NHS Funding

Norman Lamb Excerpts

Monday 31st October 2016 Commons Chamber

[Mr Hunt]

I want to get the exact figures in order to live up to my hon. Friend’s reputation for plain speaking, which is second to none. The NHS budget in 2014-15 will be £98.1 billion and in 2021 it will go up to £119.9 billion. In real terms, that is a £10 billion increase.

[Norman Lamb (North Norfolk) (LD)]

Is there not an urgent need to be straight with the British public about the resources we will need to maintain both the NHS and the care system, and to confront the fact that we will all have to pay a bit more to ensure that our loved ones get care when they need it?

[Mr Hunt]

When the right hon. Gentleman and I worked in government, we both campaigned hard on many occasions for more funding for the NHS, including mental health—a particular priority for both of us. The answer to his question is yes, and that is why we are putting in more money in this Parliament. My own view is that in future Parliaments we will need to continue to increase the amount of funding going in to the NHS. The only point I would make is that what funds the NHS is a strong economy, so we have to make sure that increases in NHS funding are sustainable and compatible with a strong economy. That is something that this Conservative Government have a very good track record of delivering.

Health Service Medical Supplies (Costs) Bill

Norman Lamb Excerpts

2nd reading: House of Commons & Programme motion: House of Commons
Monday 24th October 2016 Commons Chamber

[Mr Hunt]

My hon. Friend is right about that. The nice way of putting it is that we are closing a loophole. If one were being less polite, one might say that it is a shame we are having to do that. None the less, it is important to do what we are proposing to the House.

We recognise that it has been some time since the Government consulted on the options, and I wish to reassure hon. Members and those companies in the statutory scheme that we will consult further on the implementation of a payment mechanism in the statutory scheme, including the level of the payment mechanism, before the regulations come into force. We estimate that 17 companies would be affected by the introduction of a payment mechanism, with the 166 companies that are currently members of the PPRS not being affected. Our proposals would save health services across the UK an estimated £90 million per year.

The second key element of this Bill amends the 2006 Act to strengthen the Government’s powers to set prices of medicines where companies charge unreasonably high prices for unbranded generic medicines. We rely on competition in the market to keep the prices of these drugs down. That generally works well and has, in combination with high levels of generic prescribing, led to significant savings. However, we are aware of some instances where there is no competition to keep prices down, and companies have raised their prices to what looks like an unreasonable and unjustifiable level. As highlighted by the investigation conducted by The Times earlier this year, there are companies that appear to have made it their business model to purchase off-patent medicines for which there are no competitor products. They then exploit a monopoly position to raise prices. We cannot allow this practice to continue unchallenged. My Department has been working closely with the Competition and Markets Authority to alert it to any cases where there may be market abuse and provide evidence to support this, but we also need to tackle it within our framework for controlling the cost of medicines and close the loophole of de-branding medicines. Although the Government’s existing powers allow us to control the price of any health service medicine, they do not allow controls to be placed on unbranded generic medicines where companies are members of the voluntary PPRS scheme. Today, most companies have a mixed portfolio of branded medicines and unbranded generic medicines. For that reason, all the manufacturers of the unbranded generic medicines mentioned in the investigation by The Times are able to use their PPRS membership to avoid government control of their prices.

It should be said that that practice is not widespread, but a handful of companies appear to be exploiting our freedom of pricing for unbranded generic medicines where there is no competition in the market, leaving the NHS with no choice but to purchase the medicine at grossly inflated prices or to transfer patients to other medicines that are not always suitable. Alongside the Government, many in the industry would also like to see this inappropriate behaviour stamped out.

[Norman Lamb (North Norfolk) (LD)]

I very much agree with the point that the Secretary of State has just made. He talked about collaboration with the CMA. Can he give any indication as to whether he expects action to be taken on abuse in the marketplace, given that a small number of companies have behaved appallingly?

[Mr Hunt]

I cannot give the right hon. Gentleman that indication because, as he will know, the CMA operates completely independently, and I therefore do not know what its findings are going to be. Of course, I would support any action that it recommended. I do, however, think that this Bill can give us some security in the House that if the CMA is unable to find evidence in the specific cases it has before it, we will be able to take action as a Government, provided the House is willing to support the Bill.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

This is an uncontroversial set of measures and I confirm my support for the Bill as it stands. The great strides in medical science over the past decade and beyond are obviously to be celebrated, with cutting-edge new treatments for life-threatening and life-shortening conditions, including a number of rare diseases and cancers, offering many people the hope of improved health, longer life and a quality of life that in the past would not have been possible. As well as the enormous benefits it brings to patients, the life sciences industry makes an incredibly valuable contribution to the UK, and it is only right that we acknowledge that today. However, there is an inevitable cost attached to the triumph of modern medicine, and the challenge is to ensure patient access to new treatments as quickly as possible, while ensuring value for money for the NHS.

The Bill seeks to address some of the shortcomings. It addresses clear abuses of the current system and I think that it will bring greater consistency to the existing arrangements for controlling the cost of medicines new and old. As I have said, I find myself in agreement with the proposals.

It is good that so many companies recognise their responsibility for keeping the branded medicines bill in check by signing up to the pharmaceutical price regulation scheme. Under the scheme, manufacturers pay a rebate to the Department of Health to cover expenditure on branded medicines above agreed limits. It is a responsible approach, helping to ensure that patients can benefit from access to novel drugs in a way that is sustainable for the taxpayer. However, I agree with the Secretary of State on the need to address the current disparity whereby the statutory medicines pricing scheme delivers lower savings than the voluntary scheme. Those differences are expected to widen, which is clearly not in keeping with the spirit of either arrangement, so it makes sense that they should be more closely aligned. As he said, we have to remove the incentive to shift from one scheme to another.

I particularly welcome the proposals to strengthen the authority of the Secretary of State to intervene where unbranded medicines are priced excessively. The NHS and patients benefit immensely from medicines, which were once available only at great public expense, becoming available far more cheaply after the patent expires and generic products come on to the market. We should recognise the great value that the competitive market brings, saving the NHS more than £13 billion every year, according to the British Generic Manufacturers Association, but we also know that the overall cost of generic items is increasing at a faster rate than branded items, and that there have been some outrageous increases, to which other hon. Members have referred, in the price of some individual generic drugs in recent years when there is only a single company producing that drug. It looks like a clear case of profiteering, where the NHS is being ripped off.

Let us be clear what the implications are when a particular company makes an excessive profit from increasing the price of a drug in that way. It means that other NHS patients, particularly those in more marginal areas that do not get the attention that they deserve, lose out. There is less money to spend on, for example, teenagers with mental health problems or learning disabilities. There is a price to be paid for that excessive profiteering. It is utterly unethical behaviour. I hope that the Competition and Markets Authority can find a way to take action against these companies, which appear to have constructed a business model to exploit the loophole.

As hon. Members have said, a number of generic medicines increased in price by more than 2,000% in the last decade. The most horrific example I have come across is a medicine that increased in price from £13.98 in 2005 to £632.96 in 2015, a rise of more than £600 per item dispensed. It is utterly despicable for any private company to think that it can do that. The Government are right to take action to end that outrageous practice.

Generics account for three quarters of prescription items dispensed in the community. In those cases where competition fails to deliver value for money, it is important that there are measures at our disposal to control prices and to tackle abuses that could place intolerable pressure on NHS budgets. It makes little sense that generic medicines can be controlled through the statutory scheme, but that the Government are currently prevented from stepping in when a company’s branded products are regulated through the PPRS. It seems clear that we should remove that anomaly. I should add that, in using these powers to introduce price controls, the Government should of course exercise caution and guard against any unintended consequences that may impact on the viability of smaller companies. I am sure that the Government will be alert to that.

The aims and provisions of the Bill are admirable, but it is only part of a much wider debate about how we can sustain access to groundbreaking new treatments when the NHS is in the middle of the longest financial squeeze in its history. One intervention from a Government Member on the Secretary of State drew attention to the fact that the total bill for drugs is rising at an unsustainable rate. The right hon. Member for Chelmsford (Sir Simon Burns) also raised this question, and we have to address that because the NHS will not be sustainable at the current rate of increase in cost.

It is no secret that the NHS has struggled to adapt to modern medicines, particularly those that carry a large budgetary impact. Both NICE and NHS England have had great difficulty in figuring out which medicines to approve and how those medicines are to be afforded and brought to patients. Recently, NHS England has delayed funding for the new hepatitis C treatment, so I was interested in the points made by the SNP representative, the hon. Member for Central Ayrshire (Dr Whitford).

We also have the ongoing and deeply unsavoury case of the PrEP, or pre-exposure prophylaxis treatment. Not only is NHS England taking its legal challenge to the bitter end to avoid having to pay for the drug, but there have been reports of it pitting patient groups against each other by saying that patients could miss out on vital treatments for cancer or rare diseases for children should PrEP be funded. We do not want to get into comparing the rights and interests of one group of patients against those of another in that way.

Earlier this month, NHS England and NICE launched a consultation on proposals to change the way some drugs are funded when there is a high cost involved. NHS England and clinical commissioning groups are legally required to fund drugs recommended by NICE as being clinically and cost-effective, normally within three months of the guidance being issued, barring unique circumstances. Under the new proposals, if NICE recommends a drug that will bring an estimated cost to the NHS above a certain amount—£20 million is the suggested figure—NHS England can go back to NICE and ask it for longer to roll out the medicine if it is unable to agree a lower price with the manufacturer. Surely that is precisely the opposite of what we ought to be trying to achieve as regards speedier access to new drugs that are coming on stream. Ignoring questions about how that somewhat arbitrary cost threshold was arrived at, there is a concern that this is a creeping step towards the rationing of approved treatments in the NHS. It seems to me to be an admission that the NHS cannot afford to pay even for the drugs that are found to be cost-effective by NICE; similar concerns have been raised by Nicholas Timmins, that highly respected observer who is a senior fellow at the King’s Fund.

