E-cigarettes

Norman Lamb Excerpts

Thursday 31st October 2019 Westminster Hall

[Norman Lamb (North Norfolk) (LD)]

I beg to move,

That this House has considered the Seventh Report of the Science and Technology Committee, Session 2017-19, E-cigarettes, HC 505, and the Government Response, Cm 9738.

It is a pleasure to serve under your chairmanship for the very first time, Sir Henry, in my last appearance in this Chamber, and it has been a pleasure to have you as my constituency next-door neighbour for the last 18 years. I am pleased to have secured a debate on this important work undertaken by my Committee before this Parliament draws to a close. It is great that we have been able to hold the debate in the month of Stoptober, the big anti-smoking initiative, which I think has been successful, and which I remember launching in my time as a Minister, back in the day.

Statistics released by the Office for National Statistics show that in 2018 in England, 14.4% of adults smoked. That represents a significant advance in reducing the prevalence of smoking in our country; ONS figures show that smoking rates in England have fallen every year since 2011. It is important to say that there is one exception to that advance, and it relates to mental ill health—something I care a lot about. People with severe and enduring mental ill health tend to die much younger than others, by as many as 20 years, one key reason being the prevalence of smoking among that group, around 40% of whom smoke. Although we have been very successful in reducing smoking rates in the population as a whole, we have not been successful in doing so for those with mental ill health. I will return to that.

In Great Britain in 2018, there were approximately 3.2 million vapers—6.3% of the population—which marks a significant increase since 2014, when the figure was 3.7%. Why does that matter? The tobacco control plan stated:

“Tobacco is the deadliest commercially available product in England”—

it is important to hold on to those words from the Government—

“with tobacco regulations serving to safeguard people, particularly children and young people from the avoidable disease and premature death it causes.”

The recent prevention Green Paper clearly articulated that some people are disproportionately likely to smoke, which we should all be deeply uncomfortable with:

“Smokers are disproportionately located in areas of high deprivation. In Blackpool, 1 in 4 pregnant women smoke. In Westminster, it’s 1 in 50.”

What an extraordinary contrast! Deprivation causes that significant risk to the health of mothers and babies.

According to Public Health England, vaping is at least 95% less harmful than smoking. That does not mean that vaping is safe, and it certainly does not mean that we should encourage non-smokers to start vaping, but based on all the evidence we have, vaping is considerably less harmful than smoking.

[Graham Stringer (Blackley and Broughton) (Lab)]

I put on record my thanks to the right hon. Gentleman for his time chairing the Select Committee on Science and Technology. It has been an interesting period, in which we have gone into great detail—effectively, I think—on many subjects. I was annoyed that NHS England, which has the time to put out often crass and obvious statements on health, did not have the time to come and give us advice on e-cigarettes, the use of which, as he says, is one way get people to stop smoking.

[Norman Lamb]

I thank the hon. Gentleman for that. I will call him my hon. Friend, because I am demob-happy and I do not care about the normal rules. It has been a great pleasure to work with him on the Committee. I share his concern. Given that the Government’s own tobacco control plan describes tobacco as

“the deadliest commercially available product in England”,

one would have hoped that the body that runs the NHS in England would show a strong commitment to confronting that clear risk. Despite it being very clear from all the available evidence that vaping is significantly less harmful than smoking, I none the less absolutely encourage continued research in this area. We should always be alert to anything that indicates a potential risk; that is exactly what our Committee recommends.

E-cigarettes are not only less harmful than smoking, but appear to be an effective tool for stopping smoking, as the hon. Gentleman made clear. A study published earlier this year in the New England Journal of Medicine randomly assigned adults attending UK NHS stop smoking services either nicotine replacement products of their choice, including product combinations, for up to three months, or an e-cigarette starter pack. That study of 886 participants found that the one-year abstinence rate was 18% in the e-cigarette group, compared with 9.9% in the nicotine replacement group. That is a significant difference, and we need to make sure that we act on that difference now that we have knowledge of the effectiveness of e-cigarettes as a stop smoking tool.

Results from a 2019 survey carried out by YouGov for Action on Smoking and Health—ASH—found that

“the three main reasons for vaping remain as an aid to quitting (22%)…preventing relapse (16%) and to save money (14%)”,

because people who vape spend much less money than people who smoke. That demonstrates that users perceive e-cigarettes as a stop smoking tool. E-cigarettes are therefore likely to help the Government to meet their ambition, announced in the prevention Green Paper, for England to be smoke-free by 2030. None the less, I accept that further research is needed on the effectiveness of e-cigarettes as a stop smoking tool. Will the Government or one of their agencies request further independent research on the effectiveness of e-cigarettes as a stop smoking tool?

Our report highlights the issue of what the NHS does on smoking cessation. Cancer Research UK recently pointed out that primary care clinicians face barriers to discussing e-cigarettes with patients who smoke; one in three clinicians is unsure whether e-cigarettes are safe enough to recommend. Given the death toll from smoking, it is extraordinary that it appears that clinicians are unaware of the clear advice from Public Health England in that regard.

[Gareth Johnson (Dartford) (Con)]

I agree with everything that the right hon. Gentleman has said. Does he agree that the Government could reach their ambitious target, which he alluded to, by embracing vaping, getting more information out there to those clinicians and working through the law, particularly post Brexit, to ensure that people who want to give up smoking have all the information they require in order to take up vaping instead?

[Norman Lamb]

I totally agree. The statistics that I am citing make the point about raising awareness, even among clinicians. We thought that it was just the general public who needed to understand better the relative risks, but clearly clinicians also need to understand the relative risks so that they can advise their patients more effectively.

Two in five clinicians feel uncomfortable recommending e-cigarettes to their patients who smoke. Again, that is an extraordinary finding. Fewer than three in 10 agree that their current knowledge is enough for advising patients about e-cigarettes. That extraordinary data reveals a clear need for the awareness raising to which the hon. Member for Dartford (Gareth Johnson) has just referred.

What assessment has the Minister made of the number of smoking cessation services in the NHS that are actively promoting e-cigarettes as alternatives to conventional cigarettes? It ought to be every single one throughout the country, but are they actually doing it? Do we know? Can the Minister tell us what work the Government are doing with NHS England on increasing knowledge among clinicians of the uses, benefits and risks of e-cigarettes for current smokers?

Our report recommended that NHS England should create a post for someone who is responsible for implementing the Government’s tobacco control plan. The response said:

“The Government broadly accepts this recommendation.”

However, no specific steps to implement our recommendation were set out. We pursued that with NHS England, which in January told me:

“It is our intention to appoint an individual with lead responsibility for this role. This will be an important part of our delivery programme for the NHS Long Term Plan.”

We would all assume that that person was appointed long ago and that active work is now underway to pursue this vital agenda, which will save lives, but can the Minister confirm that NHS England has created that post and, if so, is someone actually in post and doing the job?

The Government say that, in their long-term plan, provision is made for

“all smokers who are admitted to hospital being offered support to stop smoking”.

That is not due to be fully implemented until 2023-24. Again, given the extraordinary health benefits of stopping people smoking, I would have hoped for a tighter timescale than ’23-24 to implement that. Will the Minister tell us how implementation of that proposal is going and whether consideration is being given to implementing it fully before 2023-24?

Our report recommended that the NHS should have a clear policy on e-cigarettes in mental health facilities that establishes a default of allowing e-cigarette use by patients. This comes back to my point that approximately 40% of those with severe and enduring mental ill health still smoke. The attitude and culture within mental health trusts is critical if we are to enable and help people with severe and enduring mental ill health to give up smoking. We said that it should be the default that e-cigarettes should be made available in mental health facilities unless there are clear evidence-based reasons for not doing so.

The Government response said:

“NHS England will provide guidance to mental health trusts that sets out that existing vapers should be permitted to use e-cigarettes as part of smoking cessation programmes, and…tobacco smokers should be supported to stop smoking through smoking cessation programmes”.

Can the Minister tell us whether that guidance has been issued? I very much hope that it has. If not, when will it be issued and what is the reason for the delay in issuing such important guidance? If it has been issued, what assessment has been made of how it is working?

The UK is making good progress in getting people to stop smoking and use e-cigarettes to achieve that, but that is at risk from recent concerns about e-cigarette use. Those concerns have been expressed particularly in other countries. We have put the concerns to Public Health England. The first is the claim that deaths in the US have been linked to the use of e-cigarettes and vaping products. The reality is that the US operates in a totally different regulatory context and “illicit products” were

“implicated in this outbreak…including vaping cannabis derivatives.”

That is from Public Health England. It has also explained that

“the suddenness of the outbreak across many USA states in just a few months, suggests that this is not a gradual effect of long-term use, but because of a specific agent coming into use in the affected population.”

Next are the concerns that flavoured e-cigarettes are “luring” children into vaping. Public Health England’s response explained that the data it had seen so far was reassuring that e-cigarettes were not re-normalising smoking. Furthermore, the UK and the US have different rules on advertising, nicotine concentration and education on vaping, which explains why flavours of e-cigarettes are less impactful in the UK compared with the United States.

The next issue is the introduction of a ban in India on the production, import and sale of e-cigarettes because of concerns about the risks that they pose to health and to the young. Again, an assertion has been made that is at risk of infecting the debate that we have in this country. However, Public Health England has explained:

“India is one of several countries that appears to be responding to the outbreak of lung disease among cannabis”

vapers

“by proposing a ban on nicotine inhalers.”

It has also explained that smoking is far more prevalent in India and causes 7 million deaths a year there.

[Sir Kevin Barron (Rother Valley) (Lab)]

Is it not true that India has a massive vested public interest in the tobacco industry?

[Norman Lamb]

I suspect that the right hon. Gentleman knows better than I do, but I note the point that he makes. My view, based on the evidence that the Committee heard, is that the action taken by India is not based on evidence and is likely to result in more people dying of lung cancer. I think that is shameful.

I encourage all right hon. and hon. Members to read the helpful and comprehensive reply that we received from Public Health England on these issues and others, and which we have published so that anyone can delve into the detail. I am reassured that Public Health England is in “close dialogue” with a range of international partners, and I agree with Public Health England when it says:

“It is no exaggeration to say that inflating fears about e-cigarettes could cost lives.”

Incidentally, I have concerns about the attitude at the World Health Organisation, which does not take the same evidence-based approach, as far as I can see, as this country has done. Again, that has implications through the potential loss of life for millions of people across the globe.

It seems to me that people often conflate the fact that we do not have all the long-term evidence on vaping impact with an assertion that that should lead us to conclude that we should not be recommending vaping as an alternative to smoking. Frankly, that is stupid as a public policy approach, because we know that smoking is killing—I think—more than 70,000 people in England every year, and all the evidence so far shows that nothing like that is happening from vaping. According to Public Health England, it is 95% less dangerous than smoking. Therefore, the clear public health advice has to be that vaping is an appropriate way to help people give up smoking. Of course, the best thing of all is not to vape and not to smoke, but if that is not possible for someone, the clear public health advice needs to be that vaping is better than smoking.

Will the Minister set out what contact the Government —she or other Ministers—have had with other countries on international approaches to e-cigarettes? In particular, what are they doing at the World Health Organisation to encourage a more enlightened approach? What assessment have the Government made of the effects of those international approaches on public perception of e-cigarettes in the UK? What steps will the Minister take to ensure that this misinformation on e-cigarettes is challenged?

[Graham Stringer]

It is not only the World Health Organisation that is not using evidence for its advice, but the EU. The EU’s directive on the size of the bowls used and the amount of substance put in is not based on evidence. It is likely to mean that those people getting a nicotine kick—much less dangerous than cigarettes—will not find the products satisfactory and will go back to smoking.

[Norman Lamb]

I share the hon. Gentleman’s concern about the directive and the proscriptive rules relating to vaping, which do not appear to be sufficiently evidence-based.

