E-cigarettes: Regulation

Lord Hunt of Kings Heath Excerpts

Monday 7th March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the benefits of e-cigarettes are well understood. The figure of 1 million people who have given up smoking by taking up e-cigarettes is a valid and true one. The tobacco regulation that the noble Viscount refers to does not have any proposals for an excise tax—it purely relates to ensuring that these products are used safely and are of a given quality.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister will know that the impact of this directive is to make it much more difficult for e-cigarettes to be promoted. Why is that, given the clear benefit to public health? The answer is that public health programmes can substitute for it—but this Government have slashed those programmes. Given the Prime Minister’s success in EU negotiations about a change in direction, can the Minister confirm that we will not now have to implement Article 20 if we do not want to?

[Lord Prior of Brampton]

My Lords, this directive originated partly because a number of European countries wanted to ban these products. The fact that there is a directive, which will lead to a regulated market, means that British manufacturers will have access to those large European markets. As I understand it, the main issue that the noble Lord may be concerned about is that where the nicotine content goes above 20 micrograms per millilitre, there will have to be MHRA approval, which may mean that the higher strength nicotine substitutes are less readily available. But that is done on safety grounds.

Pharmacies: Funding

Lord Hunt of Kings Heath Excerpts

Wednesday 2nd March 2016 Lords Chamber

[Lord Prior of Brampton]

The noble Lord raises an important point which I regret I cannot answer. I will have to write to him on that matter. However, for community pharmacy to play the important role in primary care that we expect it to do, it will have to have access to integrated patient records. The confidentiality that surrounds those records is very important.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this is all very well but will the noble Lord confirm that one of the ideas of his department is for doctors to prescribe medicines for a longer period so that fewer trips are made to the pharmacy, thereby compensating for the closure of up to 3,000 pharmacies? However, is he aware that it is estimated that £300 million-worth of medicines are wasted every year? I understand that a third of that is in medicines that are never opened by patients. Surely it is not cost-effective to extend the length of the prescription time because all you will do is add to wastage of medicines.

[Lord Prior of Brampton]

My Lords, there is no intention to extend the prescription time just for the sake of it. But there are many people who have stable long-term conditions, for whom a 90-day prescription period might be appropriate. We are not saying that all prescriptions should be for that length of time but some of them might be.

Health: Black and Minority Ethnic Psychiatric Patients

Lord Hunt of Kings Heath Excerpts

Monday 29th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the Government are committed to putting more resources into mental health. There is a recognition, across all parties in this House, that mental health has been a Cinderella service for ever. We are all committed to parity of esteem between mental and physical health and more resources are now going into mental health.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in his Answer, the Minister mentioned the Mental Health Taskforce report. It points out that, while there is a workforce race equality standard, there is no equivalent standard for access to services. He said that the Government will appoint a champion, but why not agree to set a standard and appoint a national director to make sure that it is implemented?

[Lord Prior of Brampton]

My Lords, there are two separate things there. We are committed to the recommendation of appointing an equalities champion. Extending the workforce race equality standard to carers and patients was recommended by the noble Lord, Lord Crisp, and welcomed by Paul Farmer in his report. I hope that we will adopt that recommendation, but I cannot promise it.

NHS (Charitable Trusts Etc) Bill

Lord Hunt of Kings Heath Excerpts

Friday 26th February 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am highly indebted to my noble friend Lady Massey for introducing the Bill. I congratulate her on a remarkable 50th wedding anniversary today. I also congratulate the noble Lord, Lord Bird, on his remarkable maiden speech. The noble Lord, Lord Patel, was so right when he described it as extraordinary, inspiring and heart-warming. As the noble Lord, Lord Cormack, rather subtly put it, it is a great advert for the benefit of an appointed House of Lords.

The point raised about the message to trustees of charities is important. The noble Baroness, Lady Barker, rightly described the last 12 months as being a very difficult time for charities. One does not need to go through the various issues that have arisen. It is clear from what she said—I very much agree with her, certainly in the context of the Bill—that the role of charitable trustees over the years has become ever more onerous and transparent. It has sometimes brought considerable pressure on those trustees. In supporting the Bill, it is right to pay tribute to charitable trustees, but also to say to the Minister that at a time when it is easy to criticise those trustees, the Government need to look at ways trustees can be collectively supported in the very difficult job that they are sometimes called on to do.

