Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) (Amendment) Regulations 2017

Baroness Walmsley Excerpts

Thursday 30th March 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for explaining the intent of this statutory instrument. The Opposition supported the transfer of public health functions from the NHS to local government, including those for children from birth until the age of five in public health services. Indeed, that was the only bit of a lamentable Act of 2012 that we did support. We also support the provision of a universal health visiting service and the prescribed reviews, which are elements of the healthy child programme. The noble Lord has said that this decision was supported by the outcome of the PHE review, and I would like to come back to that.

I want first to refer him to the question of resources. He mentioned the changes in local government funding but he will be aware that, overall, the Government’s record in funding public health services has been lamentable. In February 2017, the Department of Health told local authorities that an average 3.9% real terms cut to health service budgets per annum would take place until 2020. This is a large reduction, as it accumulates. According to the King’s Fund, which has done an analysis of the impact that has had, as a result of these reductions stop-smoking services and interventions have lost 25% between 2015-16 and 2016-17, while other areas such as the health check programmes and sexual health services lost 7% to 14% of their funding. As the Local Government Association said, given that the Government issued a firm commitment to the NHS five-year forward view, with prevention put very much at its heart, to then make significant cuts to the public health service budget over the next five years sends entirely the wrong message and could undermine the objectives that we all share to improve the public’s health and keep pressure off the NHS and adult social care.

Recent work by the King’s Fund on sustainability and transformation plans—an Orwellian phrase, if ever there was one—points out that what is actually happening on the ground is going in the opposite direction to that which was set out in this plan. It is the same in public health. I would therefore like the Minister to explain a little more about how the Government justify the reductions in funding for public health services.

I refer the Minister to table 29 on page 58 of the report by Public Health England. It is a summary of written feedback from professional representative and membership organisations. Comments were made by the Society of Local Authority Chief Executives on the issue of the mandation of services, about which clearly local authorities have some reservations. It suggests that the Government collect and review all mandated public health services next year, including health visiting, when the overall position on local government funding and business rate reforms is clearer. In a sense, the Local Government Association has made the same request. Will the Minister inform the House whether the Government are going to respond to that?

On the outcome of services so far and the PHE review, it says that there was a statistically significant increase in the eligible population reach by a universal service during 2015-16. It states also that, largely, there is a positive national picture of progress with statistically significant improvement observed in many relevant outcomes over the lifetime of the national health visiting programme. However, it points to some large local variation and trends in the rates of breastfeeding, which it says are disappointing. It points also to the fall in the number of health visitors in employment in 2015-16. Will the Minister comment on the issue of disappointing rates of breastfeeding on the one hand and the fall in the number of health visitors on the other? What action do the Government intend to take on that?

[Baroness Walmsley (LD)]

My Lords, I am delighted to support these regulations because I am an enormous fan of a universal health visitor service, and in particular the healthy child programme. Our economy is never going to keep up with the demand for health services unless we pay more attention to the issue of prevention. That really is the public health agenda. Any doctor will tell you that you really must lay the foundations for a healthy body, lifestyle and habits in the early years or you will get illnesses later on. The review of the programme so far has been very positive. As the noble Lord, Lord Hunt, said, there have been significant improvements in the populations reached. However, we will not see the true benefit of this programme until we are years down the track and find that those young children who have been given a healthy foundation grow up to have fewer of the terrible but preventable chronic diseases that are costing the country so much.

I am very proud of the coalition Government’s vision of improving the health outcomes of children, young people and their families. Transferring the responsibility to local authorities was part of that: it gives them the chance to combine services, right up to the age of 19. However, as the noble Lord, Lord Hunt, said, there are serious questions to be asked. The first, of course, is about resources. Although these services are mandated, and although the Minister may say that the money has been ring-fenced, budgets have been cut and are going to be further cut. Local authority councillor friends of mine tell me that it is getting more and more difficult for local authorities to provide even those services which they are mandated to provide because things are getting so tight financially. I hope the Minister can give us some encouragement on that, although I somehow doubt it.