The great worry is that opening up the debate on how quickly or slowly approved treatments can be adopted will put us on a slippery slope to a new discussion about whether approved treatments should be adopted at all, and at the very least UK patients will be further disadvantaged—the SNP spokesperson has already made the point that we compare very badly with other countries —and there will be more delays in getting access to new cost-effective treatments.

[Dr Philippa Whitford]

Does the right hon. Gentleman recognise that we are one of a tiny handful of OECD countries that allow that opening price to be set completely by the pharmaceutical industry and to be set as high as it likes?

[Norman Lamb]

I note that point. I suppose my overall point is that given the unsustainable increase in the total drugs bill and given the actions that NHS England and NICE appear now to be taking, it seems that we will be in a more difficult position in getting speedy access to new drugs that can be life-saving. The Government need to reflect on that. The hon. Member for Central Ayrshire made the point in her speech that this Bill tidies up things that have to be tidied up, but there is a much bigger debate about how on earth the NHS can afford vital treatments that in other countries patients are getting access to much sooner.

If we are approaching a situation in which we are unable to cope with new treatments that have been judged by an arm’s length expert body, NICE, to be clinically effective for patients and cost-effective for the NHS, it is yet more evidence that the NHS needs more resources, and I repeat again to the Minister—he will be sick of hearing me say it—that at some point the Government must recognise that they are simply drifting towards a crash with the NHS. We face an existential challenge that this evening’s debate has highlighted and that has to be confronted at some point. I urge the Government again to consider a cross-party approach so that we can ultimately achieve, in discussion with the public, a long-term and sustainable settlement for the NHS and care that recognises both this dramatic increase in the cost of drugs and that all our loved ones want to have access to those drugs in their hour of need.

We should also be mindful of the potential impact of Brexit on the life sciences industry and the additional challenges we face in keeping the NHS medicines bill under control. If trade between the UK and other EU countries becomes subject to customs duties, import VAT and border controls, thereby increasing costs to the life sciences industry, that might in turn drive up the costs of new medicines to the NHS, and impact on access for UK patients to the most innovative new treatments.

Finally, we also need to make sure that evaluation processes and methodologies are fit for purpose. Traditional appraisal methods and notions of cost-effectiveness are unsuitable for many modern medicines, especially for drugs of immense scientific innovation that target just a small number of patients, but the NHS has been slow to respond to that. The Cancer Drugs Fund is a case in point—established as a sticking plaster after a cluster of promising drugs were judged not to be cost-effective. While it is almost certainly the case that many of those treatments came with too high a price to be routinely funded, few would deny that they were being evaluated under outdated processes that could not fully capture their value. Many rare disease treatments suffer from the same problem.

Companies have a duty to ensure that their medicines are fairly priced, but NHS England and NICE also have a duty to make sure that their evaluation processes and decision-making criteria are fit for purpose, so that new medicines are given a fair hearing without some of the excessive delays we have seen in the recent past. We owe it to patients to make sure that happens.

I support this tidying-up measure and, in particular, the ending of the outrageous practice of a number of companies profiteering at the expense of NHS patients, but this debate has also raised a much bigger issue about how we in this country afford groundbreaking treatments that keep our loved ones alive.

Community Pharmacy in 2016-17 and Beyond

Norman Lamb Excerpts

1st reading: House of Commons
Thursday 20th October 2016 Commons Chamber

[David Mowat]

The access scheme to which I referred will apply to rural and urban pharmacies. Indeed, there is more urban than rural in it, but it will protect rural pharmacies in the way my right hon. Friend mentions.

[Norman Lamb (North Norfolk) (LD)]

There is no escaping the fact that this amounts to a significant cut in prevention services, which is what always happens when the finances of the NHS are under pressure. I absolutely accept the need for reform of the financial incentives involved, to ensure that we get the best outcomes from the money being spent, but surely we should be investing more in prevention in order to ensure that the NHS is sustainable.

[David Mowat]

The quality system that I have mentioned is about potentially investing more in prevention and linking the best pharmacies—the high quality pharmacies—more closely to local authorities, public health schemes and all that goes with that. I make the point again that there is a requirement for efficiency savings, but we do not believe that they will affect access overall. We do not believe that this will affect the public’s ability to use pharmacies as they do now. This will be part of modernising and digitising the service and providing resources for other parts of the NHS that need them very much.

Tobacco Control Plan

Norman Lamb Excerpts

Thursday 13th October 2016 Westminster Hall

[Alex Cunningham (Stockton North) (Lab)]

I beg to move,

That this House has considered the tobacco control plan.

It is a pleasure to serve under you chairmanship, Mr Brady. I am grateful to the Backbench Business Committee for granting us the opportunity to debate this issue in the depth and detail required. The subject has an impact on all of us, and it is right that time is allocated for a meaningful and thorough debate. I am also grateful to my colleagues from across the House who helped to secure the debate and who will, I am sure, make some incisive and insightful contributions.

I am pleased to have been part of the team that has consistently advocated tobacco control, and I am proud of the achievements we have made. The great thing about those achievements is that they have been built on strong cross-party commitment in both Chambers, with the devoted support and drive of external organisations and charities across the country that are determined to keep the harm caused by tobacco very much in the minds of the public and, of course, Ministers. Those organisations have succeeded.

A recent Action on Smoking and Health survey of more than 12,000 people found overwhelming public support for Government action to limit smoking and strong support for the Government to go further and do more. That is no surprise, really, as tobacco control is an area where Government action is highly effective.

Let me start with a parochial statistic. Back in Stockton, 250 miles up the road, smoking prevalence was estimated at 27.5%—more than one in four people—as recently as a decade ago. However, by last year various policies and interventions had seen that figure fall to 18.4%, which is a decrease of about a third. That means that some 14,000 fewer adults in Stockton now smoke than in 2005. I, for one, am very proud of that achievement.

I speak not only as a member of the all-party parliamentary group on smoking and health, the secretariat for which is provided by ASH, but as an MP who, as a humble Back Bencher, successfully pressed for the legal changes around smoking in cars when young children are present, with the support of groups including the British Lung Foundation, Cancer Research UK and the British Heart Foundation. That is on top of the principled and unwavering support I have received from north-east organisation Fresh, which covers my patch in Stockton North and whose joint conference on the harms of tobacco and alcohol I was pleased to address just a fortnight ago.

The dedication to improving public health and promoting tobacco control runs deep not only in my own psyche but in that of colleagues across the House. Back in 1998, the Labour Government introduced the country’s first comprehensive tobacco control strategy. Legislation has moved on since then to prohibit tobacco advertising, smoking in public places and smoking in cars carrying children, and to implement controls on point-of-sale displays. I welcomed all those measures, but I am only too aware that there is much more to be done.

The most recent measure was the introduction of standardised tobacco packaging, which I repeatedly called for and supported. Although the original form of the Children and Families Act 2014 contained no measures at all to protect children from the dangers of smoking or to avert uptake, the amendment on standardised packaging tabled in the House of Lords by Baronesses Finlay and Tyler and Lords Faulkner and McColl was swiftly taken up by the Government and brought to fruition.

In the spirit of debating the issues and the evidence base rather than the politics of any decision, I thank the previous public health Minister and current Financial Secretary to the Treasury, the hon. Member for Battersea (Jane Ellison), for her consistent support for tobacco control and, in particular, standardised packaging. That was duly recognised by her receipt of the prestigious World Health Organisation director general’s special award to mark World No Tobacco Day earlier this year.

A great deal was achieved under the previous plan, “Healthy Lives, Healthy People: A Tobacco Control Plan for England”. Progressive tobacco control legislation was introduced, and the three key ambitions of the plan have been achieved. Smoking rates among adults and children have fallen below the target levels, and rates of smoking during pregnancy reached the 11% target earlier this year. That illustrates perfectly why Britain is a world leader in tobacco control, with the UK coming top in a European survey measuring the implementation of key tobacco control policies and passing legislation that goes further than the requirements set out in European Union directives—perhaps that is one area in which we can expect no negative impact from Brexit. Yet there is still much to be done.

Smoking is responsible for approximately 78,000 preventable and premature deaths each year in England alone, and nearly 100,000 across the UK. In the north-east, the number of deaths from smoking-related diseases is some 30% higher than the English average. Despite the fact that we have hit the national targets on smoking prevalence laid out in the previous plan, stark variations in prevalence persist regionally and among different groups. A national tobacco control strategy should therefore be introduced without delay.

In her Downing Street speech, the new Prime Minister committed her Government to

“fighting against the burning injustice that if you’re born poor you will die on average nine years earlier than others”.

Half of that difference in life expectancy is solely due to higher rates of smoking among the least affluent members of our society, with smoking rates among those with multiple complex needs reaching as high as 80%. I am clear that we should all share that commitment.

In Stockton, just under 30,000 people smoke—that is just over 18% of the population. However, it has been estimated that 539 children between the ages of 11 and 15 start smoking in Stockton-on-Tees every year, with 964 people dying from smoking-attributable causes from 2012 to 2014. Shockingly, that is the equivalent of almost 5,000 years of life lost due to smoking. That death and disease is disproportionately borne by the poorest people in my area.

