Mental Health: Children and Adolescents

Lord Prior of Brampton Excerpts

Wednesday 16th November 2016 Lords Chamber

[Baroness Tyler of Enfield]

To ask Her Majesty’s Government what is their response to the Report of the Values-Based Child and Adolescent Mental Health System Commission What Really Matters in Children and Young People’s Mental Health, published on 7 November.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, we welcome the noble Baroness’s report and its endorsement of the direction set out in Future in Mind, our own report which puts children, young people and their families at the centre of this Government’s ambitious transformation programme to improve children and young people’s mental health and well-being. This means listening to their views and enabling them to access the high-quality care they need. This report builds on and strengthens that approach.

[Baroness Tyler of Enfield (LD)]

My Lords, I thank the Minister for his response. Does he agree with one of the key recommendations of the commission’s report that schools, if properly funded and supported, have the potential to make a really big difference to improving children’s mental health, not least because children spend one-third of their time in school? Linked to this, does he also agree that the proposed Prime Minister’s challenge on children’s mental health should incorporate this strong focus on schools?

[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?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Lord raises an important point. Interestingly, the spend on mental health in 2015-16 is up by 8.4% on the previous year compared to 3.7% for health spending overall. So there is clear evidence that the money that we have been talking about is getting through. The local transformation plans to which the noble Lord refers are being incorporated in all the strategic transformation plans. So there is evidence that it is getting through. It is taking longer than the noble Lord and I and others would wish, but when Theresa May became Prime Minister one of the things that she said on the steps of Downing Street was that she put mental health near the top of all her priorities. There is serious hope now that the money promised by the Government is getting through to the front line.

[The Lord Bishop of Carlisle]

My Lords, the commission highlighted the importance of valuing the workforce, but a 2014 survey of teachers and lecturers indicated that about 55% of them reckoned that their work was seriously damaging their own mental health. Have Her Majesty’s Government any plans to address that particular issue so that the mental health of teachers can be improved and so they are better equipped to help and improve the mental health of their pupils?

[Lord Prior of Brampton]

My Lords, I cannot answer that question effectively and would like some time to think about it. Clearly, the mental health of teachers, nurses and doctors is critical. Certainly in the medical profession we are doing quite a lot to help doctors who are going through periods of mental health problems. If it is all right with the right reverend Prelate, I shall reflect on his question and write to him at my leisure.

[The Earl of Listowel (CB)]

My Lords, does the Minister recognise the harm to children’s mental health when they and their families live in temporary accommodation? Is he concerned that there will be 120,000 children living in temporary accommodation this Christmas and that the use of bed and breakfast has increased by 15% over the last year? Will he discuss this matter with colleagues developing the housing White Paper and impress on them the importance to children’s mental health of finding stable accommodation for families on low incomes?

[Lord Prior of Brampton]

My Lords, there is no doubt that whether it is housing for young people or loneliness for old people, many factors affect people’s mental well-being. The noble Lord may be interested to know, as I know that his particular interest is in looked-after children, that we have set up an expert working group to look particularly at that case. Interestingly, 85% of the local transformation plans that have been developed single out looked-after children as a group that requires special attention.

[Baroness Walmsley (LD)]

My Lords, I welcome the mental health dashboards, which allow people to hold their local clinical commissioning group to account for how much it spends on mental health, including on children, and on the quality of the services that it provides. However, can the Minister say how those dashboards are being publicised, and whether there is any way in which local people can benchmark the performance of their local CCG compared to others across the country?

[Lord Prior of Brampton]

My Lords, transparency is critical to this and every CCG will have its improvement assessment framework. Unless I am badly mistaken, they will all be in the public domain and it will be possible to look at the relative performance of each CCG. NHS England will also produce its own matrix and integrated dashboard, which will have all the key information about funding, the numbers of people accessing mental health provision and the improvements that those people achieve once they are in the system.

[Lord Patel of Bradford (Lab)]

My Lords, from the mental dataset it is very clear that black and Asian minority ethnic adults are overrepresented in the mental health field, but the data on CAMHS are very inconsistent. They show that young black and Asian people are underrepresented, despite the fact that they are overrepresented in the criminal justice system, excluded from school more and overrepresented in the care system. Is it a recipe for disaster if young black people with challenging behaviours are being pressed through the criminal justice system as opposed to receiving good, early mental health care? Is that the reason why 40% of young people in secure institutions are from a BME background?

[Lord Prior of Brampton]

If it is indeed the case that young black and Asian people are not attending school and are going into the criminal justice system because they cannot get access to mental health services on the same basis as other children, it will be a national scandal, to be honest. I will certainly take away those figures. I have not seen David Lammy’s report, which I gather came out this morning. The noble Lord said that 40%, I think, of all young people in secure detention are black or Asian—I think in London it is 80%, which is a staggering statistic.

Adult Social Care

Lord Prior of Brampton Excerpts

Tuesday 15th November 2016 Lords Chamber

[Baroness Pitkeathley]

To ask Her Majesty’s Government what is their response to the warning by the Care Quality Commission in their State of Care report, published in October, that adult social care is approaching “tipping point”.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, we welcome the State of Care report. We know there are serious pressures on the care system. That is why we are giving local authorities access to up to £3.5 billion in new support for social care by 2019-20 so they can increase social care spending in real terms by the end of this Parliament.

[Baroness Pitkeathley (Lab)]

I thank the Minister for his usual courteous reply, but I think he knows that the funding he has announced there for the better care fund is both too little and too late. Does he agree that there have never been so many challenges for the social care system? There is terrible pressure on the NHS and on caring families, and many people have no care at all at home, however great their needs. Does he further agree that there has never been so much consensus about what needs to be done? Across all professions and political divides, we hear that what is needed is more money, and more money now. I am well aware that asking for commitments in the Autumn Statement is above the Minister’s pay grade, but could he please assure the House that he and his colleagues are stressing the urgency of this matter to the Chancellor of the Exchequer and asking him to make more funding for social care an urgent priority?

[Lord Prior of Brampton]

My Lords, I think most people in the health and care system, whether it is Simon Stevens, the chief executive of the NHS, or the Secretary of State, realise how serious pressures are in social care. There is no question about that. The State of Care report from the CQC supports that view. That is why we are putting in more money towards the end of this Parliament. It is back-end loaded—I accept that—but on the other hand the £3.8 billion that went into the NHS this year is front-end loaded. I think everyone agrees that the only way out of the difficulties we are in is for health and social care to work much more closely together.

[Baroness Brinton (LD)]

My Lords, it is good that extra money is coming into the NHS, even if it is loaded in the wrong direction at the moment. However, this Question is much more about care. The real problem at the moment is that social care is significantly starved of funding. What will the Government be doing to ensure that real cash goes into social care to help to alleviate the problems that the NHS is facing due to people remaining in hospital because there just are not the places for them to go nor the assessments for them in social care at the moment?

[Lord Prior of Brampton]

My Lords, the squeeze in social care started in 2010. Between 2010 and 2015, spending on social care declined in real terms by 12.8%. That was a significant reduction in spending when the noble Baroness’s party was in power in the coalition Government. Since then, it remains very tight in social care. As I said, we are putting more money into the NHS at the front end of this Parliament. We have introduced the 2% precept for local authorities to raise money for social care and we have put £1.5 billion into the better care fund, starting from 2017-18, which will provide more money for social care at the end of this Parliament.

