, service reconfiguration, optimising rehab services, workforce development and data. I do not have a date at this time, but I shall endeavour to write to the noble Baroness and other noble Lords with that.

The board is looking at some changes. It has been said, quite rightly, that there needs to be seven-day availability of the right workforce. We need to make sure that nurses, therapists and other medical staff are there round the clock. As we know, there is some silo thinking on clinical expertise in the NHS. As the noble Baroness, Lady Barker, pointed out, the availability of mechanical thrombectomy is hampered by a shortage not just of skilled neuroradiologists but of other trained consultants. Reconfiguration can deal with some of that, but we need to do more to deal with it at a national level.

Through the work of the programme board we intend, first, to include stroke-specific plans within workforce strategies and to support integration across care settings. Secondly, we will establish training pathways from other medical specialties to increase the interventional neuroradiology workforce. Thirdly, we will include experience in stroke medicine early on in the undergraduate curricula of foundation medical training programmes, to encourage early career choices to pursue stroke training.

The noble Baronesses, Lady Barker and Lady Wheeler, also talked about the need for better data. That is absolutely right, and is happening in a couple of ways. First, a new national clinical audit of cardiovascular disease prevention in primary care is being instigated. Secondly, in reference to one question that was put, we are making sure that the research strategy of the NHS will address key evidence gaps in stroke, particularly around post-acute care. I shall certainly take away the suggestion by the noble Baroness, Lady Wheeler, about a specific type of stroke and the under-resourced or under-researched nature of it.

Much of the funding for research comes through the National Institute for Health Research—a domestic source, although this issue is international in scale. As for Brexit, following our exit from the European Union, we are looking to achieve participation in the next iteration—the successor programme to Horizon 2020. Third countries are already participating, so it is within our grasp, as was set out in the Government’s Collaboration on Science and Innovation: A Future Partnership Paper.

On commissioning, which was also mentioned, NHS RightCare: Stroke Pathway was published in October 2017 and is the governing document. We need to ensure that the guidance that includes information about early supported discharge and community provision is adhered to. I do not know what the mechanisms are by which we will improve compliance, some of which is quite good and some, frankly, too low. That is a topic of work for the programme board. I shall write to noble Lords with its ideas on how it intends to make that bite, so that there is CCG compliance in commissioning frameworks.

Finally, we need a different approach to rehabilitation, one that is collaborative and integrated across health, social care and, critically, the third sector. In addition to rehabilitation, stroke survivors need a very broad set of services, including spasticity services, psychology, orthoptics, pain and continence services. As we have also heard, stroke survivors often need help with housing adaptations.

We have, therefore, three goals to achieve this rehabilitation revolution. First, we must make sure that there is proper commissioning of stroke specialist rehabilitation of the required intensity seven days a week for stroke victims through their in-patient stay, as recommended by the clinical guidelines. That will be driven by NHS England. Secondly, we must ensure that stroke survivors have access, within 24 hours of discharge from hospital, to a stroke specialist rehabilitation service that can provide support for the early discharged patient at the same rehabilitation intensity as stroke unit care, seven days a week. Thirdly, we need to develop a national service specification for the structure and process of stroke specialist rehabilitation services provided immediately after discharge, including early supported discharge, that describes appropriate staffing levels and, critically, addresses rurality. We must not only set those guidelines but make sure that they are complied with.

I shall briefly answer questions where I have not yet had a chance to do so. My noble friend Lord Lingfield asked about grants from public funds to rehab charities. Local authorities do that kind of work through their social care function. I am not aware of what CCGs and the NHS itself do, but I will endeavour to find out what support is available.

The noble Baroness, Lady Coussins, took us on a very interesting journey into the power of language, and second languages. I knew about its benefits for dementia sufferers, but not about its benefits for stroke sufferers. I shall certainly be happy to find out more about the scheme and whether we can help. It sounds like a fascinating idea; considering the annual cost of stroke, and what the cost of educating children in a second language at school would be, the cost-benefit analysis looks quite good. It is something to think about, and I am glad that my right honourable friend Nick Gibb is enthusiastic about it.

The noble Baroness, Lady Barker, asked about stem cell and gene therapies. It is a really good question. We have a fantastic network of biomedical research centres, funded by the National Institute for Health Research. I do not know if she has had the opportunity to visit any of them but I thoroughly recommend it. Sometimes we are a bit hard on ourselves in this country in asking ourselves whether we really have access to cutting-edge, world-leading therapies in cancer, stroke, cardiovascular, or whatever. This is where it happens—where the translation from lab to the clinical setting happens. People here are among the first in the world to get these therapies. I thoroughly recommend seeing that, and if the noble Baroness were to get in touch I would be delighted to recommend a suitable one. We have the opportunity to be involved in this field, and a good track record in it.

Finally, the noble Baroness, Lady Wheeler, asked several questions. I hope that I have responded to most of them. If I have not, I will of course follow up with a letter.

I close by once again thanking all noble Lords for their contributions. It has been a fascinating and useful debate. With the programme board in place, I think that we have the opportunity and the leadership to make sure that we improve stroke services. We are in the happy position of knowing what is necessary; now, we need to deliver it. I am sure that, working together, we can start to transform rehabilitation care so that it is of the intensity required and provides a lifeline to stroke sufferers.

Nursing and Midwifery (Amendment) Order 2018

Lord O'Shaughnessy Excerpts

Monday 25th June 2018 Lords Chamber

Moved by

[Lord O'Shaughnessy]

That the draft Order laid before the House on 17 May be approved.

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

My Lords, today we are debating legislation that puts in place provisions to regulate the nursing associate role in England.

Health Education England’s Shape of Caring review made a series of recommendations to strengthen the capacity and skills of the nursing and caring workforce. The report identified strong support from employers, managers and staff in the health and social care sectors for a new nursing support role that would act as a bridge between the unregulated care assistant workforce and the registered nursing workforce. Health Education England undertook a public consultation on introducing the nursing associate role in England. The majority of respondents, a large proportion of whom were registered nurses, supported the new role, and there was strong support for it to be regulated.

Nursing associates will have their own defined role, augmenting and supporting the work of nurses in carrying out critical functions. They will deliver hands-on care, enabling registered nurses to spend more time using their specialist skills to focus on clinical duties and take more of a lead in decisions on patient care. We do not expect nursing associates to be primary assessors of care, but they will monitor the condition and health needs of those in their care and be able to recognise when it is necessary to refer to others for reassessment.

Although this new role will open a new career pathway into the nursing profession, I reassure all noble Lords that nursing associates are not substitute nurses. We want more not fewer nurses, which is why in October 2017 the Government announced a 25% increase in funded training posts for nurses to ensure that the NHS meets current and future nursing workforce needs.

It is vital that the right safeguards are in place. The Government’s view is that the most appropriate way to achieve this is through statutory regulation. This will support employers to use the role to its full potential and help ensure patient protection.

First, the effects of the proposed amendments to the Nursing and Midwifery Order 2001 are to give statutory responsibility to the Nursing and Midwifery Council to regulate the nursing associate profession in England. Secondly, they are to extend the NMC’s current powers and duties contained in the order to nursing associates, in particular the key functions of: registration of nursing associates in England; setting standards of proficiency, education and training and continuing professional development and conduct for nursing associates in England; approving nursing associate programmes in England; operating fitness-to-practise procedures in respect of nursing associates; and recognising Scottish, Northern Irish, Welsh, European Economic Area and international qualifications for the purpose of registration to the nursing associate part of the register.

Thirdly, this order amends the offence provisions in the Nursing and Midwifery Order. These amendments provide that a person commits an offence when falsely claiming to be on the nursing associate part of the register, falsely claiming to hold a nursing associate qualification or using the title “nursing associate” when not entitled to. The offences have been drafted to reflect that nursing associates will be regulated in England only.

Fourthly, the order makes provisions that allow admission to the register for those who have completed or commenced their training by 26 July 2019 through the pilot courses being run by Health Education England or an apprenticeship route. Fifthly, it excludes nursing associates from being given temporary prescribing rights in a time of national emergency, such as a pandemic flu outbreak. Sixthly, the order also removes the screener provisions from the Nursing and Midwifery Order 2001, as these are now redundant. Seventhly, it makes consequential amendments to the Nursing and Midwifery Council’s rules and to other legislation.

Finally, the order closes sub-part 2 of the nurses’ part of the register by amending the Order in Council which determines the parts of the NMC’s register and the titles which may be used by persons included in the register.

These are important changes to the governing legislation of the Nursing and Midwifery Council which introduce the nursing associate role into regulation. Employers have told us that they need a more flexible workforce to keep pace with developments in treatments and interventions. This role will enrich the skill mix available to employers within multidisciplinary teams and support the increase of nurse numbers by providing a clear pathway into the nursing profession.