The other question on resources is about people. We have heard from the Minister about the number of health visitors in training. Are they going to be enough to serve rising demand? We have a rising population and a lot of additional young people and families who require services. A universal service is terribly important because you do not just get health problems among the most deprived. However, there is a great deal of poverty in this country and the need for these services is growing. How confident is the Minister that we will have enough sufficiently trained nurses, given the stresses on all health service staff and given that so many people are leaving and retention is getting more difficult? Are we going to have enough people?

Are there any plans to extend these services a little further up the age range? I am particularly concerned about the large number of children who are starting school between the ages of four and five already overweight, obese or with poor eating habits. So, although the healthy child programme and the reviews that are mandated here in these regulations go up to the final check at two to two and a half years, it is really important that we do it again just before the child goes to school, because at that point they are already at a disadvantage. Many of these children are from a disadvantaged background and sadly these problems occur more frequently in those backgrounds. They get to school and they are already developmentally a good deal behind children from more advantaged backgrounds. I think the proof that we have had over the few years that this programme has been in place is sufficiently convincing to tell us that perhaps we ought to extend it a little bit further.

[Lord O'Shaughnessy]

My Lords, I am grateful to both the noble Lord, Lord Hunt, and the noble Baroness, Lady Walmsley, for their endorsement of the universal health visiting service. The noble Baroness is quite right to emphasise the long-term benefits that derive from a universal health visiting service of high quality and it is true that it is a great coalition achievement that we should be proud of. I am also grateful to the noble Lord, Lord Hunt, for his endorsement of not only the programme but also the mandated reviews and indeed of local authorities taking ownership of the programme.

To deal with the funding issue first, as I set out there is both the £16 billion that is going into local authorities for public health and the extension of the ring fence for another year. I will not gloss over the fact that it is a challenging fiscal environment. We know why that is; it is because the country continues to borrow more than it is bringing in in tax. I do not want to go into the reasons for that for fear of being accused of being too political, but we do operate in a challenging environment. That is why the business rate retention and reform is so important, to give local authorities more sustainability for their own funding base. I should also point out that, whether the issue is smoking or other risky behaviours, we are still making good progress, so it is possible to continue to reduce these kinds of risky behaviours, notwithstanding the pressures that are inevitably placed on budgets. In the round, total health budgets are increasing, not just in the NHS but across all health budgets. So while I do not gloss over the fact that it is a challenging fiscal environment, we are still making very strong progress, not just on health visitors but on a number of important public health issues.

In terms of the point that the noble Lord, Lord Hunt, made about the review by Public Health England of mandated services, obviously there are no plans to review the health visiting service, as I think we are all agreed that this is something we want to happen. Health visitors are popular and desired. I am not in a position to say at this point whether any other services are under review but I shall certainly write to him about that.

Both the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, asked about the numbers of health visitors. They increased by 50% in the last Parliament, which I think is a huge achievement. It has become slightly more difficult to track their numbers because they have a number of employers now that the budget has been devolved, but there are still very high numbers of them as a result of the changes made in the last Parliament. There are over 800 training places for health visitors and there are more nurses in the system as well. So there is investment going into the workforce, and I absolutely recognise that there has got to be a high-quality workforce. It is also the case that other healthcare professionals are able to deliver some of these services. If a family, which of course will more likely be a poorer or more disadvantaged family, is receiving support from a family nurse partnership, then the nurses that are delivering that can also deliver the health visit and some of the early reviews, so it is a mixed picture. The number of family nurse partnership places has increased over the past few years as well.

There are a couple of final issues. Breastfeeding is part of health visitor training and indeed their mandate is to encourage greater breastfeeding. I am not aware of the specifics of the variability. I shall certainly look into that. It is a critical part of maternal and child health and to be encouraged. I know that there are variations from one part of the country to another. Whether they are due to training and workforce or to other cultural or longer-term issues is a different question and it is bound to be more challenging in some areas than others.

The noble Baroness, Lady Walmsley, asked about the age range. It is important for the health visiting service to stick to what it does best. I certainly recognise the picture she is describing, having worked in primary schools. There is an increase in children coming unprepared to school, or increasingly to nurseries, whether in their eating habits or toilet habits or whatever it is. The increase in formal childcare places that has been made available to both three year-olds and disadvantaged two year-olds will go some way to addressing that but I shall certainly keep an eye on that issue.

