Cataract Operations
Lord Hunt of Kings Heath Excerpts(9 years, 3 months ago)
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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.
Mental Health: Children and Adolescents
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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?
NHS: Cancer Patients
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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
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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
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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
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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
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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.
NHS: Health and Social Care Act 2012
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Lord Hunt of Kings Heath (Lab)
My Lords, as this is such a general debate, I remind the House of my interests as president of GS1 UK, the Health Care Supply Association, the Royal Society of Public Health and the British Fluoridation Society, as a trustee of the Royal College of Ophthalmologists and as a consultant and trainer with Cumberlege Eden.
I am very pleased that my noble friend Lord Hanworth opened this debate today with an extensive, and indeed passionate, analysis of the NHS. He thinks that it is in a critical position, and I agree with him. Whether it is down to the overt privatisation of the NHS encapsulated in the 2012 Act or whether it is essentially down to underfunding is, I think, a matter for some debate. On the matter of privatisation, I should say that I have no problem whatever with the involvement of the private sector in the NHS; indeed, I think that there is much to be gained from partnership with the private sector. The noble Lord will know that, as a Minister, I was responsible for some of the contracts that were put in place to enable us to reduce waiting times, which I think was an excellent thing to do.
I agree with my noble friend that the NHS seems to have been forced to tender out services willy-nilly, at great expense and, frankly, with very poor outcomes. I know that the noble Lord, Lord Lansley, said that it was not his intention that clinical commissioning groups should be forced to do that; it was going to be down to them. Indeed, when he introduced the Bill and talked about it, the emphasis was very much on local GPs making the decisions. The problem is that CCGs themselves—and certainly NHS England—misunderstood those messages, and CCGs felt under pressure to put some services out to tender. I do not think that the outcome has been very satisfactory at all.
I say also to my noble friend that I disagree with him about the NHS foundation trusts. I believe that the local governance that they have, making them much more accountable to members locally, is something to be treasured and supported.
I will just address PFI. Yes, there were some schemes that were expensive and not well-managed contractually, but the fact is that, as a result of PFI, we were able to invest huge amounts of money in the infrastructure. If you want to look at PFI, I would look no further than my own local district general university hospital, Birmingham QE, which is a magnificent example of a PFI scheme, delivering fantastic services and which, overall, is affordable. It is worth saying that unpublished figures to the Health Select Committee from the Health Foundation, which look at expenditure on PFI in 2013-14, showed that it accounted for 1% of providers’ total expenditure. It is not PFI that is breaking the bank.
We need to be more dispassionate about the kind of health service we want and how we want to see it organised in the future. What happened in the 2012 Act is a salutary lesson to us all. I, too, was surprised at the Government’s decision to go for wholesale reorganisation. After all, it had a pretty good inheritance: there had been investment; waiting times had been reduced; and the infrastructure had been invested in. I tempt fate to try to persuade the noble Lord, Lord Lansley, to say at some point, but I never understood why he simply did not get PCTs to do what they should have done, which was to delegate much more decision-making with budgetary responsibility to GPs, rather than going for the wholesale reorganisation that we saw. I accept that the health and well-being boards—the potential integration of health and social care—were a very important and supportable part of that Bill. The problem is that the rest of it has produced a chaotic system in the field.
My noble friend Lord Lipsey mentioned Sir Muir Gray. He said that no reorganisation has ever produced anything of any use. I have some sympathy with that, although I suppose I must own responsibility for two or three of them. The fact is that this reorganisation produced great confusion and fragmentation at local level and, above all, a sense that no one was in charge.
My reading of sustainability and transformation plans is, essentially, that they have been established by NHS England to replace strategic health authorities because they have to have some kind of local plan and leadership. The problem is that they lack legitimacy; I am afraid they lack openness and I hear that, in many parts of the country, they have not involved local government at the start. That is a great pity.
More worrying, I hear too that STPs have come up, in the main, with tired, old solutions. So they are going for heroic reductions in acute sector capacity. They say that they are going to have fantastic, demand management approaches to reduce the intake, but the reality is that there will be no leverage over GPs, primary care or local government to make it happen. It was fascinating listening to the comments of the noble Lord, Lord Kakkar, about the Netherlands and the way in which it should be done. I am afraid that, so far, there is very little evidence that STPs are going down that route.