E-cigarettes are positive in helping current smokers to stop smoking, and they are significantly less harmful than smoking conventional cigarettes. Yes, there are unknowns about long-term risks, and we need to maintain research on e-cigarettes, but doing nothing is not an option when people’s wellbeing and lives are at risk. I look forward to the contributions of other right hon. and hon. Members, and to the Minister’s reply.

[Bill Grant (Ayr, Carrick and Cumnock) (Con)]

It is a pleasure to serve under your chairmanship, Sir Henry. I congratulate my friend, the right hon. Member for North Norfolk (Norman Lamb), on securing this important debate.

E-cigarette use in the UK has followed a gently rising trend over the past few years, and last year, statistics from the Office for National Statistics showed that 6.3% of those over 16 were regular users—a rise of less than 1% over five years. In our August 2018 report, the Science and Technology Committee concluded that e-cigarettes should not be viewed in the same way as conventional cigarettes. They are an effective stop smoking aid and should be formally considered as such.

In its response to the letter sent on behalf of the Committee by the Chair, Public Health England confirmed that it believed, as the Committee did, that e-cigarettes are around 95% less harmful than conventional smoking. As our Committee found:

“A medically licensed e-cigarette could assist smoking cessation efforts by making it easier for medical professionals to discuss and recommend them as a stop smoking treatment with patients.”

Existing smokers should be encouraged to give up, but if that is not possible, they should switch to e-cigarettes as a considerably less harmful alternative.

We must acknowledge that there are uncertainties about the longer-term health effects of e-cigarettes. They have not been in circulation long enough for any scientific research to be certain. Concerns have been raised in the United States, as was mentioned, about an isolated outbreak of serious lung injury linked to illicit vaping products, but I suspect, as the right hon. Gentleman said, that there may have been other factors at play in that instance. In any event, we have not seen that replicated in the UK, largely because, as ASH confirms, we have a strong regulatory system in place, which is not yet the case in the US.

The Government mandate strict conditions, namely a minimum age of sale, a ban on advertising in broadcast media, print or the internet, and a stipulation that products containing over 20 milligrams per millilitre of nicotine need a medicinal licence. Products must also be child-resistant and tamper-evident, and packs must carry a health warning covering over 30% of the surface area.

Moreover, to be balanced, any judgement on the future of e-cigarettes must take account of human nature and the most likely alternative to vaping, namely returning to harmful conventional cigarettes, which have proven to be a serious health risk over time. While some groups would prefer the firmest possible line—Cancer Research UK, for instance, is pressing for a tobacco-free UK within the decade—most groups agree that e-cigarettes can provide a useful route towards quitting harmful conventional cigarettes.

We have seen clear evidence that e-cigarettes are an effective quitting aid for adult smokers and, crucially, the percentage of young smokers trying e-cigarettes in Britain is small, with continued use smaller still. They flirt with the e-cigarette, but do not continue with it. There is little evidence to suggest that such products act as a gateway to conventional smoking—they are not, as some would suggest, a stepping-stone to conventional smoking—and figures show that almost 3 million people in the UK today are using e-cigarettes as an aid to quitting harmful conventional cigarettes.

Unfortunately, the Committee found that some aspects of the regulatory system for e-cigarettes are holding back their use as a stop smoking measure. Restrictions on the strength of refills and maximum tank size have led some users to move away from e-cigarettes and return, sadly and regrettably, to conventional smoking. There seems to be little scientific basis for these limits, and I am pleased that the Government, in response to our report, intend to consider these anomalies and how to address them. It is good to see that the Government also agree with our conclusion:

“There should be a shift to a more risk-proportionate regulatory environment; where regulations, advertising rules and tax duties reflect the evidence of the relative harms of the various e-cigarette and tobacco products available.”

Such a move might well bring about the welcome improvements in health that we, as a society, desperately seek, particularly from lung cancers and other by-products and unintended consequences of smoking. It is proven beyond doubt that conventional smoking is harmful. I look forward to seeing those changes implemented.

I take this opportunity to speak directly to conventional smokers. Despite being a fire officer for 31 years, sadly I was a 50-a-day smoker for many years, although I have long since stopped. Believe me: being a smoker was a costly, smelly and unhealthy mistake in my life. I only realised that afterwards. Yes, I enjoyed my cigarettes then, as the smoker today does. Even in my time in the fire service, when I left a fire with my breathing apparatus on and pulled the face mask off, some kindly colleague would have a pre-lit cigarette for me. It was certainly madness at the time, and I indulged in it. It is not easy to stop, but anything that is good is not always easy. Believe me, it can be done. My plea to those who do smoke is: you can stop if you put your mind to it, and it is absolutely worthwhile.

[Norman Lamb]

The hon. Gentleman kept that information very quiet on the Select Committee.

[Bill Grant]

It is something to be neither proud nor ashamed of. It was part of the culture of the time. I was part of that culture. There are two things in life that I have never regretted: marrying my wife, Agnes, and giving up smoking. They are equally wonderful.

I have had the pleasure to serve on the Science and Technology Committee since shortly after I was elected to this House, and it has been a fascinating and often inspiring journey. I am incredibly proud of the work we have undertaken as a Committee, ably assisted by a very fine secretariat, and I wish to put on record my thanks to them for their support. Indeed, as my friend the right hon. Member for North Norfolk and I both intend to retire at the forthcoming election, this will be our last debate together, and I wish to thank him for his fine stewardship over the two years.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Jo Churchill)]

It is a pleasure to serve under your chairmanship, Sir Henry. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing the debate, and I thank the whole Committee for the report, for its tone, and for the intelligent way in which it has approached the difficult subject of trying to stop behaviour that is detrimental to individuals.

We want smoking to reduce to zero, and for us to be smoke-free by 2030. It is an ambitious programme, but it will benefit many more people than just the individuals who smoke themselves, as it affects those around them. I thank the right hon. Gentleman, whom I have always highly respected, for his important work leading the Science and Technology Committee, and for his broader work on the health agenda. Although today’s debate might be his last in this place, I hope that it will not be the last time I hear him waxing lyrical on the airwaves about this subject. I say the same for the right hon. Member for Rother Valley (Sir Kevin Barron), who has really been quite formative in this area, both on the Health Committee and in his work with the all-party parliamentary group on smoking and health.

It is timely that we are having this discussion at the very end of this year’s Stoptober campaign; I pay tribute again to the right hon. Member for North Norfolk for his work in starting it. There is never a better time to stop smoking, and I encourage everybody who is thinking about doing so to visit their local stop smoking service, or to go online, and consider all the options available to help them to quit.

I am really proud of the tobacco control work over the past two decades and the progress that has been made, for which we have been recognised internationally. According to the Association of European Cancer Leagues’ tobacco control scale, the UK has been rated consistently as having the most comprehensive tobacco control programme in Europe. As we have heard from the numbers discussed, it is working—but we are not there yet.

Smoking remains one of the leading causes of preventable illness and premature death, with more than 78,000 deaths a year. That is not only a waste but a personal tragedy for all families affected. We are determined to do more, as set out in our tobacco control plan, the NHS long-term plan and the prevention Green Paper, which only concluded on 14 October. I am looking forward to seeing the results of that consultation.

Our ambition is to be smoke-free by 2030. We know that we need to work harder in certain groups, including pregnant women and those with mental health issues. Like the right hon. Gentleman, I was struck by the extremely high prevalence of smoking in some areas. He mentioned Blackpool but, as he knows from representing a coastal region, in many coastal areas there is a very high prevalence of pregnant women who smoke. They interact with many healthcare professionals during what should be the enjoyable, exciting time when they are expecting a baby. We should use every single one of those interactions to help them to quit.

I have already asked officials whether there are other forms in which we can message that particular group in a way that helps them to understand the risk, as well as the things that are available to help them. I listened to the right hon. Gentleman’s point about people with enduring mental health issues. Facilities should allow e-cigarettes and provide more support. That is an ongoing part of the agenda. I will write to Simon Stevens to see where we are, and I will let the Committee know.

[Norman Lamb]

I thank the Minister for her very kind comments. I am pleased that she will write to Simon Stevens, because pressure from Government Ministers on NHS England to recognise the significance of the subject is really important. I am conscious that I asked a lot of questions in my contribution, and she may well be unable to answer them all, but will she write to me before Parliament rises next week, if possible, to answer those questions that she is able to, so that we get that on the record?

[Jo Churchill]

I will do my very best. If there is anything I have not covered, I hope that the answer will be winging its way to the right hon. Gentleman on Monday.

The Government are absolutely clear that quitting smoking and nicotine use entirely is the best way for people to improve their health. We recognise that e-cigarettes are not risk-free, as has been stated by all Members who have contributed; however, they can play an exceedingly important role in helping smokers to quit for good, particularly when combined with stop smoking services. It is an addiction, and we are trying to achieve a step change in people’s practices and behaviours that enables them to quit entirely. We do not know the long-term harms of e-cigarette use, and no authorities in the UK assert that they are harmless. Based on current evidence, Public Health England and the Royal College of Physicians estimate that e-cigarettes are considerably less harmful than smoking because of the reduction in levels of exposure to toxicants in e-cigarette aerosols compared with tobacco smoke. However, I reiterate that quitting smoking is the best option.

It is fair to say that opinions on e-cigarettes are divided, both in the UK and globally. It is important that we listen to concerns, while looking objectively at the evidence base and seeking to build it further, which I think is the point that the right hon. Member for North Norfolk was making. On the question of research, I assure him that there is an NHS England dedicated lead—a director for prevention—in place, overseeing the NHS long-term plan commitments. I note the right hon. Gentleman’s comments about India and the fact that making decisions too quickly, not based on the research that is available, has unintended consequences.

As the House is aware, we have introduced measures in the UK to regulate e-cigarettes: to reduce the risk of harm to children; to protect against e-cigarettes acting as a gateway to starting smoking—another important point that has been made today—to provide assurance on relative safety, and to give businesses legal certainty. Regarding what has happened in the United States of America, we take those concerns seriously—we are aware of the tragic deaths associated with vaping in the United States and are monitoring the situation carefully. Public Health England and the Medicines and Healthcare Products Regulatory Agency are in close contact with the US agencies. Investigations are ongoing; they have not yet been able to confirm the definite cause of the deaths, although it appears that the majority of those who died had used illicit cannabidiol with THC products, which led to those unfortunate deaths.

To date, there have been no known deaths from e-cigarette use in the UK. The MHRA yellow card reporting system is in place to report any adverse effects. It has been running for three years and, to date, has been notified of about 85 individual cases; all have been minor, and none has been considered life-threatening. However, I assure the right hon. Member for North Norfolk and all other Members who have contributed to this debate that we remain vigilant on the issue and are grateful for all research done in this area, including—my hon. Friend the Member for Dartford (Gareth Johnson) alluded to this—by those within the charity sector who do a great deal of work in looking at the harms caused.

In our tobacco control plan, we made strong commitments to monitor the impact of regulation and policy on e-cigarettes and novel tobacco products. To inform future policy, we are looking closely at the evidence on safety, uptake, health impact and the effectiveness of these products as smoking cessation aids. Public Health England will continue to update its evidence base on e-cigarettes and other novel nicotine delivery systems.

The use of e-cigarettes by young people was mentioned by the right hon. Member for Rother Valley and by my hon. Friend the Member for Dartford. Such use currently remains low, at 2%, and we have not seen the rise that has occurred in the United States. However, we will monitor the data closely to ensure that regular use does not increase and it is not seen as a gateway to tobacco use, and will also keep a close eye on any new evidence about long-term harms caused by flavourings. If the evidence shows that we need to address either or both of these issues, we will consider taking action, including further regulatory action where necessary. I would like the industry to show stronger leadership in the areas of e-cigarette product labelling and, in particular, design to ensure that its products do not appeal to young people. Some of the current naming appears to lean in that direction.