[Lord Patel (CB)]

My Lords, everybody agrees that there is enormous pressure on social care which, as has already been mentioned, is impacting adversely on the NHS. Is it not time for an independent commission with cross-party support to look at the whole area of health and social care, including something like the Japanese model, which funds social care so successfully?

[Lord Prior of Brampton]

My Lords, I know that the noble Lord is very keen on an independent commission, and he knows my views on that. I do not think we need an independent commission to tell us that social care and health care must be more joined up and integrated; we all know that. We can do that through a major reorganisation from the centre—but we know what big reorganisations do to the health service: they stymie it for years—or we can work locally in the STP and local authority areas to try to drive this at local level, which I think is the right way forward.

[Baroness Lister of Burtersett (Lab)]

My Lords, an independent commission on care reported recently. It called for a national care service and for adequate investment in the social infrastructure of care now, not at the end of the Parliament, to give care equal status with the NHS and to prevent us going over the tipping point. The tipping point is here; we cannot wait until the end of the Parliament. Will the Minister and his colleagues take those recommendations seriously and urgently?

[Lord Prior of Brampton]

There is no question but that we all recognise the enormous pressures on social care. I cannot comment on what may or may not be in the autumn Statement, but I entirely recognise the pressures to which the noble Baroness draws our attention. As I said, the Government did not have resources available to put money into the NHS and social care at the same time at the beginning of this Parliament because we have to live in the real world, which is very financially constrained. As I said, an extra £1.5 billion is going into the better care fund and an extra £2 billion will be raised by the local authority precept by the end of this Parliament.

[The Lord Bishop of Winchester]

My Lords, given the well-established engagement of faith groups in the area of social care, such as the Good Neighbours support service in Hampshire, what progress have Her Majesty’s Government made in reducing barriers to engagement by faith and belief groups, as recommended by the Local Government Association in its 2012 report, Faith and Belief in Partnership?

[Lord Prior of Brampton]

I cannot answer specifically the question raised by the right reverend Prelate, but I would say that voluntary and support groups of the kind that he mentions have a hugely important role to play in delivering social care. I visited Crossroads in Gloucester with the noble Baroness, Lady Royall, last Thursday and was struck by the extraordinary work that voluntary groups do—and what carers do, of course. If we relied purely on statutory services, the whole health and social care system would collapse tomorrow.

[Lord Lansley (Con)]

My Lords, my noble friend will recall that in the coalition Government, Andrew Dilnot and his team produced a report on how to give longer-term sustainability to social care and enable people not to suffer catastrophic losses when they are long-term care recipients. Will the Government commit not only to introducing the Dilnot recommendations but, perhaps earlier, to funding it, and to do so by bringing the domiciliary care means test in line with the residential means care test, which would raise £1.3 billion a year?

[Lord Prior of Brampton]

My Lords, the Government are committed to introducing the proposals of the Dilnot commission by the end of this Parliament in 2020, and I understand that during 2017-18, we will bring back those proposals to refresh them, but with a view to phasing in implementation in 2020.

[Baroness Wheeler (Lab)]

My Lords, the CQC report particularly highlights the crisis in residential care, showing that at a time of growing need the number of care homes in England has fallen by 8% in the past six years. Age UK’s report, published a couple of days earlier, warmed to the plight of self-funder residents in private care homes, who are having to pay higher fees because local authorities cannot afford to pay the actual care costs of the residents whom they support. Is not that the problem that the Dilnot proposals under the Care Act were designed to address, and does not it underline the fact that self-funders are ultimately paying the price for a care system under severe pressure and in desperate need of extra funding and investment?

[Lord Prior of Brampton]

My Lords, it is interesting with regard to the CQC’s State of Care report that there has been a decline in the number of residential care beds—that is absolutely true. However—and this is an extraordinary statistic—from 2010 to date, the number of domiciliary care agencies has increased from 5,700 to 8,500. The other interesting trend that came out of the CQC report was that, on balance, smaller care homes, nursing homes and domiciliary care agencies tend to perform better than the big ones. That is because they can deliver a degree of personalised care—a sort of home-from-home care—that the bigger concerns cannot. But I totally understand the point that the noble Baroness makes. This sector is under tremendous pressure; we recognise that.

NHS: Cancer Patients

Lord Prior of Brampton Excerpts

Wednesday 9th November 2016 Lords Chamber

[Lord Sharkey]

To ask Her Majesty’s Government what assessment they have made of the latest NHS data on timely diagnosis and treatment of cancer patients.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, the NHS is meeting six out of eight cancer waiting times standards, with the other two being missed by less than 3%. This is against a backdrop of a more than 90% increase in urgent referrals—that is more than 800,000 more people—and treating nearly 50,000 more patients following a GP referral compared to 2010, an increase of 20%.

[Lord Sharkey (LD)]

Why are the regional variations in early cancer diagnosis so very large? For example, the worst is Lincolnshire West at 33% while the best is West Sussex at 61%. Does the Minister agree with Cancer Research UK and the Royal College of Radiologists that an important factor in the NHS missing early diagnosis targets is the shortage of staff to actually do scans, procedures and lab tests?

[Lord Prior of Brampton]

The new cancer dashboard has given us much more transparency around the country, so at least we now know where the problems are. The noble Lord is absolutely right that the critical area is early diagnosis, which is why one of the targets coming out of the new cancer strategy is that everyone should have a definite diagnosis within 28 days of an urgent referral. He is also absolutely right that one of the major constraining factors is workforce. We will be training an extra 200 non-medical endoscopists over the next couple of years, which should help considerably, but it remains an issue and Health Education England is due to report back in March 2017.

[Baroness Gardner of Parkes (Con)]

My Lords, can the Minister tell me whether we are now widely using the form of radiotherapy for cancer which is much less invasive? I think it is called IMRT and we have discussed it in this House before. Is it widely in use now in the National Health Service?

[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.

[Baroness Masham of Ilton (CB)]

My Lords, is it not the case that many patients have their cancer picked up in an A&E department, having been sent away from their GP several times?

[Lord Prior of Brampton]

The noble Baroness is right. In 2006 one in five of all new cancers was picked up in an emergency setting. That has reduced to one in four. We are making progress. I think we all accept that our performance on cancer outcomes has lagged behind the best in Europe. The strategy developed by Harpal Kumar is designed to address that. We are making progress but we have some way to go.

[Lord Cotter (LD)]

My Lords, what is being done, additionally, towards the prevention of cancer? There is a lot of feeling that the food chain is adulterated through the use of pesticides and such like. Will the Minister consider doing work in the direction of prevention and investigating possible causes?

[Lord Prior of Brampton]

My Lords, considerable research is going on into precisely the area that the noble Lord refers to. He talked about prevention, which is a hugely important area. Early awareness is also very important. We are running these Be Cancer Aware campaigns; at the moment there is a campaign going on around lung cancer to get early detection. I will investigate further and see what we are doing to investigate the root causes of cancer—whether there is any link to pesticides, for example.

[Lord Dykes (CB)]

Further to the opposition spokesman’s comments, will the Minister confirm that in terms of prevention, treatment and cure, we are well behind the coefficients of most other advanced countries?