In July, the chief executive of NHS Improvement said that the NHS is “in a mess”. That was putting it kindly. We have huge deficits; performance has gone completely south, and I doubt that the Government are going to get back to any of those targets in any substantial way over the next four years. No one else in the health service believes that the targets are going to be recovered. At heart, we have this issue of an increase in demand for services, coupled with demographic changes, and the growth rate in resources is less than the health service has ever had in the past. We know that, historically, up to 2015, average real terms growth was 4% a year; it is now down to about 1%. It is abundantly clear that it simply cannot be done.
When you look at the OECD comparisons, they are pretty shocking. There are 29 countries which have more CT scanners per capita than we do. There are 28 with more MRI units and 25 have more hospital beds per capita. That gives the lie to those who think that the acute sector in this country is overinvested. Thirteen have more doctors per capita; 18 have more health expenditure; 18 have more nurses. On comparative terms, I agree with my noble friend Lord Lipsey, it is almost a miracle that it achieves what it does with the kind of resources that it is given.
My noble friends Lady Armstrong and Lady Pitkeathley spoke eloquently about the issues in social care and the funding squeeze. The noble Lord, Lord Lansley, was right about the disappointment over the implementation of the Dilnot report. It is very difficult to see where we are going overall in health and social care, except into a long-term decline. It feels like we are going back to the days when you had long waiting lists and disintegration between different parts of the service. The rhetoric is there. Ministers talk about integration, as do the STPs, but, from talking to anyone in the field who has either to do it or is a patient or a client experiencing the service, things just seem to be getting worse and worse and worse.
I do not have the time to talk about Brexit but, at the same time, there are issues to do with staffing. My major concern is about long-term investment in the life sciences in this country. The research issue to which the noble Lord, Lord Kakkar, referred is very serious.
We have the Select Committee, two members of which spoke in the debate today. It has a very important task ahead of it. It could come up with a soft report, looking at all the options one way or the other and then ducking out of a hard recommendation. I urge it to go in hard. As my noble friend Lord Lipsey said, we face fundamental questions about what sort of health and social care system we have, what we are trying to do and about the demographics and how we are going to afford it. It would be all too easy to shy away from making the kind of hard decisions that have to be made. I very much hope that our Lordships’ House and its Select Committee will help us do that; I do not think the Government will.
Junior Doctors: Industrial Action
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Lord Hunt of Kings Heath (Lab)
My Lords, I am grateful to the noble Lord for making the Statement.
Clearly the prospect of a series of five-day strikes is very worrying, coming after the protracted negotiations, agreement between the negotiators and then the subsequent ballot rejection. The promised action, though now delayed, would have a damaging impact on patients, the NHS and the junior doctors themselves. However, the Secretary of State and the Government cannot escape their own responsibility for the threatening catastrophe.
At the heart of this dispute is a complete absence of trust by the junior doctors in the Government and, specifically, the Secretary of State. It is not hard to see why. Towards the end of the Statement the noble Lord mentioned a seven-day service. It is the conflation of the seven-day service issue with the junior doctors’ contract which has exacerbated an already difficult situation, particularly as it is the junior doctors on whom the service is so dependent for out-of-hours working.
The Minister did not mention the advice received from officials but he knows that the documents obtained by the media outlining the risks detailed by officials on the seven-day NHS were clear in their assessment that the NHS was likely to have too few staff and too little money to deliver a truly seven-day NHS. Moreover, it gives the lie to the last sentence of the Statement where the Secretary of State comes out with all that blah about making the NHS the safest, highest-quality service in the world when everyone knows that it is crumbling through a lack of resources, a lack of staff and a lack of leadership. We have a Secretary of State who is in his own world, one that is occupied by no one else. He is charging ahead with implementing the seven-day working week without the resources, staff and support needed to do it.
Let me be clear: no one more than I would like to see a truly seven-day working NHS, but that is dependent on the resources being available to ensure its proper implementation. What I deplore—and this is a core reason for the disenchantment among junior doctors—is the Secretary of State’s distortion of the statistics in relation to weekend mortality figures to justify the imposition of the contract.
I would like to ask the Minister a number of questions. First, he referred to the contingency plans being put in place by the NHS, but clearly with the postponement or cancellation of the first proposed action there is now time for the NHS to give more consideration to those contingency plans. I wonder if he can tell the House a little more about them. Secondly, the chief executive of NHS Providers has warned that with little notice the unprecedented action,
“will cause major disruption and risk patient safety”.