Once the order comes into force, it is proposed that the Nursing and Midwifery Council will open the new nursing associate register in January 2019. I beg to move.

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[Baroness Jolly (LD)]

My Lords, my contribution will be very short, as noble Lords have already said everything. We, too, welcome the role of the nursing associate. I commend the work of my noble friend Lord Willis of Knaresborough in making this happen and say to him that he can have the Front Bench if he is happy to take all that goes with it.

The noble Earl, Lord Listowel, made the point about impact. I just make one extra point. In remote locations—I live in Cornwall, but this could account for anywhere far-flung where there are hospitals and health establishments—there will be uptake from healthcare assistants who feel that they cannot leave home to train as a nurse because the distance is too great and they have family responsibilities or other commitments, but they could manage the two-year course. That would be really positive. Nursing associates would then improve in those establishments the quality, but also the skill mix, of nursing teams in areas where it is also particularly difficult to appoint.

I understand the timing of this SI. The noble Lord, Lord Clark of Windermere, said that perhaps there was still stuff to look at. It is really important that it gets on to the statute book, because we will have real live trainee nursing associates who need to register next year. Sadly, we cannot take any more time to do this, but from these Benches we really welcome the role of the nursing associate and the help it will give the NHS.

[Lord O’Shaughnessy]

My Lords, I sincerely thank every noble Lord who has spoken in the debate and engaged with these regulations so thoroughly. It has been a really important discussion about not just the new role of nursing associate but its impact on the overall health and care workforce. I am very grateful to all corners of the House for the broad welcome, albeit with questions and conditions, for the creation of this role.

I want to deal up front with the urgency of these regulations. I agree that there has been an element of rush, and I think we are all agreed on the requirement for it. But like all overnight successes, this has been a long time brewing, as the noble Lord, Lord Willis, pointed out. A lot of work has been done, and I salute, along with all noble Lords, the many people at the RCN, the NMC and others who have contributed to this, and the many people behind the scenes. It is quite right to acknowledge them. No doubt there is more work to come.

The primary debate, or part of it, revolved around the distinction between the nurse role and the nursing associate role. It is very important to be clear, as I hope I was in my speaking note, that these are distinct professions. They may all be part of the same family—there is a certain amount of semantics involved here—but they are distinct professions, which will be regulated distinctly, albeit in a joined-up way through the same regulator, which is quite right. The NMC is currently consulting on standards of proficiency. The department, with all the necessary arm’s-length bodies and others, will develop guidance for that separate profession. While nursing associates can inevitably support nurses, doctors and others, they will not just be the handmaidens to others, in the evocative phrase of the noble Lord, Lord Clark. They will be professionals in their own right.

It is also worth pointing out that, in the consultation going on at the moment on standards and proficiency, the NMC is also looking at the code of conduct and amendments to it. That consultation ends on 2 July so, again, I warmly encourage all noble Lords to contribute to that, because some of the ideas set out today could have an important role in getting that right.

The noble Baroness, Lady Thornton, asked about the financial risks involved in setting up the courses—making sure that they are properly constituted and so on. My department has a memorandum of understanding in place with the NMC to keep the costs of the set-up within agreed cost parameters. The costs of accrediting nursing associate courses are met from the annual registration fees paid by the NMC’s registrants. Therefore, the financial modelling has been investigated and we understand what we need to stick to.

--- Later in debate ---

[Lord Clark of Windermere]

May I press the Minister a little further on the training costs? Is he saying that all students on the nursing associate courses will be apprentices and that no student on the nursing associate course will pay towards the cost of that course?

[Lord O’Shaughnessy]

I thank the noble Lord for that question. My understanding is that the nursing associate is a two-year apprenticeship that provides a level 5 qualification. Therefore, there is currently a consultation about the nature of the role—the balance between work and training and so on—but obviously if it counts as an apprenticeship any organisation providing it can draw down on the apprenticeship levy fund to pay for those training costs. Whether it is in theory possible to train through an alternative route that would involve the paying of fees is something I will need to investigate and write to the noble Lord about. Of course, I will put that letter in the Library. The funding is there and the NHS is paying it. It is not necessarily drawing it down at the moment; this is an opportunity for us, with a course that is tailor-made for apprenticeships, to take advantage of that money to fund the courses.

I hope I have been able to answer noble Lords’ questions. This is an exciting moment in the development of the workforce. It provides an extra gear to the workforce to provide for the ever more complex care needs of our population. This is a good step forward. We are moving quickly and I look forward to working with noble Lords in the coming months to make sure we can put this course and its regulation on a statutory footing, attract many thousands of people into it and welcome a new profession into the health and care family. On that basis I commend the order to the House.

Motion agreed.

Childhood Obesity Strategy

Lord O'Shaughnessy Excerpts

Monday 25th June 2018 Lords Chamber

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

My Lords, with the leave of the House, I shall now repeat in the form of a Statement the Answer given by my honourable friend the Parliamentary Under-Secretary of State for Public Health and Primary Care to an Urgent Question in another place. The Statement is as follows:

“Today, the Government have published the second chapter of the childhood obesity plan. This plan is informed by the latest evidence and sets a new national ambition to halve childhood obesity and to significantly reduce the gap in obesity between children from the most and least deprived areas by 2030.

Childhood obesity is one of the biggest health problems this country faces, with almost a quarter of children overweight or obese before they start school, rising to over a third by the time they leave. This burden is being felt hardest in the most deprived areas, with children growing up in low-income households more likely to be overweight or obese than more affluent children.

Childhood obesity has profound effects that compromise children’s physical and mental health both now and in the future. We know that obese children are more likely to experience bullying, stigma and low self-esteem. They are also more likely to become obese adults and face an increased risk of developing some forms of cancer, type 2 diabetes and heart and liver disease. Obesity is placing unsustainable costs on the NHS and our UK taxpayers, currently estimated at around £6.1 billion per year. Total costs to society are higher, estimated at around £27 billion per year, with some placing this figure even higher than that.

The measures we outline today look to address the heavy promotion and advertising of food and drink products high in fat, salt and sugar on TV, online and in shops. Alongside this we want to equip parents with the information they need to make healthy informed decisions about the food they and their children are eating when out and about. We are also promoting a new national ambition for all primary schools to adopt an ‘active mile’ initiative, such as the Daily Mile, and will be launching a trailblazer programme working closely with local authorities to show what can be achieved and find solutions to barriers at a local level to address childhood obesity.

In conclusion, childhood obesity is a complex issue that has been decades in the making, and we recognise that no single action or plan will help us to solve the challenge of childhood obesity on its own. Our ambition requires a concerted effort and a united approach across businesses, local authorities, schools, health professionals and families up and down the country. I look forward to working with them all”.

--- Later in debate ---

[Lord O'Shaughnessy]

An upgrade in our grade is, I suppose, something to be welcomed. The noble Baroness is being a little unfair. The last obesity plan probably went beyond that of almost any country in the world, and this one certainly goes well beyond that. We know that we need to do more—that much is obvious from the facts—because, unfortunately, obesity continues to rise. We have taken big action through the soft drinks levy, improvements in reformulation and so on but it has not gone as far as we want. So we recognise the need to do more.

The noble Baroness referred to consultations but, if anything, you can accuse this paper of being too honest because any action requires consultation to go forward. I would not want her to be distracted by that because within it are some hard commitments. There is a commitment to voluntarism if we can make it work but, equally throughout, there is a commitment to legislate if that does not produce the right outcomes.

The noble Baroness asked about milk products. Again, if voluntary reformulation does not work, these will be considered by the Treasury as being liable for the levy on soft drinks to bring down the sugar content.

On advertising, the idea that we should have a 9 pm watershed across broadcasting is truly radical, and it is only right that we consult properly. There is a desire to do that by the end of this year, so the noble Baroness cannot accuse us of not moving quickly enough.

The Obesity Health Alliance, which counts dozens of bodies among its membership, has welcomed the plan set out today. Of course it wants us to get a move on—and we will—but it is important to note the radical change in policy to try to deal with this epidemic that we all face.

[Baroness Jolly (LD)]

My Lords, I thank the Minister for repeating the Answer to the UQ. Anything is welcome and I am at the stage where more questions are being raised than answered. A debate in this House would be useful and perhaps put some flesh on the bones. That is absolutely the wrong thing to say, but the House knows what I mean. It would give more clarity.

I wish to push the Minister a little further on the advertising issue. I appreciate that a consultation is coming up. We welcome the idea of using the watershed, but I am not clear from the Statement or from chapter 2 whether it includes all programmes before 9 pm or only programmes that are aimed at young people before 9 pm. That is an important distinction and it will be useful to know what is going to be consulted upon.

