Tobacco and Related Products Regulations 2016

Lord Prior of Brampton Excerpts

Monday 4th July 2016 Lords Chamber

[Viscount Ridley]

My Lords, I will be extremely brief, because we need to press on to what the Minister will say. However, it is very important to point out that this is smack in the tradition of harm reduction, which was pioneered in this country with needle exchanges for HIV addicts. We did not go round saying, “That’s a bad policy because needles are dangerous things”. We said, “Let’s look at the relative risks”. We now know that there is a motorway out of smoking by vaping, and on the other carriageway there are virtually no cars at all. We have heard the data from my noble friend Lord Cathcart.

One final very quick suggestion is: if we want to get public information out there, why do we not insist that cigarette packets, which already carry a warning label, carry a label which says, “Have you tried vaping instead? There is very good evidence that it is much safer”? That would be factual and targeted at smokers. It would be beneficial, save lives and cost nothing.

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

My Lords, before this debate started I had feared that it would be a bit like Groundhog Day in relation to what happened in the Grand Committee Room earlier. However, it has been a fascinating and excellent debate. I thank the noble Lords, Lord Callanan and Lord Hunt, and the noble Baroness, Lady Walmsley, for tabling their various Motions and amendments. This has been a very good debate.

I start from the premise that all my instincts are always against regulation. In my view, there is normally a presumption against regulation. I should also make it absolutely clear that there is no doubt that vaping is far better for you than smoking. If, as a result of these regulations, more people were to carry on smoking, we would indeed have shot ourselves in the foot. To pick up the analogy that my noble friend Lord Ridley used about needle exchanges, the point is that they should at least be clean needles. I agree with his argument but we need some regulation to ensure that vaping is not abused, if I can put it that way.

I wish to make a small number of important points which have been raised by noble Lords. First, we have fought long and hard to denormalise smoking behaviours, and Members of this House have been at the forefront of that. It is right to take a precautionary approach to managing any risk that e-cigarettes renormalise smoking behaviours, particularly by restricting children’s exposure to e-cigarette marketing and imagery. Glamorising these products, with adverts reminiscent of those from the tobacco industry many years ago, can only make them more attractive to children. Recent research by the Cambridge behaviour research unit also suggests that exposure to e-cigarette adverts influences children’s perception of smoking tobacco. It reduces their belief in the harm of occasional smoking. This has the potential to undermine some of the great progress we have made over the last six decades in controlling the smoking of tobacco.

I know that there are calls for a return to self-regulation, but just last week we saw the Advertising Standards Authority rule on a glamorous advert. I do not think that props are allowed in this House, but this is a four-page advert on the front and back of the Evening Standard. On the front, there is a very attractive young woman looking out over London while smoking a cigarette. On the back, there is a James Bond lookalike jumping out of a helicopter. That is not aimed at people who are smoking but at young people who might then think about smoking. Figures have been put about showing that there is no evidence that young people are influenced by this kind of advertising. However, that is not the case everywhere. The US is seeing an upward trend in children who have never smoked cigarettes using e-cigarettes, and data from Poland show that 30% of children surveyed use e-cigarettes. The Government have therefore taken a precautionary approach to any possible risk of the renormalisation of smoking behaviours.

Some 96% of smokers are already aware of e-cigarettes, so I am clear that promotion is not about raising consumer awareness, which already accounts for 96% of that market. While businesses’ ability to communicate about their products may have been curtailed in the interests of protecting children, they have not been banned outright. The regulations will not prohibit information being provided to customers either online or in physical retail outlets. Nor will they ban independent reviews of these products or discussion in e-forums. Some advertising will be allowed, such as point-of-sale, billboards and leaflets. Essentially, these are the information routes that were used when e-cigarette sales and use were growing the fastest. My noble friend made a point about billboards, buses and the like. The reason for the distinction between outlets is to try to minimise the impact on young people. That is what lies behind the differentiation between advertising media.

Secondly, the regulations provide minimum product standards and reporting of ingredients and emissions. This should reassure smokers who are looking to quit that e-cigarettes are safe and high quality, and give the Government and health professionals such as GPs confidence in recommending them to smokers. The product standards in the regulations are a result of balancing user needs and risk of accidental exposure to children. Of the reported poisoning incidents, running at some 250 a year, one-third relate to young children under the age of four. The regulations require child-resistant packaging, and the 20 milligrams per millilitre limit for nicotine, combined with the size restrictions on tanks, ensures a maximum exposure of 40 milligrams of nicotine, which is below the level of 50 milligrams that the European Chemical Agency assesses would cause acute toxic effects for toddlers. ASH recently published data indicating that only 9% of vapers report using e-liquid containing 19 milligrams per millilitre or more of nicotine. I know that my noble friend Lord Cathcart is a heavy user of this particular substance, but he is among only 9%. Moreover, the changes in technology will make it increasingly possible for users to get high levels of nicotine uptake for any given strength. Producers can of course get a higher strength approved by the MHRA.