The first part of the Bill has arisen mainly from representations from the Association of NHS Charities and a number of individual NHS charities that have called for reform. I very much support the change that would be made. My understanding, and maybe the Minister could confirm this, is that there is a view that removing the current ministerial involvement in the appointment of trustees may encourage donors rather more in the future than in the past. I do not know whether the Minister agrees with that, but if it is true it is certainly to be welcomed.

I can only support Clause 3, on the transfer of rights to “Peter Pan” royalties. We all see Great Ormond Street as a hugely important national and international institution. The more it can be supported the better. My noble friend Lady Blackstone eloquently described the reason for the Bill, and the Opposition are wholly in support.

Access to Medical Treatments (Innovation) Bill

Lord Hunt of Kings Heath Excerpts

Friday 26th February 2016 Lords Chamber

[Lord Patel (CB)]

My Lords, I am delighted to support this Bill and hope that it will have a swift passage through this House and become legislation. I congratulate the noble Lord, Lord Saatchi, on presenting it in great detail and in his usual style, and—given the difficulties his predecessor Bill had—on his tenacity in listening to people in and outside this House and getting to the position whereby the Bill is now acceptable to all the professionals I have spoken to.

Perhaps I may briefly go off the Bill and come on to some comments that have been made. Before I do that, I will declare my interests. I am, as everybody knows, a doctor by background. I am the chancellor of the University of Dundee, which is one of the key UK universities for life sciences. I chaired until recently the UK cancer research centre in Dundee. I now chair, as a board member, another research group in Dundee that is looking at the scientific evidence as to why cancer outcomes can be worse among people from a poorer background, where they are disastrously worse. I was also responsible in this House for chairing a report on genomic medicine. That led, thankfully, to the developments in genomic medicine in the United Kingdom and the research centre which the Government support through the research councils.

It is true that as we learn more and more about genomics and genetics, we will need to have a huge database from which we can learn. What the noble Lord, Lord Ryder, said is correct: there will be patients who would be appropriate for stratifications of medicines that we know now and which are found to be effective because they are used more generically. If we learn from genomic medicine that stratification makes them more suitable for that treatment, because of their genetic make-up, such drugs will be very beneficial.

It is also true that innovations occur in the United States at a faster rate—the noble Lord, Lord Ryder, referred to this—because the processes of the different trial phases there are much more efficient. Some say they are too quick; I do not subscribe to that view. Let me give one example. The noble Lord referred to this concept briefly. Some of the breast cancer treatments do not work in all women. We know that the drug that is given will work but that it cannot be given in the quantities required because most drugs, as we know, are poison. You can use it in a dosage that will treat the disease but if you exceed that dose, you are likely to do more harm than good. But if you can limit that treatment to only the cancer cells, those drugs will be effective. We now have innovations whereby this can be done by identifying the molecular make-up of the cancer and then loading the drug with that molecular marker, so that it will attack only the cancer cells and leave the normal cells alone.

We need a different way of innovating. My own university also has a drug discovery unit. We have contributed to the development of several drugs, two of which would be regarded as blockbuster drugs, through understanding the science of disease processes—the biology of disease. Such understanding is crucial before you develop a treatment.

However, we need to move away from that to other ways of developing drugs. We try to do this by using 70,000 compounds that were previously identified by pharmaceutical companies but not used because they were not found to be effective in treatment. We are seeing if any could be used for the treatment of so-called tropical diseases that are not infectious, which a huge number of people are affected by. We do this in collaboration with other countries by supplying them with these compounds. I agree that we need to look at different ways of innovating drugs and treatments, particularly as the science develops. There will be other ways of dealing with diseases, such as gene-editing, which was how Layla, a young girl in Great Ormond St, was treated. That may also require the development of other drugs to make sure that side-effects are suppressed.

The point I am trying to make is that the Bill may well act as a catalyst. The noble Lord, Lord Saatchi, should be pleased that people are thinking more widely and outside the box. We have an opportunity to develop good databases, as the noble Lord indicated, and to use them for innovative development of treatments. I hope this will happen. I hope that the Government will bring in wider legislation on the issues that the noble Lord, Lord Ryder, referred to, such as better ways of conducting clinical trials. We need transparency and openness. I do not think the medical profession is averse to that, and it is what the public need. We have to be honest: not all the treatments we try will work, but if we try harder, we will find treatments that work which we have been ignoring.

