Pregnancy: Neural Tube Defects

Lord Turnberg Excerpts

Monday 21st December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, when my noble friend says that this House is almost unanimously agreed she may well be right. However, the decision on this matter has to be taken in the other House. As I said, my honourable friend Jane Ellison, the Minister for Public Health, is going to come to a decision very quickly.

[Lord Turnberg (Lab)]

My Lords, we seem to have been for ever on this particular question. There is an irrational fear that somehow it is dangerous to fortify flour, and this has held up people in some way or other. But scientifically that does not bear fruit. It is clear from all the experience around the world of many years of fortifying flour with folic acid that it does work. We should be doing it here now.

[Lord Prior of Brampton]

My Lords, I am certainly not going to argue on clinical grounds with the noble Lord, who knows far more about this than I do. However, the issues are not purely clinical; they are to do with the mass medication of the whole population to reach a very small minority of women of child-bearing age. There are also some administrative issues to do with making sure that people do not take too much folic acid, as some cereals have folic acid added to them. However, I understand exactly what the noble Lord is saying, and can only repeat that the Minister for Public Health is reviewing this now.

Residential Care: Cost Cap

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Thursday 10th December 2015 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I, too, am grateful to my noble friend Lady Wheeler for introducing this debate and pointing out so clearly all the difficulties we face. It is difficult not to be gloomy and I am afraid I shall not lift the gloom. Way back in 2011, we had a harbinger of what might happen to care homes when Southern Cross failed with the loss of a large number of beds. Local authorities, which are mandated to care for their needy citizens, were left to pick up the problems; they cannot refuse to do so. Now we are starting to see more of the same, as other large providers of care homes get into difficulties. The latest is Four Seasons, as we have heard, which finds that offering this type of care is increasingly non-viable financially. As my noble friend Lady Wheeler said, it is already in considerable debt, as has been laid out in stark terms in the Financial Times. We could see the loss of many more beds and Four Seasons is unlikely to be the only one so affected.

It is not difficult to see how we have got into this situation. Government funding for local authorities has been severely squeezed and the impact is clear. Since 2010 there has been a fall of 25% in the number of people receiving social care, and the fees that care homes receive from local authorities are strictly constrained. To add to their problems, they are now faced with having to pay their staff the new living wage. Quite right, so they should—these staff have been disgracefully underpaid for the critically important work that they do—but it will cost the sector some £2.3 billion over the next four years. The net result is that care home providers are hit with the double whammy of increased costs and limited income. It is little wonder that they cannot break even. Private domiciliary care providers such as Allied Health have found themselves having to face up to the extra costs due to an EU directive obliging them to pay for journey times to and from domiciliary visits, when hitherto they have been able to get away with it.

It is not only on the supply side that there are difficulties; the demand side is difficult, too. Since 2009-10, the over-75s have increased by about 500,000, a 9.5% increase. It is not simply the increase in numbers that is problematic; the elderly are living longer with disabilities. It does not help to know that in the UK the time between the onset of disability and death is now seven years. That is seven years of dependency. That compares very unfavourably with Norway, where people suffer only two years in need of support before they die.

Of course, many of the causes of dependency lie outside the remit of the Department of Health, but public health clearly does not. While lip service is paid to prevention in all the health plans that one reads about, it is sad to discover that funding for public health is to be cut—by something like £800,000, I am told. That seems an extraordinary thing to be doing when we are trying to reduce the burden of disease. I well understand that it would be difficult for the Minister to change Treasury plans, but is there anything he can do to suggest that it would mitigate the impact on public health?

All this is leaving local authorities and hospital services to pick up the tab, and neither is in a good position to do so. The fall in government support for local authorities is supposed to be bridged by permission to increase their council tax by an extra 2% a year, over the 2% that they already have the flexibility to raise, for the next four years. However, to raise a total of 4% a year across the country consistently for several years is a difficult ask, and it will be much more difficult in poorer areas of the country.