My third main argument in favour of these regulations is that the UK’s approach to the regulation of e-cigarettes has, and will remain, pragmatic and evidence-based. We have one of the most liberal approaches to e-cigarette regulation in the world. We have implemented domestic age-of-sale legislation, preventing sale to under-18s, but we have not banned flavours in e-liquids or cross-border distance sales, nor have we restricted vaping in public places. I remind noble Lords that the latter two measures have been introduced in around two-thirds of all other EU member states and are also common in other parts of the world. I am not sure whether the noble Lord, Lord Forsyth, is right when he talks about gold-plating in this context.

[Lord Forsyth of Drumlean]

I am contemplating the Minister’s argument about children being exposed to dangerous quantities of nicotine—which obviously one wants to avoid—and how there is therefore a need to reduce the packaging. Is he planning to do the same for other household products such as domestic bleach and dishwasher liquid? We cannot approach that kind of problem through regulation: surely it is about encouraging parents to behave responsibly.

[Lord Prior of Brampton]

There are of course many products which do have tamper-proof packaging and we cannot debate all the ones the noble Lord mentioned. It seems to me entirely reasonable that this particular product should be tamper-proof. If a child were to swallow nicotine in these kinds of volumes it would have a very serious impact. It is entirely reasonable to have tamper-proof packaging.

The Government have asked the MHRA, local authorities and others involved in the enforcement of these regulations to develop a compliance regime together with the businesses which are currently in this industry. We will take a pragmatic approach to implementing the new notification system. Notification fees are low—£150 per product and £60 annually as a top-up—and are set to recover costs only. The MHRA has also developed guidance that minimises the burden on business.

E-cigarettes are not harmless. Nicotine is both toxic and addictive and there are unanswered questions about the effects of longer-term use. It is better to vape than to smoke but it is far better to do neither. These regulations reduce the risk of harm to children and protect against the renormalisation of tobacco use. They provide assurance on relative safety for users and legal certainty for businesses that wish to sell these products across the EU. I also underline that the regulations have the full support of the four nations of the UK, as well as many of those in the health community that have been involved in tobacco reduction, including ASH, Cancer Research UK and the British Medical Association. The Royal College of Physicians agrees in its report on the need for regulation of e-cigarettes to protect the public, and states that although e-cigarettes are estimated to be in the order of 95% less harmful than smoked tobacco, they are not harmless.

Moving forward, the Government are committed to a full review of the functioning of the regulations, including—

[Lord Campbell-Savours]

Is there a danger that a black market will develop?

[Lord Prior of Brampton]

It is possible. There is always a possibility when there is a regulation that a black market will develop, and for the very high-strength products, which had to be regulated by the MHRA—the ones above 20 milligrams—there is a risk that there will be a black market. I think I recall that the noble Lord said earlier that a black market had already developed in this product. We are trying to bring some minimum quality standards, at least, into this market so that people who are thinking of moving from smoking to using e-cigarettes can have confidence that the product they use is regulated to a minimum standard.

I remind noble Lords that new and important tobacco control measures are also contained in these regulations. I have not talked about them specifically because they are slightly off the main point of this debate. The regulations will be reviewed within five years of entering into force. I also commit, here and now, to commissioning Public Health England to update its evidence report on e-cigarettes annually until the end of this Parliament and to include within its quit-smoking campaigns consistent messaging about the safety of e-cigarettes.

Clearly, there are strong arguments on both sides of the debate. As I said, I am not an instinctive regulator by any means but I feel that these regulations are proportionate. They do not go over the top, are entirely sensible and are backed by the RCP and all the major charities in this area. I hope that my noble friend Lord Callanan will not wish to push this to a vote, but of course that is entirely his decision.

[Lord Hunt of Kings Heath]

My Lords, I thank the Minister for his wind-up, which I think was very fair. I agree with him that this has been an excellent debate and various views have been put forward. I understand why some noble Lords have concerns about e-cigarettes, particularly in relation to young people. I understand that there are still some uncertainties. I accept that there is a need for some regulation in relation to e-cigarettes.