Although smoking rates among the adult population fell throughout the life of the previous tobacco control plan, health inequalities have remained stubbornly high. In 2013, for instance, smoking prevalence among people in the routine and manual socioeconomic group was more than twice that among the professional managerial group—28.6% compared with 12.9%. The picture is even worse for those who are unemployed, with smoking rates of approximately 35%. People earning under £10,000 a year are more than twice as likely to smoke as those earning more than £40,000 a year. The higher rates of smoking place a significant financial burden on poorer members of society. If the costs of smoking were returned to households, 1.1 million people, including more than 300,000 children, would be lifted out of poverty.

In Stockton-on-Tees, when tobacco expenditure is taken into account, almost 6,000 smokers fall below the poverty line, including more than 1,300 dependent children. Those innocent children not only suffer from the financial burden of their parents’ smoking but are more likely to be exposed to second-hand smoke and to try smoking themselves. We all know that those who grow up in a household where parents or siblings smoke are far more likely to become smokers themselves.

Those children may experience considerable peer pressure to start smoking, and tobacco is often more accessible to them in the community and at home, thus creating a cycle of inequality and leading to the life expectancy gap noted by the Prime Minister. Perhaps worse still is that when poorer smokers attempt to quit smoking, they are less likely to succeed than their more affluent peers.

To tackle inequalities, support to stop smoking needs to be specifically tailored to meet the needs of those in lower socioeconomic groups. Although the ambitions in the previous plan have been met and smoking rates continue to decline, they remain stubbornly high in disadvantaged sections of society. Further action is needed from the Government and the public sector to reduce smoking rates and associated health inequalities, and the new strategy is necessary to drive that action forward.

With that in mind, and given that the policy development work for a new tobacco control plan was in place for publication this summer, I would welcome the Minister telling us when the new plan will be published. I say to her that there is a standard to live up to, because the last time there was a debate about the plan in this room, the then Minister confirmed the timing of its publication. I hope we will hear about that in depth today.

Perhaps the Minister will also oblige the British Lung Foundation and outline the Government’s plans to prioritise lung health as an area for health improvement. Will she tell the House whether an assessment of respiratory health could be included in the NHS health check?

[Norman Lamb (North Norfolk) (LD)]

I am grateful to the hon. Gentleman for giving way, and I very much agree with what he is saying. He has talked a lot about inequality, which of course spreads beyond this country. I understand that some 80% of smoking deaths, which will rise to 8 million by 2030, are in lower and middle-income countries. Does he share my desire to see the Government publish the plan before the meeting in India in November? We could then see what the special fund for developing countries will be used for, because we need to have an impact there, too.

[Alex Cunningham]

I agree. With the huge proportion of deaths in lower-income countries, which are suffering even more than we are in this country, it is imperative that the report is published so that we can show a lead. We are a leading country, if not the leading country, on smoking control, and we must continue to demonstrate that.

As colleagues will be aware, stop smoking services are one of the most effective healthcare interventions. Smokers are four times more likely to quit successfully with the combination of behavioural support and medication provided by those local services. Significantly, smokers from routine and manual socioeconomic groups are more likely to access the support of stop smoking services, which have real potential and are an effective way of beginning to address health inequalities. In 2014-15, for example, more than twice as many smokers from routine and manual groups set a quit date with a stop smoking service compared with those in professional and managerial occupations. Such services are not only effective in supporting efforts to quit but can prevent the disability and distress caused by smoking-related diseases without the side effects of many of the drugs used to treat such diseases. Indeed, the National Institute for Health and Care Excellence considers smoking cessation treatment to be among the most cost-effective healthcare interventions.

Smoking cessation treatment is also cost-effective for those who already have smoke-related diseases. Take chronic obstructive pulmonary disease, for instance. Some 900,000 people in England have been diagnosed with smoking-related COPD, out of about 3 million sufferers. Some 25,000 people a year die from the disease, and the NHS spent £720 million on treatments in 2010-11. The British Lung Foundation estimates that in my constituency, people are as much as 60% more likely to be admitted to hospital with COPD than the UK average. We also discovered recently that the rate of lung disease in my constituency is the second worst in the country.

Yet COPD is a disease that is almost entirely preventable. Smoke is the cause of more than three quarters of COPD cases, and in this country exposure to such smoke is primarily through smoking. Although it is clearly better to prevent COPD through the provision of smoking cessation treatment to help smokers quit before the disease develops, that treatment can help improve quality of life even after the onset of COPD and is highly cost-effective compared with other treatments. Indeed, it is the only treatment that can prevent the disease from progressing in smokers. The cost of smoking cessation treatment for people with COPD is estimated to be £2,000 per quality-adjusted life year, whereas the cost of drug treatment for those with the disease ranges from £5,000 per QALY at the bottom end of the scale to £187,000 per QALY for triple therapy.

I am mindful that this is a co-operative debate with cross-party support, but I believe it is fair to highlight the impact of some of the Government’s economic measures on smoking cessation programmes. In 2014-15, despite all the evidence of their cost-effectiveness, approximately 40% of local authorities cut the budgets of their stop smoking services, with half of all services being reconfigured or recommissioned. It is not just local authority cuts that are happening; we are now hearing that clinical commissioning groups are also cutting funding for prescriptions to stop smoking medications and refusing to fund smoking cessation services.

Local authorities faced with huge cuts to their budgets are reducing investment not only in stop smoking services but in other areas essential to effective tobacco control. Trading standards staff, who are crucial to tackling illicit tobacco and under-age sales, are increasingly under threat. During the past six years, the total national spend on trading standards has fallen from £213 million in 2010 to £124 million today. Teams have been cut to the bone, with a 12% drop in staff working in trading standards since 2014, on top of the 45% drop over the previous five years identified by an earlier survey.

The importance of trading standards, working in partnership to deliver concerted multi-agency enforcement activity, is shown in my region, the north-east. After setting up a regional illicit tobacco partnership, the region has seen a significantly greater fall in the illicit tobacco trade than has been seen at national level, to the benefit of both public health and Government revenues. Between 2009 and 2015 the illicit market declined by more than a third in the north-east, from 15% to 9%, whereas the decline at national level was less than a fifth, from 12% to 10%.

Without sustained funding, such services are simply unable to continue to operate effectively. The new tobacco control plan therefore needs to prioritise cutting health inequalities rather than budgets, and in so doing must protect public health funding for tobacco control. I hope the Minister will confirm today that the Government will take steps to sustain protected funding for tobacco control, and will outline what those steps will look like.

I would similarly welcome hearing the Minister commit to bringing mass media spending in line with best practice evidence. Research has shown mass media campaigns to be highly effective in promoting quit attempts and discouraging uptake. In the UK, however, we are currently falling far below best practice spending on such campaigns. When funding was cut back in 2010 there was a noticeably negative impact on quitting, with a whopping 98% decrease in requests for quit support packs, a fall of almost two thirds in quit-line calls and more than a third fewer website hits. That should hardly come as a surprise, with year-on-year cuts seeing only £5.3 million spent on mass media in 2015, which is less than a quarter of the amount spent in 2009. Spending has actually declined further this year to £4 million. To make matters worse, it is not even clear how much, if any, of that budget is reserved for televised mass media campaigns.

This year’s annual Stoptober campaign, for instance, is being run without any televised advertising. Yet the evidence confirms that it is precisely such mass media campaigns that are essential to motivate quitting and to inform smokers of the useful resources provided by Public Health England to help smokers quit. Those campaigns, which discourage smoking and encourage quitting, are most effective when they are sustained and sufficient, with the best results being achieved when people are exposed to televised anti-smoking adverts around four times a month.

Again, I draw attention to my own patch and the “Quit 16” mass media campaign co-ordinated by Fresh and Smokefree Yorkshire and Humber, which focused on the damage smoking does to health. Some 16% of those exposed to the campaign, or roughly 53,300 people, cut down on their smoking. A further 8.4% made a quit attempt, and 4% switched to electronic cigarettes. That shows the clear impact that mass media campaigns have on triggering quit attempts and changes in behaviour, and the Government need to take such evidence seriously and commit to investing in mass marketing campaigns without delay.

Members will be aware that the decline in smoking prevalence in the UK since the first comprehensive strategy was published in 1998 has been comparable to that in Canada and Australia, both of which have consistently addressed the harms caused by smoking through comprehensive and sustained tobacco control strategies. Smoking prevalence has declined rapidly among adults and children in England since the Government first implemented such strategies from 1998. The latest figures show that adult smoking prevalence in England has declined by more than a third, falling from 27% in 1998 to 16.9% last year. The proportion of 15-year-olds in England who are regular smokers fell by two thirds between 1998 and 2014, hitting 8%, and the proportion of 11 to 15-year-olds who have ever smoked fell from 47% to 18% over the same period. Those are the lowest figures ever recorded for both adults and children.

None the less, smoking remains the leading cause of preventable premature death and the major reason for differences in life expectancy between the richest and poorest in society. Experience elsewhere shows what can happen if we do not review and renew our tobacco control strategy and ensure that it is properly funded. While the UK has seen a significant decline in smoking because of its comprehensive approach, the prevalence of smoking in France and Germany, which have not had any such strategies in place, has barely shifted over the last 20 years. We cannot rest on our laurels and assume that the long-term declines we have achieved will continue unabated if we do not take decisive action to review and renew our strategy.

On 14 September, Lord Prior committed the Government to publishing a new plan, with renewed ambitions to reduce smoking prevalence further and new ambitions on health inequalities and mental health. However, he would not commit to a publication date, so I repeat my appeal to the Minister to reassure Members across the House by filling that gap today. There is no clear reason to delay publication of a new plan further. If the Prime Minister’s ambition to reduce health inequalities is to be achieved, Ministers need a comprehensive strategy on tobacco control sooner rather than later.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

It is a pleasure to serve under your chairmanship, Mr Brady, and to follow the hon. Member for Harrow East (Bob Blackman). I find myself in agreement with everything he said. Anyone who has come here hoping to see violent disagreement and robust debate will be disappointed, because we all agree about the importance of this issue.