As we have heard, they will have access to the better care fund, money transferred across from the NHS, but they will not receive much, if any, for the next two years. By 2021 they will get about £1.5 billion, and it is interesting that this transfer just about matches the extra that the NHS is due to get. So there is not much relief for the next two years. Local authorities will inevitably have to raid other budgets—but they will already have been doing so for some time, and there is little slack left in the system.

I did not want to talk about the hospital sector in this debate, but it is hard not to when we know that some 30% of beds are occupied by patients who do not need to be there. Everyone knows that. If nursing homes start closing, more patients will be admitted unnecessarily to a place quite unsuited to their needs, and there they will stay for far too long. It is certainly true that the NHS received a very welcome boost in the recent CSR. We should not look this gift horse in the mouth as it is sorely needed, but I fear that it will be only a temporary relief. As the noble Lord, Lord Lansley, said, we desperately need a more basic change in the way that we provide health and social care. It seems inevitable that we will move much more rapidly to a joined-up health and social care system, the fully integrated service that is talked about so glibly. I am not sure that it will necessarily save money—indeed, it may even cost more to get it off the ground—but that must be the way to go for the patients.

Here and there across the country, efforts are being made by innovative and dedicated managers to do just that, but they are having to operate against the grain of the bureaucracy that we have set up centrally. What progress has been made since David Dalton’s report to smooth the path to integration by government, and can we expect a more rapid uptake locally? It will not solve all the problems we face—I fear that more funding for social care by one means or another will inevitably be required—but it will go some way to improving the care of a large number of our most vulnerable people who are currently being shipped around or, even worse, being neglected completely.

National Health Service (Licensing and Pricing) (Amendment) Regulations 2015

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Tuesday 1st December 2015 Lords Chamber

[Lord Warner (Non-Afl)]

My Lords, I start by thanking the Minister for his briefing yesterday, which I found very helpful. I also declare a forthcoming interest in that I shall shortly be chairing a short-term commission to consider the approach to commissioning specialised services, which will report next April. That may well, in the light of the debate this evening, have some fairly uncomfortable things to say about the commissioning of these services in today’s financially straitened NHS. It is very difficult to argue technically with the points made by my former noble friend—still my noble friend—the noble Lord, Lord Hunt, about this set of regulations, but in a sense that misses the bigger point raised by the noble Lord, Lord Patel.

I express my sympathy for the Minister. He is, to all intents and purposes, between a rock and a very hard place. He has to operate within the extremely clunky system provided for setting the tariff for specialist services in the Health and Social Care Act 2012—which, if I may say so, is one of the less distinguished pieces of legislation passed by Parliament. Trying to set a tariff using a system of objection thresholds is a somewhat bizarre way of doing it, even by the standards of the 2012 Act. That so-called new transparent system for reconciling the needs of commissioners and providers has clearly not worked. It is very difficult to see it working, not least because we end up leaving the decision on the tariff right up close to the start of the next financial year. If we want a five-year plan for reforming the NHS, that is about the daftest way to go about setting a national tariff. I understand why no one wants to go back to the 2012 Act and revise part of it but it is pretty bizarre, in a fast-changing world, to set the detail of how you negotiate the tariff in primary legislation. That is a fundamental flaw which we are now struggling with, as a result of that legislation. That is why we are getting into this tangle over the technicalities of this set of regulations.

If I was still the Minister trying to set acute hospital tariffs at a time of tight NHS finance and, at the same time, trying to prioritise community health services and mental health—as the Minister rightly suggests people are trying to do—I would probably be doing the same thing as the Minister, stuck as he is with this piece of legislation. I might even, if I was feeling particularly crotchety, go for 75% instead of 66%. But that is the fault of the system we have landed ourselves with, not because of a devious NHS England, devious Ministers or a devious Department of Health. We need to get to a different system. NHS providers have opened up some issues to talk about. It is certainly very difficult, in today’s age, to argue with the idea of a more open-book approach. But it also requires the open-book approach to take place further back down the food chain, before we get close to the beginning of the financial year. That is the only way these specialised services can look ahead.

