NHS: Community Pharmacies

Lord Hunt of Kings Heath Excerpts

Tuesday 6th December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the fact is that across the NHS we are looking to save £22 billion, and sadly, community pharmacy cannot be exempt from those necessary efficiency requirements. But I repeat that, over time, we will see more and more NHS services delivered by community pharmacies, whether it is a sore throat testing service or the treating of minor ailments.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in these rather strange times, can I take it that the noble Lord’s party no longer believes in competition? This policy is intended to reduce the number of community pharmacies in the high street. Why do the Government want to reduce patient choice when the profession clearly can help reduce demands on GPs and A&E services at a very pressurised time?

[Lord Prior of Brampton]

This party does believe in competition. But it also believes that the NHS’s supporting community pharmacies to a very large extent when 40% of them are in clusters of three or more within 10 minutes’ walk from each other, and paying an establishment fee to each of those pharmacies, is probably not a very good allocation of resources.

HIV Diagnosis: Clinical Guidance

Lord Hunt of Kings Heath Excerpts

Thursday 1st December 2016 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness is absolutely right. Early diagnosis is absolutely critical. We have made huge progress. The WHO guidelines aim for 90% of people with HIV to be diagnosed. We are at 87%. Sweden is the only country in the world that has hit the 90% target. I point to the It Starts With Me programme, which is based around individual responsibility and is co-ordinated by the Terrence Higgins Trust, which is making great progress.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I very much welcome the initiatives taken by the Government in this area but does the Minister accept that the NHS itself could do more, particularly in accident and emergency departments and in primary care? Would he be prepared to convene a meeting with NHS England to discuss how the NHS could be persuaded to be much more proactive in relation to testing?

[Lord Prior of Brampton]

My Lords, I am very happy to arrange a meeting of that kind. We are expecting an announcement very soon on the PrEP issue and it may be worthwhile having that meeting after that announcement.

HIV: Barriers to Treatment

Lord Hunt of Kings Heath Excerpts

Thursday 1st December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, one of the purposes of the Act promoted by my noble friend Lord Lansley was to remove the Secretary of State, and indeed politicians, from these very difficult clinical decisions. That decision will be made by NHS England, and we expect a positive decision to be made in the very near future.

[Lord Hunt of Kings Heath (Lab)]

My Lords, Ministers cannot evade their responsibility for the NHS in the end. NHS England is not a clinical body; it is a quango wholly owned by and wholly responsible to government. The decisions it has made have been purely about money, and it is continually endorsing crude rationing of services and the restriction of drugs. In the current agreement with the drug companies, the Minister’s Government have received nearly £2.5 billion back in rebates from those companies. Why on earth has his department allowed the Treasury effectively to ambush that money, instead of it being spent, as it should have been, on innovative new drugs for NHS patients?

[Lord Prior of Brampton]

My Lords, I think the noble Lord will agree that there is a clinically driven process, through the specialised commissioning groups and the clinical priorities group within NHS England, that attempts to look at all these drugs in an objective, clinical way. Surely it is better that these decisions on priorities should be made by clinicians acting in that way than by politicians, who are subject to all the pressures of which we are all only too well aware. Of course affordability is an issue in assessing whether a new drug should be commissioned; it always has been and always will be. The £2 billion, which the noble Lord has mentioned before and which I think comes from the PPRS, is taken into account when setting the overall budget for NHS England.

Mental Health: Children and Adolescents

Lord Hunt of Kings Heath Excerpts

Wednesday 16th November 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, when I read the noble Baroness’s paper over the last couple of days, I thought the part about schools was the most persuasive. School is clearly critical. The pilot project being done by the Department of Health and the Department for Education, trialling the single point of contact in schools, is very important, as is the PSHE guidance on teaching about mental health at the four key stages of education.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord’s sincerity in this area is not in any doubt. However, he knows that, despite the instructions that Ministers have given to the NHS through the NHS mandate, the health service is actually disinvesting in many mental health services. On Monday, the noble Lord will have seen the King’s Fund report on sustainability and transformation plans, on which he has rested much of his hope about the future of the NHS. Mental health services appear to be very marginal to the focus of those STPs. What action do the Government intend to take on this?