The hon. Gentleman talked clearly about the nature of this lethal product, which, as we have heard, kills 96,000 people a year across the UK. He also touched on the issue of the developing world. It is anticipated that 8 million people across our world will die from smoking in 2030, and that 80% of them will be in low or middle-income countries that do not have strategies to tackle the problem. Companies based in this country are selling this lethal product to the developing world and killing so many people. We need to be clear that that is shameful.

Many hon. Members, including the hon. Member for Totnes (Dr Wollaston) and the hon. Member for Stockton North (Alex Cunningham)—I congratulate him on all the work he has done and on leading this debate—have talked about the inequalities that are associated with smoking tobacco, including wealth and income inequalities. Smoking hits people from low-income communities much harder than others. As Members have said, smoking is about half of the reason for the difference in life expectancy between the richest and the poorest in our country.

I want to talk about another inequality, which the hon. Member for Harrow East touched on at the end of his contribution: the impact on people with mental ill health. A substantial part of the reason why such people, particularly those with severe and enduring mental ill health, die 15 to 20 years earlier than others is higher smoking rates. Here’s the thing: we have been very successful in this country—I will come back to this in a moment—at reducing the smoking rate. Public health strategies have worked effectively, although we all recognise that there is much further to go. But as the smoking rate has come down in the population as a whole, it has remained stubbornly high among those with severe and enduring mental ill health; there has been hardly any shift at all. That has been a failure of public health strategies.

Back in 2013, when the smoking rate across the population was 21%, it was 40% among those with severe and enduring mental ill health, 60% among those with psychosis, and 70% among people in in-patient care. We can start to see why those people end up dying so much earlier than everyone else. That amounts to a neglect of those people’s need for support in combating this highly addictive product, and it makes me absolutely driven—as is everyone else in the Chamber—to do more to combat the problem.

Let me come back to the successes of smoking cessation strategies. I join other hon. Members in congratulating the hon. Member for Battersea (Jane Ellison) on her work. The hon. Member for Harrow East was right; there are Government Members who take a different view. I remember hearing the hon. Member for Battersea speaking and wanting to tell her to watch her back, because there were quite a few Members behind her who took a different view. She was brave in standing her ground, particularly in pursuing the plain packaging policy. The right hon. Member for Rother Valley (Kevin Barron) has a plain packet in his pocket. The previous Government were in my view a coalition Government, not a Conservative-led Government; the Liberal Democrats played our part in important strategies such as plain packaging and ending smoking in cars with children on board, which will have a big impact on saving people’s lives.

It is imperative that the new strategy is published and becomes operational. Given the leadership role that we have played for so many years, it is important that we go to the meeting in India in November and demonstrate our continued leadership. If there is any way for the strategy to be published before that meeting, and for it to include a focus on how we will use the fund that has been established for combating smoking in developing countries, I urge the Minister to do everything possible to ensure that that happens.

Let me speak a little more about what the tobacco control plan needs to include. I come back to what I said about mental health, which the plan needs to address directly. I do not know whether the Minister has seen the iterations of the plan, which we hope will be published soon, but I hope very much that it will address directly the failure of public health strategies to reduce smoking among people with mental ill health. The plan needs to focus on the recommendations of the report “The Stolen Years”, which was published by ASH and produced in collaboration with the Royal College of Psychiatrists, and its ambitious targets for reducing smoking among people with mental ill health. We can no longer fail to confront the failure of past strategies in that respect. Interestingly, that report highlights the therapeutic benefits of stopping smoking for people with mental ill health, not only for their physical health but for their mental health. Ironically, many people with mental ill health smoke because they see it as an escape from the pain that they are suffering and a way of coping with stress, yet smoking increases stress and the risk of aggression, particularly in in-patient services.

[Kevin Barron]

I went to the launch of that report. Some 70% of people who are discharged from mental health secure units smoke, yet we have in our midst a product—e-cigarettes—that could have been designed to be put into such institutions, some of which are now putting e-cigarettes on their shopping lists. That would allow people to satisfy their addiction without creating secondary smoke and the many ailments that occur when people smoke. Does the right hon. Gentleman agree that we need more leadership to ensure that e-cigarettes can be used in institutions where, for control reasons, it is difficult to keep the customer satisfied, as it were?

[Norman Lamb]

I completely agree. If we want to focus effort where it is most needed and where smoking rates are highest, we should focus on those very mental health institutions. As well as making vaping available for people who need help to give up smoking, we need to do much more to focus on training staff in such institutions so that they know the importance of smoking cessation being one of the objectives in the care of individuals there, because of its potential therapeutic benefit.

I should also mention the move towards smoke-free in-patient settings, a strategy that I supported as Minister and that I am pleased is continuing. Guidance was published by Public Health England and NHS England in June 2015, and that strategy is having a beneficial effect on the environment in in-patient settings by reducing aggression and stress and improving physical and mental health. I encourage the Government to keep pursuing that objective.

On electronic cigarettes and vaping, although I was a committed remainer in the EU referendum debate, the tobacco products directive is flawed, because it takes an inappropriately tough approach to electronic cigarettes. I therefore hope that the Government will review that directive regularly. One of the potential benefits of leaving the EU—there are not many, in my view—is that we will gain the ability to differentiate more between the effective regulation on tobacco in that directive and the regulation on electronic cigarettes, and do much more to recognise the evidence that already exists, as the right hon. Gentleman has made clear, on the benefits of electronic cigarettes.

I will end by saying something about public health funding. The hon. Member for Totnes made the point clearly, and I totally share her view. The Health Committee has pointed out that the £8 billion or £10 billion that we keep being told will be given to the NHS by 2020 is actually nearer £4.5 billion. Extra money is being found for front-line NHS services partly by cutting other parts of the Department of Health budget, including, distressingly, public health and health education. As she said, that is completely counterproductive. When NHS finances get tight, crisis management takes over. The hon. Member for Stockton North made the point that CCGs are focusing on propping up established traditional services—the repair services, as it were—and in so doing, tragically, are cutting the prevention services that prevent people from ending up needing care in the first place. That is so counterproductive. A new settlement for the NHS and the care system, which I keep calling for, must recognise the imperative to invest more in prevention and public health, particularly given that there is so much evidence that that has a beneficial effect.

--- Later in debate ---

[Norman Lamb]

On the adequacy of public health budgets, does the Minister think it is rational in any way to increase in real terms the budget for the NHS while reducing in real terms the budget for public health?

[Nicola Blackwood]

Prevention is a core part of the NHS five year forward view and should be embedded in NHS funding, public health funding and social care funding, as the right hon. Gentleman has stated. We are looking for the STPs to show a joined-up plan for how prevention, acute delivery services and social care will work together. PHE can and does advise and support local councils to tailor their services effectively, but we need to see how we can improve that. The local tobacco control profiles are one way in which we are doing that, but we must ensure that we see some of that work implemented.

At national level, to help drive a reduction in variation, the Government are committed to publishing the new tobacco control plan that all Members have mentioned, which has tackling inequalities at its heart. The plan will build on our success so far and will include renewed national ambitions. We have to maintain the proactive, comprehensive and non-partisan approach we have seen so far. The UK is recognised as a world leader in tobacco control strategy, and we intend to maintain that. However, I am afraid that on this occasion I will not be able to match my predecessor by announcing the date of publication. [Hon. Members: “Oh!”] I know; I feel inadequate.

My hon. Friend the Member for Harrow East is right in identifying my desire to ensure that the plan is evidence-led. It is reasonable for a new Government to want to check that the plan offers the best possible strategy, based on evidence. On something as important as a tobacco control plan, which is a golden moment, we have to ensure that we do not publish the plan until we get it right. It has been valuable to have the opportunity to listen to and engage with this debate, so that I can hear from colleagues as expert and engaged as those present before going forward. I assure all Members that the Government see the issue as a matter of urgency and are pressing forward with the plan as quickly as possible. I will certainly take away the suggestion from the hon. Member for Stockton North about incorporating respiratory health monitoring into the NHS health check.

I would like to go through a few of the points that we have discussed before I finish. As I have highlighted, it is right to turn our focus to population groups in which smoking prevalence remains higher than elsewhere. In particular, we must turn our attention to reducing health inequalities in populations who already suffer from poorer health and social outcomes, such as those in routine or manual occupations or those who suffer from mental health conditions.

As my hon. Friend the Member for Totnes said, improving maternity outcomes and giving children the best start in life is an important priority for this Government, and supporting pregnant women to quit smoking will be an important factor in working towards that. We all know that smoking during pregnancy increases the risk of stillbirth, as the shadow Minister said, and of problems for a child after birth. We also know that babies born to mothers who smoke are more likely to be born underdeveloped and in poor health. Tackling that was a priority under the previous tobacco control plan, during the period of which smoking prevalence among that group fell by three percentage points, but more can be done to reduce it further and, most importantly, to tackle the variation I mentioned. We will look at that.

Alongside limiting babies’ exposure to smoke during and after pregnancy, we must continue to work to end the cycle of children taking up smoking in the first place. As the percentage of 15-year-olds who regularly smoke has fallen to 8% and continues to fall, we must press our advantage and work towards our first smokeless generation. That would be something that we could genuinely be proud of. Restricting access to tobacco remains key, and we will want to maintain the enforcement of measures mentioned today, such as age of sale laws. Evidence shows that children who have a parent who smokes are two to three times more likely to be smokers themselves. Continuing to support adults to quit is therefore vital to ending the cycle of children taking up smoking and must remain a key part of tobacco control in the future.