It is true when I look back on my time as a Minister —this is where I start to part company with the noble Lord, Lord Hunt—that there is a pretty strong track record of the big NHS acute hospital providers having everything their own way. Even when, as a Minister, I said that the commissioner’s view should determine the outcome, those providers went on pushing and pushing, way up to and past the start of the new financial year. Of course, I am not talking about trusts chaired by the noble Lord, Lord Hunt—I am sure nothing like that ever happened in Birmingham. However, let us be clear, that is how some of the big London providers, in particular, behave—not in our second city, of course; heaven forbid.

There is a long history, then, of big providers pushing the envelope on the price for the job and weak commissioners being unable to stand up to them and deal with them. We now move to a situation where that problem must be tackled, and quickly. We can quibble about the technicalities of the way NHS England and Monitor have handled this episode, but it does not get away from the point that the Minister made: at the end of the day, these guys and girls have to make the decision. They have to decide on a canvas that is much bigger than that being painted by the acute hospital sector.

We should be a bit more forgiving towards the Minister on that. It takes a bit of bottle to say that we are going to put more money into community services and give more money and parity of esteem to mental health, even in a difficult financial climate. That means taking some fairly tough decisions about how much of the collective resources you put into acute hospitals and specialised services. This is where commissioning must play its part. It may mean that we want a smaller number of providers for some of those service lines; it may mean that we have to concentrate them.

NHS providers may not have realised that an open-book approach means that we start to find out more about those who are less productive or effective. I hope the Minister will listen to some of those ideas, particularly the points made by the noble Lord, Lord Hunt, at the end of his speech and by the noble Lord, Lord Patel. We have a clunky system and we need to change how we set the tariff if we really want to deliver the vision in the Five Year Forward View. I hope the Minister will respond positively to some of those ideas for a new approach.

[Lord Turnberg (Lab)]

My Lords, I must first apologise to the Minister for not appearing at his briefing yesterday and for coming late to his initial remarks. That will not stop me speaking, if I may.

The regulations are clearly designed to save money. They have little to do with correcting what is a major underlying defect in the tariff system: the perverse incentives that tariffs have introduced. My noble friend Lord Hunt has dealt pretty well with how the regulations were aimed at raising the threshold at which objections can be raised and, equally importantly, levelling the playing field to allow small providers with limited budgets to have the same voting power as very large teaching hospitals with billion-pound budgets, which provide more than 95% of the service. It is rather like non-league football clubs and those in the Premier League having the same voice in their commercial activities. The problem is that, to get 66% of all organisations, including all the small ones, puts those trusts that provide more than 90% of the service in hock to those who provide less than 10%. So it is not much wonder that the highly specialised hospitals—the Marsden and Great Ormond Street, the Institute of Neurology, the Christie hospital and so on—are voicing strong concerns about the impact on them. Of course, that is why the Government want to shackle them—to keep costs down—but that is at the risk of denying high-quality specialised care to those who need it.

All that has been well rehearsed by my noble friend Lord Hunt and other noble Lords. I really wanted to point out that the regulations do nothing to get round the unintended consequences and perverse incentives of the tariff system, which I raised with the Minister in a previous debate. That system encourages trusts to go down the route of using devices to gain higher incomes and discourages cross-referral between specialists within a hospital when a trust can gain two fees for two referrals from general practice. It discourages consultants from using phone-in follow-up out-patient clinics to save patients the need to travel in to be seen, as a visit to a hospital incurs a higher fee on the tariff. I agree with the noble Lord, Lord Warner, as he rails against the acute hospitals, but I do not necessarily agree with all his solutions.