In future, we will have the opportunity to reappraise current tobacco and e-cigarette regulation to ensure that it continues to protect the nation’s health. I thank all Members who have spoken today, particularly the right hon. Member for North Norfolk, who will be leaving this House. Today has been a bit of a goodbye party for him, for my hon. Friend the Member for Ayr, Carrick and Cumnock (Bill Grant)—I am staggered by the revelation that he smoked 50 a day; I wonder that he had time to do much else, let alone run around being a fireman—and for the right hon. Member for Rother Valley. I am sure that all of them will continue to work in this area.

I reiterate the Government’s commitment to help people quit smoking, which is ultimately the best course of action, and to seek evidence on reduced-risk products. We will continue to be driven by that evidence. Although we can celebrate the fact that adult smoking in England has fallen by a quarter and regular smoking among children has fallen by a half, I will truly be able to celebrate—like all right hon. and hon. Members present, I am sure—if we reach the goal, which both the report and the Government are aiming for, of being smoke-free by 2030.

[Norman Lamb]

I thank the Minister for her response to the debate and for her kind comments. There has been a remarkable consensus about the action we are taking in this country, and the need for it to be evidence-based. It is clear that the United Kingdom is ahead of the game internationally on smoking cessation work, and that is something we should celebrate. However, we should never allow ourselves to feel that we have done the job. We have so much still to do, particularly given the number of people who die every year from smoking, as the right hon. Member for Rother Valley (Sir Kevin Barron) made clear. The carnage—the death toll—is enormous, so the work needs to continue.

We have heard some wonderful admissions. The right hon. Member for Rother Valley and the hon. Member for Ayr, Carrick and Cumnock (Bill Grant) have admitted to smoking heavily in the past; they are both wonderful living examples of life after smoking. [Interruption.] Less coughing, please. They are wonderful examples to others of the potential value of giving up smoking, and I wish both of them a very happy retirement from this place.

I will quickly pick up on one or two points. I agree with the right hon. Member for Rother Valley that inserts in packs are a very good way of targeting an important public health message directly at people who need to hear it, and who need to be reassured that giving up smoking and vaping instead is going to help their health—a point we made in the report. I also agree with him about the case for the tobacco industry making a contribution to the cost of smoking cessation services, on the basic principle that the polluter pays.

My hon. Friend the Member for Brecon and Radnorshire (Jane Dodds), who has had to leave, made some important points about cross-border health issues. I applaud her for championing access to mental health support in Wales, which is incredibly important. The point in this debate is that every mental health facility and, in particular, every in-patient mental health facility, whether in England, Wales or Scotland, should offer the same access and support to enable people to give up smoking, using vaping as the mechanism to do so. Giving up smoking will lead to significant gains in not only people’s life expectancy, but their mental health; smoking harms their mental health as well as killing them earlier.

The hon. Members for Dartford (Gareth Johnson) and for Blackley and Broughton (Graham Stringer) both made the point that regulation must always be evidence-based. That has not been the case with the European Union directive or internationally, given the debate we have had about the World Health Organisation and the approach that is taken in America. In this country we want our regulations to be evidence-based, to give people the best chance of giving up smoking and having a healthier life.

On a personal basis, not in my role as Chair of the Select Committee, I agree with the hon. Member for Washington and Sunderland West (Mrs Hodgson) that investment in public health is important. There is much evidence that investment in early prevention work of all sorts, and in public mental health, provides—in brutal economic terms—a return on investment. It also changes lives. The plea to whomever becomes the Government after 12 December is this: make the investment in public health, because we will all benefit.

I thank you, Sir Henry, for your stewardship of the debate, and I wish all hon. Members well for the next few weeks. I am very relieved that I am not fighting to retain my seat in the middle of winter.

Question put and agreed to.

Resolved,

That this House has considered the Seventh Report of the Science and Technology Committee, Session 2017-19, E-cigarettes, HC 505, and the Government Response, Cm 9738.

The National Health Service

Norman Lamb Excerpts

Wednesday 23rd October 2019 Commons Chamber

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to follow the hon. Member for South West Bedfordshire (Andrew Selous), whose personal leadership on tackling modern slavery is something we very much appreciate in this place. We may well have seen a reminder today of why that is more necessary than ever.

I made my maiden speech in a Queen’s Speech debate. Google tells me it was 848 days ago, which feels very strange. It feels simultaneously like a lifetime ago and yesterday. These have been very strange and tumultuous times. If I had been told then about things that have happened subsequently, I would have been sceptical, but no more sceptical than at the idea that we would still not have a social care Green Paper. We have had five delays and, despite it not being a laughing matter at all, it has become a long-running joke and a focus of derision.

The ever-delayed social care Green Paper is absolutely critical, because we know that up and down the country millions of people, paid and unpaid carers, are getting up in the dark, coming home from work in the dark, working split shifts and double shifts, and working for poor pay on insecure contracts. They are the backbone of not only the social care system, but the NHS and all public services. If only 10% of our social carers, whether paid or unpaid, walked away tomorrow, all our public services would come to a grinding halt. We need to do much, much better by them. I hope the Government, in showing movement on this issue, intend to bring forward their plans quickly.

In its latest annual assessment, the CQC highlighted concerns about cultural and geographic barriers to access to care, deficient regional staffing, a lack of stability in the adult social care market, and the Government’s failure to implement a sustainable long-term plan to fund social care. It said that that directly impacts nearly 1.4 million older people and millions of people with disabilities or illness who do not have access to the care and support they need. It is time for us to act.

The Government need to be brave and honest. If they are worried about the reaction of current service users to their proposals, I would remind them that the current service users have lived experience of the fact that the current system does not work, so they have no need to be afraid of them when it comes to change. When it comes to millennials like me, we are realistic. We know that the system that cares for our grandparents and our parents will not be the same for us. Let us be honest about that. There are profound and difficult decisions that have to be taken—let us get to that point. We do not need to be afraid.

I know that the Minister for Health, the hon. Member for Charnwood (Edward Argar) is a good and honest man, but when it comes to funding for social care—this is a really important point—we always see the Secretary of State or the Prime Minister use phrases such as, “We have given access to an extra £11 billion”. The Government should be honest about where that money comes from, because the bulk of it is from a social care precept on the local ratepayer. There is a political argument—I disagree with it fundamentally—that says, “Well, the Government believe that there should be a transition of the burden for social care from the national taxpayer to the local taxpayer”. I disagree, but if that is the belief on funding the social care system, the Government ought to say so, because that is very important.

Similarly, I know that this is a health debate, but I will not miss the opportunity to say that we must all reflect for a moment on the BBC and the removal of the free TV licence. As part of someone’s care, and as part of someone’s life in their 70s and beyond, we know that television plays an important part. We should be honest about why this has happened because that cut lands at the door of the Government, despite what they might say.

We know that failures in social care have a profound impact not only on the individual, but on the national health service. I have a real passion for integrated care—I cannot quite see the shadow Secretary of State from where I am standing, but when I was his Parliamentary Private Secretary, I used to bore him at great length about the virtues of integrated social care. When I was health and social care lead in Nottingham for three years, it was by far the least popular thing I did and I had campaign groups at my door weekly talking about my enthusiasm for certain models. There were flaws in the models for sustainability and transformation plans, accountable care organisations and accountable care systems—whatever re-branding we are on at that moment —but, fundamentally, integrating the national health service with our local authority social care is a very good thing and, if we did it properly, it would lead to people not having to ring up multiple agencies to sort out their loved one’s care. It would lead to proper, seamless care that, rather than being based around organisations, would be based around individuals. Again, I say to the Minister: Ed, let’s be bold on integrated care. Let’s be brave —[Interruption.] Madam Deputy Speaker wasn’t concentrating, I got away with it. Let’s be bold about this. If you are, you will see the best of politics working and a lot of consensus building.

I want to use the limited time available to me to refer to public health. I am proud of what I said on integrated health and what we did in Nottingham—we did good things. One area from my time in local government that I reflect on without pride is public health. We did good things on trying to be more innovative with the public health grant, but fundamentally, because of the nature of the cuts that have come down the line over the last nine years, we made cuts to public health services. I made cuts to smoking cessation services—a terrible public policy decision—because there simply was not enough money.

[Norman Lamb (North Norfolk) (LD)]

Is the hon. Gentleman aware of the Health and Social Care Committee report today that highlights the fact that there has been a 30% cut in funding for drug treatment services over just the last three years, which is catastrophic for the people involved?

[Alex Norris]

Having had a long four-and-a-bit hour vigil in the Chamber, I have not had chance to see that, but I certainly will. That is the picture up and down the country, including in Nottingham. The key thing is that as well as being absolutely dreadful for the individuals affected, it is terrible for the system not to have those good, often early, interventions on drugs and alcohol. If we let those things spiral, the impact on the individual and the costs related to the system grow exponentially. These are really bad value choices and we could do much better on public health.

I will finish with a point about cannabis on prescription. We have had important conversations on this today, and it is good that both the right hon. Member for Hemel Hempstead (Sir Mike Penning) and my hon. Friend the Member for Gower (Tonia Antoniazzi) are here. Their leadership on this has been absolutely crucial. I heeded what the right hon. Gentleman said about how to describe it, and I changed my speech from saying “medicinal cannabis” to “cannabis on prescription” as a result. I have had a case in my constituency, as many have, with a very, very frustrated parent who could not understand why their child did not fit the criteria.

--- Later in debate ---

[Luciana Berger (Liverpool, Wavertree) (LD)]

It is a pleasure to follow the hon. Member for Hartlepool (Mike Hill) and I share a number of the assessments that he made in his contribution, because as the House pursues our debate on the Queen’s Speech, it is becoming ever more apparent that the casualty of a Tory Brexit will be Britain’s national health service.

The NHS is our greatest national asset; it is the product of the fusion of radical and enlightened minds in the last century that gave us healthcare for all based on need, not means. But now, in this century, the NHS is in great peril from a toxic combination of chronic underfunding and withdrawal from the EU, and responding to very different challenges from those when it was first created so long ago.

Notwithstanding the announcements in the Queen’s Speech, let us be very clear that the NHS is not in receipt of the resources that it needs to be effective. That was discussed only yesterday at the Health and Social Care Committee, when we had with us the Secretary of State and we talked about the backlog of £6 billion in NHS repairs alone, so an announcement of half that really is no cause for celebration. We heard from the Health Foundation, and its assessment of the Queen’s Speech funding announcement says that

“it falls well short of the scale of the challenge.”

We have a Prime Minister who announced 40 new hospitals, which then was downgraded to six within days, and we see demand for healthcare from our growing and ageing population outstripping the availability and quality of services, which means rationing and a diminution of quality of care; many right hon. and hon. Members from both sides of the House have referred to that in the debate this afternoon.

[Norman Lamb]

Does my hon. Friend agree that another sign of a system under unacceptable strain is the fact that teenagers around the country are often waiting a year or more for access to mental health treatment? I know of two teenagers who have recently had their first appointment after a year of waiting, which seems to me to be utterly intolerable.

[Luciana Berger]

I thank my right hon. Friend for making that really important contribution, and waiting times are a particular issue in our NHS, especially in the Cinderella of all Cinderella services, our CAMHS. Too many young people right across our country are struggling to get a referral and then, if they do get that referral, having to wait months on end. Frankly, it is unacceptable.

NHS Long-Term Plan: Implementation

Norman Lamb Excerpts

Monday 1st July 2019 Commons Chamber

[Matt Hancock]

I wholeheartedly agree with the entirety of what my hon. Friend said. It is true that for the majority of its 71-year history—71 this week—the NHS has been run by Conservative Secretaries of State, and the largest cash injections have come from this party. It is a truly national institution that we should all support, and we have to support not only the doctors, who lead many parts of the NHS, and the nurses, but all the health service staff, because it is a true team effort.

[Norman Lamb (North Norfolk) (LD)]

The Secretary of State may remember that I brought a group of mental health reformers to see him, to make the case for culture change in mental health services to address clear human rights abuses such as locking people up when they do not need to be locked up, often for a long period, shunting people around the country in ways that would never happen with physical health and the endemic use of force in mental health services. We argued that ending inappropriate institutional care would free up money for better prevention and early intervention. He said he loved that approach. Is he doing anything to actually implement it?