In order to achieve our ambitions for the population groups I have mentioned, and to reduce smoking prevalence across all populations to even lower rates, we have to continue to draw on the things that we know work. This is an area in which we have a strong evidence base, and that work will include continuing a programme of evidence-based marketing campaigns such as Stoptober and monitoring the evidence base for e-cigarettes.

Finally, the right hon. Member for North Norfolk is right to say that tobacco use is a global issue and an international priority. Our new tobacco control plan will need to reflect that. As a world leader on tobacco control, the UK will continue to work closely with others to reduce the burden that smoking places on individuals, families and economies across the globe. As he said, we are investing official development assistance funds over five years to strengthen the implementation of the WHO’s framework convention on tobacco control. The project will be delivered by the WHO, and through it, we will share the UK’s experience in tobacco control to support low and middle-income countries to put effective measures in place to stop people using tobacco. That will happen through capacity sharing. We will carefully monitor the progress of that initiative to ensure that it delivers results, using very effective evaluation measures. I am happy to have further discussions about that with the right hon. Gentleman, if he would find that helpful.

We can be proud of the progress that successive Governments have made on helping people to quit smoking, preventing them from starting in the first place and creating an environment that de-normalises smoking. With prevalence rates at an all-time low, there is no question that good work has been done, but as the issues raised in this debate clearly show, there is more work to be done. The Government are committed to doing that work as a matter of urgency. I will take away the comments made today, which are incredibly helpful to me as a new Minister, and I will ensure that as we finalise the new tobacco control plan—

Oral Answers to Questions

Norman Lamb Excerpts

Tuesday 11th October 2016 Commons Chamber

[Mr Dunne]

The hon. Gentleman has a consistent track record in opposing PFI, even when the vast majority of the schemes were put under contract by the Government of which he was a member—so I will not take any lectures from him about how to deal with PFI. We will continue to use the new stricter terms as and when appropriate.

[Norman Lamb (North Norfolk) (LD)]

The National Audit Office concluded that the PFI contract for the Norfolk and Norwich hospital was a bad deal for the taxpayer and for the NHS, yet last year Octagon Healthcare made a record profit as the Norfolk and Norwich’s finances sank ever further into the red. Will the Minister consider making a formal approach to Octagon Healthcare to ask it to forgo part of its profit to help confront the enormous financial black hole that the trust faces?

[Mr Dunne]

We have provided access for seven of the worst affected trusts with obligations under PFI to a support fund of some £1.5 billion to help them with those obligations. I am not sure whether Norfolk is one of them; I suspect that it is not. I would be happy to talk to the right hon. Gentleman about this, but rather than raising his hopes inappropriately I have to say to him that many of the schemes are too costly to divert resource to pay them off completely.

NHS Sustainability and Transformation Plans

Norman Lamb Excerpts

Wednesday 14th September 2016 Commons Chamber

[Ms Abbott]

That is the reason for the secrecy thus far. The Government know that if the public understood what STPs meant, there would be an outcry.

[Norman Lamb (North Norfolk) (LD)]

Does the hon. Lady agree that unless the local community are fully engaged in the process of considering how the health and care system needs to change their area, the process is destined to fail and simply will not work?

[Ms Abbott]

I am grateful to the right hon. Gentleman. For nearly the whole time I have been in Parliament, there have been attempts to reconfigure hospitals and close A&Es and make other changes in London. We have found that when the local community does not take ownership of the plans, it is impossible to take them forward. That secrecy runs counter to making the reorganisations we might have to make.

--- Later in debate ---

[Mr Dunne]

I am delighted to accept that invitation from my neighbour and friend, not least because many of my constituents look to Hereford County hospital for their acute care, but also because it is one of the hospital trusts that are in special measures, which is my specific responsibility. I look forward to seeing my hon. Friend there, perhaps even during the coming recess.

[Norman Lamb]

I wish the Minister all the best in his new role. Does he share my concern about the evidence from around the country that in many areas mental health is peripheral to the STP process? Will he ensure that no STP plan will be accepted unless mental health is central to it?

[Mr Dunne]

I am grateful for that intervention from the right hon. Gentleman, who has taken such a personal interest in this subject. I can confirm that mental health is one of the issues that will be addressed in each of the plans that will be taken forward. I hope that reassurance helps.

--- Later in debate ---

[Dr Whitford]

I totally agree with the hon. Gentleman. I was about to come on to that. However, it is not just the funding, but the entire model. The tariff model that we have at the moment rewards hospitals for doing more minor things, and punishes them for doing more acute things. Taking on more A&E cases and more complex cases, working harder and doing more make their deficits grow. Our problem is that we have all sorts of perverse incentives in the system that mean that organisations will still be looking out for their budgets and their survival instead of working together.

In Scotland, we got rid of hospital trusts and primary care trusts, and, since 2014, we have had integrated joint boards. Those boards were handed joint funding that came from health and the local authority, which meant that the whole business of “your purse or my purse” disappeared. They were then able to start to look at the patient’s journey and the best way to make the pathway smooth. That is what we want to see.

Having a shared vision of where we are trying to go to is crucial. That means that stakeholders—both the people who work in the NHS and the people who use it—need to believe in where we are trying to get to. Public conversations and public involvement are the way forward. We should not be consulting on something that has already been signed off, but involving people in what they would like the plans to be, as that would make those plans much stronger.

We need to make deep-seated changes to the system, as opposed to only talking about the money for the deficits. This is something that the Health Committee has been talking about for ages. The phrase “sustainability” has become shorthand for paying off the deficit. Of the £2.1 billion earmarked for sustainability and transformation, £1.8 billion is for deficits, which leaves only £300 million to change an entire system. I know that we talk about money a lot in here, and of course it is important, but we have far bigger sustainability issues than the £2.5 billion deficit in the NHS. We have an ageing population, and those people are carrying more and more chronic illnesses, which means that we have more demand, more complexity and more complications. That is one of the things that is pushing the NHS to fall over. On the other side of that, we have a shortage in our workforce; we do not have enough nurses or doctors, and that includes specialists, consultants, A&E and particularly general practitioners. Although the advice has been very much that finances were third, and prevention and quality of care were meant to come first and second in delivering the five year forward view, finances seem to be trumping everything else.

It is absolutely correct that health is no longer buildings; there are lots of methods of health that are bringing care closer to patients, and also some things that are taking patients further away from their homes. We have hyper-acute stroke units, and we have urgent cardiac units, where they will get an angiogram and an angioplasty that will prevent heart failure in the future. However, we cannot start this process there; we cannot shut hospitals and units to free up money to do better things. We have to actually go for the transformation and do the better things first. We have to design the service around the pathways we need—that wrap-around care for patients—and then work backwards. If more health and treatment is coming closer to the patient, at some point they will say, “Actually, I don’t go to the hospital very often. I want the hospital to have everything it needs when I need it.” Then we can look at the estate to see whether we have the right size of units and the right type of units in the right place. What concerns me is that the process we have seems to be the other way around—we are starting with hospitals, which is often a very expensive thing to do, and hoping it will deliver everything else.

[Norman Lamb]

rose—

[Dr Whitford]

I give way to Norman.

[Norman Lamb]

I am grateful to the hon. Lady for giving way, even if she used my first name. Does she share my concern that, out of the original sum allocated for this sustainability and transformation process, the vast bulk appears to be going, in effect, to propping up acute trusts that face substantial deficits, and that little is available for transformation?

[Dr Whitford]

As I said, the proposals leave only £300 million. We cannot transform a system on the scale that is being considered with £300 million.

As I said, the guidance talks about prevention. We need to be tackling health inequalities. We need to be focusing on health and wellbeing—and by that I do mean physical and mental wellbeing. We need to be strengthening public health—something else that has been cut. We need to be looking at the quality of health and care, and that means right across into social care. We must fund social care, because it can make a difference to things like delayed discharges. We are not even three years into the integration in Scotland—we are only two and a half years into it—but delayed discharges have dropped 9%. Yet, the last time the Secretary of State was in the Health Committee, they had gone up 32% in NHS England. So literally just moving things around and allowing one part of the system to fail will mean that the entire system fails.

--- Later in debate ---

[Norman Lamb (North Norfolk) (LD)]

I want to start by saying that I very much agree with the point made by the hon. Member for Central Ayrshire (Dr Whitford) that this ought to present a real opportunity. It has brought people together, and discussions have started across organisations that in the past have not talked to each other nearly enough—both across the health and social care divide, and also bringing in people from outside the health service and social care system—but I fear that the opportunity will be fatally undermined for three central reasons.

First, there is the point that I made in my challenge to the Minister, on mental health: unless every STP addresses the burden of mental ill health in every community centrally as part of its plan, it will fail. There is no doubt about that. I noted the Minister’s attempt to reassure me, but the parliamentary answer I received recently did not reassure me, because it appears that it is not going to be a requirement that every plan must centrally address this problem. I understand that the more developed plans will do so, but if this is not done, it will absolutely fail. We are dealing often with some of the people who are failed most by the system, and who use A&E departments more than any other people, yet my fear is this will be a massive missed opportunity in that regard.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

I thank the right hon. Gentleman for giving way, because I want to make the point again—I will say it very clearly—that if an STP does not come forward with very clear plans as to how the mental health and dementia programmes are going to move forward quickly, it will not go ahead. That cannot be clearer.

[Norman Lamb]

I am grateful to the Minister for that, and I hope that that message goes out across the country, because Andy Bell from the Centre for Mental Health today has again raised concern about the process in many parts of the country.