[Lord Prior of Brampton]

There are lies, damned lies and cancer statistics. It is extremely difficult to make comparisons on survival rates with other countries. There is evidence that we are behind the best in Europe on five-year survival rates. There is also considerable evidence that we are making good progress—but, of course, other countries are making good progress at the same time. If we implement the cancer task force recommendations, it is estimated that we will save an extra 30,000 people’s lives per annum. We have a very ambitious programme to improve cancer outcomes, but I accept that we are starting from some way back from the best performance in Europe.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister accept that early diagnosis depends on patients or potential patients recognising the symptoms? Notwithstanding the pressure on services, are the Government continuing to encourage patients to recognise potential cancer symptoms?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Baroness makes a very good point and the answer is yes, we are. Public Health England has a big awareness campaign. As I mentioned, a campaign on lung cancer has just finished. I think that there have been 11 campaigns to raise awareness over the past six years. The National Screening Committee is constantly modernising and updating our screening processes, and has introduced new screening processes that can be done at home—both bowel cancer screening and the HPV screening process for cervical cancer.

Hospitals: Unsafe Discharge

Lord Prior of Brampton Excerpts

Wednesday 9th November 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I thank the noble Baroness, Lady Wheeler, for initiating this debate on a hugely important issue. I hope the noble Baronesses, Lady Wheeler and Lady Walmsley, will not think I am being churlish when I say that we covered a very wide range of issues today and at times strayed somewhat beyond the health ombudsman’s report, which is the substance of this debate.

The noble Baroness, Lady Wheeler, raised the issue of homelessness. That illustrates the complexity of the discharge process. I have seen a homeless person at UCLH in London who has nowhere to go. The issue is finding somewhere for that person to go—otherwise, as the noble Baroness said, he ends up back under the arches, then back in A&E, and the whole revolving door syndrome goes on. The noble Baroness, Lady Masham, mentioned the situation with someone who is mentally ill. Such discharges are very complex, so we should be careful not to oversimplify how difficult some of them are.

There has been a lot of talk in this debate about STPs. I will come to them, but I say to the noble Baroness, Lady Walmsley, that they are bottom up and are done locally. Of course, the acute hospital is going to have a major impact on the local STP: it would be strange if it did not. Some STPs, however, are run by the local authority and others by the chief executive of the local acute trust. That varies around the country, depending on the local leadership. They are not top down: these are bottom-up organisations, and they are increasingly in the public domain for discussion locally. One of the issues is that the NHS and the care system are so complex and so difficult that exceptional leadership is required to get lots of people together in the same room and come up with a plan that can be executed. Somehow, we have to move to a system in which you do not have to be exceptional to achieve results, in which average people can make progress. It is very difficult.

The noble Baroness, Lady Masham, mentioned Northumbria, where there is good local leadership that has worked in a consensual way with other partners in the system for many years. That way, you can get progress. The noble Baroness, Lady Walmsley, said it took 20 years to make the changes in mental health from the old, big, acute asylums to much greater community provision. It does take time, and you have to put the resource into the community before you can take it out of the acute sector. She talked about the difference between transformation and sustainability. Transformation means change, and change is difficult. It means people changing the way they have delivered care for many years. It does mean closing some acute activities in order to put resources into the community—there is no getting away from that. The Five Year Forward View was a view, not a plan. The STPs are, in a sense, transforming the view into a plan. We should not be surprised if there are some difficult messages in that. If we run away from those difficult messages, we will not put the Five Year Forward View into practice. I think everyone in this House feels that at least the direction of travel in the Five Year Forward View is the right one.

I do not want to sound in any way complacent because, as we heard in the story of Mrs F, when these discharge processes go wrong they are catastrophic for the individual concerned and their families. To put it in context, however, reported incidents of discharges going wrong account for less than 0.1% of the 15 million discharges made every year from hospital. Of that 0.1%, 96% are categorised as “no harm” or “low harm”. It is important to have that context. In fact, the PHSO makes it clear that the cases set out in its report should not be considered as representative of practices across the NHS and social care. However, it says:

“We are aware that structural and systemic barriers to effective discharge planning are long standing … these include the need for better integration and joint working of health and social care services, which have historically operated in silos”.

That was also acknowledged by the Public Administration and Constitutional Affairs Committee, which said that,

“discharge failures identified by the PHSO report are not isolated incidents but rather examples of problems”,

experienced “more widely”.

It, too, draws attention to the lack of integration between health and social care. It is therefore right that in this debate we have focused largely on these structural problems, which are not just between health and social care but within the health service itself.

The experience of these patients supports the strong case that this Government have made—and indeed the past Government—for closer working between health and social care and between different organisations and the NHS. We have to resist resorting to yet another major structural change in the NHS. Just as this last lot is settling down, there is a temptation to say that we should radically look at the whole structure of health and social care again, in which case the whole thing will be pushed up in the air for another few years. We therefore need to be careful before we resort to that.

I will repeat the figures that were given by the noble Baroness, Lady Wheeler. In August of this year about 60% of delays were attributable to the NHS—so it is not just the interface between the NHS and social care—33% to social care, and the remaining 10% or so to both social care and healthcare.

In December, 44 health and care systems across England were asked to come together to create their own local blueprints, called sustainability and transformation plans. STPs are designed precisely to tackle the barriers to improved patient care—the silos that were mentioned—by better alignment across organisations. This could have been done on a statutory basis, but we would have been here discussing that until kingdom come. The STPs have evolved; they are local and not top-down. They were not put out there by Jeremy Hunt: this has been done by the NHS and by social care on a local basis.

To some extent this builds on the Government’s £5.3 billion better care fund and upon the vanguard schemes—the various models of care that were described in the NHS Five Year Forward View. This is a logical evolution of those two developments. If I had more time, I could give examples of a number of the new care models in the NHS Five Year Forward View that are getting some considerable traction.

We are clear that in some areas, rising delayed transfers of care are placing considerable financial and operational strain on the NHS. However, we are equally clear that delays in themselves can prove particularly dangerous to older patients. There is a growing body of evidence on the harms associated with long hospital stays for older people. A pretty staggering statistic is that 10 days lying in a hospital bed can lead to the equivalent of 10 years of ageing in the muscles of people over 80. Therefore, delayed discharges are not fundamentally about saving money, although of course they would save money. They are about how we provide better care for vulnerable, usually elderly people with comorbidities.

NHS England and NHS Improvement have taken action to establish a number of work streams across community services and acute hospitals, because that is often where the delays occur. This will identify and deliver a series of interventions to help deliver system-wide transformation of community services, supporting timely discharge from hospital.

The decision to discharge remains a clinical one, but ensuring all discharges are safe and timely requires a multidisciplinary effort from clinical and nursing staff, allied health professionals, and community and social care workers. The imperative to discharge as quickly as possible must be balanced against the needs of each patient. I acknowledge fully that when a hospital is full and there are ambulances queueing outside in the car park to get people to A&E, the pressure to discharge patients is huge. We can pick out examples where it has gone wrong, but if you put yourself in the place of the nurse on the ward, who is told, “We’ve got to find three beds by 8 o’clock because we’ve got people in A&E who are about to breach the four-hour target”, you can understand the pressure there sometimes is in hospitals to make discharges earlier than they should be.