[Matt Hancock]

Yes. First, in terms of the review led by Simon Wessely of the legal powers set by the Mental Health Act 1983, there will be a Government response and then legislation in due course. We want to get that legislation right and bring it forward on an open basis, to ensure that we get a consensus behind it before introducing it formally to the House. On the administrative side, a programme of work is under way to deliver exactly what the right hon. Gentleman mentioned. In my statement, I specifically referenced the expansion in community mental health services that must happen, which will be good value for money and, of course, much better for many patients.

Whorlton Hall

Norman Lamb Excerpts

Thursday 23rd May 2019 Commons Chamber

[Norman Lamb (North Norfolk) (LD)]

(Urgent Question): To ask the Minister if she will make a statement on the treatment of people with learning disabilities and complex needs at Whorlton Hall.

[The Minister for Care (Caroline Dinenage)]

Many of us here today, and many of those listening and watching this urgent question, will have seen the very disturbing footage shown on the “Panorama” TV programme last night. It was footage detailing the incredibly traumatic experiences of vulnerable people with learning disabilities and autism at Whorlton Hall—somewhere they should have been safe, somewhere they should have been cared for. The actions revealed by the programme are simply appalling—there is no other word to describe them—and I condemn any abuse of this kind completely and utterly.

I want to begin by saying that I can only imagine the impact of those experiences on the people themselves, and the lasting damage and trauma that it will have caused to them and their lives. It must also have been incredibly distressing for their families, watching what has been happening to their loved ones, unable to step in and unable to do anything to help them. It is utterly, utterly tragic. On behalf of the health and care system, I am deeply sorry that this has happened.

As hon. Members will be aware, unfortunately, this is not an isolated incident; we have heard reports like this before. That is why there have been a number of reports published even this week on the care of people with learning disabilities and autistic people in in-patient settings. All those reports have been commissioned directly or indirectly by the Government, and all of them have found very clear evidence of care that has fallen way below the standard we expect and the standards that people absolutely deserve.

The allegations of abuse at Whorlton Hall were shared with my Department, NHS England, the Care Quality Commission and the provider ahead of the programme airing yesterday. Immediate steps were taken to ensure the safety of patients, including ensuring that safe staffing levels were maintained following the suspension of a significant number of staff by the provider. A Whorlton Hall incident co-ordination group was established, involving NHS England; NHS Improvement; Cygnet, as the owner; the CQC’s regional head of inspection; the local clinical commissioning group; and the local authority.

Durham constabulary opened a criminal investigation earlier this month, and the CQC and NHS England are supporting its enquiries. While that investigation is ongoing, I cannot comment on the specific incidents or individuals depicted, as Members will understand. The evidence presented, including but not limited to the “Panorama” footage, must be thoroughly examined, and where those investigations find that allegations of abuse are substantiated, action will be taken.

One thing we can all be clear on is that what was shown last night was not care, nor was it in any way caring—suffice it to say that I am clear in my mind the nature of what was occurring at Whorlton Hall.

There are three questions that we need to consider urgently. First, was the activity in Whorlton Hall criminal? The police investigation is looking into that. Secondly, is the regulatory and inspection framework working for these types of services? We want to know why, after whistleblowing concerns had been raised, was the outrageous culture and behaviour at Whorlton Hall not identified? What went wrong? We will be working to understand in detail the timeline of events, the actions taken and where things might have been addressed earlier. Thirdly, was the oversight of commissioners fit for purpose? Where were the CQC and NHS England in this?

More broadly, there is a range of questions about whether these types of institutions and these types of in-patient settings are ever an appropriate place to keep vulnerable people for any extended length of time and why community provision is not sufficient. Work is continuing on all those subjects as well. We know the problems that exist in the system and we are utterly determined address them.

[Norman Lamb]

I thank the Minister for that response. Last night’s “Panorama” was deeply shocking and particularly distressing for any family who have a loved one in an institution and are worried about their safety. We saw people with learning disabilities and autism mocked, intimidated, taunted and provoked, and care workers admitting to deliberately hurting patients—behaviour appropriately described as psychological torture. The individuals responsible must be held to account, but so must the provider that allowed this dreadful culture to persist. Will there now be an investigation by the Health and Safety Executive into the possibility of criminal prosecution against the provider?

The truth is that, seven years on from Winterbourne View, the system continues to sanction a model of care that is outdated and wrong. If people are contained in institutions a long way from home, awful things will happen behind closed doors. Will the Secretary of State now take personal responsibility for closing down institutions that provide the wrong model of care? Why does the CQC continue to register new institutions that offer inappropriate institutional care? Does the CQC need new powers? What lessons must we learn from the fact that the CQC rated this place as good? Is this another case of whistleblowers not being listened to? How much was Cygnet charging the NHS per week for this awful abuse and neglect?

This horror comes in the same week as a damning CQC report on segregation, an equally scathing report by the Children’s Commissioner on children being wrongly placed in institutions where force is routinely used and the LeDeR—learning disabilities mortality review—report confirming the extent to which people with learning disabilities and autism are fatally failed by the system. Does the Minister accept that we are tolerating widespread human rights abuses? Is it true that the Government moved forward the publication of the CQC report to pre-empt the “Panorama” report? What families want is not another review; they want action to protect their loved ones.

Will the Government take action to end the endemic use of restraint—including face-down restraint against adults and children—five years after I issued guidance to that end? When will the Government tell us what will replace the transforming care programme? It ended in March and we are still waiting—there is hardly a sense of urgency. Finally, will there now be substantial investment in the development of community facilities, so that people with learning disabilities and autism have the chance of a good life that the rest of us take for granted?

[Caroline Dinenage]

These exchanges reflect the views that I am certain we all hold, and I thank the right hon. Gentleman for raising all those questions. The culture and behaviour shown on yesterday’s television programme are absolutely abhorrent and we must stamp them out. More broadly, it is clear from the reports published earlier this week, which the right hon. Gentleman refers to, that we need to do much more to improve the quality of care in mental health wards for anyone with a learning disability or autism. I want to reassure the House that we absolutely recognise that, and steps are being taken to address it.

Societies are rightly judged on the way we treat our most vulnerable citizens. This is not just about reviewing a few individual cases in which things went wrong; it is about a system across health, education, social care and criminal justice—it all needs to change. Today, people will rightly be very angry about what has happened and what was shown on last night’s television programme, and they will want answers. They will also rightly be very angry that, eight years after Winterbourne View, we have another scandalous case in which vulnerable people with learning disabilities or autism are on the receiving end. They will rightly ask what action has been taken and what more we need to do.

As the right hon. Gentleman will know, six months ago the Secretary of State commissioned the CQC report on segregation, seclusion and restrictive practices. It was published earlier this week simply because the original publication due date of 31 May is during a recess, and he will know that the Department has come in for enormous criticism in the past for publishing reports when Parliament is in recess, post elections or when the House is not sitting and for publishing late. We wanted to avoid all those things. That is why the date was brought forward. The publication was ready and we took the view to publish it. The publication of the LeDeR report was a matter for NHS England, of course, it being an independent document.

The action we announced in response to the CQC report on Tuesday confirms how seriously we take this issue. We are adamant that no stone should be left unturned in identifying problems, poor practice and care that falls short of what we would expect for our own family members. That said, this is not about segregation or seclusion or failings at specific hospitals, but about the need for far better oversight more generally. Where it is essential that somebody be supported at a distance from their home, we will make sure that those arrangements are supervised. We will not tolerate having people out of sight and out of mind. Where someone with a learning disability or an autistic person has to be an in-patient out of area, they will now be visited on site every six weeks if they are a child and every eight weeks if they are an adult.

The host clinical commissioning group will also be given new responsibilities to oversee and monitor the quality of care provided in their area. This is an issue not just for the regulator, but for those who commission the care. We must be clear that improving the quality of specialist in-patient care is critical, but we are committed to preventing people from entering crisis and having to be admitted to in-patient care in the first place, and that is what the transforming care programme is about. This programme has not finished. As was highlighted in the NHS long-term plan, the transforming care programme and the building the right support plan continue, and we are renewing and redoubling efforts to reduce the number of people in an in-patient setting by 35%. So far, it is down 22% from 2015, but that endeavour continues. The right hon. Gentleman highlights the report from the Children’s Commissioner on Monday. We take the issues they spoke about very seriously.

The right hon. Gentleman asked lots of questions, many of which I think were answered in the three questions I highlighted earlier—the questions that we will be addressing over the coming weeks: criminal liability, oversight and commissioning. Where there have been failings, these will be addressed. Autistic children often have a range of needs or supports that must be joined up, which is why we are reviewing our entire autism strategy and will extend it to include children. As part of the NHS long-term plan, there will be a concerted effort to implement arrangements to ensure that those at the highest risk of admission to a specialist hospital get the help they need, and we will ensure that every area has a dynamic support register in place.

We think that staff in these settings must be much better trained in awareness of learning disabilities and autism, which is why we conducted a thorough inquiry and public consultation on training for learning disabilities and autism. In the coming months, we will set out our response to that consultation and proposals to introduce mandatory training for all health and care staff. We will continue to bring those in-patient numbers down and take every step to take the best practice in health and care and make it the norm everywhere. We will root out toxic cultures and behaviours of the type we saw last night so very painfully on our television screens, but I am fully aware that there is no room for complacency.

Medical Cannabis under Prescription

Norman Lamb Excerpts

Monday 20th May 2019 Commons Chamber

[Sir Mike Penning]

There is Government business later on, but I do not care about that. We need to try and flush out and identify the blockages, which is what the Health Secretary tried to do.

[Norman Lamb (North Norfolk) (LD)]

Will the right hon. Gentleman give way?

[Sir Mike Penning]

I will, but I will then try to make some progress.

[Norman Lamb]

In response to another intervention, the right hon. Gentleman indicated that there is a degree of resistance within the NHS and among clinicians, but does he agree that this is about more than that? This is also about the Government’s regulatory framework, which is restricting access to this medication. Many people in acute pain are resorting to opioids, which are highly addictive and potentially fatal, while being unable legally to access cannabis, which can often ease their pain.

[Sir Mike Penning]

The right hon. Gentleman and I often debate health issues. We were both shadow Health Ministers at the same time, and we agree on most things, including on the prescribed medical use of cannabis. The other area to which he was alluding is not for this debate. It is not referred to in the motion. The reason we have managed to get such huge cross-party support and support from families around the country is that we have stuck to the specific issue of prescribed medical use without going into casual use.

[Norman Lamb]

rose—

[Sir Mike Penning]

If I can, I will make a bit of progress, because there is plenty of time for colleagues. I am really chuffed that the Backbench Business Committee gave us this opportunity. When has the Backbench Business Committee ever had five hours for a debate on a Monday afternoon? I am simply thrilled, and I intend to use as much of that time as possible. I got a little note from the Clerks saying, “You should speak for 12 to 15 minutes, Mr Penning”—yeah, in your dreams. [Laughter.]

There is a blockage in the NHS if someone cannot pay for the prescription. There are consultants both within the NHS and outside, but if someone can pay for it in the private sector, private prescriptions are being honoured. The product is available in this country, perfectly legally, to those who can afford it, and that sticks strongly in my throat.

At the conclusion of the urgent question, although it is not in Hansard, I clearly heard Mr Speaker tell the Secretary of State for Health and Social Care that, whatever happens, we will not leave it—he was referring to me. We will go on and on about this until we get justice for these young people.

Looking beyond the small cohort of desperately ill children, there are others in the country who would clearly benefit from medical cannabis. I am not a doctor, but hundreds and hundreds of families have come to ask me whether this means they can get some help. The MS Society has sent an excellent briefing to colleagues today, and the Brain Tumour Charity and many others have also provided briefings.

