Health Service Safety Investigations Bill [HL]

Lord Ribeiro Excerpts

2nd reading (Hansard): House of Lords
Tuesday 29th October 2019 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I too thank Jeremy Hunt for his contribution as Health Secretary and his interest in patient safety, and for driving the Bill to the position it is in now. In the Queen’s Speech debate on Tuesday 22 October, I drew attention to the title of the Bill:

“The humble Address refers to new laws to establish an independent body to investigate serious healthcare incidents”.—[Official Report, 22/10/19; col. 539.]


I pointed out that this was at odds with the title of the Bill, which deals solely with health service safety incidents and those carried out in the private sector on NHS patients. It does not apply to those receiving private treatment in the private sector, a point that has already been made by others.

The Joint Committee of MPs and Peers on the draft Bill made it clear that it should be amended to extend the HSSIB’s remit to the provision of all healthcare in England, however funded. It is therefore disappointing that this Bill fails to address the issue with the private sector. I gave the example of the Sellu case, where the evidence of a root-cause analysis of the surgeon’s work was not disclosed at the trial. Today I make reference to another case, that of Ian Paterson, a surgeon who was sentenced to 15 years in prison for undertaking needless breast surgery in the private sector. After his conviction, the Royal College of Surgeons called for a review of safety standards in the private sector. Both cases indicate why the scope of the Bill needs to be widened to include the private sector. The apparent exclusion of private healthcare providers and organisations, save for those that are treating NHS patients and providing service and equipment to the NHS, would appear to limit the potential scope and effectiveness of the HSSIB.

In the Queen’s Speech I declared my interest as chairman of the Confidential Reporting System in Surgery, CORESS, which serves to support surgeons in providing confidential reports of near misses and adverse incidents in surgical practice, with the aim of disseminating the learning from these incidents to inform the surgical community and prevent further occurrences. One of the committee members, Peter Tait, previously director of flight operations for British Aerospace’s commercial section and latterly the CEO of CHIRP, the confidential human factors incident reporting programme, worked closely with the chief inspectors of the Air Accidents Investigation Branch for 20 years. He described the aviation equivalent of the current scope of the HSSIB Bill as restricting the AAIB to investigating air transport operations and their service provision but excluding aircraft, engine and equipment manufacturers, air traffic services and airport providers directly or indirectly involved in the survey safety of the air transport system. It is a whole-system effect that needs to be looked at, not just one area.

I believe that by limiting the Bill to the NHS we are ignoring the lessons learned by the AAIB and others in dealing with rail and marine accidents. The Royal College of Surgeons has similarly expressed concern about the narrowness of the scope of the Bill and believes that the Bill should give the HSSIB the power to investigate non-NHS patient safety issues in the independent sector, as recommended by the Joint Committee. It is not enough to limit the remit of the HSSIB to those who provide NHS services to the private sector.

In its response to the Ian Paterson case that I mentioned earlier, the Royal College of Surgeons published recommendations for assessing standards in the independent sector, including the need for equivalent reporting requirements for independent and NHS hospitals in terms of safety and outcome data. Thus, by extending the remit of the HSSIB to the non-NHS-funded independent sector, errors or potentially dangerous activity identified in the private sector could be addressed, to the benefit of the NHS and non-NHS patients. This is all the more important as the majority of surgeons work both in the NHS and in the private sector. The Joint Committee enforced this point when it asked for the draft Bill to be amended to extend HSSIB’s remit to cover the provision of all healthcare in England, however it is funded. This is likely to require consequential amendments to other parts of the Bill, as well as to the title, and I look forward to introducing these in Committee.

The Royal College of Surgeons is also keen to widen the scope of the Bill to include the regulation of surgical care practitioners in the UK. These practitioners increasingly support routine care of surgical patients under the supervision of senior surgeons and provide continuity of care while surgeons focus on more complex and advanced patient care. The Government believe that surgical care practitioners should be regulated by the Nursing and Midwifery Council. As more surgical care practitioners enter the profession directly, rather than through roles such as nursing, it is appropriate for regulatory oversight to be introduced. Failure to do so may pose an increased risk to patient safety.