When the NHS was founded in 1948, 48% of people died before they reached the age of 65. In 2016, this figure is only 12%, and the fastest-growing age group is the over 85s, for whom the discharge process is inevitably the most difficult. Some 80% of this group will suffer from two or more chronic conditions, which adds to the complexity in discharging patients today.

I want to dwell on two issues related to safe discharge. First, the whole thrust of the seven-day NHS is to ensure that urgent and emergency care patients have access to the same level of consultant assessment and review, diagnostic tests and consultant-led interventions, whatever the day of the week. The problems of discharge are the same on a Saturday or Sunday as they are on a Monday, Tuesday or Wednesday. Other work includes the new discharge planning guidelines published by NICE, which cover transitions between care settings for adults with social care needs.

There is absolutely no doubt that the structural difficulties of the NHS are quite profound and exceptional people are required to overcome those barriers. We are bound to see considerable variability in some of the STP plans when they are published over the next couple of weeks. However, we can also improve operational issues within hospitals: making sure that the drugs and transport are ready; that there are multi-disciplinary teams, including social workers as well as care workers; and that everyone who comes into hospital gets an estimated date of discharge, so that everything can be brought together around that discharge process.

I end by paying tribute to NHS staff, who are working under huge pressure and with people with complex conditions. I think we all recognise that the structure of the NHS means that things are not as easy for them as they might be.

[Baroness Wheeler]

I asked the Minister about the national carers strategy. Could he please write to me on that?

[Lord Prior of Brampton]

I will certainly do that. I should just say that the theme that comes out of the carers strategy is better communication. When half of carers say that they feel that a hospital admission could have been avoided or that the discharge could have been easier if only there had been better communication, that is clearly a critical area.

NHS: Primary and Community Services

Lord Prior of Brampton Excerpts

Monday 7th November 2016 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what is their response to the Carers UK report Pressure Points: carers and the NHS, concerning problems faced by carers in accessing primary and community support services for the people they care for.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, we recognise that far too many people who could be treated at home or in their communities attend A&E. Sustainability and transformation plans are bringing together commissioners and providers to deliver the five-year forward view locally and will include radically improved out-of-hospital care through stronger integration and improved access to primary care.

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his response. The report identifies major problems for carers accessing primary and community support services for the people they care for, and who therefore have no real option but to take them to A&E. Many of these emergency hospital admissions could have been avoided with adequate social care support at home, better access to a district nurse or essential local support for carers themselves. On carers’ support, councils across the country are having to cut back on vital services. My own council in Surrey has a programme of cuts of 33% over three years. With the CQC’s dire warning that social care is at a tipping point, is it not time for the Government finally to acknowledge this and use the Autumn Statement to provide the increased funding and investment that is urgently needed for carers and the people they care for to get the support they deserve?

[Lord Prior of Brampton]

My Lords, I acknowledge that there is tremendous pressure in the social care system. Looking back over the last 20 years, not enough support has gone into primary, community and social care relative to what has gone into acute care. The sustainability and transformation plans are designed to bring together social care and healthcare. They are being published intermittently as I speak.

[Baroness Brinton (LD)]

My Lords, the country owes so many carers an enormous debt of gratitude for what amounts to unpaid work they are doing on behalf of the state. The NHS website says to carers:

“If someone you know is in hospital and about to be discharged, you should not be put under pressure to accept a caring role”,

or to take one if you are already doing this as their carer. It continues:

“You should be given adequate time to consider whether or not this is what you want … to do”.

The carers report has found that three out of five carers say they felt they had no choice, and of those not consulted four out of five carers said it was way too early and that there were readmissions as a result. What will the Government do to ensure effective communication between hospitals and carers truly happens, so that there are no more unprepared discharges and carers get the support they need?

[Lord Prior of Brampton]

My Lords, delayed and inappropriate discharges are clearly a huge issue for the whole health and care system. Again, this is something the STPs are designed to address. The five-year forward view is explicit in saying that there are 5.5 million carers in England and their continuation goes to the very sustainability of the NHS. The importance of care is not in dispute. The Care Act, which the noble Baroness’s party and mine put through in the last Government, recognised that so as to give them parity of esteem with those they care for. There is no question but that better communication with carers would go a long way to improving the problems we have with inappropriate discharges.

[Baroness Pitkeathley (Lab)]

My Lords, the Minister has acknowledged that discharge from hospital is an important time for carers. You can literally become a carer overnight when your relative is discharged without warning. The carers strategy is currently being refreshed. Would the Minister consider an input into the carers strategy that meant it was incumbent on the National Health Service to consult carers and get their agreement before discharges are made?

[Lord Prior of Brampton]

My Lords, I am not sure we could go so far as to say that one should always have their agreement—sometimes, discharges from hospital are incredibly complex and difficult—but there is no doubt, arising from the Carers UK report, that where there is proper communication with carers, the discharge procedure is much better for everyone, from the point of view of the carer, the patient and the hospital. If proper arrangements are not put in place, delays arise long after the patient should have been discharged home. It could be to do, for example, with a care package or altering the patient’s home.

[Baroness Howarth of Breckland (CB)]

My Lords, I have recently become a carer myself and therefore have experience of a number of hospitals. Why is there such a postcode lottery in terms of where one finds oneself? West Suffolk Hospital, where my partner found herself, has given excellent service and—we must not run it all down—we have had fantastic aftercare in that area, whereas the London hospital does not even answer the telephone. Why is there such a difference? She was also in a mixed ward, the use of which I thought had already stopped.

[Lord Prior of Brampton]

My Lords, I am surprised that the noble Baroness’s friend was in a mixed ward because their use is supposed to have stopped unless there is an absolute emergency when only one bed is free. Unless there were exceptional circumstances, it is very disappointing to hear that that happened. Perhaps the noble Baroness would like to write to me about it. On her first point, there is variation in pretty much every aspect of health and social care around the country, which is inevitable. To some extent, it is not a bad thing, because it drives up standards if those who are not delivering great care can see how best it can be done. The STP process is designed to build in best practice, but I am afraid that a degree of variation is inevitable.

[Lord Hamilton of Epsom (Con)]

My Lords, following the question asked by the noble Baroness, Lady Brinton, will my noble friend clarify whether everybody in need of care is the responsibility of the Government?

[Lord Prior of Brampton]

The thrust of the Carers UK report is that 5.5 million carers take huge responsibility for their loved ones and that the primary responsibility often falls—I think, rightly—on carers and families rather than on the Government.

[Baroness Farrington of Ribbleton (Lab)]

My Lords, would the Minister care to join me in condemning Members of Parliament who have voted nationally to force local authorities to reduce services but have then attacked the local authorities because they wanted the libraries kept open, the bus services run and the care packages maintained—all of those things—while washing their hands of any responsibility?

[Lord Prior of Brampton]

I think the noble Baroness will agree with me that there are very difficult choices to be made when it comes to public spending. Sometimes, there is perhaps not always a high degree of consistency from our colleagues in the House of Commons.

[Baroness Greengross (CB)]

The Minister mentioned discharge procedures. Unfortunately, carers often do not know about plans for discharge early in the period during which the one they care for is in hospital. As has been said previously, surely the discharge process should start at admission. If the carer is brought in at that point and works with people to make the discharge process work, it will be better. This has never happened. Does the Minister agree that it really must?