Families were mentioned in passing. I would like to know what work is to be done with families. I appreciate that there is not in this land a typical family, but we are trying to take out 500 calories a day from people’s diets and we need to point out the high calorific value not only of chips, which may seem obvious, but of pasta, rice—which everyone thinks is healthy—bread and buttered mash. There is still work to be done with families to make them understand quite what they are putting on their children’s table which seems healthy and fine.

--- Later in debate ---

[Lord O'Shaughnessy]

It is always a pleasure to debate issues in this House. This topic is worthy of that debate because there is a huge interest in it in this House.

The noble Baroness is quite right to talk about advertising. It states in the paper:

“Consult, before the end of 2018, on introducing a 9pm watershed on TV advertising of HFSS”—


high in fat, sugar and salt—

“products and similar protection for children viewing adverts online”.

I take that to mean across the board as opposed to those solely aimed at children, which are already subject to world-leading restrictions.

The noble Baroness asked about families. Much of this is about helping families to do the right things. We know how difficult it can be when you are with young children in a shop to resist this, that or the other. You talk about protecting your teeth or eating well, but it is not always obvious what is good for you and what is bad for you. Again, in the paper there is reference to calorie labelling and going much further in terms of restaurants and store promotions. The noble Baroness and her party are always keen to make sure that we can get the most out of Brexit, and going further than the European Union will allow us with food labelling and simple nutrition information is just one of the many opportunities we will enjoy after 2019.

[Baroness Jenkin of Kennington (Con)]

My Lords, my noble friend may be aware that I chaired a commission for the Centre for Social Justice last year, so I welcome the acknowledgement that this issue particularly affects children in the most deprived areas. Can my noble friend give more clarity about the consultation and when it will end? Although I have not read every word in it yet, can he also say whether the Government will look at the “eatwell plate”, which is carb heavy at the moment? I am not sure whether that advice is covered in the paper.

[Lord O'Shaughnessy]

I thank my noble friend for her questions. I salute the work she has done and the leadership she has shown on this issue. As to the content of the consultations, that will depend on when they are launched but it refers in the paper to consulting before the end of 2018 on a number of issues, so that will go through the normal process, I suppose, of a three-month consultation.

I shall look at the issue of the “eatwell plate”. It is worth pointing out that, under the “Schools” heading, there is a desire to update school food standards, reduce sugar consumption, strengthen nutrition standards and the government buying standards for food and catering services. So there is a desire to look at the official guidance that goes out and to make sure that it reflects the best science and enables any institution that is looking after children, families, schools, adults and others to give the best possible nutritional food that they can.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I welcome the proposals for further action, but I am sorry that the Government have not seen fit, if they are taking this really seriously, to make a Statement about it without the requirement for an Urgent Question to elicit a response. I have two points. I regret that there is still no mention of the point that the noble Lord, Lord McColl, has been pressing so vigorously—that we need to bring together these numerous initiatives and try to present a single campaign for parents and children. I also regret that there is still no mention of the Government dealing with the major broadcasters, in particular the BBC, to see how a longer-term plan might be produced which would make a direct link with children and thus try to ensure that effective changes take place.

My second point is that last week the Minister was kind enough to reply to my Question for Written Answer about the extent to which the Government are aware of how much children between the ages of 12 and 16 weigh. I am surprised to hear that while we weigh children at the ages of four and 11, nothing is done about weighing children beyond that age. We do not know what the scale of the problem is up to the age of 16. A survey has been undertaken in which only 2,000 people were involved. There is a requirement that we move towards weighing these children. Is the Minister prepared to consider doing that?

[Lord O’Shaughnessy]

There is a single campaign which is exemplified in the document and we need to put that across. I know that the noble Lord is working with broadcasters. I am not sure about the merits of weighing teenagers, but I will look into that and write to him.

[Baroness Neville-Rolfe (Con)]

My Lords, I declare my interests as set out in the register. I have a few doubts about some of the interventionist proposals in this strategy and therefore I welcome a consultation process on the detail. However, I am keen that people should be able to take responsibility for themselves by helping them to develop good habits, so I congratulate the Government, and indeed the Daily Mail, ITV, INEOS and local authorities on the Daily Mile initiative, which could be transformational.

The Minister and I are both interested in the advances in the science of sleep. We know that poor sleep is linked to obesity. Could the Minister agree to making use of this new science in his strategy?

[Lord O’Shaughnessy]

My noble friend makes an excellent point and I am glad that she has welcomed the introduction of the Daily Mile initiative, which is an important national ambition embedded in the strategy. I know of the benefits of sleep by its absence, but nevertheless I agree absolutely with my noble friend. This second chapter sets out a lot of good progress and intent. Clearly it is not the last word because this is a developing science, although we know more and more both about the causes of obesity and its consequences. Given that, there is a good opportunity through the consultations to bring the science about the benefits of sleep to bear in this conversation, not only for younger people but for adults as well so that it is properly reflected in the final documents that come out.

Childhood Obesity: Yoga

Lord O'Shaughnessy Excerpts

Thursday 21st June 2018 Lords Chamber

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

My Lords, while there is some evidence that regular yoga is beneficial for people with high blood pressure, heart disease, aches and pains, depression and stress, no central assessment has been made of its benefits for obese schoolchildren.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful for the noble Lord’s observation. Is he aware that the largest NGO in India, the Kripa Foundation, uses yoga as a means of attracting young drug addicts, drunks and people with HIV into recovery? Given the success there and the problems we have with our current obesity plan, which fails to get into the heads of young people—we have great difficulty in making connections so that they can become more self-aware about the need to take responsibility for their own health—might we explore methods such as yoga with them? It might be a means whereby they could take a closer look at themselves, their problems and the opportunities they have to make a better life in the future.

[Lord O’Shaughnessy]

I am not aware of the charity that the noble Lord mentioned, although after university I spent six months in India as a teacher. The school I taught in practised yoga with its children and it seemed to have a calming effect on them—which is just as well, because I am not sure my teaching skills had such an effect. I am sure many noble Lords know personally the benefits of yoga. It has not been proven to have any impact on obesity, although it has many other benefits, as the noble Lord pointed out. It is something that schools can and do use as part of their repertoire in the PE curriculum to provide exercise for children, although it does not count towards the moderate and higher levels of activity demanded by the PE curriculum.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that exercise does not deal with the obesity problem at all? There is only one way of dealing with obesity: eating less. Does he also agree that pregnant women who are obese transfer that tendency of obesity to their offspring by a mechanism, which we do not understand, called epigenetics? While we are on the subject, I congratulate the Minister on being a shining example of controlling his measurements. I have noticed that his waist measurement is less than half his height.

[Lord O’Shaughnessy]

I am wondering how my noble friend has made such an accurate assessment. He did not see my weight on the scales this morning. He is quite right. Of course, it is a combination of exercise and healthy eating, which is why there has been a push for both those things in our schools. There are great risks to pregnant women from being obese, not only to themselves with diabetes in pregnancy, which tends to reappear in later life, but in the impact on their children. That is why it is so important that pregnant women get good advice about healthy eating.

[Lord Stone of Blackheath (Lab)]

My Lords, today is International Yoga Day, on which we are about to launch the All-Party Parliamentary Group on Yoga in Society. As with mindfulness, we will be offering staff here on the Estate, MPs and Peers courses in seated yoga and breathing techniques, which have other benefits besides tackling obesity. I ask the Minister and other noble Lords to sign up to such courses.

[Lord O’Shaughnessy]

I will bring my mat.

[Baroness Jolly (LD)]

My Lords, as the Minister said, there really should be an evidence base before we pursue this too far. Does the department know whether there are sufficient teachers trained to teach children in yoga? Would there need to be appropriate safeguarding?

[Lord O’Shaughnessy]

I am afraid I do not know whether we know that. I suspect we do not. Yoga is an incredibly popular pastime for children and adults. Indeed, I think there are mother-and-baby yoga classes, which are also popular. I am sure safeguarding concerns will always be foremost when dealing with young children.

[Lord Geddes (Con)]

Will my noble friend join me in wishing the noble Lord, Lord Brooke of Alverthorpe, a very happy birthday?

[Lord O’Shaughnessy]

I wish the noble Lord a very happy birthday and I hope he has done his sun salutations this morning.

[Baroness Morgan of Huyton (Lab)]

My Lords, widening the conversation, when the NHS settlement is detailed in full, will the well-being of schoolchildren be looked at very carefully, particularly in relation to school nurses and the support that a lot of young people, particularly teenagers, need in schools and possibly are not getting sufficiently at the moment?