Cataract Operations

Lord Hunt of Kings Heath Excerpts

Wednesday 16th November 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare an interest as a trustee of the Royal College of Ophthalmologists. I understand from the Minister that NICE is preparing guidelines, but in the meantime, will he take this opportunity to condemn CCGs in which there is crude rationing of cataract services? I refer him to the Daily Mail freedom of information survey in July, which showed that under some clinical commissioning groups, a person not only had to have poor eyesight, but had to demonstrate that they had fallen twice in the last year, lived alone and had hearing problems, or that they were caring for a loved one. If that is not crude rationing, I do not know what is.

[Lord Prior of Brampton]

Clearly the case that the noble Lord mentions is totally unacceptable. Where CCGs are rationing access to cataract operations on such a crude basis, we would all deplore that. But as I said, there is variation around the country, and the new NICE evidence-based guidelines will help to address that.

NHS: Cancer Patients

Lord Hunt of Kings Heath Excerpts

Wednesday 9th November 2016 Lords Chamber

[Lord Prior of Brampton]

My noble friend is right; the use of IMRT has increased from around 10% to about 40% in the past year—so it is increasing greatly. There is much less collateral damage with IMRT. We have also, as my noble friend will know, commissioned two proton beam centres, at the Christie and UCLH, which will also make a difference. We have just announced a £130 million investment in new linear accelerator machines. Those three developments will, I think, greatly improve our ability to deliver world-class radiotherapy.

[Lord Hunt of Kings Heath (Lab)]

My Lords, is it not time for a bit of honesty on this? The two targets the Government are missing are the crucial ones of the 62-day cancer treatment waiting time and the two-week wait for referral for patients with suspected cancer. The Government have said that early diagnosis and quick treatment are essential, but those two targets relate exactly to those key points. The Minister knows that, in the mandate for this year, the Government said to NHS England that this must be a priority. But, given the huge funding and staffing pressures on the NHS, is it not time for the Government to come clean and admit that they cannot deliver this?

[Lord Prior of Brampton]

I think I was being honest, actually. I have never hidden the fact that these targets are very tough and difficult to meet. But we have increased activity enormously. We accept that early diagnosis is critical and probably as important as the 62-day referral for treatment target, which is why the 28-day target from urgent referral to diagnosis is so critical and will be one of the four key targets that will be in the CCG assurance framework. I accept what the noble Lords says; early diagnosis is critical. We are making progress and Sir Harpal Kumar, who developed the cancer strategy a year ago, is overseeing performance and progress towards meeting those targets.

NHS Funding

Lord Hunt of Kings Heath Excerpts

Monday 31st October 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for repeating that, but I am afraid that his attempt to gloss over the real story of the Government’s manipulation of NHS funding figures simply will not wash. The Government have been found out by the considerable and Conservative chairman of the Health Select Committee, Dr Sarah Wollaston. She has pointed out that the so-called extra £10 billion can be arrived at only through significant manipulation of the figures, including an extra year in the spending review period, changing the date from which the real terms’ increase is calculated, and disregarding the total health budget.

The Nuffield Trust pointed out in a report this morning that the £8 billion figure—which is the real figure, not the £10 billion figure—

“has been flattered by redefining what counts as ‘the NHS’. In the past, the government used to count NHS spending as the entire Department of Health budget for England. Now it only counts the subset of that spending that comes under the control of the department’s commissioning arm, NHS England. Only ‘NHS England’ is protected with ‘real-terms increases’ while the rest of Department of Health spending will be cut by £3 billion by 2020-21”.