[Baroness Walmsley]

Sorry to spring this on the noble Lord but there was something that I forgot to ask him. He mentioned the accessibility of school nurses. The fact is that if a school nurse is looking after five schools they are not terribly accessible. I wonder if he might write to me as to whether there are any plans to increase the number of school nurses, because that is part of increasing the child’s health right the way through the age range.

[Lord O'Shaughnessy]

Yes, I shall certainly be happy to do that, probably looking at it in the round in terms of all the local health support that is available for school-age children. I hope, in responding, that I have been able to talk to all the points that have been made by noble Lords in this debate. I am glad that we all agree that health visitor support to families is vital and is about giving children the best possible start in life. It is why the Government have taken this action to continue to ensure the provision of the five mandatory health and development assessments and reviews so that this service continues to be provided for all families with children aged nought to five. I beg to move.

Motion agreed.

Alcohol Abuse

Baroness Walmsley Excerpts

Thursday 30th March 2017 Grand Committee

[Baroness Walmsley (LD)]

I, too, congratulate the noble Lord, Lord Brooke of Alverthorpe, on securing this important debate. Last January, I chaired a seminar run by the All-Party Parliamentary Health Group on developing a long-term strategy to reduce the harm from alcohol consumption. We heard from several eminent contributors whom I shall mention as I go along. We started with Professor Sir Ian Gilmore, chair of the Alcohol Health Alliance, who described the burden of alcohol harm. He told us that, statistically, alcohol is the number one risk factor for premature death in the UK today. The BMA tells us that 60 different medical conditions are caused by alcohol abuse, and are therefore preventable. Sir Ian Gilmore said that 70% of presentations at A&E on a Friday or Saturday night, and about 20% of all hospital admissions, are related to alcohol. Interestingly, mental and behavioural disorders due to alcohol use account for almost 20% of those admissions, so we know that we are talking about mental, as well as physical, diseases. We know what the diseases are; several noble Lords have referred to them today. In addition to those physiological diseases, of course, accidents are caused by alcohol use, and there are a lot of hospital admissions because of those, as well.

Sir Ian was followed by Dr Mirza, an emergency medicine consult from West Middlesex University Hospital. He began by shocking us all with four real-life but typical situations that had taken place in his department over the past month. They included drunken patients attacking staff or police officers, running rampant and breaking thousands of pounds- worth of hospital equipment, requiring to be restrained and taking up hours of time of the staff, meaning that other sick patients were not treated for hours. The disruptive effect on the department was enormous, he said, and added additional strain to an already overstretched A&E department.

What does all this cost the nation? The Government themselves estimate that it costs £3.5 billion a year to the NHS, £11 billion a year on criminal justice and £7.3 billion in lost production, a total of £21 billion a year. What could the NHS and social care do with that money?

In addition to these costs and the burden of disease, there are costs for children and families. My daughter-in-law is currently writing a PhD thesis about the scale of domestic violence following excess alcohol consumption after major sporting events. Dr Mirza pointed out that there are many children living with one or more parents with an alcohol-related problem, resulting in mental and emotional strain and poor academic attainment for the child.

What are the options for reducing these harms? First of all, we have to ensure that young people are educated in their PSHE lessons about the harm that alcohol can do. We heard from Professor Yvonne Kelly, Professor of Lifecourse Epidemiology at University College London, that, of those adults who drink, 80% to 90% of them start in the second decade of life. Pleasingly, as someone has said, there has been a fall in the number of underage drinkers in the past 25 years, and I put that down to education. However, she told us that the amount being drunk by each underage drinker shows no sign of falling, so these are the people we need to target. A number of options were suggested to us, including those affecting price, labelling, marketing, advertising, availability, low-alcohol options, help with behaviours, et cetera. Many of these have excellent evidence of effectiveness, according to the academics.