The safe space proposals have been modelled on approaches used for many years by the air accident and transport safety investigation bodies, which have contributed to safety in these industries. However, the provision in Part 2(3)(19), on disclosure to coroners, differs from the UK regulation relating to disclosure for the AAIB. The International Civil Aviation Organization sets out regulations relating to disclosure in Annex 19:

“The State conducting the investigation of an accident or incident shall not make the following records available for purposes other than accident or incident investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs the adverse domestic and international impact such action may have on that or any future investigations”.


All of this was highly pertinent to the Shoreham air display accident, which noble Lords may recall, as a full statement was given to the Air Accidents Investigation Branch and the judge refused to give the police access to this evidence. It is important that a public interest case should be made by a High Court judge in order to release information, and this approach should be applied similarly to HSSIB.

I am advised that when applications for disclosure have been made in the case of the AAIB, only one successful application for the release of cockpit voice recording data, fitted to a privately owned aircraft, was granted to the estate of the deceased pilot. The High Court judge ruled that the disclosure would not set a precedent for the release of information related to public transport systems and their investigation. Any exceptions to the safe space protection to accommodate coroners will be problematic and the same standards should apply across the board, whether to the AAIB, the Marine Accident Investigation Branch or HSSIB. Otherwise, HSSIB will not hold the same powers or protections and coroners will be able to draw on their access to individual statements to determine how they question witnesses during inquests. Thus, information taken in confidence by HSSIB could be indirectly made public. I am reassured by what my noble friend the Minister said earlier in this respect, but we may need to tease this out in Committee, as the noble Lord, Lord Hunt of Kings Heath, observed.

Safe spaces do not prevent coroners accessing information if they have justification for it and can do so through the High Court. Healthcare staff need to be confident that HSSIB can protect their information in line with the original safe space proposals. Fear of legal, regulatory or managerial sanctions against clinicians is high and recent high-profile court cases such as Sellu and Bawa-Garba do little to reassure the profession. HSSIB must be allowed to enjoy the confidence of the profession, otherwise its work will be seriously compromised.

Queen’s Speech

Lord Ribeiro Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I add my appreciation to that of others for the contribution of the noble Baroness, Lady Emerton, to your Lordships’ House. She has been not only a spokesman for nursing but a stalwart in maintaining standards in the profession. We will miss her wise counsel in our proceedings.

The humble Address refers to new laws to establish an independent body to investigate serious healthcare incidents—no, not health service incidents, as in the new Bill. I will come back to that later.

Sir Bernard Jenkin MP, chairman of the Public Administration and Constitutional Affairs Committee, stated:

“There is an acute need for the Government to follow through on its commitment to turn the NHS in England into a learning organisation; an organisation where staff can feel safe to identify mistakes and incidents without fearing the finger of blame”.


The Bill achieves that objective, but its remit needs to be wider. The Joint Committee’s report, in its recommendations 4 and 5, was clear that the legislation should be called the healthcare safety investigation Bill, and consequently should establish the healthcare safety investigation body—the HSIB—in statute. Indeed, it was originally referred to as such. The committee wished the remit of the HSIB to be extended to the provision of all healthcare in England, which of course includes the private sector. The Government in their response agreed to look at that in both the title and the extent of the remit of the new body to investigate independently funded healthcare in England.

I make that point because, in the recent Sellu case, in which a surgeon was sent to prison on gross negligence manslaughter charges and later exonerated on appeal, there was evidence that the root-cause analysis of the surgeon’s work at the Clementine Churchill Hospital, a private hospital, which showed evidence of system failures, was effectively buried and not made available at the original trial. Extending the legislation to the private sector would prevent such failures in future and ensure equal standards between the NHS and the private sector. Can my noble friend confirm whether that recommendation will be accepted? If it is not accepted now, will an answer be provided during next week’s debate on the Bill?