The Royal College of Physicians produced an excellent and dispassionate report but in the end it concluded that, while not absolutely safe,

“the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco”.

That is a pretty powerful statistic. The royal college supports the regulations—I understand that. We have been told by the noble Baroness, Lady O’Cathain, that 2.8 million people currently use e-cigarettes. We know that often it is the poorest people in society whom many of the traditional approaches to giving up smoking have not touched. Equally, we know that there is a problem with smokers who think that e-cigarettes may be much more harmful than they actually are.

The noble Lord, Lord Prior, rightly said that smokers are aware of e-cigarettes: I take that point. However, there is this worrying statistic that many smokers feel that e-cigarettes are very harmful—almost as harmful as smoking cigarettes. That worries me. I worry that the regulations may make that worse. This is where the absence of cohesive, strongly financed public health programmes comes in. That is why I believe that my amendment finds a delicate way through the morass that we have been debating today and why I wish to test the opinion of the House.

Health: HIV

Lord Prior of Brampton Excerpts

Monday 4th July 2016 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they will instruct NHS England to commission the use of pre-exposure prophylaxis (PrEP) for patients with HIV.

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

My Lords, after taking legal advice, NHS England has concluded that it has no legal power to commission pre-exposure prophylaxis. NHS England’s decision is currently subject to judicial review by the National AIDS Trust and we are therefore unable to comment further on the legal position. We will consider the options available following the outcome of the legal review.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this is a perverse decision on a ground-breaking drug that could save many people’s lives. Essentially, NHS England is hiding behind the responsibilities of local authorities in relation to sexual health services. How long must we wait before the public get the use of this drug, which is widely available in other countries? The Government should instruct NHS England to get on and make it available.

[Lord Prior of Brampton]

My Lords, the judicial review is being held next Wednesday, which is only 10 days from now, at which point we will know the exact legal position. I really cannot comment further on it today. As far as this drug being widely available as a prophylaxis, it is widely available only in some countries for very specific groups of people. If we commission it in the future, it is important that we are clear about where we can get the most benefit from it.

[Baroness Walmsley (LD)]

My Lords, the PROUD study reported in the Lancet last year showed that the PrEP use of Truvada in high-risk groups reached nearly 100%. Are there any other preventive treatments for life-threatening diseases which are 100% effective but for which NHS England is refusing to take responsibility?

[Lord Prior of Brampton]

It is true that in the control group used in the PROUD trial there was a very high level of success—85% or 87%, I think—but it is critical to identify the right group of people. That is why NHS England is providing £2 million to test Truvada as a prophylactic among a wider group of people to see whether it is equally efficient.

[Baroness Gould of Potternewton (Lab)]

My Lords, I declare my interests as a member of the All-Party Parliamentary Group on HIV and AIDS and as a patron of many HIV organisations. Further to the Minister’s last reply and to the fact that trials are going to take place, will he indicate what action the Government are taking to ensure that there is no gap in the provision of Truvada—PrEP—for those who are on the PROUD trial? Those people will be in great difficulty if they have to stop taking the drug. Will they be included in the trial, how are the trials going to be determined and who is going to decide how the money is going to be spent? Lastly, we think the trial will be a two-year process, so it will be 2019 before we get a decision. Will the Minister say how the decision is ultimately going to be taken?

[Lord Prior of Brampton]

I can confirm that all the people who are receiving PrEP as part of the PROUD trial will continue to receive it going forward, which I think answers the main point made by the noble Baroness. In terms of the conduct of the trials that I referred to earlier, they will largely be organised and shaped by Public Health England.

[Baroness Jay of Paddington (Lab)]

My Lords, I have to declare an interest because my husband chaired the Medical Research Council committee that oversaw the original trial on this. The trial was suspended because it was so successful. It was suspended on ethical grounds because it was thought that the people in the control group must receive the drug. Do the Government agree that it is unethical, whatever the legal or financial situation, not to make the drug more available now, particularly given the alarming rise in new cases of HIV in gay men?

[Lord Prior of Brampton]

I am not an expert in this area, but having thought and read about this issue a lot over the past few days, it seems to me that the number of people who have not been diagnosed with HIV is a critical issue. As those people are not aware that they have HIV, their behaviour is not adjusted and because they are not taking treatment, they have a greater amount of the HIV virus. It is estimated that 18,000 people have not been diagnosed so, if one had to make a choice, increasing our rate of diagnosis must be crucial. However, I do not disagree with the noble Baroness that the evidence around PrEP as a prophylaxis is strong.