I have a number of questions for the Minister. Has he done an impact assessment of the reduction in alcohol abuse services following the cuts to public health budgets? Is he aware that this money is well spent? For every £1 spent on alcohol treatment, £5 of public money can be saved. We know that a five-minute chat from a health professional can have a major effect on a person’s drinking habits, yet GPs do not have time to do this in a 10-minute appointment. Will the Minister publish imminently the Government’s new alcohol strategy, and will he consider including in it minimum unit pricing to tackle products such as white cider, which I was staggered to discover costs only 15p per unit of alcohol and is used mainly by very problematic drinkers? Will he ask the Chancellor to increase the general cost of alcoholic drinks? Given what the noble Lord, Lord Brooke, said, what can he do to reduce the comparative cost of low or zero-alcohol products? Will he issue guidance to local authorities which authorise licences to ensure that health is a factor in licensing decisions, so that they understand the effect of long opening hours and high density of premises selling alcohol? Alcohol action areas have already proved the effectiveness of reducing density and hours.

Will the Minister also look at what can be learned from the policies on tobacco? I agree with the noble Lord, Lord Brooke of Alverthorpe, about labelling. Labelling of tobacco products showing the health damage they can do could easily be replicated with alcohol. Alcoholic products should not only show the calories and units of alcohol they contain but also have a reminder of the Chief Medical Officer’s advice about maximum weekly consumption and alcohol free days. Perhaps we can do that after Brexit.

There is evidence that increased exposure to alcohol increases the chances of children drinking, so will the Minister also include in the policy a ban on advertising of alcoholic products before the watershed? Will he also consider banning alcohol sponsorship of sports events for the same reason? The health and economic benefits of all these actions would be immense.

Gene Editing: Agriculture and Medicine

Baroness Walmsley Excerpts

Monday 27th March 2017 Lords Chamber

[Lord O'Shaughnessy]

My noble friend is a leading advocate of this technology and is correct that getting the regulation right is absolutely important. It is currently regulated at the EU level, and there is debate on and an inquiry by the European Court of Justice into current exemptions for gene editing. We support the current exemptions, although others have challenged them. But it is also important to recognise that any discussion about gene editing, whether in agriculture or especially in a human health setting, involves big ethical questions and it is only right that we tread carefully as we move ahead.

[Baroness Walmsley (LD)]

My Lords, given the potential of gene editing of non-reproductive cells for treating HIV, sickle cell, haemophilia and, as the noble Viscount said, cancer, what plans do the Government have to ensure continued research in this important and valuable area after Brexit?

[Lord O'Shaughnessy]

The noble Baroness is quite right to talk about the important therapeutic benefits that can come. I do not think this has anything to do with Brexit, other than the fact that the UK has been and continues to be a leader in the world of genomic sequencing, which of course enables us to identify the genetic issues that lead to some of the diseases and illnesses she has described. Within our regulatory framework, it is possible to use gene editing for therapeutic reasons but in ways that do not impact on inheritability, which is of course ethically an incredibly difficult question.

NHS: Sustainability and Transformation Plans

Baroness Walmsley Excerpts

Monday 20th March 2017 Lords Chamber

[Lord O'Shaughnessy]

As the noble Baroness has pointed out, it is important that there is sufficient capacity in the social care service and in the NHS. In fact, the NHS accounts for more of the delayed discharges, for example, than does social care. Simon Stevens, the head of NHS England, has been clear that, in addition to the four reconfiguration tests, any bed closures would need to show that there was redundancy in the system, that there is alternative provision—to come to the noble Baroness’s point—and that there is clear potential for efficiency. It is clear that the STPs must be able to plan ahead and provide alternatives if there are going to be changes to A&E or other services.

[Baroness Walmsley (LD)]

My Lords, given that 50% to 60% of patients attending A&E in some hospitals hit the four-hour target, how many more hospitals will hit the target when some adjoining hospitals close their A&E departments? This does not sound like excess capacity.

[Lord O'Shaughnessy]

The noble Baroness is right to point out that the four-hour target is critical for the NHS and it is committed to making sure that that target is hit. Some A&E closures have been mooted but only seven areas, according to the Health Service Journal, have clear proposals, and that is before there has been any public engagement and any application of the reconfiguration test. I point the noble Baroness to the comments of Simon Stevens about the importance of demonstrating alternative provision and that it cannot be a case of closing beds without that being in place.