I have to admit to something here, which I hope the GMC does not hear me say—although it might, and if it does, I do not care. I have used off-licensed drugs on several occasions, with the full consent of the patients I was treating, when no other treatment was working. Lots of my colleagues do this. If any doctor stands up and says they never do it, I would not suggest that they might not be telling the truth, but I would be surprised if they were innovators in the true sense.

Then, there is research. I have done research that I am not very happy about and that I wish I had not done, but at the time I did it with a clear conscience. In retrospect, I now know that it probably did not work as well as expected and was probably not all that good for the patient—I hope it did not do any harm—but if I had not tried it, I would never have known. It is important that we stop arguing at length and trying to regulate and control in the minutest detail innovations in medicine that we can drive forward. We do this more easily with innovations in surgical and other procedures. We are much freer about that and clearly understand that, as doctors, you work with people in other countries to introduce the same procedures and use a common database to learn.

[Lord Hunt of Kings Heath (Lab)]

Would many current surgical procedures have been authorised if they had had to go through the kind of clinical trial process that medicines do?

[Lord Patel]

We would not have had stents put in hearts, bypasses, ablations—

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I thank the noble Lord for bringing the Bill to your Lordships’ House and I commend him for his perseverance and stamina as he sought to take it and the previous Bill through. I, too, pay tribute to the honourable Chris Heaton-Harris for taking the Bill through the House of Commons.

When the noble Lord opened his speech he referred to the adoption of new medicines, and I am very sympathetic to the point he raised. The fact is that we have a shocking record in the UK on the adoption of new medicines. We use fewer branded medicines per person than comparable countries; we tend to use older rather than the latest medicines; fewer patients in the UK receive new, innovative medicines than those in comparable countries; and we have a problem in that NICE-recommended medicines—even those that have been through the NICE process and have been shown to be clinically effective and cost effective—face further reviews and restrictions at local level, even though there is a legal requirement on clinical commissioning groups to make sure that NICE technology appraisals are put into action. For me, that adds to the concerns of the noble Lords, Lord Patel and Lord Ryder, about the position of the UK when it comes to investment in R&D by the pharmaceutical sector. We know that we have a very strong science base and at the moment we have a strong pharma R&D base, but those are at risk, partly for the regulatory reasons that noble Lords have already referred to. I do not think that that is so much the case in this country but I take the point made by the noble Lord, Lord Ryder, about European regulation.

The other big problem we have is that the NHS is hopeless at adopting new medicines. We have the Hugh Taylor Accelerated Access Review, which has been sponsored by Mr George Freeman, to whom I pay tribute for the work he is doing in this area. The review has produced an interim report and the final report will come out in the summer. It is concerned with access to innovative drugs, devices and diagnostics, which it aims to speed up. But however good the recommendations are and will be, unless the NHS and NHS England completely change their perspective and recognise that we have to adopt these fantastic new innovations that are coming to the UK or are developed here, in the end we will not be seen as a country in which it is worth investing. My experience—it may also be the noble Lord’s experience—is that the big problem is that there is a culture within the NHS that regards drugs as a cost rather than a benefit to patients. There is a need to take a very different approach, even in relation to new equipment and clinical staffing. There is a huge cultural barrier that we have to face up to.

Noble Lords, including the noble Baroness, Lady Masham, mentioned that we have received briefings from a number of medical bodies—the ABPI, the BMA and many of the royal colleges—which are still expressing concern, even though the Bill has changed considerably since the noble Lord took it through in the last Session. We know that they still have some concerns about the database and about what they regard as the perverse incentives. Is the Minister confident that his department can help to assuage those concerns? If we are to see this Bill progress—and we all want to see the benefit that the noble Lord wishes to bring to healthcare in the UK—it is important that there be some way of reassuring those bodies that what is intended here will not put at risk some of the things they have put forward.

I also hope that the noble Lord will respond to my noble friend Lord Murphy on the very important point about off-patent drugs. I am not convinced that the authorities in the UK have ever understood the importance of making progress in this area. In the end, only Ministers can kick people to make progress. I agree with him—let us hope that this database is at least a start in giving prescribers confidence to prescribe off-patent drugs.

Finally, I come to the recommendations in the Delegated Powers Committee’s report published on 25 February. I do not know whether the noble Lord has seen it but it makes reference to this Bill and I am slightly concerned about it. The committee is concerned about Clause 2, which,

“enables the Secretary of State, by negative procedure regulations, to confer functions on the Health and Social Care Information Centre … in connection with the database”.