Therefore, not only is the £10 billion or £8 billion a wild exaggeration: but the fact is that the NHS is facing an acute funding crisis, wholesale rationing of services and the denial of life-enhancing medicines to many patients.

I would like to put three points to the Minister. First, I see that he quoted OECD figures, but looking at the latest OECD per-capita spend on health, I note that 18 countries in the OECD group have a higher GDP spend on health than we do in this country. Can he confirm that, compared to any country of equally sizeable wealth, we have fewer doctors, fewer nurses, fewer beds and less access to medicines and new medical equipment?

Secondly, when the Minister says that the £8 billion was what the NHS asked for, can he confirm that the NHS did not ask for £8 billion, but indeed took no part in any discussions? There were discussions with NHS England, which is a government-appointed quango and is not the National Health Service. Can he also confirm that, in negotiations, the Government themselves—including the Treasury—told the chief executive of NHS England that £8 billion was the maximum amount that he could call for?

Finally, on the five-year forward plan—the underpinning of it by sustainability and transformation plans—can the noble Lord confirm that first analysis shows that swingeing reductions are to be made in acute care without any guarantees that community and other services will be put in their place to reduce demand on acute services?

[Lord Prior of Brampton]

My Lords, I will try to respond to those last three points. First, the noble Lord is right: the NHS is—and I would regard it still as—the highest-value healthcare system in the world. It does have fewer doctors and MRI machines—however you want to measure it—compared to many other OECD countries, but its outcomes, on the whole, are very good. I can, therefore, certainly confirm that the NHS is a very high-value healthcare system. As far as the involvement of the NHS in the plan is concerned, it was very much put together by the NHS and signed by all of the arm’s-length bodies at the time. This is a quote from Simon Stevens about the spending round settlement:

“This settlement is a clear and highly welcome acceptance of our argument for frontloaded NHS investment. It will help stabilise current pressures on hospitals, GPs, and mental health services, and kick-start the NHS Five Year Forward View’s fundamental redesign of care”.

This brings me to my last point, the fundamental redesign of care. That was possibly not really recognised at the time of the NHS review, because it is a fundamental redesign of care. As the noble Lord said, it means moving resources away from acute settings into community settings, very much as mental health care was restructured 20 or 25 years ago.

Mental Health: Young People

Lord Hunt of Kings Heath Excerpts

Tuesday 11th October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the issue of suicide clusters and contagion is serious and real. By 2017, as recommended by the Five-Year Forward View on Mental Health prepared by Paul Farmer, every authority will have a multiagency plan addressing that issue. I agree with the noble Baroness that we need to do a lot more in schools. Interestingly, 255 schools are now part of a pilot scheme where there is a single point of contact within the school, so that when a child is feeling suicidal or has mental health problems, it is at least clear who they should go to to seek advice.

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is clearly not just an issue of funding, but you cannot escape the issue of funding. Yesterday, police chiefs said that they were being forced to act as emergency mental health services because of the inadequacy of provision up and down the country. Recently, an FoI request showed that two-thirds of CCGs which responded are spending less as a proportion of their budget on mental health this year, rather than more, as Ministers required them to do. The Minister mentioned the review to come out later this month, which will reflect on this distressing issue. The question is how one can have confidence in what the Government are saying, because they clearly are having such little impact on what the NHS does locally.

[Lord Prior of Brampton]

My Lords, this is a difficult issue. As the noble Lord will know, a key part of the five-year forward view is to take resources out of acute physical care, out of acute hospitals, so that there is more available for mental health care, community care and primary care. It is very difficult to do that. As the noble Lord will know, we have been trying to do this since 2000 but all that has happened is that more and more of the available resource has been sucked into the big acute hospitals. Getting that resource out and into the community and into mental health is extremely difficult. The STP process is going on at the moment. We are committed to seeing more money going into mental health, but I acknowledge the difficulties.