Another area of concern in the Bill relates to the safe space, an approach used for many years by the air accident and other transport safety investigation bodies, which has contributed to improved safety in those industries. This approach has been challenged by coroners and other groups but is strongly supported by the Joint Committee. I am sure we will discuss this at length on the Bill, but assurances from the Government at this stage would be welcome and would give participants in the Healthcare Safety Investigation Branch confidence that information they share candidly will be investigated and protected. I declare an interest as chairman of the Confidential Reporting System for Surgery. We have supported the work of the Healthcare Safety Investigation Branch, and look forward to working collaboratively with the new body in future.

Another area of the Queen’s speech relates to shortages in the workforce and the need for more investment. Nowhere is this more urgently required than in mental health—we have heard much about that already today. It is encouraging to read of the pilot scheme to recruit 1,000 additional staff as part of the £2.3 billion extra investment in mental health in the NHS long-term plan. However, Sir Simon Wessely, previous president of the Royal College of Psychiatrists, in his independent review stressed the need for capital spending to restore the fabric and conditions of many of our institutions. I hope that will be part of the £1 billion boost to NHS capital spending promised for 2020-21.

NHS Long-term Plan

Lord Ribeiro Excerpts

Monday 1st July 2019 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I welcome the development of the five new medical schools that are going onstream. Two weeks ago, I was fortunate to be at Chelmsford when the Duke of Kent opened the Anglia Ruskin University medical school. But it is quite clear that a lot of medical graduates are leaving the profession, for whatever reason. There is also good evidence that those who come in at graduate entry last the distance a lot better than those who perhaps come in much younger. Your Lordships may ask, “Where is the evidence for that?” What efforts are being made to look into why people are giving up medicine early, and what is the possibility of increasing the number of graduate entries?

[Baroness Blackwood of North Oxford]

I thank my noble friend for his question. The core of the work my noble friend Lady Harding is doing is to analyse recruitment and retention patterns in the health service, obviously not just among core clinicians but across the whole system, to identify best practice for improving the workplace environment to recruit and retain. I am not sure whether she has done specific work on the difference between direct entry and graduate entry but I will be happy to find out for my noble friend.

Healthcare (International Arrangements) Bill

Lord Ribeiro Excerpts

Report stage (Hansard): House of Lords
Tuesday 12th March 2019 Lords Chamber

[Baroness Chisholm of Owlpen]

No, let me finish. The Bill will not replace or limit the prerogative power to enter into international healthcare agreements. My understanding is that agreements will still be subject to appropriate parliamentary scrutiny.

It is surely right for us to take advantage of the Bill and look at the opportunities it can offer us. We are not trying to shoehorn something dastardly into it. It could offer all kinds of things. It seems to me that planning ahead is a refreshing thing to do. Many of the arguments raised have nothing to do with protecting or giving peace of mind to travellers. As a nurse, my main priority will always be those needing care. The Bill allows them reciprocal healthcare outside the EU and just that. Should there be a Division, I hope that noble Lords will keep in mind those people who, under the Bill, will be able to travel globally with renewed peace of mind about their healthcare.

[Lord Ribeiro (Con)]

My Lords, this is an enabling Bill and no more. In a letter to the chairman of the Delegated Powers and Regulatory Reform Committee on 8 March, the Minister confirmed that these powers would be used only in the exceptional circumstances of EU exit. We will discover the outcome of that tonight.

In these circumstances, the regulations’ implementing powers would be subject to parliamentary scrutiny. The assurances and clear message from our debates in Committee—when the Minister was very clear, in answer to a question from the noble Lord, Lord Brooke of Alverthorpe, that reciprocal healthcare arrangements with the United States would present significant challenges because of the different payment systems and such an arrangement was unlikely—should surely be enough to satisfy those who believe that the Government still have a cunning plan to sell the NHS to Donald Trump and others.

As I said in Committee, I believe that the implementation of our international arrangements should be phased, giving priority to our overseas territories, as has been noted; our Commonwealth partners, of which Australia and New Zealand have already been mentioned; and our important international partners, perhaps excluding Venezuela and the Galapagos Islands from that list, as suggested by the noble and learned Lord, Lord Judge.

Anything enabling this to happen should be considered seriously, given the risks of what I believe is likely to be a no-deal Brexit. I do not support these amendments and I hope that the Minister will be able to come up with suggestions for how this can be implemented to overcome some of the concerns expressed from the other side.