I support my noble friend’s amendment. The regulations are unwarranted and damage those who provide the vast majority of the service, while doing nothing to get at one of the major defects in the tariff system.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners, an academic health science centre which has a number of important providers. The Minister made a very important point about the five-year forward view and the need to encourage new models of care working that ensure collaboration beyond institutional boundaries —and, indeed, to go further and look at new models of funding, including those of accountable care organisations. With a view to a potential journey towards more effective commissioning, and therefore more intuitive constructing of a tariff to support general acute services and more specialised services, will the proposals that the Minister brings to the House today aid that journey? Will looking at these regulations in the way proposed help institutions to work more effectively together, recognising the opportunity to look at tariffs that focus on pathways of care rather than individual segments of care, so ensuring the Government’s objective to ensure that valuable resources committed to the provision of healthcare are used most efficiently? There is a recognition that there will have to be greater attention to these matters as we go forward, and every opportunity should be used to ensure that that objective is achieved. One of the most important is the approach to setting the tariff and, therefore, these regulations.

Palliative Care

Lord Turnberg Excerpts

Thursday 22nd October 2015 Grand Committee

[Lord Turnberg (Lab)]

My Lords, I too congratulate the noble Lord, Lord Farmer, for his immaculate timing in having this debate and for his very wise words. There is little doubt that hospices do a wonderful job, and I for one am lost in admiration for the way they go about caring for dying patients. However, hospices care for only about 3% or 4% of dying patients, and more than 50% finish up in acute hospitals. These hospitals often do a very good job, but they have some problems. For one, they have young doctors and nurses who are ill prepared to deal with death. Too often they have not yet gained the confidence which is needed to give the care and compassion which are so vital. On top of that, they have to deal with their own sense of inadequacy when faced with dying patients. It is not easy. It is no help that they are distracted by having to rush around to deal with seriously ill patients and that they have to focus on saving someone’s life rather than helping someone else to die.

None of that is an excuse for the failing standards, and it is not possible to read the ombudsman’s report with any degree of equanimity. Indeed, as someone who has spent much of his life trying to educate medical students and train post-graduates in the proper practice of medicine, I feel deeply ashamed. As an aside, I should say that there is a peculiar fear that giving adequate doses of morphine for pain relief is somehow dangerous. The correct dose of morphine is that which relieves a patient’s pain, and there is no excuse for withholding it when it is needed. I feel some sympathy for Woody Allen, who said, “I don’t mind dying, but I don’t want to be there when it happens”.

Despite the fact that there is absolutely no shortage of guidelines on how to care for the dying, there is still a huge gap between what we can do and know should be done, and what is actually achieved in too many places. First, it is clear that many patients would prefer to die at home, as many have said. It is obvious that too few social services and primary care facilities can cope with the heavy demand that this sort of care puts on them. Hospices at home can be very successful—as they are in several places, as the noble Lord, Lord Farmer, and my noble friend Lord Judd mentioned—but we need to provide more resources to spread that good practice.

Secondly, we must face an obvious lack of the leadership that is needed in hospitals to ensure that palliative care services are provided in a timely and effective way. We need someone with clout to take responsibility to oversee this service, somebody everyone knows and can turn to when needed. Thirdly, we must place much more emphasis on education and training. This is an area of clinical practice which you cannot just pick up as you go along. You need high-quality training by experts, and it is good to see that tomorrow’s Bill emphasises this. Finally, we have to make sure that CCGs, trusts and those with the money take responsibility for these services being funded, delivered and monitored. Are the tariffs for palliative care adequate? Are these services monitored, and by whom? Many questions are being raised in this debate, and we have to answer them if we are to be judged to be a society that cares for its most vulnerable citizens. I very much look forward to the Minister’s response.

NHS: Reform

Lord Turnberg Excerpts

Thursday 16th July 2015 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I, too, welcome the Statement and many of the things in it. We accept that higher mortality rates at weekends in hospital are unacceptable, so we have to try to think of ways of reducing them. Seven-day working for consultants is just one element. Consultants are important, of course. The Minister is probably aware of Brian Jarman’s publication some years ago which showed that there was an inverse correlation between the number of doctors in a hospital and the mortality rate; that is, a hospital with more doctors had a lower mortality rate. There are lessons to be learned there, especially as we in the UK seem to have fewer doctors per head of population than almost any other OECD country, and fewer beds come to that—so we are starting from a low ebb, and the points made by noble Lords about where we are going to get the extra people from are important.