End of Life Care

Baroness Walmsley Excerpts

Tuesday 14th March 2017 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, as the King’s Fund report Understanding NHS Financial Pressures commented yesterday, terminally ill patients have very little political voice. Therefore, I am delighted that the noble Baroness, Lady Finlay, has spoken up for them this evening. Indeed, I am very grateful that I live in Wales and will probably die there.

Over the last five years, we have seen several reviews of palliative and end-of-life care with multiple recommendations. Therefore, I hope that, at the end of this debate, the Minister will be able to provide us with an update on progress towards meeting those recommendations. For example, the Government’s response to the review of choice made two commitments that are particularly relevant to the topic we are debating today—namely, to,

“engage with clinical commissioning groups and Health and Wellbeing boards on improving end of life care provision through local strategic planning and commissioning”;

and,

“to provide commissioners with data, tools and palliative care currencies to help identify palliative care needs in local areas and the best ways to commission services to meet those needs”.

I hate jargon, so I looked up what “palliative care currencies” means. I found that it refers to payment models for palliative care. As the Minister will know, the majority of community palliative care providers in England, which are largely in the voluntary sector, are currently commissioned by block contract, and a lot of hospices in particular have been working within the same cash envelope for many years. Indeed, yesterday’s report from the King’s Fund commented that one of the factors that make some services particularly vulnerable is that block contracts have not been adjusted to match rising demand, and that demand is continuing to rise.

In 2010, Marie Curie’s review of funding recommended that the NHS move to a per-patient funding model, defined by phase of illness, so that providers would be paid more for patients with more complex care needs. One of the major difficulties encountered was the fact that most voluntary sector providers have a mixture of NHS and charitable funding, so it was difficult to identify which aspects of care were NHS-funded and which were charitably funded. Therefore, moving every provider to per-patient funding has its problems. Can the Minister now confirm that NHS England will provide a number of different palliative care currencies so that commissioners can choose which method is right for their locality? If that is the case, how will value for money be audited and by whom?

We have heard that palliative care in this country can be the best in the world. However, successive national care for the dying audits have found wide variations in the quality of care in different hospitals. I welcome the fact that end-of-life care is now a key area for assessment in the Care Quality Commission’s inspections of hospitals, but can the Minister update us on the plans in place for those that perform badly to learn from the best?

However, poor patient and family experiences are often due to poor commissioning, planning and co-ordination, as well as insufficient provision for family support, rather than poor delivery. Clinical commissioners have a vital role in co-ordination because it is increasingly rare that individuals’ needs will be met by one service alone and they often need to be moved from one location to another as their needs change. Co-ordination is particularly crucial when terminally ill patients wish to die at home. Last year I spoke in your Lordships’ House about a particularly distressing case that I know of where that all went wrong. Obviously it makes sense to get services right in the community rather than have the patient admitted to hospital when the family can no longer cope.

Despite the numbers needing these services, according to Marie Curie, just over half of health and well-being boards in England made no mention of palliative care in their strategies, only a third had comprehensive plans, and 30% of STPs made no mention of end-of-life care at all. Given that NHS England says that it requires local leaders and professionals to ensure that a strategy for end-of-life care is in place, this is pretty disgraceful, and, having made that statement, it does not audit what is in place, so there is no accountability. Therefore, I ask the Minister how CCGs and health and well-being boards are being held to account for this state of affairs.

Finally, I want to raise clinical training. A professor of palliative care who is a friend of mine told me recently that some medical graduates have no more than one day of training in end-of-life care. In other places, such as Royal Liverpool University Hospital, students spend three weeks in local hospices, which equips them much better. Although we need palliative care specialists, we also need generalists with enough knowledge of pain management and other issues linked to end-of-life care, including how to help the bereaved. I understand that Health Education England’s end-of-life care core skills education and training framework—what a mouthful—is soon to be published. Can the Minister say how soon it will be implemented?

Nursing and Midwifery (Amendment) Order 2017

Baroness Walmsley Excerpts

Tuesday 28th February 2017 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, I understand where the noble Lord is coming from. I would never want to propose a situation of a silo, but there are instances where it is necessary to give—I do not think that “protection” is exactly the word—some kind of underlining to the importance of a particular profession. The noble Baroness, Lady Cumberlege, is here, and it seems to me that the fact that she had to undertake a review recently is a visible sign of the problems that we have had in getting midwifery issues to the top of the table. I am not seeking to create a whole hierarchy of new directors at a cost of money and to silo it, but I think that we have some problems at the moment.