[Lord Cashman (Lab)]

My Lords, I have a simple question. Does the Minister agree that we cannot afford not to provide PrEP on the NHS, given that it saves lives and prevents HIV infection?

[Lord Prior of Brampton]

The critical issue is: to whom do we provide it? The whole purpose of the trials that NHS England is now funding is to ensure that when we provide PrEP, we do so for those who can most benefit from it.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise that the number of new cases in London is not falling, despite all the public health measures, and that there is therefore an urgent need to address the continuing at-risk behaviours? Will the Government also consider a trial of PrEP in the prostitute population, in which heterosexual transmission can occur and who are often not spoken about in relation to HIV, partly because all their activities are underground?

--- Later in debate ---

[Lord Prior of Brampton]

That is a good point. I am sure that Public Health England is aware of the risks to sex workers and that it will factor them into the trials it is devising over the next two years.

Health: Diabetes and Obesity

Lord Prior of Brampton Excerpts

Thursday 30th June 2016 Lords Chamber

[Lord Harrison]

To ask Her Majesty’s Government what steps they are taking to ensure that those with diabetes have adequate support to tackle obesity.

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

My Lords, it is for healthcare professionals to identify, in consultation with their patients, what support is needed to manage diabetes effectively. This includes people with diabetes accessing programmes to help manage their weight, eat healthily and be more active.

[Lord Harrison (Lab)]

Can the Minister give us a date for the obesity strategy and, when it appears, can he ensure that in the reformulation advice to the food industry not only sugar but salt and saturated fat will be taken into account? Secondly, following Brexit, can he make a statement or at least write to me about the breakdown in the research being done across the whole of the European Union with our United Kingdom colleagues to defeat obesity and diabetes, as was worried about this morning by the former research director of the European Commission on the “Today” programme?

[Lord Prior of Brampton]

My Lords, it is still our intention to announce the obesity strategy soon. Clearly, there have been other events, which may create some delay, but we will announce the strategy as soon as possible. When we do, I am sure that there will be clear recommendations on diet that will include not just sugar but saturated fats and salt. Finally, as the noble Lord knows, I am arranging for him and the noble and learned Lord, Lord Morris, to meet people from the research community to discuss the outlook for research into diabetes, and I am sure that it will include any impact that Brexit might have.

[Baroness Gardner of Parkes (Con)]

My Lords, will specialist diabetic nurses be involved in this? They are enormously valuable to patients and provide a very practical way of getting direct help to patients instead of involving consultants on all occasions.

[Lord Prior of Brampton]

My noble friend is absolutely right that specialist diabetic nurses have a huge role to play in helping to identify and then manage and treat people with type 1 and type 2 diabetes. I am sure that that role will grow over time.

[Lord Rennard (LD)]

My Lords, projections show that, in 20 years, 40% of the UK population may be defined as being obese and one-third as overweight. Is it not therefore important that we introduce restrictions, very shortly or even now, on the marketing of junk food to children?

[Lord Prior of Brampton]

My Lords, that issue will be addressed in the obesity strategy, which comes out later this year. The levy that has been announced will, I think, lead to the reformulation of high-sugar fizzy drinks, which is a start in the right direction. It is largely a question of diet, as the noble Lord said, but also exercise and many other factors, which will be in the obesity strategy that comes out later in the year. Clearly, making it more difficult for young people to access junk food will be an important part of that strategy.

[Baroness Masham of Ilton (CB)]

Does the Minister agree that diabetes is a very complex condition and can be very expensive to every country in the world? Does he also agree that many diabetics love sweet things? Will the Government stimulate more health education in schools so that children grow up learning about diabetes?

--- Later in debate ---

[Lord Prior of Brampton]

That is a very good point, and I hope that it will be covered in the obesity strategy for young people when it comes out later in the year. A key part of our diabetes prevention strategy is to identify more and more people who are at high risk of developing type 2 diabetes and give them a personalised programme to reduce the likelihood of their getting diabetes. We hope that, by 2020, 100,000 people a year will be on that programme.

[Baroness McIntosh of Pickering (Con)]

Does my noble friend agree that we do not need to wait for the obesity strategy for doctors to recommend which diet, salads and fruits those borderline diabetes patients should be taking? Could not doctors be giving that advice now?