What discussions have taken place between Mr Hopson and Ministers to discuss his concerns? Thirdly, where elective operations and clinics may be cancelled as a result of the promised late action, what assurances can the public be given that new dates will be scheduled as quickly as possible?
Can the noble Lord say what discussions have taken place between the Department of Health and junior doctors? In its statement today announcing the postponement of the action, the BMA has said that it will call off further action if the Secretary of State stops his imposition of the contract, listens to the concerns of junior doctors and works with the BMA to negotiate a contract based on fresh agreed principles that have the confidence of junior doctors. What is the Minister’s response to that statement by the BMA? It has been reported in the media that the Secretary of State has refused to engage with the junior doctors. Can he confirm whether that is the case, and if so, why is that the position?
Finally, what are the Government’s plans to restore junior doctors’ trust in the National Health Service? There is a clear risk that the morale of a whole generation of doctors is being destroyed as we speak. When that is put alongside the implications of Brexit and the potential loss of experienced staff through the decision by many junior doctors to leave the profession or to go abroad, this is a worrying position. I have met a number of junior doctors over the past few months. They are clever, articulate and passionate about the NHS, but they have told me about the pressures that they are under, of the risky gaps that we now have in rotas which have developed over the past few years, of locums not always being available, of existing staff having to cover gaps at short notice, and of being hugely dependent on the good will of many staff, including junior doctors. The Statement of the Secretary of State is full of warm words about junior doctors’ working conditions, but as the Minister knows, the fact is that they do not have confidence in them. Frankly, I also do not think they have confidence in local management to implement the proposed contract in a way that is sensitive to their working conditions.
At the annual meeting of the Royal College of Physicians, its chairman pointed to the need for junior doctors to be valued, supported and motivated. Some months ago the RCP wrote to the Secretary of State outlining recommendations for improving conditions in training, including protected time for training and the promotion and support of flexible working, publishing rotas earlier and prioritising handover sessions. What progress has been made in responding to the sensible suggestions made by the Royal College of Physicians, and above all what are the Government going to do to endeavour to get back the confidence of junior doctors in the NHS and thus seek an end to this action?
Lord Prior of Brampton
My Lords, the noble Lord has raised many questions in his response to our Statement. He may well have read the article published earlier this week in the Times by Sir Simon Wessely, the president of the Royal College of Psychiatrists, which goes to the heart of what I would call the non-contractual issues that have bedevilled, coloured and provided the context for this dispute:
“Changes to the way that doctors are trained means that juniors face switching not just jobs but addresses every few months without much say about where they end up and when. Many seem condemned to spending years rootlessly shuffling from one place to another like lost luggage. Without any familiar faces, long hours are endured in relative isolation and managers who change all the time provide little or no recognition, let alone reward”.
This in a sense is what lies behind much of the dispute. The fact is that we had a contract that was wholeheartedly welcomed by Dr Ellen McCourt, now the president of the BMA, and by the association itself. The issues of difference in the contract were pretty small.
We have been discussing this contract for three years now and the Government have made 103 concessions. The Secretary of State’s door has been open throughout that time. The new contract is due to be introduced in October and at some point we really have to get on and introduce it. There is provision within it to review aspects as it goes forward. We have committed to looking at the gender pay issues that have been raised by the BMA and today HEE has published the work that it is doing on non-contractual issues with the BMA when the association is prepared to talk to it. The Government are bending over backwards to meet the BMA, but there comes a point where we just have to bite the bullet and go ahead with the contract that has been agreed, and that is the place we are in now.
The noble Lord referred to a lack of trust in local management and in the Secretary of State, but we now have the guardians of safe working hours built into the contract. They have a contractual commitment to report every quarter to the boards of trusts and to the GMC and the CQC every year. Plenty of independent safeguards have been built into the new contract. So while of course I understand many of the issues raised by the noble Lord, the Government have gone the extra yard every time they have been asked to do so and now we must get on and introduce this contract.