This issue was raised in the other place when the order was debated there. I actually think there is a case for there to be a chief midwifery officer at government level. In the other place, the Minister said that the Government consider that,

“the chief nursing officer is the professional lead for both nursing and midwifery and we intend that to continue. That role is supported by the head of maternity in NHS England, which will continue to be the case. … There will be a regional maternity lead and a deputy regional maternity lead in each of the four NHS England regions”.—[Official Report, Commons, Delegated Legislation Committee, 22/2/17; cols. 9-10.]

I must say that I do not like the term “maternity lead”, as it seems to understate and undermine the position. I know that you cannot say that everything is in the title, but “maternity lead” to me means a lower status—it is quite clear to me that you use “maternity lead” to indicate a lower status.

Let me be clear that the current head of midwifery in NHS England is a distinguished and highly respected midwife—there is no question about that—but I think that there is a problem. What does “head of midwifery” mean? Why do we not use the word “director”? There is an issue about authority and status. At the end of the day, as I understand it, the head of midwifery is the head of the profession in England, and I think that NHS England should recognise that in that person’s title and position.

It is very important that midwives as a whole look to the chief midwife for that essential professional leadership. It is clear from what the NMC has said, and from the order before us, that the NMC cannot provide that professional leadership. It is there to regulate, so we need strong professional leadership. I hope that the Minister will give this some further consideration. I am not seeking to create a whole new edifice; I am concerned about the voice of midwifery not being heard at the highest level.

That brings me to the proposed abolition of the midwifery committee. Again, I am the last person to believe that, if you have a committee, everything is well. Of course, I understand entirely why the NMC does not like the statutory midwifery committee. I completely get that; no chief executive of any body ever likes to have a statutory committee, particularly if the other bits of the area that it regulates do not have one. We all understand that, but you have to look at the fact that the NMC currently has 640,000 nurses on its register and 40,000 midwives. Inevitably, issues to do with nursing are bound to dominate the NMC consideration. So the benefit of having a statutory committee is again to give some kind of protection and recognition that midwifery needs to have some consideration within this very large regulatory body.

As a result of discussions, for which I am grateful, the NMC has given various assurances about the strategic midwifery panel and the number of advisers that will be appointed. Can the Minister ensure that Parliament is kept informed of the work of the NMC and, in particular, about how it will ensure that it is fully apprised of midwifery matters by the new arrangements? He said earlier that the NMC would keep these matters under review—and I think that he referred to the new disciplinary procedures—but I took that to mean these arrangements in general. “Under review” falls within governance and quango-land; it is not really a high status. Could he ensure that, at the very least, the NMC reports to Parliament on a regular basis on how it ensures that midwifery issues are fully heard by the council?

In conclusion, in moving this amendment I do not seek to criticise the NMC. I believe that the current chief executive inherited a mammoth challenge. I have been impressed by the progress that she has made, but the distinctive role of midwifery should be recognised, particularly at a time of extreme pressure on the profession. It is important that we do not dissipate its voice. I would welcome some reassurance from the Minister. I beg to move.

[Baroness Walmsley (LD)]

My Lords, midwives have a very special role in the local medical and nursing team. They should be seen as an integral part of that team; their role should not necessarily end at the point of birth. I know from many cases that the personal relationship built up between a mother and her designated midwife during the antenatal period can be enormously valuable at a time when she is very vulnerable. The mother often has the confidence to confide in the midwife if she has any health or personal security worries. I am talking here about domestic abuse, which so often occurs when a woman is pregnant. It is important that this relationship is nurtured and nothing gets in the way of a midwife adding all the value of which she or he is capable. I would hope that in future there would be more integration between the midwife, the health visitor and the district nurse. There is a lot of potential for that.