Constituents come to my surgery, and I tell them that we need to make sure that their specialists, the experts in their area, are saying that they need medicinal cannabis, and then we can fight their corner. We have such specialists in the sector now who are saying that children and young people with epilepsy—my constituent has just turned 18, so their mum will want me to talk about post-18, too—get a tangible benefit from treating their seizures with these prescriptions, prescribed by a suitable specialist.

We know exactly what are in those pharmaceuticals, yet we still have a crazy situation in which hospitals are telling parents that if they bring these products on to a ward when their child is ill, as part of their ongoing medication, social services will be called to look into what they are doing with their family—for a product prescribed by a consultant.

My constituent has just turned 18. When I wrote on behalf of the family to her GP and the clinical commissioning group, which was blocking the prescription, they said, “We are not interested in homeopathic products.” What on earth is going on inside the medical profession in this country? If they do not know what it is, they should go and ask someone before they write stupid letters back to people and break their hearts. I had to send the letter on.

We should look carefully at what we can do to help. It is not for any politician in this House who is not suitably qualified to say to anybody that they deserve to have this product. What we must do is break down the blockages—that is what the Secretary of State alluded to in his answer to the UQ—and find out the reason for them.

[Sir Mike Penning]

I completely agree with my hon. Friend. I have been referring to Teagan, and he is her MP. As he knows, she got her medication seven days late, and I am convinced that she would not have got it if we had not secured the urgent question, which is why such debates are important.

I used to be a Minister, and I always panicked about UQs. I always asked, “Why don’t we just do a statement? It is a damn sight easier, and we can control the agenda going forward.” The business managers did not always agree with me on that point.

I might be wrong, but as far as I am aware from our investigations the only NHS prescription that has been issued was through the Home Office. Alfie Dingley got his medication through the panel the Home Secretary set up with the expert group in the Home Office. As far as I am aware, since we changed the law in November no NHS prescription has been honoured. We have had trusts clearly threatening consultants not to do this and we have had their professional bodies do the same—I have seen some of the correspondence. As I alluded to earlier, families have been threatened with social services for bringing the product into the hospital where their child was being treated, even though this was a prescribed drug that is perfectly legal in this country today.

The real issue is: why can only those who have the money, those who have a donor and those who have crowdfunded, or, as in the case of my constituents, those to whom one of the manufacturers has given it for free—there is no way in the world they could afford this, and I thank the manufacturer for doing that, particularly for the family—get this? In the country that is so proud of the NHS, how on earth have we got into a situation where those who are poor do not get it?

[Norman Lamb]

I agree with the points the right hon. Gentleman is making, but the fact that the one prescription that has been issued has been through the Home Office raises an important point: the Home Office should have nothing to do with a health issue and this should be transferred, without delay, by the Government to the Department of Health and Social Care?

[Sir Mike Penning]

To be fair, it has been, and that was before we changed the law in November. The Home Office set up a panel while we looked at the changes of the law. This does not really matter, but a Health Minister is at the Dispatch Box today and a Health Secretary was there for the urgent question, so this is clearly sitting in that Department, but the connotations are still there in respect of, for instance, bringing this into the country—

[Norman Lamb]

And licensing?

[Sir Mike Penning]

I understand that point, but this drug has been moved out of its category into the Department of Health and Social Care and it can be prescribed. The issue is not prescription. Even though there were a limited amount of private prescriptions, they are being issued. I thank the consultants who have met me and my colleagues from across the House who have been campaigning on this. They are willing to do this. As far as I can work out, the blockage is that this was moved too fast to help the families whom we wanted to help; the Department of Health and Social Care and the Home Office were not ready.

That fascinates me, because four and a half years ago— it is that long since I have been a Minister—I stood in Westminster Hall as the Minister responsible for drug policy and said then that the Government were minded to allow the medical use of cannabis under prescription. Do they not read our debates? Do they not listen to what Ministers have to say? I do not know whether they thought I was having a flier and as a Minister of State was just doing this because I felt like it on that day. But the then Home Secretary is now the Prime Minister, and of course I did it with her permission.

[Norman Lamb]

What did Ministers do after the right hon. Gentleman made that point in Westminster Hall? He says that that was four years ago. Why did it take until last year for the Government to do anything?

[Sir Mike Penning]

You should have seen the reaction of some of my civil servants when I got back to the Department after making that comment in Westminster Hall! You would understand then why this went exactly nowhere, even though I pushed and cajoled. Sadly, or fortunately, I was moved to the Ministry of Defence after the 2017 election.

So why are we here today? Why have colleagues come into the Chamber, which was completely empty 10 or 15 minutes ago, when they could probably go, as I do not think there is going to be a vote? I say that because the Government have indicated to me that they have accepted the motion, which is votable, if we needed to do that. I have indicated to the Whips that if we needed to do this, I would push it to a vote. I do not think we need to, simply because, after listening to the debate, the Minister will realise, “Hey, we’ve got to move faster.”

Are we moving fast? No. Are we moving faster than we were? Yes, but more needs to be done. Why is that? Because young people are having massive seizures that are affecting their lives and those of their loved ones. They are affecting their families and their quality of life in this country today.

We can do something about that. We are on the journey of doing more about it, but I ask more as a father than as a politician: why do they have to find the money and go to Holland or to Canada? If they cannot find the money, they are not going to get it, unless someone donates it to them or they crowdfund. In the 21st century, why are we allowing these children to be given drugs that are not working and that were never designed for the use for which they are being given, while we have products out there that the pharmaceutical companies are producing, and we know exactly what is in them? It may not help—it may not stop those seizures—but for some people it clearly does. It is morally wrong for us to sit back and allow those children to suffer, and I have no intention of doing that.

Learning Disabilities Mortality Review

Norman Lamb Excerpts

Wednesday 15th May 2019 Commons Chamber

[Caroline Dinenage]

This is really important. We have seen an increase in reports of segregation and restraint, but that is partly because we have seen much better recording of the data. That is also very important, because we need to understand where people are being kept in seclusion or restrained inappropriately. The Secretary of State has asked the Care Quality Commission to review the matter and make recommendations about the use of restrictive interventions in settings that provide all sorts of residential care. The first part of that review will be reporting back very shortly.

[Norman Lamb (North Norfolk) (LD)]

I welcome the Minister’s clear statement that it is wholly unacceptable that people with learning disabilities continue to experience much shorter life expectancy. It is wholly unacceptable, but the problem is that we have all been saying this for years and nothing ever changes. We do not appear to be capable of learning the lessons that she says are necessary. One problem is that people with learning disabilities are often under the care of people who do not have the training necessary to understand the interaction between physical health conditions and learning disability. That is often the cause of that premature mortality. I brought together a group of clinicians who make the case for a new specialty in learning disability so that we have people who understand those crucial interactions between physical ill health and learning disability. Will the Minister meet me and those clinicians so that we can really understand how we can start to make a difference here rather than continuing to say that it is unacceptable and doing nothing effective about it?

[Caroline Dinenage]

I start by saying that I am always very happy to meet the right hon. Gentleman because he has great expertise, knowledge and understanding of this field and often makes incredibly valuable suggestions. In response to his question, that is why the commitment to mandatory training for all health and care staff is absolutely vital. We should not forget that this is not just about medical professionals, but about people such as receptionists. The way that adults with learning disabilities and autism are treated by someone at the front desk of a health and care setting can immeasurably affect their interaction with that provider. That is why this training is so important, why we have consulted so widely on how to deliver it, and why we will set out some really coherent plans later on in the year.

Human Medicines (Amendment) Regulations

Norman Lamb Excerpts

Monday 18th March 2019 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I beg to move,

That the Human Medicines (Amendment) Regulations 2019 (S.I., 2019, No. 62), dated 14 January 2019, a copy of which was laid before this House on 18 January, be revoked.

This motion concerns the serious shortage protocol. I thank the business managers for allowing time for this debate, but it really should not have come about as a result of the Official Opposition tabling a prayer against the regulations. The Government should have brought these proposals to the House for full debate and scrutiny, because the serious shortage protocol is perhaps one of the most far-reaching and contentious of the Government’s changes to medicines regulation in recent times.

The Government are using Henry VIII powers to enable Ministers to issue a serious shortage protocol for pharmacists to follow. The Department of Health and Social Care has stated that the protocol

“could be issued…in instances of serious national shortages and would enable community pharmacists and other dispensers to dispense in accordance with the protocol—rather than the prescription—without contacting a GP.”

These reforms represent a quite extraordinary power grab whereby Ministers can grant themselves the authority to instruct local pharmacists to ration drugs, overrule the GP’s prescription and dispense therapeutic generic equivalents or reduced dosages in the event of a medicines shortage.

[Norman Lamb (North Norfolk) (LD)]

Is the hon. Gentleman aware of the particular concern among people with epilepsy, who require absolute consistency of supply and for whom any change in medication can have dire consequences? The brilliant organisation SUDEP Action has raised very specific concerns about the risks to people with epilepsy.

[Jonathan Ashworth]

I thank the right hon. Gentleman. He is quite right to raise those concerns about patients with epilepsy, which I will touch on in the course of my remarks, echoing the point that he made with great eloquence.

These changes represent an extraordinary power grab. Ministers should have brought them to the House for proper scrutiny, and then, of course, they should have gone out for proper consultation with patients, patient groups and health stakeholder. That is why the Academy of Medical Royal Colleges stated that it is

“inexplicable and unacceptable that an issue of this importance is not the subject of wide consultation and that medical royal colleges as doctors’ professional bodies were not specifically engaged in the process.”

The British Medical Association said that it

“should have far more time to adequately consider the Government’s proposals for change.”

That is why we have brought this prayer motion and why I am pleased that we have the opportunity to debate these proposals today.

It is worth saying a word about the context in which we debate these proposals. Notwithstanding the confusion on the Government Benches about when we actually do exit the European Union—the Under-Secretary of State for Exiting the European Union, the hon. Member for Spelthorne (Kwasi Kwarteng) has given us no greater guidance today in his remarks at the Dispatch Box—it is worth recalling that, as The Lancet said only last month, Brexit, especially a no-deal Brexit, will affect the healthcare workforce, NHS financing, the availability of medicines and vaccines, the sharing of information and medical research.

Our effective joint working with our European partners has been vital for the NHS over recent years, in everything from infectious disease control to the licensing, sale and regulation of medicines. Developing new medicines depends on the international co-operation that is fundamental to accessing clinical trials. Patients in the UK are currently able to access EU-wide trials for new treatments, and the UK has the highest number of phase 1 clinical trials across the EU.

Thanks to the strength of our pharmaceutical base, every month, 45 million packs of medicine move from the UK to the EU, with 37 million packs going from the EU to the UK. We know that 99% of the insulin used in the United Kingdom is not manufactured in the UK. Current EU legislation allows for the legitimate trading of medicines quickly and swiftly cross-border, but the cost of no deal could see pharmaceutical products subject to 44 separate checks and controls at the borders, hugely delaying access to medicines.

--- Later in debate ---

[Jonathan Ashworth]

The hon. Lady makes an entirely reasonable observation. I trust that the Minister took note of it and look forward to her reply to that point.

[Norman Lamb]

Does the hon. Gentleman agree that this puts individual pharmacists into quite an invidious position because they may well be having to make decisions that may impact adversely on a patient’s health and wellbeing when they are not necessarily skilled to make those judgments? My concern particularly relates to epilepsy but it applies to other areas as well.

[Jonathan Ashworth]

The right hon. Gentleman hits the nail on the head. That is exactly the point that has been put to me when I have visited community pharmacists and discussed this with them. Of course there are other pharmacists who have perhaps done more training and want to work at the top of their licence and believe that there is a role for more autonomy. However, there are real concerns about the way in which these changes are being rushed through without any resource put into education, explanation or wider training that may be needed. In those circumstances, it is appropriate that we raise our concerns, support our motion and oppose the Government’s proposal today. He is absolutely right—I have heard that concern expressed directly. Many community pharmacists do not necessarily want this responsibility, given the wider concerns and implications that he highlighted.