[Baroness Brinton (LD)]

My Lords, both the noble Lord, Lord Ribeiro, and the noble Baroness, Lady Chisholm of Owlpen, are missing the point of these amendments. While this is only an enabling Bill, it increases the scope of reciprocal health agreements with countries outside the EEA and Switzerland to include trade agreements. The noble Lords, Lord Lansley, and Lord O’Shaughnessy, at earlier stages of the Bill, raised exactly this point about setting up trade agreements. We are extremely concerned, for all the reasons given by the noble Baroness, Lady Thornton; this is the sort of large change that requires considerable consultation with the public prior to Green Papers, White Papers and bringing it through the House. We should not try to rush it through as one of the Brexit Bills, which it is, regardless of what happens over the next few days. This is one of the Bills that we were told must be passed by 29 March. Increasing the scope of the Bill means that we are moving into another area that the country, let alone this House, has not had a chance to consider.

I do not believe that reducing the scope would prevent some of the agreements already made; in fact, as the Minister has said when summing up previously, a number are already available. What it does is protect the NHS from being a bargaining tool, particularly—although not only—with the United States. Until the country has a chance to have that debate, it is important that we reduce the scope.

I endorse entirely the comments made by the noble Baronesses, Lady Thornton, and Lady Jolly, the noble and learned Lord, Lord Judge, and the noble Lords, Lord Marks and Lord Foulkes. Our task is solely to replicate the arrangements that may become out of date on 1 April; it is important that we remain focused on that.

Brexit: Import of Radioisotopes

Lord Ribeiro Excerpts

Thursday 7th March 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

I think I answered that in my response to the noble Baroness. We have assessed that we do not expect any patient harm to arise from this, and the changes to clinical pathways and practices are expected to be minor and short-lived. It is one of the reasons why we started working with industry early in the process to ensure that air freight capacity was put in place. It is also why we have been working with the Royal College of Radiologists, NHS England and the department to ensure that the guidance was put in place, so that clinics could be prepared to adapt to these changes in delivery times.

[Lord Ribeiro (Con)]

My Lords, the EU Home Affairs Sub-Committee looked at this matter and debated it in a take-note debate in July last year. At the time, I flagged up the importance of developing a new generation of alpha- and beta-emitting isotopes for cancer treatment in helping to mitigate the problems of importation. The then Minister, my noble friend Lord O’Shaughnessy, reassured the House that quite a lot of work was indeed going on with regard to proton beam treatment, that the Christie Hospital would be starting that very soon—that was last year—and that another unit was on the go. So there are alternative provisions for cancer treatment with proton beam therapy. None the less, there is an issue about what would happen in a no-deal Brexit as regards the gap between what we currently receive and what we are able to provide. Can the Minister say anything about when we can expect these new systems to come on stream? It is a challenging question, so she may wish to write to me on that.

[Baroness Blackwood of North Oxford]

I thank my noble friend for that helpful question. I assure him that both the Christie and UCL proton beam programmes are well under way, and we can be proud of our world-leading programmes in cancer proton beam therapy. I cannot give him an exact progress update on that, so I shall write to him on it. However, he is absolutely right that we must make sure that we progress those programmes, as well as ensuring that our supply of imported radioisotopes remains protected during the Brexit period.

Healthcare (International Arrangements) Bill

Lord Ribeiro Excerpts

Committee: 1st sitting (Hansard): House of Lords
Tuesday 19th February 2019 Lords Chamber

[Lord Brooke of Alverthorpe (Lab)]

My Lords, first, I apologise to the Committee for not having been able to speak at Second Reading. Secondly, I welcome the Minister to her new post and wish her well with it, although I am sorry, like the noble and learned Lord, Lord Judge, that she has been given a hospital pass on this one. I shall speak briefly in support of Amendment 1 in the name of the noble Baroness, Lady Thornton. I am sorry to hear that the clause stand part may not be pushed to a vote, but perhaps the way that the debate goes may necessitate that.