[Lord Prior of Brampton]

I entirely agree with the noble Baroness. Good practice means that as soon as a patient comes into a hospital, an estimated date for discharge should be agreed then with the carer, which would enable all the services to come together at the point of discharge. Where that does not happen, one can have long delays.

NHS Funding

Lord Prior of Brampton Excerpts

Monday 31st October 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, with permission, I will repeat as a Statement the response given by my right honourable friend the Secretary of State for Health to an Urgent Question in another place on NHS finances.

“Mr Speaker, compared to five years ago, the NHS is responsible for a million more over-75s. In five years’ time there will be another million. Our determination is to look after each and every NHS patient with the highest standards of safety and care, but there is no question that the pressures of an ageing population make this uniquely challenging. I therefore welcome the chance to remind the House of this Government’s repeated commitment to support the NHS. The NHS budget has increased in real terms every year since 2010. NHS spending has increased as a proportion of total government spending every year since 2010 and was 10.1% higher per head in 2014-15 in real terms than when we came to office. The OECD says that our spending is 10% higher than the OECD average for developed countries and, at 9.9% of GDP, it is about the same as other western European countries, for which the average is 9.8%.

Given the particularly challenging current circumstances, however, in 2014 the NHS stepped back and for the first time put together its own plan for the future. It was an excellent plan, based on the principle that because prevention is better than cure, we need to be much better at looking after people closer to or in their homes instead of waiting until they need expensive hospital treatment. The plan asked for a minimum of an £8 billion increase in NHS funding over five years. It asked for this to be frontloaded to allow the NHS to invest in new models of care up-front. Following last year’s spending review, I can confirm to the House that the NHS will in fact receive an increase of £10 billion in real terms over the six years since the Five Year Forward View was published. In cash terms, that will see the NHS budget increase from £98.1 billion in 2014-15 to £119.9 billion in 2020-21—a highly significant rise at a time when public finances are severely constrained by the deficit this Government regrettably inherited.

Because the particular priority of the NHS was to frontload the settlement, £6 billion of the £10 billion increase comes before the end of the first two years of the spending review, including a £3.8 billion real terms’ increase this year alone, something that represents a 52% higher increase in just one year than the party opposite was promising over the lifetime of this Parliament”.

[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.

[Baroness Walmsley (LD)]

My Lords, the Secretary of State said that there were going to be another million over-75 year-olds in five years’ time, and I very much hope that I am going to be one of them. May I give the noble Lord a couple of other statistics? The King’s Fund quarterly monitoring report found that, for each month in the first quarter of this year, there were an additional 54,000 attendances at A&E departments and 14,200 emergency hospital admissions compared to the same time last year. All these emergencies are no way to run a health service.

The noble Lord and the Secretary of State pray in aid the five-year forward view as if it were a statement of fact. It is a plan; it is an aspiration, and at the time it was written, the hole in the funding of the NHS was not £4.5 billion, as the Select Committee says has been given to the health service; it was not £8 billion or £10 billion: it was £30 billion. The Government gave about a third of it and suggested, through the five-year forward aspirational plan, that the rest could be done by efficiencies. We have the STPs, which are supposed to find those efficiencies. We have heard many times in this House over the last few weeks about the shortcomings of those, so when will the Government respond to my right honourable friend Norman Lamb when he calls for a cross-party commission on proper funding of social care and the health service?

[Lord Prior of Brampton]

My Lords, I am sure that the noble Baroness will be here well past the age of 75, and that there are many years to come before she reaches that age.

The noble Baroness is absolutely right: for many elderly people, the worst way to be treated, frankly, is to be blue-lighted in an ambulance into an A&E department of a very busy acute hospital. The whole purpose of the five-year forward view is to deliver care to many more such people outside. I think we all agree with that. The noble Baroness’s party, like ours, agreed with the £8 billion of extra government spending over the course of this Parliament, and accepted the fact that very significant efficiencies could be generated from the NHS. We still subscribe to that view, and the STPs will be the right vehicle for delivering many of them.

[Lord Sutherland of Houndwood (CB)]

My Lords, the Minister rightly referred to the realities that are required of a fundamental redesign of care. The point has just been made, and was made in the report from the House of Commons this morning, that that must include looking, at last, at the connection between social services budgets and the health service budget. This is one of the major factors. It will not solve all the problems, but it is a critical point that Government after Government have ignored for the last 20 years.

[Lord Prior of Brampton]

I entirely agree with the comments made by the noble Lord. We have to integrate health and social care to a much greater extent. We also have to integrate healthcare: healthcare is delivered in silos and is highly fragmented around the country, and that comes out of the same budget, so he is absolutely right. However, we have to recognise that another massive reorganisation between social care and healthcare could be highly disruptive. The great beauty of the STP process is that people in local areas—local authorities, health providers and commissioners—are sitting around tables coming up with plans for their local areas.

[Lord Lansley (Con)]

My Lords, does my noble friend agree that it is only by virtue of the 2012 Act that NHS England is an independent body, able to express, on behalf of the NHS, a plan for the future, and that this would not have been possible otherwise? Will he further confirm that the coalition Government, in the last Parliament, met their promise to increase the NHS budget in real terms, year on year, but that that promise applied to an NHS budget that included public health and NHS education and training? The NHS’s future sustainability requires a more preventive approach and increased numbers of domestically trained NHS staff.

[Lord Prior of Brampton]

I entirely agree with my noble friend that the independence of NHS England has been very important. Had the NHS plan been developed by politicians it would have had a lot less credibility. I entirely agree that prevention and public health are hugely important, but of course it takes a long time for public health initiatives to have an impact, so I do not think that any reductions in them in the last two years will have any major impact over the five-year period. Clearly, it will have an impact over a longer period. As for the changes to Health Education England, those savings have largely been generated by moving from a bursary system for nurses to a loans system, which will actually deliver more nurses and therefore help to deliver the five-year forward view.

[Lord Patel (CB)]

My Lords, is the Minister saying that there are no financial pressures on the NHS? If he is, that is contrary to every piece of evidence that the House of Lords Select Committee on the Long-Term Sustainability of the NHS has heard. Furthermore, it is the lack of a settlement in social care that is killing healthcare. Is it not time that we had a new settlement for both healthcare and social care that is sustainable in the long term?

[Lord Prior of Brampton]

My Lords, I acknowledge that there is tremendous pressure on all parts of the health service and in social care, but if there is not pressure, there will not be change. Getting the radical, fundamental change we need in the health service will not be achieved if we just pour more money into the existing system: we have to have change.

Children: Oral Health

Lord Prior of Brampton Excerpts

Monday 31st October 2016 Lords Chamber

[Baroness Benjamin]

To ask Her Majesty’s Government what plans they have to promote oral health for children.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, Public Health England continues to lead a wide-ranging programme to improve children’s oral health. The childhood obesity plan has also introduced two important measures for oral health: a soft drinks industry levy and a sugar reduction programme.

[Baroness Benjamin (LD)]

My Lords, I thank the noble Lord for that Answer but oral health is not mentioned in the Government’s childhood obesity plan, even though there is an epidemic of child tooth decay along with hospital admissions for extractions. The state of the nation’s children’s teeth is shocking and a huge cost to the NHS. Common sense says that we need targeted action now. Can the Minister tell the House what is happening with the 10 pilot oral health improvement programmes announced in May and whether the Government will at least consider making oral health part of the daily school regime as a preventive measure?