In particular, the regulations may include requiring or authorising the centre to disclose information to specified persons. The Delegated Powers Committee has no problem with the use of subordinate legislation to do that, nor with the use of the negative procedure, but it says that,

“clause 2 appears to envisage no provision, either in the Bill itself or in the regulations, for the enforcement of conditions imposed by virtue of subsection (4)(b), and we draw this matter to the attention of the House so that it may seek an explanation, either from the Member promoting the Bill or from the Minister”.

I do not expect the Minister to be able to respond today. However, if the committee has identified a drafting issue, the question of how it is going to be dealt with is a concern.

I end with the point that the noble Lord, Lord Blencathra, made about timing. Presumably, he is basing his assumption on the Commons rising in May, but he seemed to be saying that 11 March would be the last time in this Session that the Commons would deal with it.

[Lord Blencathra]

My assumption is not based on when the Queen’s Speech would be or when the Commons rises. In the Commons, the days for Private Members’ Bills are announced at the start of the Session, and Friday 11 March has been announced as the last day. Even if the Commons ran into June or July, there would not be an extension beyond 2.30 pm on Friday 11 March.

[Lord Hunt of Kings Heath]

But on that basis, even if there were no Committee or Report stage, it would still be too late. Will the Minister join me in asking the usual channels whether we can find some time before 11 March to take this Bill through, even if the Government may need to table a technical amendment? Obviously, a recommendation from the Delegated Powers Committee cannot be ignored. We on this side of the House would certainly support the Minister in doing that.

National Health Service: Workforce Race Equality Standard

Lord Hunt of Kings Heath Excerpts

Wednesday 24th February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the ability to undertake the duties of a post is absolutely fundamental. The tragedy is that so few people from BME backgrounds are encouraged to put their names forward. It is more important that we get the actual recruitment process right.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister should be commended on his approach to this issue. Has he seen the survey undertaken in 2015 which shows that when looking at the national bodies of the NHS such as NHS Executive Search, Monitor and the NHS Trust Development Authority, none of their boards had any BME representation at all? Given that those appointments are made by Ministers, can the Minister tell us what they are doing to rectify that?

[Lord Prior of Brampton]

My Lords, I am not sure that the noble Lord is quite right. I can certainly think of two people from BME backgrounds on the board of NHS England. We can influence this, but it is important that the appointment process is independent of political bias. We have to rely on the chairs and the boards of these arm’s-length bodies to make those appointments.

Accident and Emergency Services: Staffing

Lord Hunt of Kings Heath Excerpts

Tuesday 23rd February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I can perhaps be excused for not following all that carefully Private Members’ Bills in the Welsh Assembly promoted by the Liberal Democrats. Safe staffing is obviously very important. I quote Mike Richards on this, who says that it is,

“important to look at staffing in a flexible way which is focused on the quality of care, patient safety and efficiency rather than just numbers and ratios of staff”.

That is extremely important.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister tell me why the Government told NICE that they could not publish safe staffing levels for accident and emergency departments, when they accepted fully the recommendations in Sir Robert Francis’s Mid Staffordshire inquiry report, which said that safe staffing levels should be published? Will he also tell me how NHS trusts are enabled to achieve safe staffing levels when they have been told by the regulator, NHS Improvement, that they have to cut their workforce to cut their financial deficits?

[Lord Prior of Brampton]

My Lords, NHS Improvement never said that trusts should cut staffing levels to below safe levels. It has said that there is a right balance between efficient and safe use of staff. Getting that balance right is so important. That is what Mike Durkin, the national patient safety champion at NHS Improvement, is doing. His work will be reviewed by NICE and by Sir Robert Francis.

Mental Health Taskforce

Lord Hunt of Kings Heath Excerpts

Tuesday 23rd February 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister for repeating this Statement. The final report, which came out recently, gave a very frank assessment of the state of current mental health services and describes a system which is said to be ruining some people’s lives. It is entirely consistent with the report by the noble Lord, Lord Crisp, on acute in-patient psychiatric care. It makes a number of recommendations which, if implemented in full, could make a significant difference to services that have had to contend with funding cuts and staffing shortages as demand has continued to rise, leaving too many vulnerable people without the right care and support.