Health: HIV
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Lord Hunt of Kings Heath (Lab)
My Lords, I too very much welcome the debate and the thrust of the argument put forward by the noble Lord, Lord Black, for the elimination of HIV. Like many other noble Lords, I echo the tribute that he made to organisations such as the National AIDS Trust and the Terrence Higgins Trust, as well as, of course, to the noble Lord, Lord Fowler, whom it is marvellous to see in the Speaker’s chair tonight. The noble Baroness, Lady Bottomley, mentioned Sir Donald Acheson, who was the powerful, dynamic Chief Medical Officer at the time, and it is right that we remember the role that Chief Medical Officers have played in this story over many years.
In opening his debate, the noble Lord reminded us that HIV is a global issue. The UK has played a proud role in global efforts but HIV remains a major challenge in this country. The noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley, referred to some of the statistics but, for me, the two most striking are the 2014 statistic showing that more than 6,000 new people in the UK were diagnosed with HIV and that in the same year an estimated 18,000 people were living with HIV but were unaware of their infection. The argument that the noble Lord put forward for testing, and for publicity about testing, is very important, and I hope that the Minister will be able to respond positively in that regard.
That then leads us to the wider issue of tackling stigma. I very much commend the argument that the noble Lord, Lord Black, made for a public information campaign. However, I would link it, as the noble Baroness, Lady Walmsley, did, with sex and relationship education. That is vital but the statistics are frightening. We know that only 40% of secondary schools in the state maintained sector have proper sex and relationship education on the curriculum and that primary schools, academies and free schools do not need to teach SRE. I do not think that that is right. I hope the noble Lord’s department is in earnest discussions with the Department for Education about a proper change in policy in this area.
The noble Lord mentioned that the last government advice around these areas was produced 16 years ago, and it is the same in relation to sex and relationship education and guidance. There is a need for new guidance. A lot of water has flowed under the bridge in those 16 years—not least the introduction of same-sex marriage, the mass use of mobile phones, the internet, and all the issues in social media that that brings in relation to sex and relationships. The Government need to look at these issues very carefully.
I cannot add much in relation to PrEP because noble Lords have covered the subject adequately. The argument for its use is overwhelming, as is the economic case if we look at it in the round rather than from a narrow departmental point of view. It has never been explained why NHS England has taken this perverse point of view. It is equally puzzling why it is carrying on with the case having been comprehensively shown, in the judgment, the error of its ways. I am also puzzled why Ministers have simply not called in the chairman of NHS England and told him to sort his body out. We have had no cohesive explanation as to what this is about.
I completely put aside the argument that this should be for local government. It is a nonsensical argument which no one in the field believes is true. Clearly it is a device for NHS England to avoid committing itself to the expenditure of this money. If it is, it should come clean on it. If you look beneath the emotive language, essentially that is what the press release to which the noble Lord, Lord Scriven, referred is saying. I agree that many of the organisations involved in specialist services feel that blackmail is being undertaken by NHS England at the moment. It is a hard word to use, but when a senior medical official talks about making comparisons between people who indulge in high-risk sex and children with cystic fibrosis, I find it a disgraceful use of words. I am surprised that Ministers have not called that official to account.
We all know that in the current climate hard choices are being made. However, I cannot believe that Ministers do not think that PrEP should be funded. The noble Lord may quote the 2012 Act in terms of the relationship between Ministers and the NHS Executive, but he knows only too well that Ministers are accountable to Parliament and that they should discharge that accountability.
On public health budgets, the noble Lord, Lord Lexden, pointed out one of the problems with the 2012 Act—the fragmentation of effort in this area. There are two issues here: one is that there is fragmentation between local government and the health service; the second is that some local authorities are not taking their responsibilities and that others, particularly those in the big city areas, are having greater pressure put on them because individual patients are going to them because their own local services are not available. This needs review. We should probably work in partnership with the Local Government Association to see whether we can iron out the inconsistencies.
Another problem is the issue of public health budgets, which have taken more than their fair share of reductions as a result of the financial stringency. It makes it difficult to make sense of the overall five-year forward plan of NHS England, which promotes public health and prevention, yet in the budgeting decisions seems to detract from the ability of services to play their full part.
This has been an excellent debate and I endorse the points put forward by all noble Lords. It would be nice if the Minister were to say that it is the Government’s intention and aim to subscribe to the thrust of the noble Lord’s Question and, above all, to sort out some of these problems, particularly the issue of PrEP and the integration of services between health and local government.