[Lord Prior of Brampton]

The noble Baroness is right to say that childhood oral health is very poor, but it is getting better. Some 75% of children no longer have tooth decay compared with 69% in only 2008, but it is still not good enough. The Government’s policy is very much around prevention rather than treatment. The new contract being discussed with dentists will put this work on to more of a capitated basis rather than an activity basis. NHS England has identified 10 areas of deprivation for special treatment and we are looking at a new programme with Public Health England to improve education in this area. Quite a lot is happening.

[Lord Watts (Lab)]

My Lords, surely the way to prevent this is by introducing fluoride into the water supply and to ignore those people who think it is a bad thing. Does not all the evidence seem to suggest that it would be very good, especially for deprived communities?

[Lord Prior of Brampton]

My Lords, the evidence for fluoride is incontrovertible: it is good for teeth. There may be other issues attached to fluoride, but in terms of dental health it is unquestionably a good thing. It is interesting to note that in Birmingham, which has been adding fluoride to its water for many years, the incidence of child tooth decay is 29% whereas in Blackburn it is 57% and in Hull, which is considering fluoridation, it is 37.8%. The evidence is very strong, but it is up to local authorities to decide.

[Baroness Gardner of Parkes (Con)]

My Lords, when I have asked Questions, as I have done repeatedly, mainly for Written Answer, about the difference in health between Birmingham and Manchester, with people in Manchester having the worst teeth in the whole of the UK—that was where the problem was with blocking hospital beds—the answer has always been that the only difference in health pattern is in teeth. I have had that point queried and asked what research the Government have done and whether they can really substantiate that fact. I am very much in favour of fluoridation, but I think that people are confused and want to be clear that there is no other health implication of fluoridation. I respect that view. What action will the Minister take to ensure that thorough, general health tests, as compared with the two arrangements referred to, are undertaken?

--- Later in debate ---

[Lord Prior of Brampton]

My noble friend has slightly confused me, I am afraid. There is no question that fluoride has an impact on oral health. I am not aware of any evidence to suggest that it has other, detrimental impacts on children’s or other people’s health. We have huge inequalities throughout the United Kingdom, most of which are as a result of social deprivation, poor housing, high unemployment and the like. Those are the fundamental drivers of health inequalities, rather than health systems per se.

[Baroness Janke (LD)]

My Lords, given the harm caused by high levels of sugar added to some processed foods, does the Minister agree that the present restraints on the food industry are woefully inadequate? Does he further agree that much tougher measures need to be taken if the Government are to meet their own public health objectives on oral health, diabetes and obesity?

[Lord Prior of Brampton]

My Lords, the introduction of the sugar levy is evidence that the Government take this matter extremely seriously and believe that it cannot be left solely to industry to reduce sugar levels. The Treasury is due to report on the extent of the sugar levy on 6 December. As part of the obesity strategy, targets are being set for nine key categories of food eaten predominantly by children. The results of reduction over time will be made transparent and open. A combination of those measures should have an impact.

[Lord Colwyn (Con)]

My Lords, although dental decay can easily be prevented by reducing sugar consumption, regular brushing and adequate exposure to fluoride, it has been shown to be the number one reason why children aged five to nine are admitted to hospital. It is painful, can be dangerous and wastes millions of pounds of NHS resources. When will the Government reverse those statistics and facilitate the fluoridation of all public water supplies?

[Lord Prior of Brampton]

My Lords, I think that I have already answered my noble friend’s question on fluoridation. On his second point about regular tooth-brushing, Scotland has a scheme called Childsmile, where there is supervised tooth-brushing in primary schools and nurseries, as well as a fluoride varnish twice a year. We can learn something from Scotland in that regard. It is expensive, but Public Health England is nevertheless looking at it and we may adopt it in our country soon.

[Baroness Uddin (Non-Afl)]

My Lords, do the nine categories of food to which the Minister referred also include baby foods, which are packed with sugar? I declare an interest, having a granddaughter, Imaan, who has allowed me to taste the enormous amount of harmful sugar contained even in organic baby food. Will the Minister consider adding baby food to his basket list of things to look at?

[Lord Prior of Brampton]

My Lords, I cannot recall whether baby food is one of those nine categories that have been identified in the obesity strategy, but I will look into that and write to the noble Baroness.

Mesothelioma

Lord Prior of Brampton Excerpts

Thursday 27th October 2016 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, this has been another really excellent debate on this subject. I join others in thanking the noble Lord, Lord Wills, for raising it again—it is really important to keep it in the public eye. I thank the noble Lords, Lord Giddens and Lord Alton, for collaring me on this subject many times over the last year. It is one of the privileges of being in this House that one is able to take an interest in these issues and try to do something about them—otherwise, what is the point of being here? The point is to make a difference. What this has demonstrated is that if there is persistence—real, dogged persistence, often in the face of all kinds of tribulations—you can make progress. It has been a long and tortuous journey, as the noble Lord, Lord McKenzie, said, but there are signs of progress.

I shall pick up a few points before I get into my speech. First, I cannot answer the point of the noble Baroness, Lady Couttie, in detail today, but the level of compensation is certainly something I shall look at in view of her comments about the cost of these new drugs. This is probably an issue more for NICE and NHS England than the compensation scheme. The noble Baroness, Lady Walmsley, asked whether we are learning from the reviews of these cases, in view of the importance of time. I will certainly look at both those issues. They are, in a sense, related to the remarks of the noble Lord, Lord Freyberg, about the huge benefits of specialisation. I have the guidance from NHS England on the treatment of mesothelioma here. I shall not read it out today, because there is not time, but the noble Lord’s point about having a centre of excellence and looking at the improved outcomes from people doing these things repetitively, many times, rather than spreading very complex surgery over many different sites, is absolutely true. Having proper data in registries which can be made transparent is also a hugely important driver of change.

The noble Lord, Lord Giddens, and the noble Baroness, Lady Finlay, raised the issue of data. Data are hugely important. In a way, if one looks at all the advances that are coming along in cell therapy, gene therapy and the like, in health analytics and big data, the artificial intelligence and machine learning that come from these offer huge potential for improving healthcare in this country. I should also mention that it is clear that many people here have been touched, directly or indirectly, by this devastating disease. That adds not just poignancy but urgency to our discussions. It is interesting how often a patient’s story can bring data to life—data on their own are not enough. It is when you hear about individuals who have suffered and whose lives have been changed or who, indeed, have died, that it is brought home to all of us just how important it is.

We expect the rates of mesothelioma to increase in coming years, due to high exposure to asbestos in the 1960s and 1970s. The noble Baroness, Lady Finlay, raised the issue of schools. It is the responsibility of the Health and Safety Executive, as she will know. The advice is often to leave it where it is and not disturb it—it is not dangerous to children if it is left dormant. If anyone has any evidence that the HSE is not doing the rounds or that there are local authorities in the country where schools are in need of repair, they should bring it to my attention and I will ensure that the HSE follows that up.

Rates of mesothelioma have increased by nearly five times in Great Britain since the late 1970s. In 2014, there were 2,343 registrations of mesothelioma in England: 1,954 men and 389 women. The incidence is expected to peak in the 2020s but, as has been mentioned, it will remain a significant health problem into the 2050s. It is not a legacy disease. It is going to kill many people over the next 30 or 40 years. In 2014, 2,236 deaths were caused by mesothelioma in England, and the latest survival figures suggest that 46% of men survive for one year, compared with 51% for women. Five-year survival is much worse: only 5% for men and 11% for women. It is a death sentence—there is no getting away from that. Others have mentioned that this is a worldwide issue. One research group estimates that, on average, 14,200 cases are diagnosed worldwide every year, and that will be going up, not down.