We return to a question which was debated yesterday: the £1 billion by 2021. A number of questions remain unanswered. Can the Minister confirm that there is no actual, additional money other than the existing £8 billion that has been set aside for the NHS up to 2020, as previously announced by Her Majesty’s Treasury? Given that mental health services receive just under 10% of the total NHS budget, surely these services would actually expect to receive much of this additional money anyway, as part of the NHS settlement. Will the Minister explain how this can be expected to deliver the transformation that he and the task force say is urgently required?

In a recent Oral Question, there was the usual discussion of whether there should be a national debate about NHS funding. The Government need to get on, not just to debate it but to ensure that the NHS has enough money. Has the Minister studied the advice given by Professor Don Berwick, the Government’s safety adviser? He said, “I know of no nation that is seeking to provide healthcare at the level that western democracies can at 8% of GDP, let alone 7% or 6.7%. That may be impossible”. His advice to the Secretary of State was that it is crucial that the Government reflect on whether they have overshot on austerity. What is the Minister’s response to his own safety adviser?

[Lord Prior of Brampton]

My Lords, we have strayed somewhat from the subject. On the money, the Prime Minister announced an extra £1 billion in January. It is the same £1 billion and is within the £8 billion—or £10 billion—that was in the settlement in November. The Government asked Paul Farmer to set out in his report where the priorities are and where the money should be spent, and that is exactly what has happened. Interestingly, I saw Don Berwick last week. He is a very distinguished American with a lot of experience in patient safety and health improvement. There is no question: it is going to be tough. It will be very difficult to do on around 7% of GNP, but there is absolutely no doubt, from the work of the noble Lord, Lord Carter, and others, that there is a lot to go at. If it was not tough, we would not be going at it. We must take advantage of the fact that it is going to be tough by addressing some of the difficult issues which we should perhaps have addressed in the past but did not.

Health: Adult Psychiatric Care

Lord Hunt of Kings Heath Excerpts

Monday 22nd February 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, that is a complicated question, or number of questions.

[Lord Hunt of Kings Heath (Lab)]

It is very simple.

Pharmacy (Premises Standards, Information Obligations, etc.) Order 2016

Lord Hunt of Kings Heath Excerpts

Monday 22nd February 2016 Grand Committee

In summary, the key proposals concerning the continuing development of an outcomes-based approach to standards for registered pharmacy premises build on best practice. The proposal that the standards should not be placed in legislative rules follows as a consequence of this approach and will enable the GPC, and eventually the Pharmaceutical Society of Northern Ireland, to respond quickly when reviewing and updating the standards to keep pace with the increasingly rapid changes in pharmacy service provision. I commend the order to the Committee and I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the noble Lord for his careful explanation of the order. On the whole, the changes seem sensible, and I note that some of them follow the Law Commission’s recommendations. As the noble Lord will know, there has been disappointment that the Government did not bring forward a Bill or a draft Bill in relation to the whole package, and I know from our previous discussions that the Government are considering what further to do in relation to the regulation of individual health professionals. Is he able to update me on where the Government are on that?

On the detail of the order, I noted that overall the consultation outcome showed a great deal of support for the proposals, although perhaps less so in respect of the change in relation to standards for registered practices, which are no longer to be placed in legislative rules. I noted that some concerns were expressed, according to the Explanatory Memorandum,

“that removing the ‘black and white’ rules could lead to unhelpful variation for employee pharmacists in the way pharmacy owners choose to meet the standards”.

I assume that the proposal for an outcomes-based approach would ensure that there will be consistency about the standards themselves but leave more discretion for individual community pharmacies to decide how to meet them. Could the noble Lord confirm that for me?

The noble Lord made a very interesting comment at the end of his speech about the rapid change in the way community pharmacy services are provided. I certainly agree with that. I am sure he is aware that an estimated 1.6 million people visit a pharmacy every day. There is no question but that they have huge potential, not just in dispensing medicines but in many of the other services that are now available in community pharmacies, for example home delivery, compliance aids and other support to help old and frail people in particular live independently. There is also no question about the strong professional advice community pharmacies can give, particularly in relation to medicine management. We know, again, that older and frailer people in particular can be prescribed individual medicines without perhaps the GP or other doctors looking at the whole impact, whereas community pharmacies, through medicine management approaches, can have a very beneficial impact. For instance, this winter, NHS flu vaccines were available for the first time through community pharmacies. Again, that shows the benefit of recognising the professional expertise they have and of trying to ensure that they can relieve some of the load on other pressurised parts of the National Health Service.