--- Later in debate ---

[Jackie Doyle-Price]

I come back to what I said to my hon. Friend earlier. The terms under which pharmacists will be able to exercise their discretion will be clearly set out in each protocol, and there will be full consultation by an expert panel, with ministerial approval in such an event.

[Norman Lamb]

Will the Minister clarify whether, if there are adverse effects as a result of some change that has been made in these circumstances, the prescriber, the dispenser or the Government would ultimately be liable?

[Jackie Doyle-Price]

The protocol will be very tightly drafted, which will really limit the ability of the pharmacist, who would only be able to prescribe outside the terms of the prescription within the narrow confines of the protocol. As I say, this has been done to secure continuity of supply when there is a potential challenge, but I would expect to take advice from a pharmacy panel, in conjunction with those most affected, to make sure that we put in place appropriate risk management on those occasions.

--- Later in debate ---

[Dr Whitford]

It is critical that the patient’s dose is not changed or put in danger. The management of any condition is dose sensitive. We cannot go down to homeopathic doses of antibiotics or blood pressure medication—that would be crazy.

Pharmacists can give a different form, such as liquid, solid or capsule. Again, for some patients that will not be a problem; for others, it will. The hon. Member for Newton Abbot (Anne Marie Morris) mentioned generic drugs. Generally, NHS prescribers use generic drugs as the default to save money. However, I have had patients who had appalling side effects from the generic form of tamoxifen, but not from the non-generic brand. There always has to be a right for GPs to say, “In this case, I will use the brand.”

The most important bit of this statutory instrument is that it allows a change to a completely different drug. It may be a drug that is approved by a panel sitting somewhere in London with the colleges, who say that it is a reasonable replacement for the other drug, but that does not take into account the fact that patients are all individuals. I can tell you that they are all individuals.

Pharmacists are very knowledgeable—in Scotland, we have had community pharmacists for over a decade and they contribute massively—but they work to their own protocol, they work within limits and they do not have access to the patient’s notes. Therefore, they cannot see that the patient has been on a drug in the past and had terrible side effects. They will replace with a protocol drug, but what about the responsibility? Why is this happening right now?

It suggests to me that the Department of Health and Social Care is expecting massive shortages, to the point where the simple act of picking up the phone and saying to the GP, “I don’t have drug A. Would drug B be reasonable for Mrs Smith?”, is somehow impractical. I find that very worrying. It may be that Mrs Smith has had six drugs to control her blood pressure. Drug 2 and drug 5 caused her to faint or have blackouts, but the pharmacist does not know that.

Epileptics have been mentioned. The issue with epileptics is that any change can destabilise their epilepsy. They are therefore never prescribed by generic, but are prescribed by brand to avoid precisely that.

[Norman Lamb]

The hon. Lady makes a very good point. Does she agree that there is often an interaction between epilepsy drugs and other drugs that the patient may be on and that any interruption of that relationship may cause problems?

[Dr Whitford]

The right hon. Gentleman makes a very good point, and one that applies to many drugs. When we prescribe, we sit and look at the interactions. I would expect a pharmacist to look at that. They will have the patient’s full prescription and should, therefore, be able to look at interactions.

[Norman Lamb]

They do not have the patient’s records.

[Dr Whitford]

That is the key thing: they do not have the patient’s records and they do not know what problems a drug may have caused in the past.

This change could have a real impact on epileptics. It brings the danger of a fit, and the fit itself may be a threat to them. Obviously epileptics are exposed to sudden unexpected death in epilepsy and can suffer from trauma, depending on where they are when they take the fit. They can even lose their driving licence for a year because they have one fit. The social impact of that on epileptics is enormous.

It says in the explanatory notes that, because of that, epilepsy drugs and biological drugs would not be considered suitable for the protocol. However, it does not say that in the SI—they are not excluded. It is important that such people are protected.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

I very much agree with the concerns that were raised by the Scottish National party spokesperson, the hon. Member for Central Ayrshire (Dr Whitford). Let me make a general point first. I recognise that this statutory instrument is not being introduced purely for no-deal planning, but clearly, there is a recognition that the risk of shortages increases in a no-deal scenario. To me, it absolutely beggars belief that Cabinet Ministers in this Government were willing last Thursday purposefully to vote against an extension and therefore in favour of the risk of no deal in just a few days’ time, knowing that the risk to patients would increase as a result. It is extraordinary that Ministers in a Government could choose to vote in that way knowing that patients would be put at greater risk.

I want in particular to address the concerns of patients with epilepsy, including the concerns raised by the really good organisation, SUDEP Action. For those who are unaware, SUDEP means sudden unexpected death in epilepsy, so we are talking here about all those people who lose their lives as a result of epilepsy. There are very real and legitimate concerns about the impacts that the measure will have on those people. To bring this into really sharp focus, Simon Lees, one of the trustees of SUDEP Action, who has epilepsy, was today refused the supply of one of his three epilepsy medications because of a shortage. His brother died from epilepsy shortly after his medication was changed, so the risk to patients is very real.

As others have said, pharmacists are highly skilled professionals, but they are not specialist prescribers or skilled in assessing the risk of unexpected death through epilepsy. There is a particular concern about people with a learning disability who may also have epilepsy, who are particularly at risk. As the SNP spokesperson said, pharmacists do not have access to the full patient record. The need for consistency for these patients in the supply, dosing, timing and formulation of anti-epileptic drugs is absolutely critical. There is a real risk when medications change. That is why specialist prescribers play such an important role in any change for a patient with epilepsy. Person-centred prescribing and medication management is the most effective way to keep these patients safe, so it is little wonder that those people and the organisation that supports them are so concerned about this issue.

I also want to make some particular points that SUDEP Action has raised. The current documentation on the protocol indicates that there is no requirement for patients to be made aware of medication changes—that seems extraordinary to me—or a recognition of the channels available to them should they wish to challenge or question those changes. Without those safeguards, people with epilepsy may be unaware of medication changes that have occurred, putting them at significant risk, particularly if these changes result in increased side effects or changing seizure control. It is also unclear whether the pharmacist, the original prescriber or the Government are ultimately accountable for adverse effects—I made this point in my challenge to the Minister—caused by one of the protocols being activated. Should a death occur following a lack of consistency of supply of the usual medication, who will be held to account for that change? As others have said, it seems essential that the Government make publicly available a list of the medications that are at risk of shortage. There should be an early warning system for prescribers so that they are aware of the risks of medications running short in supply.

In conclusion, there are legitimate and serious concerns here, and that is why I will be joining others in voting in favour of the motion to revoke the regulations.

Mental Capacity (Amendment) Bill [Lords]

Norman Lamb Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Tuesday 12th February 2019 Commons Chamber

[The Minister for Care (Caroline Dinenage)]

I am here today to prove my mettle.

I will start by stating the obvious: our liberty is our most fundamental human right. The challenge today is that the current system of deprivation of liberty safeguards no longer provides protection to all the vulnerable people entitled to it. The system has proved to be overly bureaucratic and inefficient to apply, and case law has resulted in article 5 of the European convention on human rights being understood in a very different way, and this has, in effect, widened the definition of deprivation of liberty eighteenfold. The result is a long backlog of applications that has built up over time such that today about 125,000 people may be subject to a deprivation of liberty without formal authorisation.

The Bill introduces a new system—the liberty protection safeguard—based on work of the Law Commission that involved more than three years of consultation and consideration. It is designed to provide robust protections and to be simpler so that protections may be afforded quickly and effectively to those who need them. It is absolutely right that any proposed changes to the protection of some of the most vulnerable people in our society be scrutinised closely, however, and I am grateful for the close examination of the Bill by hon. Members and noble Lords during the Bill’s passage here and in the other place.

I thank the hon. Member for Rhondda (Chris Bryant) for raising the issue of how liberty protection safeguards will work for people who have a brain injury or may need to be deprived of their liberty while receiving care or treatment. I also thank him for his chairmanship of the all-party group on acquired brain injury. He does an outstanding job and is a great advocate for the group.

A leading charity in this area, Headway, reports that every 90 seconds someone is admitted to a UK hospital with an acquired brain injury or related diagnosis, such as trauma, stroke, tumour and neurological illness, and many of these will require some form of rehabilitation. For some people, this can be a lifelong need. Having met the hon. Gentleman yesterday to discuss his concerns, I understand that neurorehabilitation can in some cases help people to regain capacity over time and that his amendments are intended to account for this and to ensure that a deprivation of liberty occurs only when strictly necessary.

I would like to provide some reassurance that the first principle of the Bill is that a deprivation of liberty should occur only where it is considered essential and where authorisation conditions are met. I can assure the hon. Gentleman that we have considered carefully how this model will work for this group of people and are confident that the reformed model will embed consideration of deprivation of liberty into the earliest stages of care and treatment planning so that from the outset these arrangements will work alongside neurorehabilitation therapy and adhere to the less-restrictive principle of the Mental Capacity Act 2005.

[Norman Lamb (North Norfolk) (LD)]

I understand the Minister’s concern not to impinge on the rights of disabled and elderly people, but is she not concerned that more than 100 social care and disability organisations have written to her raising continuing concerns, including about the Bill adversely affecting the rights of people who rely on care and support services. Does she think they are wrong, or does she think they have legitimate concerns that still need to be properly addressed?

[Caroline Dinenage]

Of course, any organisation representing these vulnerable people that raises concerns deserves to have them listened to, and I am sure that the vast majority are legitimate concerns, which is why we have been listening so carefully up until this point. The right hon. Gentleman will know how many amendments we have made in the other place, in Committee and today.

We will continue to listen and collaborate as we deal with the code of practice, about which I shall say more in a moment. A working group of third-sector organisations is helping us to put the document together so that it is not rushed. It is not being prepared for the purposes of Parliament, but it will come before Parliament. Following a wide public consultation, both Houses will vote on it. That collaboration has been and will continue to be important: it is not the end of the conversation, but very much part of it.

--- Later in debate ---

[Caroline Dinenage]

I am afraid that I will not take any more interventions because Mr Deputy Speaker might fall out with me entirely. In short, care home managers will be responsible for consultation, which is already part of good care.

Amendment 50 would require an approved mental capacity professional to complete the pre-authorisation review, where care home arrangements are being authorised and where the care home manager provides a statement to the responsible body. The Law Commission recommended the creation of the AMCP role and also recommended that their use should be focused on those cases where their input is needed. The commission recommended that AMCPs should consider cases where an objection is raised and the Bill does that. The Bill also allows other relevant cases to be referred to an AMCP. We expect, for example, cases where there are complex circumstances, or particularly restrictive practices are proposed, to be referred by the responsible body to an AMCP. We have also specified that an AMCP must carry out the pre-authorisation review in independent hospital cases. However, we agree with the Law Commission that not every case should be considered by an AMCP. By having a targeted system, with a greater focus on more complex cases, we can ensure that people receive the protection to which they are entitled.

Turning to amendment 51, I thank hon. Members for raising advocacy, about which we spoke at length in Committee. Advocacy is of the utmost importance for ensuring that the voice of the person is heard. That is why this Bill creates a presumption of advocacy for everyone who is subject to arrangements under liberty protection safeguards. During our engagement with stakeholders, many people and their families told us that the DoLS system was something that was done to them without family involvement. That is why this Bill introduces the appropriate person role described by the Law Commission. Family members and those close to the person will be able to be an appropriate person and provide representation and support. We recognise that that role can be challenging, which is why it will be conducted only by those who are willing to do it. Otherwise, people will be able to request an independent mental capacity advocate to support them in providing that important representation.

Like Opposition Members, we want to ensure that people receive advocacy, but we recognise that we should not impose it on people, nor should it become a formality without real effect. Our Bill already delivers on amendment 51.

[Norman Lamb]

Will the Minister give way?

[Caroline Dinenage]

I am afraid that I cannot take any more interventions at this stage.

Our Bill allows the person themselves to request an IMCA from the responsible body if they have the capacity to do so, and it explicitly states that an appropriate person can request an IMCA or that the responsible body should appoint an IMCA if it believes that the appropriate person having the support of an IMCA would be in the cared-for person’s best interest.