The second issue that causes me very real concern is the financial backdrop and the ability to deliver on the plans given the finances that are available. We have already heard that the bulk of the money that is available is going into clearing the deficits of providers, rather than into the transformation that is so necessary in order, as the hon. Member for Spelthorne (Kwasi Kwarteng) made clear, to spend money more efficiently and effectively in delivering care for our communities.

Chris Ham, chief executive of the King’s Fund and a well-respected commentator, says that its assessment of the draft plans

“shows that, in the absence of eye-watering efficiency improvements, there will be a financial gap running into hundreds of millions of pounds by 2020/21 in most of the footprints”—

not across the country, but in most footprints. This is completely unachievable, and he questions the deliverability of plans which include the closure of cottage hospitals in many areas—the very things that can keep people out of acute hospitals, yet we are planning in many areas to close them down. This seems to me to make no sense at all.

There is a related concern about governance. Currently in the NHS we regulate organisations, not systems, so within an STP footprint every organisation still has to focus on its own financial survival, rather than looking at the best approach for the entire health and care system in that locality. I fear that that in itself will be a central flaw.

Finally, there is the question of openness and transparency. I note the point that there will be a consultation process, but let me just tell the Government that if they really think that a formal consultation process after full draft plans have been produced in a secret process will in any way convince the public that they are being properly involved, it will fail. It is inevitable that it will fail. People are so suspicious of consultation processes that they simply do not believe that they are being properly engaged in them.

The hon. Member for Spelthorne made a good point: people are often prepared to go on a journey. They are prepared to listen to potentially radical changes and potentially to use money more effectively, but the only way they will do that is if they are involved from the start—involved in shaping the proposals, rather than responding to something that has been fixed behind closed doors. The hon. Member for Bedford (Richard Fuller) knows full well how the public react when they are presented with what looks like a fait accompli. If the public are not involved in the development of plans to close cottage hospitals, to slim down acute hospitals and to merge hospitals around the country, we should be in no doubt that those plans will be rejected. The Government will be facing a political disaster if they plough on in this way. They must, for example, open up and involve the non-executive directors, who have been told that they cannot even be part of the discussions. That is ridiculous. For goodness’ sake, if we are to take people with us, we have to take them on a journey, engage with them and involve them in the plans.

[Matthew Pennycook (Greenwich and Woolwich) (Lab)]

rose—

[Norman Lamb]

I will give way very briefly to the hon. Gentleman—[Interruption.] I am being given a clear signal by Mr Deputy Speaker that I should not—

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. You have only 30 seconds to go.

[Norman Lamb]

I take your point, Mr Deputy Speaker, and I am sorry for my ill discipline.

I will conclude by saying that this is the right approach but it will be undermined because of the rushed process which does not involve the public, because it does not take people with it on the journey and because there is not enough money to deliver the transformation that is required.

[Several hon. Members rose—]

Psychosis: Early Intervention

Norman Lamb Excerpts

Wednesday 7th September 2016 Westminster Hall

[Norman Lamb (North Norfolk) (LD)]

I beg to move,

That this House has considered access and waiting time standards for early intervention in psychosis.

It is a pleasure to serve under your chairmanship, Sir Roger. May I welcome the Minister to her new role? I spent a great two and a half years in the Department of Health; it was the most invigorating time in my life. I wish her every success.

The debate is on something that I care a lot about: a new standard of access for people who suffer a first episode of psychosis, a cruel and punishing condition that can have a massive impact on people’s lives—incidentally, at enormous cost to statutory services. When I came into my role as Minister, I recognised that there was a complete inequality of access, standards and rights between those who suffer from mental ill health and those who suffer from physical health problems. That inequality of access has existed for many years. In the last decade, the Labour Government introduced comprehensive access standards in the NHS for physical health problems, and they were right to do so—the cancer standards that have transformed cancer care in this country are a leading example of those—but they left out mental health.

It is not just that individuals sometimes end up having to wait interminably for treatment in some parts of the country; that complete imbalance of rights between mental health and physical health drives where the money goes. There is enormous political interest in meeting those demanding access standards. The national media look at the four-hour A&E standard. Certainly in my time in the Department of Health, all the great and the good of the NHS gathered around the Secretary of State’s table every Monday morning to look at spreadsheets showing the performance of every hospital in the country against those access standards. That extraordinary almost micro-management from the centre on access standards in physical health sets the tone for the whole system and makes it clear that meeting them is critical. So what do clinical commissioning groups around the country do? They trim a little bit off funding for mental health, which is still funded primarily through block contracts, to feed the beast of those exacting access standards in physical health.

I was determined from the start to address that injustice—that is what it is; it is a discrimination at the heart of our NHS—and introduce access standards in mental health. We went through a long deliberation before coming up with two specific standards, which were set out in a Government document published in October 2014, that we wanted to introduce as the start of a process that would lead ultimately to comprehensive access standards in mental health so that everyone with a mental health problem had the same right to get treatment in our NHS as anyone else.

The first standard that we identified was a six-week standard for access to psychological therapies. That is part of the improving access to psychological therapies programme, a well-regarded, world-leading programme that does not do everything but has been a significant development. The other was a two-week standard to start treatment when someone suffers a first episode of psychosis. Those people are typically teenagers or perhaps in their 20s—that is the most common age—but such an episode could happen at any time in one’s life.

[David Simpson (Upper Bann) (DUP)]

I congratulate the right hon. Gentleman on securing this very important debate. He has hit somewhat on the point that I was going to raise about early intervention. At what stage does he believe that we should deal with this condition? He talks about 18 or 20-year-olds, but should we go right back to primary or secondary school and deal with it in younger children?

[Norman Lamb]

We should always be guided by clinical judgment. That is critical. The standard that was introduced was for people between the ages of 14 and 65, which gives a clue about the appropriate level. This condition could emerge during teenage years, but we know that 50% of adult mental health problems start by the age of 14, so getting in and addressing problems early is critical.

[Dr Lisa Cameron (East Kilbride, Strathaven and Lesmahagow) (SNP)]

I thank the right hon. Gentleman for securing this important debate. Does he agree that although not everyone will suffer mental health problems in childhood, it is important that mental wellbeing is focused on in schools—both primary and secondary—to ensure that good mental health is promoted?

[Norman Lamb]

I thank the hon. Lady for that intervention, because I totally agree. When I was Minister, we set up a taskforce to look at how we could modernise children’s mental health services. It published a report last March called “Future in mind,” the whole focus of which is on shifting fundamentally towards prevention: establishing wellbeing, particularly in schools, and intervening much earlier to stop deterioration ever happening. That approach is much more effective. It can help teenagers through difficult years as they grow up, but it also stops the enormous cost to the system later of neglecting those problems.

Psychosis costs the NHS £11.8 billion a year. That is a vast cost. Only 8% of people who suffer from psychosis are in work, so the cost of the illness to society is enormous. The evidence of the effectiveness of early intervention in psychosis is overwhelming. It is clear that if we intervene quickly, we can have an impact on that condition, stop it in its tracks and give sufferers the chance of a good life, which the rest of us take for granted. If we neglect the condition, those people will almost inevitably suffer lives on benefits and with difficult relationships, at—this is critical—enormous cost to the state. Analysis shows that if we invested £1 in services for early intervention in psychosis, the return on that investment over a 10-year period would be £15. We might ask, “What is the reason not to do that?” It is overwhelming common sense. It is both morally right and the economically sensible thing to do.

[Johnny Mercer (Plymouth, Moor View) (Con)]

I pay tribute from the Government Benches to the immense work that the right hon. Gentleman did in government, and to my right hon. Friend the Member for North East Bedfordshire (Alistair Burt), who is no longer in his former position as Minister. Does the right hon. Gentleman agree that it is not acceptable to talk about parity of esteem unless that is matched by parity of provision and parity of funding so that those who suffer from mental ill health have the same provision as those who suffer from physical ill health? Parity of esteem means nothing to our constituents unless we actually deliver it.

[Norman Lamb]

I am grateful to the hon. Gentleman for his kind comments. I totally agree. There is an awful danger of a damaging gap emerging between the rhetoric and the reality. The coalition Government legislated for parity of esteem, so it is in the legislation that people should be treated equally, but unless the reality of people’s experience is that they are treated equally, the rhetoric is absolutely meaningless waffle and they lose trust in the Government. That is why I feel so passionately that we must do concrete things to make parity of esteem a reality for people, and that is an example of how we can make a difference to people’s lives.

The standard was announced in October 2014, to be implemented by April 2016—it had to be met by this year. Why is it so important? If we fail on that, we fail so many people whom we have the chance to help and surely it would be scandalous if the NHS neglected a standard accepted by Parliament and introduced by Government that we know makes a massive difference to people’s lives. It gives people the chance of a better life and surely the NHS is fundamentally about giving people the chance to have happy, good lives.

What has happened in that period? We undertook a comprehensive Freedom of Information Act survey—now that I am out of government, I have to rely on such surveys to find out what is going on—and the answers from clinical commissioning groups and mental health trusts are deeply troubling. On the key findings, first the overall conclusion is that the implementation of the standard is just fundamentally flawed. It has failed to deliver what we committed to. If the Minister, on advice from her officials, is tempted to refer to the nationally published data that suggest that the standard is being met, I would discourage her from doing so because the data are a fiction—we have established that through our work.