My interest goes back before the Minister came into the House. I asked a series of questions about the proposed trade agreement between the UK and the USA. I have been particularly concerned, as have many in the health industry, that this agreement will open up an opportunity for the USA to come in very strongly indeed. The health industry in America is a very big part of the economy, and one area in which it has not been able to make great movement is within the NHS. Some of us have been concerned that the trade agreement would open that up, and we have been seeking to have it taken off the agenda. I have tabled Questions asking for it not to be on the agenda, and the Government have so far not been prepared to give any such assurance. I have contemplated moving an amendment to this Bill to ensure that, while the Minister is saying that this has nothing to do with that, she could accept such an amendment and set my mind at rest very quickly.

I read very carefully what she said in response to similar criticisms of the Bill at Second Reading:

“The Government are completely committed to the guiding principles of the NHS—that it is universal and free at the point of need. Our position is definitive: the NHS is not and never will be for sale”.—[Official Report, 5/2/19; col. 1488.]


She was not saying anything there with which I would disagree, but one worries about trade agreements whereby people can effectively take over and, while not owning it, can run parts of a major utility such as the NHS. That is why some of us have been seeking an agreement that it would not be on the agenda at all and the NHS would be left as it is, free of any trade agreement, particularly with the United States. I would be grateful, therefore, if the Minister could reassure me that in no way would a trade agreement with the USA have the NHS as part of it. If not, I may have to go away and see whether I can bring back an amendment on this issue.

[Lord Ribeiro (Con)]

One can see why, in the event of a no-deal Brexit, the amendment moved by the noble Baroness, Lady Thornton, would be attractive, as it focuses our minds on restoring reciprocal healthcare arrangements with the EU 27, other EEA countries and Switzerland. As I said on Second Reading, a disproportionate number of UK citizens benefit from the S1 scheme compared with EU citizens in the UK, so there is much to lose in a no-deal scenario.

In March 2018, the UK reached an agreement in principle with the EU on the implementation period which would ensure continuation of the current reciprocal healthcare rights until 31 December 2020. If we crash out, there has to be a plan B which allows us to consider reciprocal healthcare arrangements with other countries. Although I understand the need to write “international arrangements” into the Bill, it presents problems. They were identified by the Delegated Powers and Regulatory Reform Committee, as mentioned by the noble Baroness, Lady Jolly, which described as “fanciful” the idea of providing the Secretary of State with wide powers to fund the costs of healthcare anywhere in the world—for example, as the noble Baroness described, mental health provision in Arizona or all hip replacements in Australia.

This is far too wide, and the focus of international arrangements should in the first instance be applied to Britain’s 13 overseas territories, far-flung as they are—some in the Falklands and the Galapagos, as the noble and learned Lord, Lord Judge, stated—but the closest of which is Gibraltar: close to us and close to Europe. Ninety-six per cent of Gibraltarians voted to remain in the EU, and our focus should be to ensure reciprocal healthcare for those overseas countries for which we have responsibility. Post Brexit, whatever the arrangements are, we can then think about the wider international arrangements; but for now, we should focus on the areas for which we have responsibility.

I hope that my noble friend can provide assurances as to how best to protect the overseas territories in the event of no deal and give further consideration to what the Government intend “international arrangements” to cover.

[Lord Lisvane (CB)]

My Lords, it is a great pleasure to welcome the new noble Baroness to the Front Bench and I echo the welcome offered by other noble Lords. I am only sorry that the first task that has fallen to her is, as described by my noble and learned friend Lord Judge, a hospital pass. I prefer to see it as a sort of legislative grenade with the pin out.

As my noble friend Lord Patel mentioned, I am a member of the Delegated Powers and Regulatory Reform Committee, but of course I do not speak on its behalf: this is an entirely personal set of observations. Delegated powers of unacceptable scope and inadequate arrangements for scrutiny are simply getting worse. Noble Lords may recall our extended debate on the EU withdrawal Bill in Committee and at Report, when noble Lords rightly became very agitated about the use of the word “appropriate”—widening the way in which ministerial powers might be used—as against “necessary”, which provided some sort of objective test as to whether those powers should be deployed. Amendments which would have fixed that went down the oubliette in the Commons. With my noble friend Lord Wilson of Dinton, I declare a degree of interest because my name and his, along with that of other noble Lords, were on those amendments.