No debate about midwives and nurses is complete without talking about numbers. The noble Lord, Lord Hunt, mentioned rates of attrition. A couple of weeks ago, at Oral Questions, I asked the Minister how data are collected on the rate of attrition. It is not consistent. It makes it very difficult to know which areas of the country are good at keeping their midwives and nurses and which are not, so that we can see and spread best practice.

We have an enormous number of nurses from EU countries and, indeed, from other parts of the world. Brexit is looming and there is uncertainty—which we debated in this House yesterday and on other occasions—over the status of people from other EU countries working here. At the same time, we have a Government who are trying to reduce their immigration rates to a maximum of 100,000 a year, which could affect midwives coming from countries outside the EU. This is a big concern and we must not ignore it when we are talking about regulation.

I turn to the order before us and the amendment in the name of the noble Lord, Lord Hunt. We on these Benches are broadly supportive of the order, which will bring more flexibility into the regulation of nurses and midwives, in line with the way in which the GMC and other medical regulators are able to carry out their fitness-to-practise processes. It is right that the regulator should be able to deal more proportionately with cases where there is a finding of “no case to answer” and where the person concerned accepts that the practice in that case falls short of what should be expected. There is currently no power for examiners to consider alternative ways of resolving these cases. However, the Secondary Legislation Scrutiny Committee raised some questions about the new power to issue a warning. It accepted that this power is permissive but felt that, if examiners are to use the power to give a warning, and guidance is intended to direct users as to how terms should be interpreted, then the detail of the threshold for issuing a warning should either be in statutory guidance or in the order. What is the Government’s response to the committee’s suggestion?

Turning to the role of midwives in the governance of the NMC, it is important that the particular role of midwives is both recognised and catered for. However, if you are taking away the role of development support and supervision, and separating it from regulation, you do not necessarily need the existing structure of the midwifery committee. It is important and right that regulation and supervision are separated. I understand that there is to be a new midwifery panel which should be consulted and that supervision is to be replaced by new support and supervision structures in the four countries of the UK. There is also to be a new senior midwifery adviser. I take the point of the noble Lord, Lord Hunt, about status, which is important, particularly to the morale of the midwifery profession. Concerns have been raised that the new structures for support and supervision will not be ready in time for the changes at the end of March. I understand that, of the four nations, only Wales is ready to take over. What can the Minister tell us about the state of readiness of the other three nations?

I recognise that the new structures that the Government are proposing present a challenge to the midwifery profession. This is right, in response to the reviews discussed earlier. There are concerns that the new structures within the NMC cannot, for example, put midwifery matters on the council’s agenda. Can the Minister assure us that specific midwifery issues will be appropriately dealt with under the new structures?

The effectiveness of the proposed new structures will take a while to be demonstrated, so it is right that we seek these reassurances at the outset. In the end, patient safety must be at the forefront and that depends on the quality of development, training and supervision of the midwives. It is a challenge for the profession, and it is only right that we give midwives the opportunity to demonstrate that they can rise to that challenge. However, it is right that the powers and structures of the regulator are up to date and able to cope with the workload in an appropriate manner at a time when, as the noble Lord, Lord Hunt, said, the demand is rising.

Health Service Medical Supplies (Costs) Bill

Baroness Walmsley Excerpts

3rd reading (Minutes of Proceedings): House of Lords
Thursday 23rd February 2017 Lords Chamber

[Lord Lansley (Con)]

My Lords, I do not propose to detain the House. I merely wish to thank my noble friend the Minister for the further clarification that Amendments 1 and 2, in particular, give to Clause 9.

I was among those who raised a concern. Although the industry completely understood that in order to make the PPRS effective there was a requirement for a scheme for the acquisition of data in aggregate, as my noble friend described, the powers would have enabled there to be a lot of demands for information which went beyond what had previously been required and which had the potential to be very intrusive. Under those circumstances, an information notice system, with proper details supplied to companies and with a potential appeal right, was required. We discussed that and I am very grateful to the Minister for taking it on board and putting in place something which I think will give considerable reassurance to the industry that the scheme will not be as burdensome as it could have been.