[Lord O’Shaughnessy]

The noble Baroness is quite right to raise that issue. Of course, it is something we are looking at. I also point to the pledge made in the children and young people’s mental health Green Paper to dramatically increase the number of staff on mental health support teams, which are providing not just help for children who are in crisis or having difficulties but well-being skills so that they do not experience those problems in the first place.

[Baroness Jenkin of Kennington (Con)]

My Lords, my noble friend will be aware that I am an enthusiastic advocate of the Daily Mile for schoolchildren. With the terrifying rise in obesity among schoolchildren, I hope it will be included in the updated childhood obesity plan. Can the Minister give us any idea when that plan might be coming?

[Lord O’Shaughnessy]

I am glad that my noble friend has highlighted that. I can confirm that the next chapter of the plan will be coming very shortly. We will be discussing some proposals on the Daily Mile in that plan.

[Lord Dubs (Lab)]

My Lords, while yoga is undoubtedly important—although I know nothing about it—surely there is one simple point about childhood obesity: excessive sugar consumption, in drinks or elsewhere. We have to tackle that much more positively. I hope that the Government’s new plan will do that.

--- Later in debate ---

[Lord O’Shaughnessy]

The noble Lord is quite right: it is not just sugar that is eaten but sugar that is drunk as well. The sugar levy has been a significant success. Half the drinks it applied to have been reformulated to reduce their sugar, saving 45 million kilograms of sugar being consumed each year. We have more to do on sugar reduction beyond fizzy drinks. We did not hit our target in the first year but we will take further action to make sure that we do so.

[Lord Wallace of Saltaire (LD)]

My Lords, is the Minister aware of recent research by the Institute of Education of University College London that shows that communal singing in primary and secondary schools has a strong calming effect and improves concentration, discipline and everything else, yet many schools are losing their music teachers, leaving no one in the school with any music qualification? I declare an interest as a trustee of the VCM Foundation.

[Lord O’Shaughnessy]

I understand that the noble Lord is a member of the parliamentary choir, so he is a living example of the benefits of communal singing, or maybe not. I am sure he is very tuneful. The noble Lord is quite right: singing and, indeed, all arts are good for the soul and should be part of the school day.

Cannabis-based Medicines

Lord O'Shaughnessy Excerpts

Thursday 21st June 2018 Lords Chamber

[Baroness Meacher]

To ask Her Majesty’s Government what the terms of reference will be for the expert panel of clinicians to advise ministers on applications to prescribe cannabis-based medicines.

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

My Lords, the commission from the Home Secretary is clear: he has asked Professor Dame Sally Davies to set up an expert clinical panel to provide advice to Ministers on licence applications made by a patient’s medical team for the use of cannabis-based products. Professor Dame Sally Davies is currently establishing a clinical panel that will agree the terms of reference.

[Baroness Meacher (CB)]

My Lords, I applaud the Home Secretary for his decisive action on medical cannabis. My Question relates to the second part of Professor Dame Sally Davies’s review. Bedrocan cannabis medicines have been used very safely and successfully in Holland for more than 20 years and are used increasingly across Europe. These medicines are currently subject to 23 random controlled trials and are also approved by European manufacturing standards. Can the Minister assure the House that the terms of reference for the wider review—I am not referring to the initial piece of work—will include the need for the MHRA, which regulates medicines, to consider defining a special category for whole-plant cannabis medicines? This idea came from within the MHRA, so I do not think it is unreasonable. If the review fails to make these medicines available in this country, is the Minister aware that 200,000 people in the UK with uncontrolled epileptic seizures will continue to be further brain-damaged every single day? This is a matter of urgency.

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for her question. Like her, I applaud the speed with which the Home Secretary and the Health Secretary have acted in this matter. It is incredibly important to think about the various stages and actions that have been taken. First, there is an urgent need for the panel which Professor Dame Sally Davies is setting to consider specific licence applications. The second part is to review whether there are therapeutic benefits of cannabis and cannabis-derived products. Then there is the evidence-gathering process, and all the relevant evidence, including the major piece of work done by the US National Academy of Sciences and the paper to be published by the WHO, will be collected as part of that. As the Home Secretary set out on Tuesday, it will make recommendations to the Advisory Council on the Misuse of Drugs subsequent to proposals for rescheduling. That will happen this autumn, if those proposals come forward.

If I may just take the time to say this, the noble Baroness raises a third issue, which is long-term horizon scanning for Schedule 1 drugs for which a therapeutic benefit has not yet been demonstrated but which may be demonstrated in future. We clearly need to set up a device to do that, and the MHRA may be the right vehicle. That is something we are considering.

[Baroness Wheeler (Lab)]

My Lords, can the Minister update the House on the number of cases the expert panel is expected to consider? Assuming they are current cases, can we be reassured that they will be dealt with in a way that avoids the awful situation faced by Alfie Dingley and his parents and ensures they have the best possible medical treatment?

[Lord O’Shaughnessy]

I completely agree with the noble Baroness about the need for speediness. Frankly, at this point we do not know the number of cases. The Home Secretary said on Tuesday that the service will be up and running and receiving applications within a week of his Statement—so from next Tuesday onwards, with a panel constituted rapidly so that it can start considering them.

[Lord Forsyth of Drumlean (Con)]

My Lords, will my noble friend pass on the good wishes of this House to the Home Secretary and the Health Secretary for the speed with which they have acted in making cannabis-based medication available for the treatment of certain conditions? However, will the Health Secretary also take steps to make people aware of the real damage that cannabis taken for recreational use can do to our young people, in particular creating paranoia and mental illness? It would be irresponsible for any Government to condone the use of recreational cannabis given the damage that is caused to our young people in some cases.

--- Later in debate ---

[Lord O’Shaughnessy]

I will pass on my noble friend’s thanks to my right honourable colleagues. We agree with him that there is a very clear distinction: we know cannabis-based products can create harm but the question is whether they can also have therapeutic benefits. If they can, they need to be weighed in the balance and rescheduled appropriately. That does not diminish the negative impact that he has described that the recreational use of cannabis, particularly very strong strains, can have on young people.

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for showing that he quite clearly understands the distinction between recreational and medicinal use. Is he also aware that Epidiolex, which is medicine produced by GW Pharmaceuticals for epilepsy sufferers and which will soon be approved, will not help children like Alfie Dingley who have uncontrolled epilepsy seizures? I understand that the cannabinoid CBDV is very important to such sufferers, and there is none of it in Epidiolex. Will the Minister ensure that the review takes account of the special needs of the 200,000 patients with uncontrollable seizures? Will the panel be able to hear from patients as well as studying research?

[Lord O’Shaughnessy]

The noble Baroness makes excellent points. I know she has been deeply involved in the Alfie Dingley case and I thank her for her work on that. What we are discovering is that it is not the case that just one drug is going to fix this for the 200,000 people who are suffering. There is a need for variety. So it cannot be the case that just because one thing is licensed it is used for everyone; it needs to be specific to the needs of the patient, which is the noble Baroness’s main point. The interim panel is there precisely to make decisions on an individual basis. It is a patch to the system, if you like, not a long-term change, which is why the review is in place so that we can ensure that many other products derived from cannabis, if they are proven to have therapeutic benefits, can be developed into drugs for the range of needs that are out there.

[Lord Blunkett (Lab)]

My Lords, 15 years ago trials were undertaken, one of which led to a separate authorisation of a derivative from cannabis for MS sufferers. I have not been clear on this from any of the reporting, so will the Minister say what trials are currently taking place in this country that could be brought to fruition? What evidence can we very quickly obtain from trials and evidence of legitimate use for medicinal purposes from the rest of the democratic world? How can it possibly be justifiable for us to provide 45% of usage for derivatives from cannabis grown in this country but not to be able to use it ourselves?

[Lord O’Shaughnessy]

The noble Lord speaks with great wisdom on this topic. The problem, as he knows, is that these drugs have been in Schedule 1 and, although in theory that allows for research, in reality it creates a very cautious environment that makes research difficult. That means that apart from Sativex, which has been licensed, and Epidiolex, which is in the process of being licensed, there are very few, if any, other drugs actually going through the clinical trials process in this country because of the very tight rules that have governed usage. Other countries have of course relaxed their rules and developed that evidence, and it is precisely that kind of evidence base that will be considered by Professor Davies in her review.

National Health Service: Assaults on Staff

Lord O'Shaughnessy Excerpts

Wednesday 20th June 2018 Lords Chamber

[Lord Clark of Windermere]

To ask Her Majesty’s Government how many attacks on NHS staff were reported in 2016-17 and 2015-16.