However, the consultant element is just one part. The noble Baroness, Lady Finlay, made a very good point about the need for radiologists, physiotherapists and pathology laboratories. All the machinery of the hospital has to be there. Equally, there is the whole business of general practice and community care. Primary care at the weekend is poor, by and large; that is one of the major problems. Patients are not getting into hospital until they are in greater extremis, so they are more ill when they get there: then they require more service, and once they are there, they cannot get home because there is no one to see them home. Concentrating on consultants is just one element. What is the Minister’s response?

[Lord Prior of Brampton]

The noble Lord, Lord Turnberg, knows the situation on the ground as well as anybody in this House and, of course, he and the noble Baroness, Lady Finlay, are absolutely right that this will not be solved just by having more consultants in acute hospitals. We have to look right the way across social care, primary care, community care, mental health care and acute care. We are talking about a system. In many ways, one of the reasons why we find ourselves in the position we find ourselves in today is that we have not had a system for some time. We have deliberately broken up the system for good reason.

I was very much in favour of foundation trusts having their own balance sheet and their own profit and loss account because of increased accountability, but disadvantages have flowed from that. Chief executives in acute hospitals look after their own. They have treated themselves as an island. We are not part of an island. Rebuilding the system will take some time. It is not going to happen tomorrow, and there is no silver bullet. All I can say is that the Government are committed to the five-year forward view, the new models of care and joined-up care. We are committed to experimenting with accountable care organisations, integrated care organisations and all kinds of joined-up models. We are seeing exciting developments in Manchester and possibly, in time to come, in Cornwall and other parts of the country where we will have pooled budgets between social care and healthcare. I am confident that over the next five years we will if not solve these problems, at least go a long way to doing so.

Local Authorities: Public Health Budget

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Wednesday 15th July 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Lord makes a good point that goes considerably broader than the Question. I accept that many of these things are inextricably linked.

[Lord Turnberg (Lab)]

My Lords, does the noble Lord accept the report from NICE, which showed that investment in public health improves not only the health of individuals but the economy? Can I tempt him to agree that cutting funding by as much as—I think—7.5% is counterproductive in trying to improve the nation’s health?

[Lord Prior of Brampton]

The noble Lord may be interested to know that the McKinsey institute assessed that the cost of obesity to the British economy was some £46 billion. I am under no illusion about the importance of proper prevention.

National Health Service: Sustainability

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Thursday 9th July 2015 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I, too, congratulate the noble Lord, Lord Patel, on introducing this important debate in such a powerful and impressive way. I, too, resonate very much with the idea of a royal commission. Indeed, I suggested it some time ago in a previous debate.

When the noble Earl, Lord Howe, was Health Minister he must have got used to me banging on about the parlous state of NHS finances, so I see no reason why I should not continue that theme with his esteemed successor, the noble Lord, Lord Prior. But I say at the outset that I do not go along with the “black hole” or the “bottomless pit” theory that we will never be able to fund the NHS adequately. The bottomless pit argument is faulty because, while we may not be able to afford everything that everyone wants, we can and should afford what they need. That is, we can afford a service that is widely regarded as satisfactory and which can meet all reasonable expectations at a reasonable level. Indeed, many countries manage to do this very well.

However, it is clear to virtually all observers that we are not in that position now. We are falling behind. I look back to the halcyon days of the previous Labour Government, when, by 2010, we were putting in almost 9% of GDP, we had got rid of the waiting lists, accident and emergency waits were down, GPs could be seen on the same day and patient satisfaction was high. Now we have problems in all those areas. We have cut the share of the national cake from more than 9% to around 7%. I understand the need for austerity measures, but may I ask the Minister: what is the justification for reducing the proportion of GDP spent on health? Bringing the share of GDP up to a reasonable level is something a country with as high a GDP as ours, and more billionaires per square inch, can afford. All the problems due to these stringencies have, of course, been spelt out in reports from the King’s Fund, the Nuffield Trust and the health service managers who are heading for huge deficits this year. I fear that these are just the conditions in which research and innovation are squeezed out. As the scientific adviser of the Association of Medical Research Charities, I find that particularly disheartening.