Drug-Resistant Infections

Lord Hunt of Kings Heath Excerpts

Thursday 15th September 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to congratulate the noble Lord, Lord Lansley, on raising such an important and interesting Question for our debate today on the risks that we face, now and in the future, in relation to AMR. It is of course very timely, because of the imminence of the UN high-level meeting and also because of the work of the noble Lord, Lord O’Neill of Gatley, to whom I pay tribute—indeed, I am grateful to him for his summary of his report, which we received yesterday.

We have had the interim response to that report, and I understand that a full response is due shortly. Can the noble Lord, Lord Prior, say a little more about that full response and what he thinks might be in it? Can he also say a little more about the approach we are likely to take at the UN high-level meeting next week?

Noble Lords have referred to a lot of the recommendations of the noble Lord, Lord O’Neill; I will ask about two areas. The first relates to a global public awareness campaign. We know, as noble Lords have said this afternoon, that some have what can best be described as a cavalier approach to the use of antibiotics. I am interested to know what the UK’s approach is to negotiations on an international response, particularly on the need for a global public awareness campaign. The noble Baroness, Lady Walmsley, from her experience in Kolkata, intimated the kind of response that was possible, but we need a level of awareness for that to happen.

I also want to ask about work with the global finance and health community to develop a system that can reward pharmaceutical companies that develop new and successful antibiotics. I understand that the ABPI is working with the Minister’s department to create a UK model that would delink payments for antibiotics from volumes of sales, which would guarantee companies a return on investment. The current financial model does not provide the incentives that the companies need. Can the Minister say a little more about the progress that is being made in those discussions?

Vaccines have been mentioned by a number of noble Lords. I have had a comment from one of the companies that have briefed me—it was from Pfizer, in fact—that while the UK is a world leader in national immunisation programmes, its sense is that immunisation is not regarded by the Government as an,

“important component of its strategy to address AMR”.

Can the Minister confirm whether that is true or not? As Pfizer points out,

“This is despite evidence that improvements in vaccination could help to contain the rise of four different types of drug-resistant infections”.

The noble Lord, Lord Rees, very clearly set out the real risks faced, and he offered some interesting insights, I thought, into the use of prizes to stimulate solutions and to work up novel ideas. Does the Minister think that this might be something that is developed in the future?

We have heard a number of ideas. The noble Lord, Lord Colwyn, raised the issue of reactive oxygen. I am not sure that I entirely followed the technical details, but I got the point. He essentially said that there is a regulatory difficulty with its introduction. It would be interesting to know whether the Government are looking at this as a potential area for development.

I should also say that we have had an amazing amount of briefing for this debate. I was interested to hear from Brightwake the potential for using disinfectants as chemical agents, since they have excellent biocompatibility and can be used more on topical infections or wounds with a high risk of infection. Brightwake says that use in Germany has shown pre and post-surgical infections are the lowest recorded. My understanding is that there is a problem for manufacturers to get these agents through the regulatory process, because the cost of introducing a so-called “medical substance” into a medical device is very prohibitive.

None of us knows the impact of Brexit on the regulation of medicines and medical devices, but it might be worth looking at areas in which a speeded-up and rather more streamlined approach might be helpful in the future. Can the Minster’s department have a look at that?

The noble Baroness, Lady Hayman, made some very telling points about malaria and the all-party report. I think that she and I are both interested to know whether the Government will take forward the recommendations and how they will do so.

We have talked about what is to be done globally, but there is much that can still be done in this country. GPs are clearly at the front line in terms of the prescribing that they undertake, and my impression is that many of them have responded to the challenge but there is a clear variation in performance. I was interested in the reference by the noble Lord, Lord Colwyn, to veterinary surgeons and the guidance—or what I think is rather more than guidance—issued by the Royal College of Veterinary Surgeons; it sounded much more like a requirement in relation to their clinical practice. I wonder whether there is something to be learned there in relation to the inappropriate use of antibiotics in human medicine. Can the Minister comment on where we are with GPs and whether there are things that we can do, none the less, to improve their overall performance?