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

My Lords, the Government are committed to taking action against those who abuse or attack NHS staff. In 2015-16, NHS organisations, which are responsible for protecting their staff, reported 70,555 physical assaults. Of those, 52,704 were due to patients’ conditions or treatments they were receiving. Data has not been collected for 2016-17. We are reviewing with the NHS how in future information about assaults and abuse of NHS staff can help trusts promote best practice.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer. Can I give him a little help with the updated figures? Has he seen the figures produced by the Health Service Journal and Unison which show a 10% increase in violence against NHS staff in the latest year? That is just unacceptable. Why did the Government in November 2017 abolish NHS Protect, which had the responsibility to protect NHS staff against violence? I know that it was replaced and that its staff, but not its functions, were transferred to the NHS Counter Fraud Authority, which focuses on fraud and protection of buildings. Will the Minister confirm that there is now no body responsible for the safety of NHS staff? I am drawn to the conclusion that this Government value property more than people.

--- Later in debate ---

[Lord O’Shaughnessy]

I have to take issue with the point the noble Lord makes. It is absolutely not the case that the Government value property more than staff. We all value the work that NHS staff do every day in very difficult conditions. That is one of the reasons that we announced our historic funding settlement at the beginning of this week. On the problem that the noble Lord raises, he is right to say that, looking back over NHS Protect’s data, starting in 2008-09, there has been a steady rise in the number of assaults on and incidents of abuse of NHS staff. Clearly that is completely unacceptable. However, there is disagreement about the reasons for that, and it is worth dwelling on that. They include not just the greater volume of patients and better reporting, but the increase in mental illness and dementia, and more severe mental illness being dealt with in hospitals rather than police cells. I do not use that as an excuse, but merely to explain that there is some uncertainty about the reasons for it. It was under NHS Protect’s aegis that this steady rise happened. It has fulfilled its function, which is to make sure that security management services are available to every NHS trust—but in the end it has to be down to every trust to take responsibility for the safety of its staff, and that is the system we are moving ahead with now.

[Baroness Finlay of Llandaff (CB)]

My Lords, given that alcohol is involved in more than 60% of assaults in the acute sector, more than 30% of assaults in the mental health sector and more than 70% of assaults in the ambulance sector, will the Minister explain why the Government have abandoned progress with the sobriety scheme pilot, which showed a very high success rate in avoiding reoffending in alcohol-fuelled crime? It would provide a tool for non-custodial sentencing where people are known to have assaulted NHS staff under the influence of alcohol.

[Lord O’Shaughnessy]

I will look into the specific issue that the noble Baroness mentions. I do not have the details in front of me. I know that all local authorities provide free, taxpayer-funded rehabilitation services for those who are suffering from alcohol addiction. I should also point out that this Government have increased progressive taxation on stronger alcohol, such as white cider, specifically to try to change people’s drinking habits and to reduce alcohol-related violence.

[Lord Ribeiro (Con)]

Following the theme of alcohol, the Minister was kind enough to meet me and members of the Alcohol Health Alliance on 30 April. We stressed that accepting a minimum unit price, as in Scotland, would do much to remove alcohol—and, particularly, cheap alcohol—from vulnerable people, some of whom are responsible for the attacks to which we are referring. When will England accept a minimum unit price and implement it?

[Lord O’Shaughnessy]

I was delighted to meet my noble friend on this topic. I know he cares passionately about it. We have said—and I have said in this House before—that we are looking at the Scottish example with interest now that Scotland has gone ahead with it. There is a growing evidence base to demonstrate the benefits of minimum unit pricing, but we want to see what transpires in Scotland before making any decisions about whether to move ahead.

[Baroness Jolly (LD)]

My Lords, in England around 200 attacks on NHS staff occur every day, and this is nothing short of scandalous. Next week we have the Second Reading of a Private Member’s Bill, which has come from the other place, on assaulting emergency workers. Will the Minister confirm whether the Government are minded to support it—and, if not, what further action will be taken to protect health workers?

[Lord O’Shaughnessy]

I agree with the noble Baroness that it is scandalous and that we therefore want to support the Bill. I believe that it will have its Second Reading here on 29 June. I can confirm that the Government will be supporting the Bill.

[Baroness Donaghy (Lab)]

I am grateful for that reply from the Minister. I have the privilege of taking the Bill through its Second Reading next week. It will create, for the first time, an aggravated offence for those who attack all emergency workers, including paramedics, nurses, doctors and all those associated with helping NHS staff in emergency work, such as St John Ambulance and other volunteers, if they are doing emergency work. So I am thankful that the Government have provided time, and I hope that we will be able to get the Bill through quickly by the summer.

[Lord O'Shaughnessy]

I salute the noble Baroness for taking it through its stages in the House of Lords. I reiterate our support for it—not just the principles behind it but the specific measures in it. Clearly it is unacceptable to assault the very people who devote their lives to serving.

Branded Health Service Medicines (Costs) Regulations 2018

Lord O'Shaughnessy Excerpts

Wednesday 20th June 2018 Lords Chamber

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

My Lords, I begin by thanking the noble Lord, Lord Hunt of Kings Heath, for tabling the Motion on this topic, and I thank all noble Lords who have contributed for their, as ever, wise and incisive interventions.

As we have discussed this evening, there are two separate but intertwined issues here. The first is the appropriate treatment and associated clinical guidance from NHS England to CCGs about the use of the two drugs under discussion in the treatment of hypothyroidism. The second is the powers we have and the actions we take in clamping down on unjustified high prices in generics. I will deal with them in that order, as well as answering other questions that noble Lords have posed.

As we have heard in very evocative descriptions from my noble friend Lord Borwick and the noble Baroness, Lady Jolly, hypothyroidism can be a very debilitating condition in some perhaps slightly unexpected ways, but it can affect every area of someone’s life. One of the principles on which the NHS is founded is that, if someone has a clinical need for a medicine, it is right, provided that it can be done cost-effectively, that they get the most appropriate medicine for their condition.

The drug levothyroxine, T4, is beneficial for the majority of patients with hypothyroidism, as we have heard, but it does not treat the condition in all patients. For some, the alternative drug, liothyronine, commonly known as T3, which is the subject of this evening’s debate, is a treatment which better alleviates their symptoms. NHS England has set out that liothyronine should be prescribed for patients only where levothyroxine does not alleviate symptoms. Following its recent consultations, NHS England guidance states that, where clinically appropriate, liothyronine can be prescribed but its use should be initiated by a consultant endocrinologist in the NHS.

My noble friend Lord Borwick shared the case of Maureen Elliott, and I would be very grateful to him if he could give me details of her case. The care and medicines that have been provided to her do not appear to be in line with NHS England’s guidelines, and that obviously raises some very serious concerns. As I have said, patients for whom liothyronine is deemed clinically appropriate should receive it on the NHS and should not be asked to purchase it abroad. I ask my noble friend and indeed all noble Lords who have contributed to this debate to share details of the case. Tonight, I will commit to pursuing further with NHS England ways in which they can clarify to CCGs the guidelines setting out the circumstances under which liothyronine should be prescribed, including looking at whether greater clarity on the criteria for appropriate patient usage is merited. I will also inform the House—through a letter to the noble Lord, Lord Hunt, a copy of which I will place in the Library—about the progress that we are making on the regional medicines optimisation committee.

I want to touch on one other area that my noble friend Lord Borwick described, and that is the poor understanding of that group of the population who are not able to turn T4 into T3. He mentioned that there might be a genetic factor and I would be interested in pursuing that further. Clearly, some very interesting work on rare diseases is going on in the NHS at the moment through the 100,000 Genomes Project. This might be a qualifying illness where the conversion does not take place naturally, and that might be something that we can pursue. I will take that up with him separately.

As the noble Lord, Lord Hunt, freely admitted, the Motion expresses regret that the Branded Health Service Medicines (Costs) Regulations 2018 do not propose any action in respect of the high cost charged for liothyronine. However, he also knows that this relates to the new statutory scheme to regulate the cost of branded medicines, so that is not the vehicle by which we would act in generics. Nevertheless, it provides a good opportunity to discuss the actions that we are taking, not just in regard to this medicine but more broadly, to clamp down on excessive prices for generic medicines.

For unbranded generic medicines, the Government do not set selling prices. Instead, we rely on competition between suppliers to keep prices down. Several noble Lords expressed concern about the prices that we pay for medicines, but I should stress that the available evidence demonstrates that in general our system works well. Recent studies by the OECD and Milbank Quarterly have shown that the UK has among the very lowest prices for generic medicines as a group in the developed world. However, there are occasions when there are only one or two suppliers, so there is no effective competition.