The Government have made clear in a number of publications how they value community pharmacies, so I have been puzzled by the reductions that are going to be made in the community pharmacy budget, which is the subject of an Oral Question next week. I am puzzled by the thinking behind that reduction, which I think will start in October 2016, according to a letter that the Department for Health and NHS England sent out to community pharmacies. I just wanted to ask two or three questions about this.

First, in the letter that was sent out to community pharmacists, or to their representative organisations, there was a clear implication that the Government think there are too many community pharmacies at the moment. The letter points out:

“In some parts of the country there are more pharmacies than are necessary to maintain good access. 40% of pharmacies are in a cluster where there are three or more pharmacies within ten minutes’ walk. The development of large-scale automated dispensing, such as ‘hub and spoke’ arrangements, also provides opportunities for efficiencies”.

The department is also looking at ways of online ordering, which will make it easier for the public. The letter also says it is looking at,

“steps to encourage the optimisation of prescription duration”,

which I assume means prescriptions for a lengthier period than currently.

The Pharmaceutical Services Negotiating Committee has told me that it feels that the cut in budget is incompatible with the Government’s ambitions in relation to the contribution of community pharmacy. It wants to know whether it is government policy to see a reduction in community pharmacy premises. It would be a brave Government who said that they wanted to see that, but clearly it would be helpful to know if that is a stated intention. The development of an online pharmacy service is clearly to be encouraged. The record of community pharmacy has been very good in relation to being able to adopt a digital approach. Will that be done in a way that does not bypass the actual value of the advice that pharmacists can give to individual patients, particularly about medicine management?

Finally, on the question of increasing the length of time of a prescription, we know that a lot of medicine is wasted. Often, patients give up the course before they reach the end, even though they are recommended to take the full course. I can see that making the length of a prescription longer will mean that they will need fewer visits to the community pharmacist, thereby reducing the money going to the community pharmacist. However, if it leads to a greater waste of medicine, it might be a false economy. Has the department undertaken any work on that?

Overall, the SI itself is eminently sensible, but it cannot be considered without looking at the context of where community pharmacy is going. When we debated the Health and Social Care Bill in 2012, we discussed whether community pharmacists should be represented, as of right, on the board of a CCG. The Government resisted that, but there is evidence that because community pharmacists are not around the table at CCG level, the contribution they can make is often missed when it comes to issues such as how you make a health economy work effectively together or how you can, say, reduce pressure on A&E. We may be missing a trick here in not embracing community pharmacy rather more than we have been for the past year or two.

[Lord Prior of Brampton]

My Lords, I had a feeling that we might stray beyond the order, and we duly have. The noble Lord raised three broad points. The first was to request an update on the Law Commission’s report into the regulators. I do not have much to say that we have not already said. We think that a lot of what was in the Law Commission’s report was absolutely right, but it was a long and fairly prescriptive approach to the matter. We are considering it and may return to it in this Parliament, but it is not a priority in the short term.

The noble Lord referred to the outcomes-based approach and raised concern about whether the standards will be consistent. The intention is that they will, but there will be more discretion in how the outcomes are achieved. We are at one on the intent that lies behind his question.

I turn to the much more difficult matter that the noble Lord raised, which does not relate directly to the order, although he is right to say that it provides some context. The first thing to say is that I agree wholeheartedly with what he said about the vital role of pharmacists not just in dispensing but in how we manage medicines, perform vaccinations and look after the old and frail. I was interested by his comment at the end about why pharmacists are not represented on the board of CCGs. When we come to debate our whole approach to community pharmacy in more detail, we will set out our views on how pharmacy should be more integrated with the delivery of health and social care. It may well be that we should revisit whether pharmacists should be on the board of CCGs. Perhaps I can take that away to think about it further.

I do not want to be taken down the route of the number of pharmacists, because we are out to consultation at the moment. It is a fact that 46% of pharmacists are located in very close geographic proximity to each other. That is one reason why we have been looking at the structure of delivery of community pharmacy. On the one hand, we absolutely recognise that in rural areas we must have community pharmacies close by, and we want them to be much more integrated with healthcare delivery; on the other, there must be a question mark about the structure of community pharmacy. The number of outlets has grown from 9,000 to 11,500 in the past seven or eight years, which is a huge increase. Much of that increase has come from people setting up shop in very close proximity to existing pharmacies. It is right that we look at the whole delivery of healthcare by pharmacies, and it will be interesting to see what emerges from the current consultation.