On the research aspect, there is some better news. On 16 March, the Chancellor announced an award of £5 million to establish a national centre for mesothelioma research. A number of noble Lords have said how important it is that this is co-ordinated—that various universities and research centres around the country do not all have a crack at it, but there should be a national centre for research. This announcement was in response to an application from Imperial College to urgently address the anticipated imminent high mortality rate among Royal Navy veterans and dockyard workers. The award is one of a series funded by the LIBOR fines that have been made since October 2012.

It is envisaged that the national centre will be a collaboration between four leading institutions which have a major interest in the treatment of mesothelioma: the National Heart and Lung Institute at Imperial College, the Royal Brompton Hospital, the Institute of Cancer Research and the Royal Marsden Hospital. It is pretty impressive standing here naming four institutions that are absolutely world class. This is an extraordinary country when it comes to research. The Marsden, the Brompton and all these institutions are fantastic. They bring together expertise in the genetics of cancer susceptibility and in targets for treatment. Of course, the work being done in genomics will have a huge impact on this in years to come—not quite yet but soon, I hope.

The Department of Health has been in discussion with the British Lung Foundation to work together to bring about the establishment of the research network. The plans are not yet finalised, but the aim, which the department supports, is to attract further donations, to be channelled by the British Lung Foundation so that it can continue its role as the body through which voluntary donations for mesothelioma research are being channelled competitively to the best science centres across the UK. As the organisation which currently administers mesothelioma research grants funded from insurance industry donations, the BLF is well placed to do this. I add my thanks to Aviva and Zurich, the only two insurance companies which have lived up, I think, to a very important moral obligation. We should not give up in our talks with the insurance industry to persuade it. It owes a moral duty but, as pointed out by the noble Lord, Lord Alton, it is not just a moral duty; there is also some enlightened self-interest in this. Maybe the lawyers would like to chip in as well; that would be good.

We understand that on 1 November—next week—the BLF, alongside the Association of British Insurers, will be hosting a seminar in this House on the future of mesothelioma research. The seminar will focus on the previous research which the insurance industry has funded across the UK, how it can be built on, and how to ensure that mesothelioma projects across the country tie into the work of the new national centre. Together, the MRC and the NIHR spend more than £1 billion annually. In 2015-16, they spent more than £3 million on mesothelioma research. I will be sending a copy of this debate to Sally Davies, the Chief Medical Officer, and Chris Whitty, the Chief Scientific Adviser, to ensure that they pick up all the important arguments that have been made today.

Last month the Government announced £816 million over the next five years for the biomedical research centres across the UK. These centres host the development of ground-breaking new treatments, diagnostics, prevention, and care for patients in a wide range of diseases. Around £118 million of the funding will be for cancer research and we would expect some of that to support mesothelioma research. The fact that we have this £5 million ought to attract more money from the more conventional cancer research programmes.

In March 2016 the National Cancer Research Institute co-ordinated a meeting with the British Lung Foundation, the MRC, Cancer Research UK and the Department of Health to discuss research opportunities in mesothelioma. This was followed up with a community workshop at the International Mesothelioma Interest Group meeting in Birmingham in May this year and has led to the formulation of a draft research priorities document. This will be further developed at a second workshop currently scheduled to take place in February 2017.

There is room for hope that some progress is being made here. We have to keep the momentum going and the profile high. I think we all accept that some cancers seem to have caught the public imagination to a greater extent than this one, which in a sense puts a greater obligation on us to keep it in the public eye. I have been delighted to do what I can and will continue to do so. Again, I thank all noble Lords for continuing to raise this very important topic.

Committee adjourned at 5.56 pm.

Medical Students

Lord Prior of Brampton Excerpts

Wednesday 26th October 2016 Lords Chamber

[Lord Naseby (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and, in doing so, declare an interest in that my wife is a retired full-time GP practitioner.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, my right honourable friend the Health Secretary announced on 4 October that the Government plan to increase the number of medical school places by up to 25%. From September 2018, the Government will fund up to 1,500 additional medical school places each year. Students will be able to apply for the extra places from 2017 in order to take them up from the academic year 2018-19.

[Lord Naseby]

Is my noble friend clear that the Secretary of State is to be congratulated on beginning to grasp this nettle? In the last three years, we have lost 3,500 medical students, but the problem goes deeper, does it not? Today, 56% of the intake of medical students is female. Furthermore, 70% of female GPs today work part-time, and a recent survey by the King’s Fund says that 90% of all medical students in training want to work part-time. Given that it costs £200,000 to train anybody as a medical practitioner, surely the time has come to consider a minimum full-time commitment of at least four years after qualification, similar to what they do in Singapore and, indeed, in our own Armed Forces.

[Lord Prior of Brampton]

My noble friend is absolutely right that more than 55% of those who go to medical school are now women; that is a fantastic change that has happened over the past 20 years. It is true that more women than men tend to work part-time, as they have children and bring them up, and that is taken into account in the planning done by HEE. When my right honourable friend the Health Secretary made his announcement, he said that we will be looking in our consultation at requiring people whom we have paid to go through medical school to give at least four years back to the NHS, which I think is reasonable. The figure is actually six years if you become an Army doctor, so four years is not unreasonable.

[Lord Winston (Lab)]

My Lords, is the Minister aware that, although there may be enough people wanting to apply to medical school, many of the brightest and the best are now completely turned off doing medicine because of the relationship with the Secretary of State for Health? This is a very serious mistrust and, whether they are male or female, the brightest and best are often not applying. There is increasing evidence for this in most medical schools, and indeed in schools as well.

[Lord Prior of Brampton]

I respect the views of the noble Lord but I have looked very carefully at the number of applications coming into medical schools in 2016 compared with the previous year. In 2016, there were 20,100 applications for all medical schools, including in Scotland. The previous year the figure was 20,390, so there is no firm evidence to support the view that the noble Lord expresses. There were some rumours that St George’s was having trouble filling its places. I have investigated that and understand that it was a result not of any lack of demand but of the fact that it wanted to wait until A-level results had come through so that it could choose the best candidates based on those results. So I do not think there is any evidence to substantiate the noble Lord’s point.

[Baroness Walmsley (LD)]

My Lords, one of the objectives in Health Education England’s mandate is to reduce our dependency on temporary staff. However, the National Audit Office tells us that we are short of 50,000 clinicians, and that HEE is failing to be sufficiently proactive in addressing the,

“variations in workforce pressures in different parts of the country”.

Is the noble Lord’s department monitoring how well HEE is responding to these challenges?

[Lord Prior of Brampton]

My Lords, predicting the future requirement for doctors is extremely difficult. It is more a matter of prophesy than science. The fact that we are now going to fund an extra 1,500 doctor places a year, which is a 25% increase, should make a huge difference.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman of University College London Partners. Beyond undergraduate medical education, do the Government believe that there are sufficient opportunities for the established workforce to continue to develop itself to meet the changing needs of the population of our country?