As several noble Lords set out, for a long time Concordia was the sole supplier of liothyronine. That is why the department took action in the summer of 2016, asking the Competition and Markets Authority to investigate this product. The CMA has very extensive powers to investigate companies suspected of abusing a dominant position in the market, and my department has been supporting the CMA in its investigation. As a result of this investigation, the CMA provisionally found that the manufacturer abused its dominant position and overcharged the NHS by millions of pounds for liothyronine tablets. The CMA also found that, although the price of liothyronine went up by almost 6,000%, production costs remained broadly stable.

I should stress that the findings are provisional at this stage. There has been no definitive decision that there has been a breach of competition law. The CMA is carefully considering representations from the company before deciding whether the law has been broken. In response to the question from the noble Lord, Lord Turnberg, I hope that the CMA’s decision will be issued this year. If it finds that the company has infringed competition law, it can issue it with a penalty of up to 10% of the company’s global turnover and direct it to lower the price. Noble Lords should be assured that on top of any CMA penalty, where companies have breached competition law we will also seek damages and invest that money back into the NHS.

In addition to the CMA’s investigatory work, the department, since last year, now has stronger powers to set the prices of generic medicines following the Health Service Medical Supplies (Costs) Act 2017, which we discussed at about this time last year. We can now also set the prices of generic medicines from companies that are members of the voluntary PPRS. Concordia is in the PPRS, so it is important to say in response to the question posed by the noble Lord, Lord Hunt, and my noble friend Lord Borwick that before the 2017 Act we would not have been able to act on the price, even if we had wanted to, without referring it to the CMA.

The department has also taken new powers to require pharmaceutical companies to disclose information about the sales values and costs of medicines in order to support the department’s powers to set selling prices. These are set out in the Health Service Products (Provision and Disclosure of Information) Regulations 2018, which come into force on 1 July.

Several noble Lords asked why we are not setting a selling price for liothyronine. I also note that my noble friend Lord Borwick said that Concordia had told him that the department had agreed the price of liothyronine. However, following investigations in the department, I can confirm that that is not the case.

On the face of it, I understand the attractiveness of price setting in this case but at this point in time, when the CMA is carrying out an investigation—and notwithstanding the discussion we had earlier—it is the right approach for that to continue, while also taking steps to make sure that appropriate prescribing behaviour goes on within the NHS. Therefore, in this case I believe it is appropriate to separate the two issues. I have confidence in the CMA’s work on this case and I want it to conclude its investigation and come to the judgment that it sees fit.

However, this is not the only tool in our box. We are actively monitoring the price increases of other generic medicines and, where they are not already under investigation by the CMA—and once our information requirements are in place—we will open discussions with some companies shortly, although noble Lords will appreciate that it would be wrong to disclose which companies or which drugs are involved at this stage. Where we believe that a lower price is justified, we may consider imposing a price if the company is not willing to lower it voluntarily. I can confirm to the House that we have the powers to do so and are prepared to act if necessary.

However, we need to act carefully. Typically, where there is little or no competition for an off-patent or generic medicine, this is because, as has been stated, it is a relatively low-volume product. As a result, manufacturers do not benefit from economies of scale and, if they think the price is too low, they may withdraw their product from the market. This would mean that patients would not have access to their medicines at all, which could obviously have detrimental impacts. We have seen that happen in other European countries.

However, in the case of liothyronine, I am pleased to tell the House that there are now multiple marketing authorisations in the UK for the drug. Increased competition traditionally leads to more resilient supply chains and lower prices. We will be watching carefully to see whether that happens in this case and are prepared to act if it does not.

In response to a specific question from my noble friend Lord Borwick about whether regulatory requirements from the MHRA were the cause of the price increase, I know that Concordia suggested this and we have discussed it with the MHRA. However, it is unlikely that that could have led to a price increase of 6,000%. Liothyronine is an old product and when Concordia applied for a marketing authorisation, it was only right that the MHRA required compliance with the minimum standard. But as I said, I do not believe that is a justification for that scale of increase.

My noble friend also talked about imports from other countries. Medicines licensed in the UK and other member states can be parallel imported as long as the imported product has no therapeutic difference from the UK product. As has been stated in this case, small differences in the formulation can significantly change the therapeutic effect on the patient. That is not to say that imported products are unsafe, but if a patient changes to a different source of the product their symptoms may not be controlled to the same extent, which only emphasises how important it is to get the right medication for the right patients through the NHS.

My noble friend Lord Lucas made some observations about the current operation of the PPRS. It undoubtedly has some flaws, which we will attempt to rectify as we negotiate a new one. In 2016-17, the PPRS paid £1.7 billion back to the NHS from drugs companies. I should also point out that it does not apply to unbranded generics, of which liothyronine is one, but it obviously applies to the vast bulk of medicines bought by the NHS. He suggested tendering for generics, which the Commercial Medicines Unit and NHS England are starting to do. It is also one of the options under consideration for getting the prices of specials down, which, again, was something we made progress on in discussions on the Bill last year.

My noble friend made an interesting and radical proposal for a state generics manufacturer. Intermountain Healthcare, which serves the Mormon community in Utah, is setting up a not-for-profit generics manufacturer. I have asked the department to get in touch with it, to understand the work it is doing. It might be possible through a university but I am not sure that state aid rules would allow us to set up a state-owned generics manufacturer. Once we have left the European Union, however, perhaps that could be one of the Brexit dividends.

The noble Baroness, Lady Jolly, asked specifically about the cost of other free medicines. Prescription entitlements were last reviewed under the last Labour Government, who looked at the cost of making all drugs free, which would be about £500 million. As the noble Baroness knows, when the coalition Government came in we decided that that would not be the right use of money and there is no intention to review that at this point. I am sorry to disappoint the noble Baroness.

The noble Baroness asked specific questions about the regulations themselves, which I think was the first time they were discussed this evening. I am grateful to her for that. I will need to write to her on some of the specifics but the review will be completed on 1 April 2019, so I can provide her with that reassurance. We have calculated the QALY benefits of specifying prices in the usual way and I am happy to write to the noble Baroness on the technical aspects of that.

She also asked about deciding on temporary pricing. As I have hinted, this is something we are starting to test. We are taking on these powers and we need to move cautiously. Ideally, we do not want to exercise them at all but if we do, we will do so in consultation with industry bodies.

I hope I have answered noble Lords’ questions. I thank the noble Lord, Lord Hunt, for using the regulations to highlight the challenges we face in prescribing the right medicines for hypothyroidism and in making sure that we have the right powers to ensure that the NHS is not being ripped off by unscrupulous providers of any kind of medicine. In the commitments I have given to pursue this issue, I hope I have satisfied the noble Lord, Lord Hunt, and other noble Lords of the seriousness with which we take this issue. On that basis, I hope he feels able to withdraw his Motion tonight.

Gosport Independent Panel: Publication of Report

Lord O'Shaughnessy Excerpts

Wednesday 20th June 2018 Lords Chamber

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

My Lords, with the permission of the House, I will repeat the Statement made earlier today in the other place by my right honourable friend the Secretary of State for Health and Social Care about the Gosport Independent Panel. The Statement is as follows:

“Mr Speaker, this morning, the Gosport Independent Panel published its report on what happened at Gosport Memorial Hospital between 1987 and 2001. Its findings can be described only as truly shocking. The panel found that, over the period, the lives of over 450 patients were shortened by clinically inappropriate use of opioid analgesics, with an additional 200 lives likely to be have been shortened if missing medical records are taken into account. The first concerns were raised by brave nurse whistleblowers in 1991, but then systematically ignored. Families first raised concerns in 1998, and they too were ignored. In short, there was a catalogue of failings by the local NHS, Hampshire Constabulary, the GMC, the NMC, the coroners and, as steward of the system, the Department of Health.

Nothing I say today will lessen the anguish and pain of families who have campaigned for 20 years for justice after the loss of a loved one, but I can at least on behalf of the Government and the NHS apologise for what happened and what they have been through. Had the establishment listened when junior NHS staff spoke out, or had the establishment listened when ordinary families raised concerns instead of treating them as ‘troublemakers’, many of those deaths would not have happened.

I also want to pay tribute to those families for their courage and determination to find the truth. As Bishop James Jones, who led the panel, says in his introduction,

‘what has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power…it is a lonely place seeking answers that others wish you were not asking’.

I also thank Bishop Jones and his panel for their extremely thorough and often harrowing work. I particularly want to thank the right honourable Member for North Norfolk, who as my Minister of State in 2013 came to me and asked me to overturn the official advice he had received that there should not be an independent panel. I accepted his advice and can say today that without his campaigning in and out of office, justice would have been denied to hundreds of families.