Of course, I recognise that there are more efficiency gains to be made. I want to provide one or two examples where the system under which the NHS labours is causing a terrible waste of money, and where efficiency has gone out of the window. I have a friend who is a distinguished gastroenterologist and who is desperately trying to do his best for his patients and at the same time save money for the NHS. Here, I must express my interest as a one-time gastroenterologist way back in the dark ages. My friend was trying hard to fulfil one of the major requirements of NHS England—to move much more care out into the community and reduce the cost of hospital care—so he started running out-patient consultations by telephone instead of bringing the patients up to the hospital. That saved them much time and effort, and they loved it. He also knew that the tariff paid by the CCG for each out-patient consultation was around £150, while a telephone or face-time consultation cost £29. That is a considerable saving to the NHS and a win-win situation. However, noble Lords might imagine how that was perceived in his trust. He was called in to meet a middle manager, who told him in no uncertain terms that he must stop this because the trust could not afford to lose the funding that his activities were causing, so he stopped for a while but has reintroduced the practice surreptitiously and is waiting for the trust to call.

My friend also wanted to set up a one-stop clinic for patients needing endoscopies, seeing them in the morning, treating them the same day and giving them their results later the same day. This saved patients waiting 12 weeks for an endoscopy and three more weeks for the results—just what the NHS should be about: efficient, convenient service. But again, the incentives for the trust got in the way. Trusts lose money when patients attend only once instead of three times.

I doubt whether this is a unique phenomenon, and it is a clear result of the disincentives we have set up in the internal market. So long as providers are desperate for funds from purchasers, we will run into this type of problem. So my question for the Minister is: is the internal market broken and counterproductive, and, especially when we are under such financial constraints, would not an integrated budgetary system be more suited to our needs? How do the Government envisage achieving their objectives of integrating community and hospital care, hitting savings targets and improving the care of patients while we have this dysfunctional internal market? The question is not whether we can afford a health service free at the point of delivery but whether we can afford one that is hidebound by disincentives in the way I have described. I look forward to his response.

NHS: Innovation

Lord Turnberg Excerpts

Thursday 11th June 2015 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I am very grateful to my noble friend Lord Wills for introducing this debate in his usual eloquent and powerful way and for emphasising the importance of giant cell arteritis, which is such a devastating condition, but potentially treatable if it is diagnosed early enough. It is a particular pleasure to know that the noble Lord, Lord Prior, is at the Dispatch Box for the first time and giving his maiden speech. I know that he is extremely knowledgeable about the NHS, so I am sure he will have no trouble at all in answering all our questions.

The topic of innovation is very close to my heart. How could it not be, as someone who spent his life—rather a long time ago—as an academic physician and constantly tried to innovate in my practice, and who is now scientific adviser to the Association of Medical Research Charities, which produced that very far-sighted document a couple of years ago, Our Vision for Research in the NHS? In that vision, we wanted to see, first, every patient being offered the opportunity to be involved in research, for example in clinical trials. It is clear that most patients want to be involved. Perhaps they know that there is good evidence that patients who are in trials do better than those who are not. Secondly, we wanted research to be embedded in the NHS and every healthcare worker—doctors, nurses and others—to know that they can contribute to research. They should be motivated to engage in understanding the benefits of research for their patients. Thirdly, we wanted the NHS itself—the CCGs and trusts—to ensure that there is a research culture in its organisations.

How far have we come since then? Of course, some things have got better, but I fear that others have become worse. On the positive side, we have a very strong basic science sector. We are very good in the UK at innovation. We punch way above our weight in our research outputs internationally—citation indices, Nobel prizes and the like. We are being overtaken by China and Singapore, and India is coming up fast on the outside, but we are still pretty good.