I also refer the Minister to a comment that I have received from the BMA:

“In hospitals it is often unclear which staff have ‘ownership’ of antimicrobial prescribing and responsibility for minimising resistance”.

That is very interesting because—as the noble Lord, Lord Lansley, referred to—it has clearly been important that, at the end of the day, both the board of the organisation and individual senior officials have a clear responsibility for infection control. I wonder whether we need a similar approach when it comes to antimicrobial prescribing.

Three speakers—the noble Earl, Lord Selborne, and the noble Lords, Lord Lansley and Lord Trees—spoke about the issue of animals. They made some very telling comments. The noble Lord, Lord Lansley, asked about veterinary supervision of the use of antibiotics in animals; he also referred to the inappropriate use of what might be described as the antibiotics of last resort in animals, which should be reserved only for humans—I think that there is a great deal of sympathy for that.

The noble Lord, Lord Trees, spoke of the responsible attitude of veterinary bodies in the UK and EU and the considerable progress that has been made over the past few years. I think that it is right to acknowledge that progress and to acknowledge the farming community as a whole for its general co-operation on those measures.

But what about countries where there is absolutely no control of the use of antibiotics in animals? Is the Minister confident that this will be tackled in future global negotiations and discussions because this is clearly a very worrying situation? I am not an expert on the international food trade, but one of the major concerns of UK farmers is that very high standards are required of them, whether in relation to the inappropriate use of antibiotics or on animal welfare, but they are forced to compete with countries which do not have these high standards. This is a very broad canvas, but clearly the issue of animals should be taken very seriously.

Overall, this has been an extremely constructive debate. I recognise that the Government, particularly under the previous Prime Minister, were taking a progressive approach in this area. I very much hope that this will continue under the current Prime Minister, and that we will see a wholehearted response to the report of the noble Lord, Lord O’Neill, very soon.

Smoking-Related Diseases

Lord Hunt of Kings Heath Excerpts

Wednesday 14th September 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I first declare an interest as a president of the Royal Society of Public Health. Principally, I would like to reinforce the argument made by my noble friend Lord Faulkner about the need to tackle health inequalities, in which smoking clearly plays a key part. He said smoking was responsible for half the variation in life expectancy. My noble friend Lady Gale also spoke eloquently about the impact of smoking on mothers during pregnancy and after the birth of their children.

The principal question I would like to put to the Minister focuses on the tobacco control plan. It is generally agreed that the last tobacco control plan produced a huge number of positive outcomes. Clearly, it is vehicle by which further improvements can be made. However, despite the UK’s leadership and the advances that we see, there is no room for complacency. Will the Minister tell the House exactly when we can expect to see the plan published?

Secondly, may I raise with the Minister the problem of local authorities reducing funding for stop-smoking services? He will know that, with the transfer of budgetary responsibility to local government, there were great hopes that local government would use its position to enhance public health programmes. I am afraid that so far the opposite has been the case. How much is his department monitoring what is happening with local authorities and smoking cessation services? Can he make it clear to Public Health England that it is empowered to make interventions when it feels that local authorities are not doing the right thing? I have a great deal of time for Public Health England but it feels inhibited in challenging local authorities where they are not investing sufficiently in these kinds of services. It would be good if the Minister was prepared to say that it can do that.

Will the Minister also help us on mass media campaigns? They have proved very effective. Will he assure us that in the plan there will be sufficient investment in those campaigns in the future? On the question of electronic cigarettes, I agree with the noble Lord and the noble Baroness that they ought to be part of the smoking cessation programmes. Equally, some research would also be welcome to pick up some of the issues that have come to the fore recently. On the general principle, I have no doubt that for adult smokers who find it difficult to give up smoking, e-cigarettes definitely have their part to play. It is important that the Government continue to signal their support for that.