In order to maintain trust with the families, the panel followed a ‘families first’ approach in its work, which meant that the families were shown the report before it was presented to Parliament. I too saw it for the first time only this morning, so today is an initial response and the Government will bring forward a more considered response in the autumn. That response will need to consider the answers to some very important questions. Why was the Baker report, completed in 2003, only able to be published 10 years later? The clear advice was given that it could not be published during police investigations and while inquests were being concluded, but can it be right for our system to have to wait 10 years before learning critically important lessons which could save the lives of other patients?

Likewise, why did the GMC and NMC, the regulators with responsibility for keeping the public safe from rogue practice, again take so long? The doctor principally involved was found guilty of serious professional misconduct in 2010, but why was there a 10-year delay before her actions were considered by a fitness-to-practise panel? While the incident seemed to involve one doctor in particular, why was the practice not stopped by supervising consultants or nurses, who would have known from their professional training that these doses were wrong?

Why did Hampshire Constabulary conduct investigations that the report says were,

‘limited in their depth and … range of … offences pursued’,

and why did the CPS not consider corporate liability and health and safety offences? Why did the coroner and assistant deputy coroner take nearly two years to proceed with inquests after the CPS had decided not to prosecute? Finally, more broadly, was there an institutional desire to blame the issues on one rogue doctor rather than examine systemic failings that prevented issues being picked up and dealt with quickly, driven, as this report suggests it may have been, by a desire to protect organisational reputations?

I want to reassure the public that important changes have taken place since these events which would make the catalogue of failures listed in the report less likely. These include the work of the CQC as an independent inspectorate with a strong focus on patient safety, the introduction of the duty of candour, the learning from deaths programme and the establishment of medical examiners across NHS hospitals from next April. But today’s report shows that we still need to ask ourselves searching questions as to whether we have got everything right, and we will do this as thoroughly and quickly as possible when we come back to the House with our full response.

Families will also want to know what happens next. I hope that they and honourable Members will understand the need to avoid making any statement that could prejudice the pursuit of justice. The police, working with the CPS and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps, in particular whether criminal charges should now be brought. In my own mind I am clear that any further action by the relevant criminal justice and health authorities must be thorough, transparent and independent of any organisation that may have an institutional vested interest in the outcome. For that reason, Hampshire Constabulary will want to consider carefully whether further police investigations should be undertaken by another police force.

My department will provide support for families from today, as the panel’s work is now concluded, and I intend to meet as many of the families as I can before we give our detailed response in the autumn. I am also delighted that Bishop James Jones has agreed to continue to provide a link to the families and lead a meeting with them in October, to allow them to understand progress on the agenda and any further processes that follow the report. I also commend the role played by the current Member for Gosport, who campaigned tirelessly for an independent inquiry and is unable to be here today because she is with affected families in Portsmouth.

For others who are reading about what happened and who have concerns that it may have affected their loved ones, we have put in place a helpline. The number is available on the Gosport Independent Panel website and the DHSC website. We are putting in place counselling provision for those affected by these tragic events and those who would find it helpful.

Let me finish by quoting again from Bishop Jones’s foreword to the report. He talks about the sense of betrayal felt by families because:

‘Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted they will always do that which is best’,


for them. Today’s report will shake that trust, but we should not allow it to cast a shadow over the remarkable dedication of the vast majority of people working incredibly hard on the NHS front line. Working with those professionals, the Government will leave no stone unturned to restore that trust. I commend this Statement to the House”.

--- Later in debate ---

[Baroness Jolly (LD)]

My Lords, I shall crave the indulgence of the House for a moment while I read out the first two points in the summary and conclusions of the report:

“In waiting patiently for the Panel’s Report, the families of those who died at Gosport War Memorial Hospital … will be asking: ‘Have you listened and heard our concerns, and has the validity of those concerns been demonstrated?’ … It is over 27 years since nurses at the hospital first voiced their concerns. It is at least 20 years since the families sought answers through proper investigation. In that time, the families have pleaded that ‘the truth must now come out’. They have witnessed from the outside many investigative processes. Some they have come to regard as ‘farce’ or ‘cover-up’. Sometimes they have discovered that experts who had found reason for concern had been ignored or disparaged. Sometimes long-awaited reports were not published”.


I commend my right honourable friend Norman Lamb for having a quiet word with the Secretary of State to ensure that this was moved forward.

This report makes for shocking reading. It hangs on a confusion of responsibilities between two organisations, the NHS and the police force, and there is a multitude of questions to be answered. I shall put only two questions to the Minister and hinge them on two points in the report. The first is paragraph 12.62. Health bodies felt prevented from taking action because police investigations were under way. The report points out:

“All concerned assumed not only that the police investigations took priority, but that they prevented any other investigations from proceeding”.


There is clearly a need to clarify lines of responsibility between the police and the NHS regulatory bodies when there are allegations of wrongdoing and systematic failings of this kind so that organisations simply do not pass the buck. Can the Minister assure me that this work will start?

Secondly, how will the Government take forward the call for action in paragraph 12.60? I welcome the Minister’s commitment to an independent inquiry in future in such circumstances to be carried out by the police force, but the report states that,

“the evidence … suggests that, faced with concerns amounting to allegations of unlawful killing in a hospital setting, there are clear difficulties for police investigation. It is not clear to the Panel how the police can best take forward such investigations, and how they are to know whose advice to seek from within the health service without compromising their enquiries. This is … significant if the problem concerns the practice on a ward where more than one member of a clinical team is involved. It is a need that calls for action across different authorities, rather than a matter for the police service in isolation”.

We cannot guarantee that something similar to this could not happen elsewhere—please God that it does not—but what action will be taken to ensure that there is not such a muddle and confusion in a resolution? What processes are either in place or being put in place within NHS settings and with police forces to make sure that this does not happen again?

[Lord O'Shaughnessy]

I thank the noble Baronesses, Lady Wheeler and Lady Jolly, for their very perceptive questions—as ever. First, I extend my personal sympathies to the families and join my right honourable friend in expressing our apologies on behalf of the Government and the NHS for what has happened to them and their relatives. Like the noble Baronesses have done, I pay tribute to those families and all the others who have fought so tirelessly in seeking justice. As has been acknowledged, we owe a huge debt of gratitude to Bishop Jones and his panel.

The story told in this report is of a litany of failure across many institutions, which often had very closed cultures. Unfortunately, those piled on to one another across many different agencies of government, which is what created that highly unacceptable cover-up for so long. It is about getting to the bottom of that culture. Let us face it: unfortunately these circumstances are not unique. We come across this in different parts of our society all the time, and we need to get to the heart of that closed culture to lead to a culture of accountability and transparency.

The noble Baroness, Lady Wheeler, asked some specific questions, including about the 200 additional patients without notes. Clearly, further investigation is warranted because we need to substantiate that claim. It is obviously one of the work streams that will be going forward. She asked about streamlining professional regulation, given the obvious inadequacies of the GMC and NMC regulators during this process. As my right honourable friend the Secretary of State said, every part of government needs to look to itself with great honesty about what we need to do to put in place the right environment to prevent this happening again. I think we all agree on the need to move forward to streamline professional regulation. It is not something we have yet been able to do, but the tragic news we have been discussing today gives that fresh impetus. It is clearly something we will be looking at.

Patient safety is a great passion of the Secretary of State. There were changes in the oversight of medicines, particularly opioids, after the Shipman inquiry. The noble Baroness raised some good questions about whether there is a need for an independent body, or whether in the Health Safety Investigation Branch we have that body but its remit needs to be reconsidered as part of the Bill going through. I am sure that we will be doing that.

The noble Baronesses, Lady Wheeler and Lady Jolly, asked about the issues around inquiries. One of the things that has been exposed here is that there were overlapping inquiries that were impeding each other or preventing one another moving forward. Making sure that there is a clear process for how that ought to take place when someone—a family member, a staff member, the police—has raised a concern is something we have to get to the bottom of because that bureaucratic muddle was clearly at the heart of the delay and, because of the delay, more people died unnecessarily. It is not just a case of clearing things up and making them neater; it has a massive impact on harm.

The learning from deaths programme is a big step forward. It has been taken into many bits of the health service already. It is now moving into the primary care area. Trusts are already obliged to publish deaths that ought to be in the scope of mortality reviews. From next April, all non-coronial deaths will be subject to investigation by medical examiners. That is yet another part of the patient safety environment that we need to put together.

Going beyond that, there are clearly some very challenging questions that the criminal justice authorities, coroners, the Home Office, the Department of Health and Social Care and all parts of government need to ask themselves to see whether they are really doing everything they need to do to provide a safety net to make sure that when things go wrong we find out about them quickly, we stop them and we learn from them. In the next few months, as we move towards publishing a plan for what we should do next, it is imperative that all Members of this House and the other place, who have great contributions to make in this area, feel free to engage with this process and make their recommendations to it, so that when we report we have done as thorough and comprehensive a job as we possibly can so that we can prevent these tragedies happening again in future.