This Bill takes us into new realms of the use of delegated powers, albeit that the Trade Bill and the Agriculture Bill, both of which have already been mentioned this afternoon, are strong competitors for this legislative wooden spoon. I congratulate my noble and learned friend Lord Judge on his forensic dismantling of the need for the powers contained in the Bill and his warnings about the way in which they might be used. Any thought of his grandchildren saying that he was “banging on” should not inhibit him in any way from continuing to bang on about those subjects, and I hope that many other noble Lords will do the same.

Two points of principle have a general application but are particularly lively in the context of this worrying Bill. The first is the use of Henry VIII powers. I think that His late Majesty would be extremely jealous of some of what is contained in the Bill, as with the Agriculture Bill, the Trade Bill and the other Brexit Bills to come trooping our way. I accept that Henry VIII powers are sometimes needed, perhaps when there are urgent issues for which you need to make primary legislative provision, but you cannot get a Bill through in the normal course of events. However, where such powers are used, I suggest that there should be a test: that of the three Ss.

Healthcare (International Arrangements) Bill

Lord Ribeiro Excerpts

2nd reading (Hansard): House of Lords
Tuesday 5th February 2019 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, it is indeed a pleasure to take part in this debate, and in particular to follow the noble Lords who have spoken and to welcome our new Minister to the Front Bench in her new position. I declare an interest as a member of the EU Home Affairs Sub-Committee and commend to the House its report, Brexit: Reciprocal Healthcare, published in March 2018.

Like many of your Lordships, although I use travel insurance when I am in Europe, I am always grateful to have in addition my EHIC. Some years ago, while I was on holiday with my family in France, one of my children broke a toe while going down a slide. Faced with having to pay for her surgery and then claim back the cost, I produced my E111 form with a flourish—noble Lords may remember those days. I managed to convince the hospital authorities in my pidgin French, although that was more challenging. The E111 form worked a treat and surgery was performed at no cost to me. The current EHIC is equally reassuring, but mine runs out in May 2019, so I seek reassurance from my noble friend the Minister that I will be able to renew it during the implementation period of the withdrawal Act—if it is finally implemented.

What happens in the event of a no-deal Brexit, the drums for which are continuing to beat in some quarters? Our report confirmed that some 27 million cards, as has been mentioned, exist in the UK, from which only 250,000 claims—less than 1%—have been made so far each year. In relation to UK citizens living in Europe, approximately 190,000 UK state pensioners, as we have heard, rely on the S1 scheme. This provides ongoing access to healthcare, the costs borne by the member state with the social security system to which the individual has contributed the longest. The scheme supports the elderly and ensures that reciprocal healthcare is a portable benefit. On page 10, paragraph 16 of our report says:

“A disproportionate number of UK citizens benefit from the S1 scheme. There are only around 1.2 million UK citizens living in other EU countries compared with around three million EU citizens living in the UK. But some 190,000 of those UK citizens are pensioners, who are more likely to benefit from the S1 scheme, compared to only 5,800 EU/EEA citizens who have registered for the S1 scheme in the UK”.


That is quite a disproportionate number.

In all this, we remain net beneficiaries. I hope that noble Lords will forgive me for focusing on the no-deal scenario, but the implications are dire for this group of UK citizens and the 27 million EHIC holders I mentioned, many of whom, as we know, voted to leave the EU. If the EHIC is not maintained—which is a distinct possibility with no deal—short–term visitors to the EU would need travel insurance. In giving evidence to the committee, Mark Dayan of the Nuffield Trust told us that the highest cost of travel insurance was the medical cost. Without the EHIC, the cost of travel insurance is bound to rise.