The first detailed finding is that there is a complete lack of robust commissioning in many parts of the country. The whole purpose of the commissioner-provider split, which of course is fairly controversial in the NHS, is that the commissioners hold the money and are there to design services for their community to meet the needs of that community, yet a third of CCGs could not identify how much funding had been allocated to early intervention in psychosis. That in itself is scandalous. They just say that there is a block contract and that it is up to the mental health trust—a total abdication of responsibility. Later, I will ask what the Government are doing about that, because that is not acceptable and completely contradicts the national guidance that was published.

Incidentally, I should say that one of the excuses used around the country for slowness of implementation is that the final guidance was published in April this year—when the standard was supposed to have been met. That does not demonstrate particularly helpful leadership from the centre. Having said that, the draft guidance had been in place for the best part of a year, so clinical commissioning groups around the country knew the direction of travel and could absolutely have been getting on with the job of preparing for meeting the standard.

When we did the survey back in May and June, well into the financial year, another 18 clinical commissioning groups—that is 11%—were still in negotiation for funding for early intervention in psychosis for a standard that was supposed to have been met in April. The question I will keep repeating is: why is that is not being treated with the same seriousness as the cancer standards? Why do we treat that as less important than someone suffering from cancer? I absolutely support and endorse the cancer standards, because it is critical that people with cancer get access to treatment quickly, but why should not someone with psychosis? It is scandalous. No one stands up for them. The Government have to lead on that. More than one in three clinical commissioning groups could not provide an estimate of the number of people in their area in need of early intervention services, in spite of the national guidance that says that commissioning should be underpinned by estimates of the local incidence to ensure that services are designed to serve the needs in a particular locality fully. If CCGs have no idea because no work has been done to establish the need in that area, how on earth can they commission a service to meet that need?

Next, according to NHS England, the estimated annual cost of providing the full package of treatment is about £8,250 per patient per year. Only 60 CCGs in our study were able to estimate their investment at all and only 11 estimated that they will meet the NHS England guideline on the level of investment. The average investment per patient from those who were able to say was £5,199, but of course an average hides the fact that many are way below that level. To draw an analogy, that is like saying to a cancer patient, “Well, you can have the chemotherapy but we can’t afford the radiotherapy, so you’ll have to put up with what we can offer.” Of course, we would never allow that to happen—the Daily Mail and many others would be up in arms, and they should be about this issue as well because the situation is exactly the same.

On age, which the hon. Member for Upper Bann (David Simpson) raised earlier, as I said in response to his intervention, the access standard is to provide the service to people between the ages of 14 and 65, in line, I should say, with guidelines from the National Institute for Health and Care Excellence, which has done the work and provided the evidence-based guidance. Almost a quarter of trusts—23%—commission services only up to the age of 35, including my own county of Norfolk. How on earth can trusts justify anyone over the age of 35 not getting access to a service that we have deemed it appropriate to provide to people across the country? They are just ignoring the national guidelines. Again, that seems to me to be completely unacceptable. That totally conflicts with the clinical commissioning groups’ responsibility. Out of the 39 CCGs which commission only up to 35, nine said they had plans to expand the service—they have plans, but why are they not doing it now?—and another 10 said that that was under review, but the rest had no plan to provide a service to people over 35. Outrageous, in my view.

Next is staffing and skill mix. We found a widespread failure to provide the full range of interventions required by NICE as part of the package of treatment, which is due to the shortage of staff with appropriate skills to deliver the service. Most trusts reported shortages of staff trained in cognitive behavioural therapy for psychosis and there were many other training shortfalls.

On data recording, NHS England introduced new information standards to support the monitoring of standards so that we could have some confidence that they were being met. Providers are expected to use electronic care record for patients to enable the collection of data and monitoring of performance against the standard. The guidance says that commissioners should assure themselves that local providers have made the necessary updates to the electronic care record system to ensure that clinicians are able to enter the data required to monitor performance against the standard, but we have heard that many trusts have not upgraded their systems and so are incapable of doing what is in the national guidance. We talked to someone who was at the heart of the implementation of the standard in one part of the country who mentioned widespread failure to do that. That means, as I said earlier, that the national data published by the information centre, which we are all supposed to rely on to tell us what is happening in the NHS, cannot be relied on. I put this point to the Minister: can the information centre investigate that further to ensure that the data it publishes tell a true story of what is going on?

There was also a scandalous variation between regions. I met the woman who has been responsible for implementation in the southern region. She was driving a programme of implementation and had a complete handle on the whole of her region. She had enormous variation of performance across her region, but there was someone in charge, doing it. She was an impressive woman. She told me that she was being made redundant; she was told that her job was done, even though palpably it is not. However, in other regions there has been no programme of implementation—no one in charge, to take responsibility for making things happen. The situation in the midlands and east in particular is in my view a disgusting, outrageous shambles, which should not be tolerated.

[Mr Gregory Campbell (East Londonderry) (DUP)]

I congratulate the right hon. Gentleman on securing the debate. On several occasions he has talked about this important matter in the context of the entire country; he is now discussing comparisons. Does he agree—I have raised this issue on a number of occasions, particularly on health matters—that we need to ensure that best practice is replicated not just in local commissioning groups in England, but across the United Kingdom? Ministers would then share information across the devolved settlements, to ensure that best practice was replicated and improved on for all our citizens.

[Norman Lamb]

I very much agree. We should all be learning from each other—and internationally, as well; but so often we fail to do that in the NHS. People on the outside may think that the NHS is a Stalinist organisation where everyone does the same thing. Far from it—it is too often anarchic. In the context of the NHS England infrastructure that we are considering, there are regions of the country that just have not done their job as they should have, which is scandalous.

[Johnny Mercer]

Does the right hon. Gentleman agree that it is not good enough simply to understand an experience—because it affects someone close to us—when it is part of day-to-day life for the most vulnerable people? In Plymouth we have someone who is intimately involved in the system, and whose daughter is involved in the system, and who really gets mental health. However, it is not good enough in this place just to understand something because it happens to someone close to us. The vulnerable often do not have a voice, and we have to work harder. As the right hon. Gentleman is saying, it is not good enough to push the statistics away.

[Norman Lamb]

I totally agree. Everyone across the country who suffers this damaging, tragic illness has a right, surely, in anything that amounts to a national health service, to get good evidence-based treatment on a timely basis; but, tragically, that is not happening. I appreciate and welcome the fact that the Secretary of State has now taken specific responsibility for mental health. However, if I may be bold enough to offer some advice from my experience as a Minister, I would say that if a new standard of the type in question is to be embedded into the day-to-day life of the NHS, to make it something that happens as a matter of course and that is considered in the Monday morning meeting in the Secretary of State’s office exactly as the physical health standards are, there must be leadership from the top, including from Government. I appreciate that there are changes to Ministers’ roles under the Health and Social Care Act 2012; but they can demonstrate leadership. They can monitor, push, cajole and encourage, and set the moral tone about what is necessary for the approach we are discussing to become standard practice. That level of focus is needed from the Secretary of State downwards.

Will the Government consider the dossier of evidence and data that we have collated, and report back to us on their findings? Will they commit to addressing properly the defects and flaws in the implementation of the programme, as I think is necessary? One thing is clear: the Paul Farmer taskforce report published as part of the five-year forward view process sets out an ambition for mental health—for how we achieve equality for people who suffer mental ill health; however, if the lessons from the flawed implementation are not learned, every other part of Paul Farmer’s programme will fail to deliver the results that are so desperately needed. How will clinical commissioning groups be held to account for failure to implement the programme properly? What is the sanction for those who decided to ignore it—which is unacceptable to their communities? What is the Minister’s response to the findings I have talked about, and how does she respond to the clear evidence that people with mental ill health are not being treated with the same seriousness, or as if they have the same importance, as those suffering physical health problems?

It is time for mental health to come out of the shadows. We have started a national debate about mental health. The issue is much more out in the open than it used to be. However, as the hon. Member for Plymouth, Moor View (Johnny Mercer) said, there is a great danger of a damaging gap, which undermines confidence and trust in Government, between rhetoric and the reality that people experience in their lives. It seems to me that there is an absolute moral responsibility on the Government to ensure that the standard is delivered.

--- Later in debate ---

[Kerry McCarthy]

There is also the issue of whether people feel they are self-medicating by smoking. They may feel that it helps their symptoms, whereas it quite often exacerbates their symptoms.

[Norman Lamb]

I appreciate the constructive and really helpful speech that the hon. Lady is making. She is absolutely right that we need to understand this issue better. Does she agree that whatever the link may be, we should not criminalise people for the use of cannabis in such circumstances? The idea of someone resorting to cannabis as a relief from pain and then being criminalised seems awful.

[Kerry McCarthy]

As I said earlier, I think that diverting mental health issues into the criminal justice system is completely the wrong approach. That includes people who have engaged in taking cannabis, which is an illegal activity. It serves no purpose at all to treat that as a criminal situation when people clearly need the intervention of the health services. The medicalisation of the problem is certainly something I endorse. On that note, I conclude my remarks.

--- Later in debate ---

[Ms Abbott]

It is true of many communities, and in particular the black and minority ethnic community, as the statistics prove, that they are reluctant to take family members into the national health system. When they finally have to engage with the national health service, their symptoms are much worse and it is far harder to get positive outcomes. I tell the Minister that it is really important to look at this issue of black and minority ethnic people and the mental health system, because it is causing real misery and problems within the community. We are less likely to be offered talking therapies and more likely to be offered electroconvulsive therapy. Again, mental health facilities within the prison service, such as Rampton, have disproportionate levels of black and minority ethnic persons inside those institutions.

[Norman Lamb]

I am grateful to the hon. Lady for giving way. She is making an incredibly important point about the over-representation of black and minority ethnic people in the system. Does she agree that they are also more likely to be subject to coercion—to sectioning under the Mental Health Acts—and more likely to suffer restraint and physical force within mental health settings?