[Lord Carlile of Berriew (CB)]

Does the Minister agree that it is particularly shocking that those who did not cover up—the brave staff who expressed concerns about what was happening—were ignored for so long? Does he agree that the culture of closing ranks among some medical staff should be regarded in itself as serious professional misconduct by doctors and others? Does he also agree that there should be training in the whole of the NHS which makes it easier for staff to identify the excessive use of opiates and to have action taken upon it?

[Lord O’Shaughnessy]

The noble Lord makes two excellent suggestions. His suggestion about whether cover-ups should count as serious professional misconduct will be something the regulators will want to consider, as is better training on the use and prescription of opioids. We have made some progress in recent years. The freedom to speak up guardians are in place, and we talked about the learning from deaths programme. There is also the duty of candour. They are clearly steps forward but the panel has exposed that we are still not there yet. The suggestions the noble Lord makes are good and serious and we will want to consider them.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I had ministerial responsibility for this area in 2002 and the beginning of 2003, which is reported in the report. First, I associate myself with the Minister’s remarks, his commendation of Bishop James and his panel and the apology that has been given. Reading this report, the question I think about is whether, if those circumstances arose now, the response would be very much different. I am not at all sure it would. First, the report shows the reluctance at local level to have what it saw as interference from the centre in causing inquiries to take place. Secondly, while the police investigations were going on the other inquiries felt they could do nothing, as the noble Baroness, Lady Jolly, said. Thirdly, once the police investigation had been completed and the decision that no prosecutions would take place had been taken, there was an agonised debate within the coronial system about whether inquests would be appropriate. The real issue seemed to be resources. The local coroner’s office did not feel that it had the resources to conduct the inquests and if it did so it would undermine the rest of its important work. In the work now being undertaken, will a real effort be made to grip the issue of the deadening impact of police investigations in stopping us learning lessons immediately? Is the Minister confident that the changes in the coronial system will prevent the kind of unseemly debate that prevented inquests taking place for some time occurring in future?

[Lord O’Shaughnessy]

I thank the noble Lord for associating himself with that apology. He asked the right question. It was very well put. If the circumstances arose now, would the response be different? I think there is reason to believe it would be, for the reason I have set out—the improvements that successive Governments have made on patient safety—but we should not be complacent. We cannot assume that those things are enough. I hope they are an improvement. We believe they are an improvement, but we need to ask ourselves that very difficult question about whether they would be enough. That is what we will be doing through this process.

Resources are one of the issues. We need to make sure not only that there is clarity about the circumstances under which the different bodies can carry out inquiries without impinging upon inquiries by other bodies, but that they feel that they are capable of doing so. That is one of the things we are going to need to investigate.

[The Lord Bishop of Lincoln]

My Lords, I declare an interest as my wife is a lead clinician in the office of the Parliamentary and Health Service Ombudsman. My friend the right reverend Prelate the Bishop of Portsmouth cannot be in his place today as he is in his cathedral church with the families of those whose loved ones were patients at Gosport War Memorial Hospital, as they properly received the report prior to it being laid before Parliament. On his behalf, and sharing his profound concern and with some anger as a vicar and archdeacon in that area at that time, I politely remind the Minister of the evidence of disregard for human life, a culture of deliberately shortening life, and a regime of systematic overuse of opioids and of the way in which those raising concerns were treated as troublemakers. The Statement repeated by the Minister raises many questions. My questions and the questions of the right reverend Prelate the Bishop of Portsmouth are simple pastoral questions: how will the Government now guarantee the families the support they deserve? How and when will the Government act on the wider issues the report raises?

--- Later in debate ---

[Lord O'Shaughnessy]

I thank the right reverend Prelate for his comments and for conveying those of his colleague, the right reverend Prelate the Bishop of Portsmouth. It is absolutely right that he is where he is today, ministering to that group of deeply affected people.

The facts as he set them out, and as are set out in the Statement, are truly shocking: hundreds of lives prematurely shortened because of these practices; institutional behaviour led by an individual but with others being complicit in it; cover-ups; whistleblowers being discouraged; and so on. It is hard to imagine a worse scenario. What the panel and Bishop James Jones have exposed through working so closely with families is the extent of the behaviour and the poor practice that went on.

The question now is, quite rightly, what we should do about it, and the right reverend Prelate quite rightly takes the pastoral position. There is counselling on offer and a helpline for those who think that their families may have been affected—there may be yet more people who come forward. There is also a commitment from the Secretary of State, and indeed all Ministers, to meet families to provide them with the support and information that they may need. There is an intention to meet those families at an event convened by Bishop Jones in October, and the panel secretariat is setting up specific conversations between the advisory clinicians on the board and individual families. One of the needs for counselling, sadly, will be after those conversations, when the truth about specific cases comes out—which is why it is about providing counselling not just today but on an ongoing basis. I can give the right reverend Prelate a commitment from the department that we will provide that for as long as necessary.

[Baroness Masham of Ilton (CB)]

My Lords, this tragedy has similarity to Shipman and Stafford Hospital. Does the Minister agree that there should be a far better and quick complaints procedure? This has been needed for years. Nurses should feel free and safe to bring up matters of worry concerning their seniors and colleagues, and relatives should have help to complain and be listened to.

[Lord O'Shaughnessy]

I completely agree with the noble Baroness. Clearly, improvements have been made—freedom to speak up guardians came out of the Francis review into the Mid Staffs tragedy—but I reiterate the point that I made earlier: we cannot be complacent and just assume that what exists now is up to the task, as the noble Lord, Lord Hunt, said, of guaranteeing that this will not happen again. Looking at complaints procedures, protections for whistleblowing and so on will be part of the investigations that we make.

[Baroness Meacher (CB)]

My Lords, the events at the Gosport War Memorial Hospital all those years ago are indeed shocking, but will the Minister consider that they are perhaps a symptom of the fact that we do not have an assumption in end-of-life care that patients’ wishes must be respected? One aspect of this, perhaps slightly removed from Gosport but nevertheless relevant, is that, if people are terminally ill and enduring unbearable suffering but are mentally competent, they have no way of ensuring that they, the patients, can take control and decide when they have suffered enough. In this culture of paternalism—and this really does apply to Gosport—doctors take matters into their own hands and, in a situation such as that in Gosport, paternalistic decision-making by doctors can become extremely dangerous. Does the Minister agree that we need to bring to an end paternalistic decision-making by doctors without reference to patients’ wishes, particularly in end-of-life care?

[Lord O'Shaughnessy]

Giving patients and of course their families much more control over the circumstances in which their lives end is clearly the right thing to do. Some very good practice has been going on—for example, Coordinate My Care across London makes sure that somewhere between 70% and 80% of people who would prefer to die at home are able to do so, as opposed to in hospital. However, it is important to emphasise that in this case by and large we are not talking about palliative care; only a small number of the people concerned whose lives were shortened were in a position where they were, in an objective sense, near end of life. Many were in after a fall, a hip replacement or something else from which they could easily have recovered and lived for many more years. That is the tragic fact. So, while I agree with the noble Baroness, it is important that we do not view the tragedy just in those terms; unfortunately, it is much broader.

[The Lord Bishop of Coventry]

My Lords, like others, I was very moved by Bishop James Jones’s foreword and the way that, as the noble Baroness, Lady Jolly, put it, the panel thought to listen to and heed the concerns of those who have been aggrieved. I have been impressed by the methodology, I suppose, of the independent panel and the way it has done exactly as the Minister says: seek to work closely with the families and, so far as I understand, build its terms of reference from the particular concerns of the families, the aggrieved and the victims—the sort of questions they are wanting to ask. Have the Government made any assessment of whether independent panels are more effective than judge-led inquiries at not only excavating the truth in historic cases but, in so doing, thereby attending to the trauma of the bereaved?

[Lord O'Shaughnessy]

The right reverend Prelate makes a very incisive point about not only the personal qualities of Bishop James Jones in chairing this panel, with the great compassion, understanding and patience that he has displayed, as indeed has the panel, but about the methodology, as the right reverend Prelate put it, which has been non-confrontational, independent and family-focused. Unfortunately, we grapple with these problems across government from time to time, and this methodology gives us a new way of doing things. It will not be appropriate in every circumstance—something smaller or swifter might be required; equally, it might be something that requires a judicial element—but it gives us a different way of doing things that provides a very sympathetic and compassionate way of listening to families and a way to get closer to the truth.