I agree that the appropriate person has a challenging role with vital duties to ensure that the person exercises their rights, and we want to work with others in the sector to establish how best to support them in this role. There is existing provision in the Bill to address the concerns raised by amendment 51. In some areas, the amendment adds uncertainty and over-complication.

This Bill is about protecting vulnerable people and replacing a one-size-fits-all system.

--- Later in debate ---

[Norman Lamb]

I want to speak primarily in support of the amendments in the name of the shadow Minister, the hon. Member for Worsley and Eccles South (Barbara Keeley), and others. However, I want to comment right at the start—I realise this is not the decision of the Minister—about the time we have to debate a Bill that deals with fundamental human rights. I just think it is absolutely outrageous, and we should place on the record our total opposition to the way in which, wholly inappropriately, it has been rushed through.

I should also say that I completely understand the need for reform. I said that on Second Reading, and I acknowledge the Minister’s sincerity on that. I recognise that we breach the human rights of the people who are on a long waiting list for anything to happen to them, but that is no justification for getting it wrong at this stage. Surely we must not weaken the protections for very vulnerable people, yet the organisations that have followed this process all the way through are very clear that that is precisely what we will do.

I just think this is extraordinary: the Government have commissioned a review of the Mental Health Act, and although we have not had the formal response yet, I expect that much of what the review calls for will be supported by the Government, yet the review moves in a diametrically opposite direction to this Bill. The review talks about “rebalancing the system” and about

“a real shift in the balance of power between the patient and the professional”.

The review also talks about

“a right to advocacy based on an opt-out approach.”

That is what the amendments in the name of the shadow Minister seek. This will not, as the Minister implied, force advocacy on anyone; this is about having it as the default option. The Law Commission has called for a right to advocacy as an opt-out approach, yet the Government are resisting it. Why are they resisting it? This reduces the rights and protections of vulnerable people, and for that reason it seems to me that it is unacceptable.

On Second Reading, I said that I would not oppose the Bill at that stage, and I said:

“Our assessment will be at the end of the process: is it workable? Does it genuinely respect and safeguard individuals’ human rights? Does it result in very vulnerable people being better protected than they are under the existing…flawed system?”

At that time, I asked the Minister to meet all of us, including interest groups, before going into the Committee stage. I said on Second Reading:

“Do not rush headlong into the Committee stage.”—[Official Report, 18 December 2018; Vol. 651, c. 744.]

Yet, within a fortnight, we were in Committee, which is exactly what I had urged her not to do.

Then we come to the views of the sector. I mentioned earlier that over 100 organisations, including care providers, disabled people’s organisations and charities, have written to the Minister. They make it clear that reform should not be at the cost of the human rights of people who rely on essential social services. I want to deal, specifically and finally, with the conflict of interest issue. They say in that letter to the Minister that

“serious conflicts of interest will be placed upon care managers who will be in control of key information about assessments and review processes.”

The Law Society—surely we should take its concerns seriously—says of care home managers that

“any task or role they undertake must be completely conflict free”,

and that they should not be arranging or carrying out critical assessments. Care home managers should not be responsible for consultation with the cared-for person. It describes the current process—it is not a past but a current concern about the Bill, as amended—as “deeply flawed”. It says:

“It is not difficult to envisage a vulnerable person being uncomfortable or reluctant to give an honest answer when questioned by the care home manager on their willingness to stay”—

in that care home—

“or their ‘happiness’ in the current placement.”

The Law Society’s concern is also about the capacity of care home managers to undertake this work, given that the whole system is under massive pressure. Bluntly, the quality of care home managers is such—many of them are really good, but some of them are not, frankly, good enough—that we cannot rely on them to undertake this vital work, which goes to the protection of the civil liberties of vulnerable people.

[Barbara Keeley]

On the training that the Minister has talked about and the hon. Member for Congleton (Fiona Bruce) just referred to, I understand from impact assessments that there is half a day’s training for care home managers and two hours of training for social workers. What does the right hon. Gentleman think of that?

[Norman Lamb]

That is clearly insufficient when it comes to the vital task of playing a role in the protection of people’s civil liberties and human rights. That is what the Bill envisages.

Sue Bott, the deputy chief executive of Disability Rights UK, says:

“Given the rare unanimity across the health and social care sector and disabled people’s organisations we urge the Government to delay the Bill and look again at its provisions. It is better to have a co-produced piece of legislation that works for everyone than rush through a new law that, in its current form, will seriously undermine the human rights of disabled people.”

I urge the Minister to listen carefully to that—the “rare unanimity” across the sector. When I was responsible for taking the Care Bill through Parliament, we ensured that by the end pretty much everyone was on board, although it was a slow and sometimes frustrating process.

The Minister will be applauded if she now recognises that these concerns about the amended Bill are not past ones but current ones. If we are to get people on board and ensure that everyone agrees that we are properly protecting the human rights of very vulnerable people, the right thing to do now is pause, before the Bill goes back to the House of Lords, to ensure in particular that the provisions on conflict of interest of care home managers and the rights of advocacy are properly addressed. If the Minister can do that, she will go a long way towards bringing people on board. I am sure that that is what she wants.

[Kevin Foster (Torbay) (Con)]

Given the restrictions on time, I will curtail my speech and take out remarks I might have made; I am conscious that colleagues would also like to speak.

I always agree with the passion of the right hon. Member for North Norfolk (Norman Lamb) on these issues, but I do not agree with his conclusions on aspects of the Bill. I am reassured by the Government amendments, particularly in relation to independent hospitals: such a hospital might have a potential business interest in keeping someone in its service, so it will not at any time judge whether that person needs to be under the deprivation of liberty safeguards.

It is important that we have a modern system; as has been mentioned, the backlog of 125,000 people under the existing system is utterly unacceptable. What standards there are will need to be changed. When I look at the Opposition amendments, particularly amendment 49, I take the Minister’s point that the consultation—actually talking to someone about their views and their care—is part of what we would expect a care provider to be doing. There must be clear, independent safeguards around deprivation of liberty, and the ability to have an independent check. In some cases, it would be better for someone who works with the individual every day to do the consultation, rather than someone literally turning up from the local authority or health board, who may not have had any contact with them. We are talking about people with issues when it comes to interacting and understanding some of the engagement, so I do not see why there should be consultation in all cases. We are talking about consultation, not decision, and I do not see what the issue is with that.

I turn briefly to the amendments moved by the hon. Member for Rhondda (Chris Bryant). The attention he brings to the issue of acquired brain injury is always welcome—particularly in the football world, on the day when an England 1966 hero passed away. The hon. Gentleman mentioned that those from that era often acquired head injuries as a result of heading heavy leather balls, particularly when wet. That is still an issue in football today. I join the hon. Gentleman in saying that the rules should be looked at. If that can be done in rugby without affecting the flow of the game, there is no reason why it cannot be done in football. Similar arguments were advanced in relation to video referees and they are now in place.

I am conscious of the time remaining for others to have their say, so I will just say that I support the Bill and that I do not see the need for the amendments tabled by the Opposition.

--- Later in debate ---

[Barbara Keeley]

It is appalling that we should have had less than two hours for Report stage of a Bill affecting the human rights of some 2 million vulnerable people who lack capacity—and we had less than two hours for Second Reading. Given that there is no appreciable business to occupy ourselves with next week, it is ludicrous that the Government should have forced the Bill through today.

The Bill that we are being asked to pass today is simply not fit for purpose; it simply replaces the current flawed system, which the Minister has just described, with a new one that is actually more flawed. There are a number of issues that we still consider unacceptable. The largest is that the Bill still creates a major conflict of interest in relation to the managers of private care homes. It is simply wrong that a business with a financial stake in seeing a deprivation of liberty authorisation granted can do all the legwork and then just have its recommendation rubber-stamped by the local council.

I hope that care home managers will seek to carry out their new role well, but we know that they are already overstretched. The Bill creates extra pressures.

[Norman Lamb]

Does the shadow Minister share my confusion and concern that the Mental Health Act review, which the Government commissioned, appears to be moving in one direction—strengthening the rights of individuals—while this Bill appears to be moving in precisely the opposite direction?

[Barbara Keeley]

That is very much the case. We asked on Second Reading for some consideration of the interface between the two.

As well as the issue of care home managers, there is a real concern about the restrictions on access to advocacy under the Bill. Advocacy is a fundamental pillar of any system for authorising deprivation of liberty. The Bill means that vulnerable people who need an advocate may not get one, and amendments that could have changed that have been rejected. The use of a best interest test to decide whether someone gets an advocate has been widely criticised. The Government could and should have removed the reliance on the best interest test.

The maximum renewal period of a deprivation of liberty authorisation is tripled by the Bill. As the right hon. Member for North Norfolk (Norman Lamb) said, the Mental Health Act review is moving in one way while this Bill moves in another. The Bill could see people being detained for three years at a time without a full reconsideration of their case. The only safeguard against that being misused is a series of regular reviews, but we do not know how regular those will be or what they will look like.

In Committee, the Government introduced a new definition of deprivation of liberty to the Bill. It is woefully inadequate and will inevitably result in costly litigation. The Government introduced the definition late on, with next to no consultation. The clashes between that definition and existing case law will lead to court challenges. The definition will see some people deprived of their liberty without the safeguards they need, while the issue is sorted out in the courts.

The process that the Bill has been through could be used as a case study of how not to make legislation.

Mental Health First Aid in the Workplace

Norman Lamb Excerpts

Thursday 17th January 2019 Commons Chamber

[Norman Lamb (North Norfolk) (LD)]

After yet another week of fractious and angry political discourse, what a pleasure it is to work with two honourable friends—I use that term advisedly—the hon. Members for Plymouth, Moor View (Johnny Mercer) and for Liverpool, Wavertree (Luciana Berger) on an issue of incredible importance. It is important that those watching or reading about this debate recognise that it is possible for right hon. and hon. Members to focus on important issues such as mental ill health, as well as fractious arguments over Brexit.

I thank the hon. Member for Plymouth, Moor View for what he said about his experience of OCD. Interestingly, OCD has also affected my family as our oldest son was diagnosed with it as a teenager. He has since spoken about his experience, and I speak with his authority and approval. What the hon. Gentleman said about the importance of people in his position speaking out about such conditions is important. I remember the moment when, as a teenager, Archie said to me, “Why I am the only person who is going mad?” For a parent to hear that from their child is awful and incredibly distressing, and it makes one realise what a teenager must be going through if that is how they feel about their situation. Of course that is an entirely false perspective, because one then realises that so many others are experiencing their own challenges, and when that realisation dawns, it makes it much easier for individuals to speak out. I thank the hon. Gentleman for what he said and for talking to the press about this issue, because cumulatively that makes a difference.

The Time to Change campaign has been incredibly powerful in helping to normalise mental ill health, and every time someone in a public position speaks out, it becomes a little easier for another teenager to seek help and not be frightened about opening up. I join the hon. Member for Liverpool, Wavertree in acknowledging the work of Natasha Devon, who is a great campaigner for mental health issues, and I thank Bauer Media and Mental Health First Aid England for championing this important cause.

On the cost of mental ill health, I wish to focus first on the cost to the individual, because it is often not recognised by those who do not experience it just how painful and disabling mental ill health can be. If someone is experiencing anxiety, depression or a condition such as OCD, their life is completely dominated by that. They often cannot enjoy life or be happy, and whenever we speak about the economic cost of mental ill health, we must focus on the most important thing, which is the cost to individuals of the ill health that so many experience.

Alongside that, however, there is a significant cost to employers—not just private sector employers, but the public sector, charities and so forth. Health and Safety Executive data show that 57% of days off work through ill health are due to mental ill health of one sort or another, and not confronting that represents an enormous cost to employers. This is not just about time off work, because many people end up falling out of work and on to benefits, and others turn up to work but under-perform—the concept of presenteeism—because they are not feeling on top of their game, or because they are obsessed by anxieties or concerns that prevent them from performing their work responsibilities effectively.