Also on the positive side is the investment that the Department of Health is putting in through NIHR, under Sally Davies’s direction. The academic health science networks and centres are doing very important work in encouraging clinical research around the country—long may that continue. My first question for the Minister is about what plans the Government have for the longer-term funding of AHSNs. The last Government were rather cagey about that. Then, again on the positive side, we have the Health Research Authority, under Jonathan Montgomery’s chairmanship, which is doing good things in easing the regulatory burden on clinical researchers. There is more rapid approval through ethics committees and through local trust research committees.

However, of particular importance and value has been the rapid licensing of new drugs by the European Medicines Agency and the MHRA. That will prove invaluable in getting drugs through regulation and into practice. Yet too many hurdles still interfere with the uptake of innovations in clinical practice, and there are too many delays before patients begin to gain the benefits of innovation. Some of these were brought out in the Lords Select Committee report on regenerative medicine. I had the privilege of sitting on that committee a year or so ago. The report suggested that, first, funding for research was problematic. We found that although many original discoveries were made in the UK, lack of research funding and in particular venture capital investment prevented us from keeping ahead of the game. Researchers in other countries capitalised on our inventions—a very familiar story. We now hear that funding for universities might be cut back in the Chancellor’s proposed new austerity measures. What assessment have the Government made of the cuts to universities on research outputs, particularly medical research outputs?

Then there is the problem of how we can encourage doctors to engage in research at a time when clinical pressures on them increase all the time. That is certainly true of hospital doctors but even truer of GPs. Here, there is much greater resistance to engage in or contribute to research activities—clinical trials and the like. When I speak to GPs it is very clear why: they are simply rushed off their feet and overwhelmed by their clinical and administrative load. They just do not have the time. Are the Government doing anything to ease that burden? How can they even contemplate seven-day working and at the same time think about research?

The workload of GPs has another effect too. It impinges on their willingness to take up novel treatments as they come along. I am afraid that a natural antipathy to accepting something new is made worse when they do not have the time to even look at the evidence. If we are to achieve our ambitions for research in the NHS we need GPs to be much more involved. Do the Government have any ideas about getting round this serious difficulty?

Then there is the problem of access by researchers to data about patients. Clinical and other data are vital to the research endeavour and, indeed, for good clinical care. However, the care.data fiasco last year put that back far too far. What is being done now to untangle that mess? When will the planned pilot studies take place? What care is being taken to reassure the public and patients that their confidentiality will be protected, while at the same time explaining how vitally important it is that their data are made accessible to legitimate researchers?

Finally, we have the knotty problem of approval for funding of new treatments, particularly those for patients with cancers and rare diseases. These are often very expensive and must go through specialised NICE or NHS England assessment processes. There is the rub, because these are extremely slow and tortuous. Even though drugs may get a licence quickly through the new systems offered by the EMA and MHRA, they must then jump through the hoop of NICE for funding in the NHS. However, NICE can deal with only three of these requests a year and usually takes well over a year to approve any one of them. It is even worse for those drugs that it cannot take on. It can deal with only three; any more it must pass on to be examined by NHS England. Here, they must be considered by no less than seven serial committees—that is, seven committees in series. If you wanted to invent a system to avoid making a decision, then this is it. What can be done in NICE and in particular in NHS England to reduce this bureaucratic nightmare, set up to approve funding of these new treatments? Is there anything that can be done to rationalise the number of committees employed in NHS England that are needed to do this work?

It has been repeatedly stated by Ministers, including the Chancellor and the Prime Minister, that the Government give high priority to research and, in particular, to medical research. Indeed, the Health and Social Care Act made it mandatory for CCGs and trusts to include clinical research in their strategies, but it is equally clear that these ideals are being frustrated. There are other reasons, but funding for the service is going to be important—funding for GPs; funding for expensive drugs; and funding simply for the service—which makes it even harder for it to engage in the research agenda. But it is not just a question of funding, as I have said, and I look forward with interest to the response from the noble Lord, Lord Prior, and wish him well in facing the difficult times ahead.