[Ms Abbott]

I am grateful to the right hon. Gentleman for that important point. It is absolutely true that, partly because they are presenting late and often have quite advanced psychotic symptoms, they are more likely to experience coercion and restraint. We know that some of those incidents of restraint have had very unhappy outcomes, and families continue to campaign against the misuse of restraint on mental health patients. All these decades after people first started to look at issues relating to black and minority ethnic communities and the mental health service, we have made little progress. Is the Minister willing to meet me to discuss this issue, which I have looked at for many years? One of the basic problems is statistics. It took years to get the health service to keep statistics broken down by ethnicity within the mental health service, and I am not sure what is happening to those data.

As we have heard, it is vital that psychosis is treated early as that prevents complications, improves outcomes and is more cost-effective. We know that psychosis costs £11.8 billion a year and we also know that mental health problems are on the rise. It is very disturbing to find that the research shows that a quarter of CCGs seem to be ignoring the access waiting time standard for psychosis, and the National Audit Office reports that there are insufficient funds available for the strategy to achieve parity of esteem to have any reality. We know, because we have heard, that too many CCGs cannot even specify how much money is devoted to early intervention; that gives rise to the suspicion that not enough is devoted to it.

The right hon. Member for North Norfolk made the fundamental point that this issue is still not being treated with the same seriousness as cancer standards are. This goes back to the issue that many Members have raised of stigma, shame and an unwillingness of the families of psychosis sufferers to speak out in the way that the families of people who suffer from cancer are willing to go into the public space and to the media to speak out.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Nicola Blackwood)]

It is a pleasure to serve under your chairmanship for my first outing as a Minister, Sir Roger, and I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing this important debate. He has rightly pointed out that many areas of our mental health services are not yet meeting the standards that patients and their families deserve and have a right to expect, and he is absolutely right to say that improving access and waiting times for early intervention in psychosis must be a top priority among those. I assure him that both I and the Government share his determination and sense of urgency in such matters.

I think we can agree that for far too long as a nation we tolerated poor mental health services in this country, and we all know the terrible price that some have had to pay for our collective failure to step in earlier. That time is now over and we are in the process of creating a mental health service that we can be proud of—one in which, no matter where someone lives, they will be able to access the services they need when they need them, and just as importantly, one that people feel safe and confident using.

But we have to be honest about this, or we will get discouraged and lose momentum: it is not going to happen overnight. Although there are already some areas of outstanding practice that we should be encouraged by, we are, in general, coming from a low base, and only a sustained effort over the next few years is going to bring about the change that we are all demanding.

For that reason, I would like personally to thank the right hon. Member for North Norfolk for his pivotal role in securing parity of esteem and for supporting the introduction of the first waiting time standards for mental health services. With the previous Prime Minister, the Health Secretary and my predecessor, my right hon. Friend the Member for North East Bedfordshire (Alistair Burt), the right hon. Gentleman has set us on the road to better mental health services. Now we have to follow it through, no matter how bumpy the journey may become at times. I hope that he will meet me and give the benefit of his advice, because I suspect I am going to need it.

I would also like to thank everybody who has contributed to today’s debate. Some have given moving accounts of personal experiences or those of family members or friends. Others have taken the opportunity to raise difficult constituency cases. I know that all here today are committed to keeping mental health at the top of our agenda as the Government shape their new programme.

That brings me on to the challenges of the early intervention pathway for psychosis, which is designed to deliver the improvements to psychosis care that are urgently needed, as the right hon. Gentleman so clearly laid out. He pointed out that psychosis is more common than people realise: it affects one in 2,000 people in England in any given year. We know that the early intervention in psychosis programme is crucial in ensuring that mental health services maximise their opportunity to intervene at the earliest possible moment to prevent patients from relapsing, so that they are less likely to be admitted to hospital and have less severe symptoms. As the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) so expertly described, such services are recognised as the best model for helping young people to recover from the first episode of psychosis. They have the potential not only to save the NHS tens of millions of pounds but to reduce the serious impact of psychosis on those patients’ lives and those of their families and carers.

The hon. Member for Strangford (Jim Shannon) asked about funding. When waiting times for mental health were introduced for the first time, they were backed by £120 million of investment. In addition, we have invested £33 million in developing EIP services. Further funding for early intervention in psychosis was announced in NHS England’s “Five Year Forward View for Mental Health” implementation plan earlier this year. That funding is designed to support delivery of the target to ensure that 60% of people who experience their first episode of psychosis receive treatment with a NICE concordant package of care within two weeks of referral by 2021.

[Norman Lamb]

I am encouraged by what the Minister is saying. I assume that the money she has talked about that will be allocated is part of the baseline that CCGs will receive and not a separate allocation. The question is how she ensures that CCGs actually spend the money as intended.

[Nicola Blackwood]

As the right hon. Gentleman is aware, this work is in its early stages. He is right that services are working hard to develop this process. NHS England has set out in its implementation plan how the services will need to grow and improve to meet the new standards. In particular, it has noted that the current block contract arrangements can result in poor transparency on spend per patient, as he has seen with his freedom of information request.

NHS England has been looking at alternative funding models that will link an element of payment to achievement of quality and outcomes, including the EIP access and waiting time standard. When there are variations in spend, we will need to consider the reasons for that and ensure that necessary action is taken to address any impact on the quality of care available. I hope that reassures the right hon. Gentleman.

In addition, the Royal College of Psychiatrists College Centre for Quality Improvement has been commissioned to undertake continued assessment and quality improvement work. This will be through a quality improvement network, supported by an annual self-assessment that will be independently validated and scored. All early intervention in psychosis services are going to be expected to participate. The first results will be published in April 2017, but any earlier results will be published before that. It is intended to provide a transparent assessment of services across England. This will give us a clear picture of service provision and enable us to target areas where additional development will be required, so that we can ensure that the standard is met and that people receive the care they need.

The right hon. Gentleman also mentioned the important issue of age caps. The most likely age for a first episode of psychosis to occur is between 14 and 35, as has been pointed out.

Junior Doctors: Industrial Action

Norman Lamb Excerpts

Monday 5th September 2016 Commons Chamber

[Mr Hunt]

The BMA should talk to its members much more because, as far as I could tell, the consultation over the summer showed that only a minority actually wanted this extreme series of rolling one-week suspensions of labour that the BMA supported in the end. Most junior doctors are perplexed and worried about the situation and would love to find a solution. There was a bitter industrial dispute, but we actually started a process through which trust was being rebuilt on both sides. In a series of meetings, I met the junior doctors’ leader to talk through the areas of her greatest concern and we made progress in addressing two of those four outstanding areas. Building that trust means actually sitting around the table and talking, not having confrontational strikes. I think that that is what most junior doctors want.

[Norman Lamb (North Norfolk) (LD)]

I want to return to the critical issue of how we ensure safe cover during the week if we expect doctors to work more hours at weekends. The Secretary of State has repeated again today that he will employ more junior doctors, but what is the timescale? What will the net increase in doctors be this year, next year and in the rest of the Parliament?

[Mr Hunt]

I do not have figures to hand for exactly what the number will be this year—I will certainly let the right hon. Gentleman know—but around 11,500 extra doctors will be trained during the course of this Parliament.

As I said in the statement, it is important to recognise that the changes involve not only junior doctors. We need more weekend consultant cover—that is particularly important—and more people who are able to do the diagnostic tests. A whole range of people need to take part in the changes to improve standards of care at the weekends.

Oral Answers to Questions

Norman Lamb Excerpts

Tuesday 5th July 2016 Commons Chamber

[Mr Hunt]

Without wanting to reopen the debate that concluded on 23 June, the overwhelming view in the NHS is that we are very lucky to have the incredible support of 110,000 EU nationals working in the health and social care system. I want to put on record to this House what a fantastic job they do and how much we are all in their debt.

[Norman Lamb (North Norfolk) (LD)]

Very many of those 110,000 people are now acutely anxious about their future in this country, because of the despicable suggestion that they should be used as a bargaining pawn in negotiations with the EU. Will the Secretary of State ensure that the Government, as a matter of urgency, guarantee their future in this country doing their dedicated work in our NHS and care system?

[Mr Hunt]

I can reassure the right hon. Gentleman that we are incredibly aware of the brilliant work that EU nationals do, not just in the NHS but in the social care system, which he was responsible for, in care homes up and down the country. We recognise that, and I hope that he will be reassured by statements made by the Foreign Secretary and the Home Secretary yesterday that we want to find a way of allowing those people to stay in the UK for as long as they wish to. We recognise the incredibly valuable contribution that they make, and we are confident in the negotiations ahead that we will be able to secure the outcome that they and we all want.

Dietary Advice and Childhood Obesity Strategy

Norman Lamb Excerpts

Monday 23rd May 2016 Commons Chamber

[Alistair Burt]

My hon. Friend is absolutely right—that is important. The strategy has been awaited, and if it is to do the job we all want it to do, it should deal with the myths and concerns that have been raised, and do so in a proper evidential manner.

[Norman Lamb (North Norfolk) (LD)]

May I join in a partial, and rather surprising, alliance with the hon. Member for Shipley (Philip Davies) in questioning the sense in taxing just one particular type of product? Would not the Government instead—this is where I part company with him—consider taxing sugar as an ingredient to create an incentive for reformulation of products to reduce sugar content across the board, rather than just picking on one type of product?

[Alistair Burt]

I thank the right hon. Gentleman. He was not on my accumulator, so it has gone down. What he is calling for is exactly what the strategy does. It is designed to be quite wide and to take into account the possibility of other action in other places. He is absolutely correct about that.