[Baroness Walmsley (LD)]

My Lords, we on these Benches are also happy to support the amendments. Like the noble Lord, Lord Lansley, I have no intention of detaining the House with long-winded thanks. However, I want to voice my recognition that the Minister, in his new role, has both understood and responded to the issues raised on the Opposition and Cross Benches about the shortcomings of the Bill, which had been through the House of Commons without anybody noticing or trying to amend its unintended consequences, rather like the Article 50 Bill that we debated in this House on Monday and Tuesday.

[Lord Warner (CB)]

My Lords, I thank the Minister for listening so intently during the proceedings and for his response. I am also grateful to those on the Front Benches opposite for their co-operative approach—they are a shining example to their colleagues in the Commons of how to be effective in persuading the Government to change their mind. I hope the Minister’s emollient approach will continue when the Bill leaves this place in relation to the new clause that we have put in at the front of the Bill, despite the advice he was given. I hope that good will will continue to operate as the Bill completes its passage through both Houses of Parliament.

National Health Service: Nurses

Baroness Walmsley Excerpts

Wednesday 22nd February 2017 Lords Chamber

[Noble Lords]

Order!

[Baroness Walmsley (LD)]

My Lords, are there any plans for post-qualification training grants for specialist nurses in some of the shortage areas, such as psychiatric nursing, and/or golden handcuffs to keep them in their jobs?

[Lord O'Shaughnessy]

The noble Baroness is quite right to raise the issue of retaining nurses and bringing them back into the profession. That is why, last year, to aid retention, there was an average 3% increase in pay for nurses. Health Education England has also introduced a return to practice campaign, which has brought 900 nurses back to the front line in the last three years.

Hospital Beds: Availability

Baroness Walmsley Excerpts

Thursday 9th February 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for that question. He is quite right that integration of services is the main thrust of policy and has been under successive Governments. This is happening in two ways. First, the Better Care Fund is pooling health and social care budgets at local authority level in order to achieve what he is asking for. Also, NHS England is producing sustainability and transformation plans, several of which are moving towards what is called an accountable care organisation, whereby a single grouping takes responsibility for all the healthcare needs of a population, rather than it being split into different services.

[Baroness Walmsley (LD)]

My Lords, integration is of course very important, but has the Minister ever met anybody in the health service who does not believe that you will never fix the pressures in the health service until you put more money into social care? That means helping areas with low-value properties, not just those with high-value properties, such as in leafy Surrey.

[Lord O'Shaughnessy]

The noble Baroness is of course quite right about the need for more money. I re-emphasise that an additional £7 billion or more for social care is going to councils during this Parliament. Councils have the ability to raise council tax, although the leverage obviously varies from place to place. This is why the Better Care Fund was created—to provide extra help to areas that do not get the same income from council tax increases as the better-off places.

Nursing and Midwifery: Student Applications

Baroness Walmsley Excerpts

Tuesday 7th February 2017 Lords Chamber

[Lord O'Shaughnessy]

I am sorry to hear that the noble Lord no longer supports a higher education policy of loans and fees that was originally instigated by a Labour Government. He is right about the differing impacts in Scotland and Wales, which have different systems. He also knows that, whenever fees have been introduced in the past, there has been a dip and then a rebound. Two of those rises in fees happened under Labour Governments. There are around 37,000 applicants for around 23,000 places at this point in the cycle. As he knows, there will be further applications directly to universities and through clearing. He may also be reassured by the words of the head of policy at the Council of Deans of Health, which represents the universities affected. She said:

“The scale of the fall in application numbers is not the critical factor for universities or the health and social care sector. Courses that were previously heavily oversubscribed can survive a significant dip in application numbers as long as the quality of applicants is good, and our members report that this remains so”.

[Baroness Walmsley (LD)]

My Lords, filling the places is one matter, but the level of attrition is another, and that is dreadful. Apparently, one in four student nurses leaves during their training, and in the first two years after qualification two out of five leave the profession. Part of the problem is that the data are not consistently collected. If they were, we would be able to know which settings are very poor at keeping their young nurses. Will the Government do something about collecting those data in a consistent way so that something can be done about the level of attrition?

[Lord O'Shaughnessy]

The noble Baroness makes an important point about attrition. It is one of the reasons that, within the new package of support, there is extra support for living expenses, both for mature students, who feature particularly in the case of nursing, and in cases of hardship.