[Lord Prior of Brampton]

That is a very big question, which is hard to answer. My personal view is that I do not think that the training we give to our young doctors in management, leadership and how to structure new models of care is sufficiently broad. You could argue that the curriculum at medical school is too narrow and should be broadened.

[Baroness Gardner of Parkes (Con)]

Can the Minister tell me how many overseas doctors, particularly Commonwealth doctors—if he has a figure for that—are working in our National Health Service? On a separate topic, what can be done to encourage people to go into some specialties that we are told do not attract doctors, which is why there are not sufficient numbers in them?

[Lord Prior of Brampton]

My Lords, overseas doctors account for about 25% of the total number of doctors employed by the NHS, which is a very high number. I do not have the breakdown for the Commonwealth countries but it is an interesting question; I will research it and write to my noble friend. She is absolutely right that there are shortages in particular specialties. General practice and psychiatry are probably the two areas where there is the biggest shortage. HEE is determined to increase the intake in those areas. Certainly, the number of doctors going into GP specialty training this year is just over 3,000. That is an increase on last year but is still not enough.

[Lord Clark of Windermere (Lab)]

My Lords, we welcome the increase, but is it sufficient to meet the problem? I understand that about 100,000 overseas doctors, including European doctors, work in the NHS. Given an extra 1,500 places a year, it will take many years to reach the target. Why do we not make a gesture to those overseas doctors working in the health service and offer them permanent residence here?

[Lord Prior of Brampton]

I think it will be helpful if I quote from the Health Secretary’s speech at the Conservative Party conference, talking about overseas doctors. He said:

“They do a fantastic job and the NHS would fall over without them. When it comes to … EU nationals, we’ve been clear we want them to … stay post-Brexit”.

Let us be absolutely clear: we want overseas doctors from the EU or elsewhere to stay here post-Brexit.

[Baroness Masham of Ilton (CB)]

My Lords, how many medical students drop out during training? How many, when qualified, do not take up medicine and go into other specialties?

[Lord Prior of Brampton]

My Lords, the attrition rate for students at medical school is about 5%. Some of those leave for medical reasons and come back subsequently, so the figure will be less than 5%. I do not have the drop-out rate for doctors who are further advanced in their training but I will find out and write to the noble Baroness.

Breast Cancer: Innovative Drugs

Lord Prior of Brampton Excerpts

Monday 24th October 2016 Lords Chamber

[Baroness Massey of Darwen]

To ask Her Majesty’s Government whether the Accelerated Access Review will address the availability of innovative drugs for breast cancer.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, the report of the Accelerated Access Review, published today, makes recommendations to the Government on reforms to accelerate access for National Health Service patients to innovative medicines and medical technologies, which may include drugs for breast cancer, making our country the best place in the world to design, develop and deploy these products. I warmly welcome publication of the report. The Government will consider the recommendations in the review carefully and provide a formal response in due course.

[Baroness Massey of Darwen (Lab)]

I thank the Minister for that Answer. I am aware that, fortuitously, the final report of the Accelerated Access Review was published this morning, and, again, it is fortuitous that Thursday of this week will be breast cancer awareness day. The Secretary of State for Health has commented that we wish to make the UK the best place in the world to develop new drugs, as the Minister said. Do the Government therefore intend to commit to full delivery of the Accelerated Access Review, and what estimates have been made of the resources that will be necessary for this, if any resources are required?

[Lord Prior of Brampton]

We received the report today. We warmly welcome its principles and believe that by combining the great depth of our research base in this country with the NHS, which is the largest single integrated provider of health services in the world, we can create a world-leading life sciences base in this country. The detailed response to the report and the costs attached to it will come in due course.

[Baroness Walmsley (LD)]

My Lords, repurposed off-patent drugs often fall in the cracks between the processes of NICE and the processes of NHS England, both of which organisations take the role of approving these drugs. The Accelerated Access Review recognises this problem and recommends that the new streamlined process involve both organisations talking to each other to make quite sure that that does not happen. What will the Minister’s department do to ensure that under this new streamlined process these drugs do not fall between the cracks, because many of them are very useful to patients?

[Lord Prior of Brampton]

My Lords, I need to consider the report in detail. I do not believe that repurposed generic drugs naturally fall within the AAR streamlined procedures, although it is very important that they do not fall between the cracks. The AAR is largely designed for new products rather than for repurposing old products.

[Baroness Greengross (CB)]

As the Minister will know, there is an enormous delay in innovative drug production due to the regulatory bodies internationally not working very closely together or taking a very long time to work together. Will the Minister tell us whether there has been any progress on bringing those regulatory bodies together, as was initiated after the former Prime Minister did a lot of good work in this respect regarding dementia?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. The delay in bringing a new drug to the market can very often be between 12 and 14 years, which is a huge amount of time. Part of the reason for that is indeed the regulatory process. The whole purpose of the Accelerated Access Review is to truncate that time. The report talks about reducing for some drugs the time it takes to bring them to market by up to four years, which would be very considerable progress. In terms of international regulatory bodies, if one takes the EMA in Europe and the FDA in the US, clearly they do work together at one level but probably not closely enough, and I suspect that there is too much duplication in regulation. Certainly, as we leave the European Union, we need to be very careful that we do not have a duplicatory regulatory system in this country.

[Baroness Wheeler (Lab)]

My Lords, the Minister will know that since 2014 the Government have received nearly £1.5 billion from the branded pharmaceutical sector as part of the PPRS to hold down pharmaceutical costs. Why is not some of that sum being used to fund innovative drugs for breast cancer?

[Lord Prior of Brampton]

My Lords, I think it is a mistake to regard the PPRS and the savings made in that scheme as a separate pot of money. Any savings generated from the PPRS are funnelled back into the NHS. As for new innovative drugs, the cancer drugs fund has been changed substantially and one should regard it now largely as an incubator fund with the same purpose as the Accelerated Access Review, which is to bring forward new drugs more quickly.

[Lord Hamilton of Epsom (Con)]

Can my noble friend give the House some indication of the costs of bringing new drugs on to replace old? Invariably, new drugs are far more expensive than the ones that they replace.

[Lord Prior of Brampton]

My noble friend makes a perceptive point. There is always going to be tension between new drugs and affordability, although there are new drugs and new medical devices that can, in the long run, actually save money. The whole purpose of the Accelerated Access Review is to try to square the circle. There are three factors that we have to consider: first, we want a strong and vibrant life sciences industry in this country; secondly, we want to bring forward new drugs as soon as possible if there are big patient benefits; and thirdly, it must be affordable.

[Baroness Finlay of Llandaff (CB)]

Following the statement of the Academy of Medical Royal Colleges this morning urging caution over chemotherapy in advanced cancer, does the Minister agree that it is very important that, at the time of diagnosis, patients have a serious illness conversation and are prepared for what might come so that they are not hanging on with false hopes for drugs which might not be of benefit to them but can have treatments that are appropriately targeted to the individual patient and their needs?

[Lord Prior of Brampton]

The noble Baroness is describing good clinical practice. One would hope that that conversation would take place between a doctor and patient. What was disturbing about the report from the Academy of Medical Royal Colleges was its overall estimate that £2 billion a year was being wasted on unnecessary tests, drugs and the like. The issue that the noble Baroness raises is where people’s lives are prolonged right at the end but they are not given any quality of life at the same time.