Addressing mental ill health is a win-win-win for everybody, because this issue affects not just individuals, but employers and even the Government, who gain as a result of us taking it more seriously. If someone falls out of work because of mental ill health, they end up claiming benefits, and that is an enormous cost to the Government and also impacts on the NHS. Everybody benefits by us taking this issue more seriously. The question then is how best to achieve an advance. The hon. Member for Waveney (Peter Aldous) made a very important point when he said that we need to think carefully about how we frame that.

Under existing law, employers are under duties to protect the mental health and wellbeing of their workforce. The Institution of Occupational Safety and Health makes that point very strongly in its brief for this debate. It makes the point that under the Health and Safety at Work Act etc. 1974 and associated regulations, employers are under a duty to manage the psycho-social risk to their employees at work. There is also the duty under the Equality Act 2010 to make reasonable adjustments where people are suffering from some sort of disability, including mental ill health. I also applaud the Health and Safety Executive for the new guidance it issued in November 2018. For the first time, it includes a section on mental health. That is important. These are all advances worth acknowledging. I would also like to acknowledge the work of Paul Farmer and Lord Stevenson, which was commissioned by the Government. Their report “Thriving at Work” recommends mental health core standards for every employer.

None the less, the first aid legislation is very much framed in terms of physical health. It is very important to establish clearly in legislation—just as we did in the coalition Government, where we legislated for parity of esteem in the NHS—a very important principle for the workplace: an equality in the importance of both physical and mental health in the workplace. I want to stress that it is about much more than just mental health first aid, vital though that is—I totally endorse all the comments made by the hon. Member for Liverpool, Wavertree.

I want to highlight the potential risks, as the hon. Member for Waveney made clear, of not getting this right. There is a risk of the tick-box exercise, where an employer can just say, “Yes, we have trained someone up in mental health first aid. We’ve done nothing else, but we have ticked the box and therefore we have met the regulation.” That would be a failure for all of us if that was the outcome of this exercise.

The more fundamental point is that the approach we should be taking is about preventing ill health in the workplace. The whole focus should be on creating healthy workplaces, where people are treated with dignity and respect. It is vital that employees across the workforce have the opportunity to raise their awareness and understanding of mental health. Alongside that, however, we have to think about the causes of stress and anxiety in the workplace. Often, it is due to unhealthy workplaces, where people are not respected and where there is a bullying culture. Depressingly, we see that quite often in the NHS. That has to be confronted, because that is the cause of so many people feeling anxious, distressed and depressed as a result of what happens at work.

[Mr Kevan Jones (North Durham) (Lab)]

Does the right hon. Gentleman agree that there are very simple things companies can do—BT and quite a few others do this—to improve work-life balance? For example, they can ensure that people do not have to answer emails late at night or over weekends, or, when people have bereavements, they have a sensible bereavement policy that supports the individual, rather than just allows for a number of days for an individual to get over it.

[Norman Lamb]

That is an incredibly helpful intervention. I totally agree with the right hon. Gentleman. It is about getting the whole culture in the workplace right on flexible working, understanding that parents sometimes have responsibilities to their children and carers have responsibility for an elderly loved one. Not working ludicrous hours of the day and night is also incredibly important. How we achieve the legislative change is very important. It is vital that we raise awareness through mental health first aid, but we also need a fundamental focus on the prevention of mental ill health in the workplace.

In the remaining minutes, I want to focus on some of the things we did in the west midlands. After I was chucked out of the Department of Health by the electorate in 2015, I was asked to chair a commission on mental health in the west midlands. Our whole focus was on how to prevent mental ill health and take a more public mental health approach. We focused particularly on the workplace. We first focused on how to get people who had experienced mental ill health and had been out of work—often for years and years—back into work. Work is actually good for people. Meaningful work, where we gain a sense of dignity and self-respect, is really important. We are undertaking—with £8.5 million of Government support, I should say—a randomised control trial, applying a strong evidence-based approach called individual placement and support. We give people intensive support to get them ready for employment, get them into a proper job and then support them in that job. We are looking at how we can apply that in primary care, so we capture people earlier, and give them access to someone who can train them and support them for employment. We want to change the mind set of GPs, so they are not just thinking about the sickness of their patient but how they can help them to recover and get back into work—that is critical.

I hope that as a result of the randomised control trial, we will be able to learn lessons which we can then apply across the country. If we can get lots of people with severe and enduring mental ill health back into work, we will achieve something very significant. Sadly, at the moment this extraordinarily strong, evidence-based approach is the exception rather than the rule. Most people across the country do not get access to it. The Government have made a commitment to double the numbers, but that is still a very small proportion of the total. It needs to be expanded rapidly.

[Mr Kevan Jones]

Is the problem that mental wellbeing is not hardwired into Government policy? Some policies, for example Department for Work and Pensions work capability tests and others, actually work against individuals. Voluntary work is very useful in getting people back into work, but at the moment there are limits around what people can do while they are still on benefits. Does the right hon. Gentleman think that some flexibility on that would help this process?

[Norman Lamb]

I absolutely do. I was going to say, “Don’t talk to me about the work capability assessment, because it will get me very angry.” We need reform of the welfare system to help to facilitate people returning to work, rather than just treating them as second-class citizens, as it often does.

[Luciana Berger]

I am listening very carefully to the right hon. Gentleman’s remarks, which are very pertinent. On people being in work or not in work if they are affected by a mental health condition, I was struck to learn that for my local mental health trust, Mersey Care, which provides services for the whole of Merseyside, the latest available figures—not the most recent financial year, but the previous one—show that just 3% of the patients under its care, in both the community and in in-patient services, were in any form of work. That figure is similar for patients under the care of many mental health trusts across our country. Does he believe that people outside this place might not be aware of that fact, but it is staggering and should concern us all? We should be doing everything possible to support people with mental ill health conditions into the workplace.

[Norman Lamb]

I totally agree. My plea to the Government is that, as we hopefully commit to spending more on mental health, we spend at least part of that on preventive measures. If we can get someone into work, it makes a whole difference to their lives. The evidence shows that many people who are helped back into work are then able to stay in work; reducing the burden on the NHS and the benefits system, but giving people dignity and self-respect.

Another initiative we are undertaking in the west midlands is the wellbeing premium. It was my idea, which again is being supported by the Government and I am grateful to them. The idea, which we are trialling over a year, is to give an incentive to employers to improve the way in which they support people in work by training their line managers—the most critical thing one can do—and see whether we can reduce the number of people who end up on sickness absence. The idea is to give them a temporary incentive for one or two years, for example by a reduction in the business rate or a reduction in national insurance payments. If by that we can reduce sickness absence, the number of people falling out of work through ill health and the problem of presenteeism, everyone benefits. It will be interesting to see how that succeeds.

In the west midlands, we are also pursuing the thrive at work commitment, which is trying to build a social movement of companies that all sign up to a commitment to up the level of support that they provide people, changing the culture in workplaces. A toolkit is provided to companies, and that could make a substantial difference across the region.

The action plan also has a commitment to train up 500,000 people across the west midlands in mental health first aid. That is a totally different approach to what we have been used to, which is an NHS very much focused on sickness and providing treatment for sickness after what is often a very long wait, as the hon. Member for Plymouth, Moor View pointed out. Instead, the whole focus of the system should be on prevention. If we do that, we can achieve a real breakthrough.

To conclude, let us amend the legislation and get mental health first aid to become the standard in every workplace. Critically, that should be part of a much wider programme that is focused on prevention and on building good healthy workplaces with the right culture, where people have respect, are engaged in the work they are doing and are treated with dignity. With that commitment is a dedication to the work they are doing and a commitment to raise awareness of mental ill health among all staff and to train managers properly. Through a combination of regulation and incentives, we can make a real difference for people.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Jackie Doyle-Price)]

I should like to thank all the contributors to the debate. It has been marked by a lot of enthusiasm and passionate advocacy in support of improved mental health. In particular, I would like to pay tribute to the hon. Member for Liverpool, Wavertree (Luciana Berger), the right hon. Member for North Norfolk (Norman Lamb) and my hon. Friend the Member for Plymouth, Moor View (Johnny Mercer) for securing the debate and for bringing their characteristic ambitious agendas into play, alongside their well-informed and passionate advocacy on behalf of them. It can often be challenging to respond to all three of those Members, but on this occasion I have really enjoyed listening to their contributions and I agreed with much of what they said.

We all share the same objective, which is to secure support as early as possible for people who are suffering mental ill health and, more specifically, to enable more people with mental ill health to stay in work. That is good for their health—as long as it is good work and they are well supported—but it is also good for the economy when more people are encouraged to work. That was clearly illustrated by the figures cited by the hon. Member for Liverpool, Wavertree for those receiving care from Mersey Care, which bring into stark relief the size of the challenge. They show that only 3% of those patients are in work, which is something we should all reflect on. It underlines the importance of ensuring that we get better at supporting people who are suffering mental health challenges and at encouraging them into work.

I am pleased to be joined on the Front Bench by the Minister for Disabled People, Health and Work, my hon. Friend the Member for Truro and Falmouth (Sarah Newton). She is also responsible for the Health and Safety Executive, which obviously has a big role to play in this agenda. She has been listening carefully to all Members’ contributions today. She and I are united in an objective to ensure that we keep more people with all kinds of disability in work, and that we get those who are currently excluded from the workforce into it. We have a wide package of measures that we are taking forward in that regard, some of which have been referred to today.

The Government are committed to building a country that works for everyone, and that must include ensuring that disabled people and people with mental health conditions can go as far as their talents can take them. Too many people with a mental health condition are unable to do that, and that is a burning injustice that must be tackled. As the right hon. Member for North Norfolk pointed out, people who are unemployed for more than 12 weeks are between four and 10 times more likely to suffer from depression and anxiety. That statistic illustrates why it is good for society, as well as for the individual, that we tackle this issue. The good news is that staying in or returning to work after a period of mental ill health really does aid mental health recovery. It really does make perfect sense.

[Norman Lamb]

The Minister will be aware of the objective in the five year forward view to double the number of people who get access to individual placement and support. Can she indicate how that programme is going? If she cannot do so now, will she write to me?

[Jackie Doyle-Price]

I can say that we are making progress, but I would prefer to write to the right hon. Gentleman with more details, if I may. I have seen some of that individual placement and support in operation, and it is hugely inspiring. In those mental health trusts that are giving one-to-one support, people are finding that the reward and discipline of going to work really does aid their recovery, even in some of the most challenging cases. I will write to the right hon. Gentleman with more information on that.

Oral Answers to Questions

Norman Lamb Excerpts

Tuesday 15th January 2019 Commons Chamber

[Mr Speaker]

Order. We are running late, but I do not think Health questions would be complete without the right hon. Member for North Norfolk (Norman Lamb).

[Norman Lamb (North Norfolk) (LD)]

20. What assessment he has made of the effect of changes to local authority public health budgets in 2019-20 on his Department’s ability to achieve its “Prevention is better than cure” vision.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

Local authorities will receive £3 billion in 2019-20, ring-fenced exclusively for use on public health, but our ambitions for prevention go far beyond any one pot of money. “Prevention is better than cure” was widely welcomed, and we will build on it with a comprehensive Green Paper later this year.

[Norman Lamb]

The number of people attending sexual health clinics is up 13% over four years, and the number with gonorrhoea and syphilis is up 20% over the last year, yet the Health Foundation says that funding for sexual health is down 25%. Will the Secretary of State and the Minister be making a powerful case, as part of the spending review, for proper investment in public health, and particularly in sexual health, given their commitment to prevention?

[Steve Brine]

Yes, of course. Matters for the spending review are just that, but one thing that the right hon. Gentleman, as a former Health Minister, will have noticed—and probably welcomed—in the long-term plan is that we are going to look at the commissioning of, and therefore the funding flow for, sexual health services as part of the long-term plan.