There is also concern about the onward movement of UK citizens living or working in the EU in relation to free-movement rights or rights to reciprocal healthcare, which are not covered by the joint agreement or the withdrawal agreement. It has been suggested that bilateral and multilateral arrangements, as currently occur with countries outside the EU such as Australia or New Zealand, could be applied to the EU. But these arrangements largely cover emergency healthcare and not the arrangements we currently enjoy through the S2 scheme in relation to planned treatments. For example, as I mentioned in my speech on 3 July 2018, the proton beam cancer treatment available in Prague and other European cities is not currently available here, although we hope it will very soon come on stream. So what reassurances can the Minister give that future relations and arrangements will protect the current S1 and S2 arrangements, which form part of the four routes to reciprocal healthcare? Reciprocal healthcare is assured until December 2020, as we have heard—if we have an agreement. In the event of no deal, which is fast approaching, what assurances can the Minister give that the deadline of December 2020 can still be maintained to allow “alternative arrangements” to be negotiated between individual EU countries and the UK?

It is important that we provide reassurance to UK citizens, many of whom are in their twilight years and have chosen to reside in EU member states, that their health needs are protected. This should happen, deal or no deal. If we end up with no deal, analysis by the Nuffield Trust shows that British pensioners will lose healthcare cover in EU states and have to return to the UK to access care. The cost of that care in the NHS is estimated at about £1 billion—pounds, not euros, although it is about the same—which is twice as much as the UK currently spends on the care of people abroad under the S1 scheme, as spelled out earlier by the noble Lord, Lord Foulkes, when he referred to this. The resource implication of such expatriate return to the UK is the equivalent of two new NHS hospitals the size of St Mary’s Hospital, Paddington. We noted in our report a large amount of evidence expressing concern at the additional costs to the UK and the NHS of returning expats. What contingency plans do the Government have in the event of such an outcome occurring?

Health: Pancreatic Cancer Treatment

Lord Ribeiro Excerpts

Wednesday 19th December 2018 Lords Chamber

[Lord O’Shaughnessy]

I absolutely agree on that point. I hoped we would pass the “Lord Young test” with a jargon-free and, at least, succinct White Paper—the Life Sciences Sector Deal 2, which we published recently. It outlines some very important commitments to research in this area, including the creation of new early diagnosis cohorts, using a cohort of healthy people to look for early signs. That is one of the investments we are making, as well as investment through the National Institute for Health Research. We are looking for those exciting innovations, like liquid biopsies, that can help us get the signs earlier.

[Lord Ribeiro (Con)]

My Lords, as has been pointed out, it is not about the time to treatment but the time to diagnosis. Clearly, early diagnosis is the key. In Europe, the outcome for pancreatic cancer is often better than in the UK because patients have access directly to specialist care, whereas we rely on our GPs to be the gatekeepers, and that is where the problem lies. What measures will be taken to ensure that patients can have access to specialist care much earlier?

[Lord O'Shaughnessy]

My noble friend speaks with great wisdom on this topic, and he is absolutely right. I would point to two improvements that have happened in recent years. First, the NICE standard threshold for when GPs should make referrals has been lowered, so they ought to refer more often. Secondly, we are seeing a big increase in referrals to cancer specialists: there have been over 115% more referrals since 2010. We are starting to see much greater referrals from GPs to specialists.

Organ Donation (Deemed Consent) Bill

Lord Ribeiro Excerpts

2nd reading (Hansard): House of Lords
Friday 23rd November 2018 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I support the Bill and hope it will pass. I thank the noble Lord, Lord Hunt, and my noble friend Lord O’Shaughnessy for the briefings they gave us before today. However, I have a few reservations, which I will address shortly.

As we heard from the noble Lord, Lord Patel, the black, Asian and minority ethic—BAME—community is one group of patients most in need of a change in legislation. BAME people are often the most in need of transplants—particularly kidney transplants for renal failure due to secondary high blood pressure—but, for various reasons, they often refuse consent because of faith or cultural concerns. In 2017-18, 1,487 BAME patients were on the renal transplant waiting list, many as a result of high blood pressure—a particular problem for this ethnic group—but only 49 deceased kidney donors from BAME backgrounds to help out. That represents a fraction of the need. As a surgeon and an African, I understand the difficulties faced by BAME people in becoming donors. There may be religious, cultural or ill-informed reasons for saying no.

I have experience of working as a patron of Transplant Links Community, or TLC, a charity that has transformed the lives of many people in Africa and the Caribbean who suffer from kidney failure, especially children. Without transplantation, such people have to endure regular dialysis, often three times a week, which can be challenging in a rural setting and extremely expensive. The charity was founded by two kidney specialists from Queen Elizabeth Hospital in Birmingham: Dr Dwomoa Adu, a fellow Ghanaian and a nephrologist, and Dr Andrew Ready, a transplant surgeon.

In 1974, Dr Adu and I worked in the renal service at Korle-Bu Hospital in Accra, Ghana, the hospital chosen by the Birmingham team for their first live-donor kidney transplant in Ghana in 2007. We have heard about a boy called Max, but Felix, the young boy on whom this transplant was performed, has completed a chemistry degree and hopes to become a doctor. The programme has now been extended to Trinidad, Jamaica, Barbados and Zambia and is supported by my fellow patrons, the noble Baroness, Lady Benjamin, and my noble friend Lady Cumberlege. By their very nature, live-donor transplants can help only a small number of patients, while cadaveric donation has the potential to help many by offering more than one organ for transplantation.

As a surgeon working in the UK, I know how difficult and distressing it can be to approach the deceased’s family with a request for organ donation, often after heroic efforts to save the person’s life. As we have heard, it is not surprising that at this most sensitive time, some families say no—even if the deceased had indicated a desire to donate. Eight out of 10 patients on the transplant waiting list are hoping for a kidney; currently, 4,375 people in England are waiting for a kidney. A change from opting in to opting out will make an enormous difference and provide more organs for transplantation.

However, as the noble Lord, Lord Hunt, said, unless the infrastructure is improved, with more specialist nurses, transplant co-ordinators and so on, we will not see much change. The British Transplant Society warns that,

“assessments of the effects of opt-out laws on donation rates are hampered by differences in cultural attitudes, economic conditions, availability of intensive care units, numbers of transplant co-ordinators, degree of governmental support and other factors, whose influence may be important but uncharted”.

Spain, as we have heard, has the highest rate internationally of transplantations with the opt-out policy, but it introduced the system in 1979 and saw a significant increase only,

“ten years after the law was introduced. Much of Spain’s success is attributed to the establishment of a new national transplant organisation to co-ordinate the donation and transplantation process, including the appointment of transplant co-ordinators who instigate conversations with the family of potential donors”.

As I said, doctors faced with repeated rejections by families often fail to press the case and so opportunities are lost. We must invest in more staff as well as raise public awareness of the need to donate. The Government will, I am sure, launch a campaign to highlight the need for more organ donors. Public awareness will, we hope, lead to an increase in donors, especially from BAME communities, who face the greatest challenge with donations, as the noble Lord, Lord Patel, told us.

I started by referring to live-donor transplants. These reflect a personal commitment—a gift, as has been said, from one loved one to another. This altruistic giving should continue and not be impacted by the belief that it is no longer necessary as the opt-out programme will remove the need for it. Tissue- matched live-donor transplants give the best results and we must encourage families to continue to engage in the programme.

The noble Lord, Lord Hunt, referred to an organ donation consent rate in Wales of 77%. I have a publication here from the Welsh Government, dated 16 November, which suggests that Wales has reached the highest organ donation consent rate in the UK, at 80.5%. This compares to 66.2% in England, 63.6% in Scotland and 66.7% in Northern Ireland. This is the first sign of Wales’s opt-out programme working. It is time for us to catch up, but let us not assume that a change in the law will be the end of the matter, like waving a magic wand—it will not. It will require preparation and information to drive a public awareness campaign and I look to the Minister to tell us how this will be achieved. I can also tell the House that I have spoken to the president of the Royal College of Surgeons, who personally supports the Bill and will be raising it with his council in December.

Government Vision on Prevention

Lord Ribeiro Excerpts

Tuesday 6th November 2018 Lords Chamber

[Lord Ribeiro (Con)]

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

[Lord O’Shaughnessy]

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

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