[Lord Prior of Brampton]

Of course they should be giving that advice, and indeed they are. There is also clear advice on the Public Health England website as to what is the right diet. Confusing messages have been given over the past couple of months. Therefore, I think it would do no harm to repeat in the obesity strategy what is the right diet.

[Baroness Young of Old Scone (Lab)]

My Lords, is the Minister aware of recent emerging research that confirms the view that has been held for some time that if people with type 2 diabetes—and there are 3.5 million of them in this country—reduce their weight by 10% and take modest regular exercise, in a significant number of cases the effects and complications of their diabetes can be put into long-term remission with consequent reductions of pressure on NHS resources and capacity? Despite that, less than 10% of people with diabetes get any such help in reducing their weight and increasing their exercise, and therefore having the option and opportunity of turning off their diabetes. This issue has been raised significantly over the past five years. What urgent steps can the Minister outline, rather than simply relying on local action that is clearly not working?

[Lord Prior of Brampton]

The noble Baroness is clearly right that weight reduction can reverse diabetes. My father, for example, has lost weight and his diabetes has, effectively, been put into remission. There is no question that it works. However, it is very difficult to lose weight once you are overweight. The figure is that only one in 210 people with a BMI of over 30 can reduce it to a normal level; hence the emphasis that the Government are putting on explaining this to children and young people before they get fat. That is the critical place to aim. However, I entirely agree that greater access to structured education programmes is very important.

[Baroness Finlay of Llandaff (CB)]

I fully endorse that reply from the Minister, but will he also ensure that the guidance includes recognition of emerging research that children, if they never become obese, have a different type of fat—brown fat—which maintains a higher metabolic rate and therefore decreases their long-term risk of diabetes? The importance of avoiding obesity in the first place, particularly in children and in women, in pregnancy and post pregnancy, is the only way that we will stop this ever-growing curve of diabetes associated with adult obesity.

[Lord Prior of Brampton]

I entirely endorse the words of the noble Baroness, which I am sure will be reiterated in the obesity strategy when it is announced later in the summer.

[Lord Watts (Lab)]

My Lords, does the Minister agree with me that far too much attention has been given to sugary drinks, the consumption of which has been in decline for the past 10 years, and not enough attention given to other unhealthy foods that are causing the problems?

[Lord Prior of Brampton]

I think that the levy on sugary drinks has been universally welcomed as a start. That the proceeds of the levy will be put into the sport premium in primary schools and lengthening the school day in secondary schools is all for the good. If we are to address obesity, it has be across a very wide front.

[Lord Roberts of Llandudno (LD)]

My Lords, with the cuts in education budgets and consequent reduction in the number of nurses in schools, who are able to keep a special eye on diabetic pupils, will the Minister give an instruction that is helpful to education authorities and schools to replace somehow the specialised nursing staff who have done such a great job over the years?

[Lord Prior of Brampton]

My Lords, I cannot address the specific issue of the number of nursing staff in schools, but the Government are well aware that encouraging children to eat well and take exercise is a crucial part of any obesity strategy. As I said, our strategy will be revealed later in the year.

NHS: Unsafe Hospital Discharges

Lord Prior of Brampton Excerpts

Wednesday 15th June 2016 Lords Chamber

[Baroness Walmsley]

To ask Her Majesty’s Government what action they are taking, in the light of the report of the Parliamentary and Health Service Ombudsman, to prevent unsafe discharges of frail and elderly people from hospital.

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

My Lords, unsafe discharge of frail elderly patients is unacceptable. Discharge can be very complex, and the integration of health and social care is vital for safe, joined-up care. We are using sustainability and transformation plans to promote integration, supported by the better care fund, creating a seven-day NHS and supporting local systems to develop integrated discharge systems and new models of care.

[Baroness Walmsley (LD)]

I thank the Minister for his reply, but is he aware that the ombudsman reports patients being discharged before they are clinically ready, without being assessed or consulted and without a care plan or their family being told that they are coming? Does he know why this is still happening 12 months after Healthwatch England’s report on the same issue? Does he agree that this not only puts an enormous financial burden on the NHS but is an appalling way to treat vulnerable people?

[Lord Prior of Brampton]

My Lords, there are millions of interactions between patients and consultants and doctors every day of the year, and there will be some mistakes. We cannot draw conclusions from one or two desperate situations. In so far as they reveal systemic problems, it is valid to draw attention to individual cases of this kind, and there are some systemic issues lying behind the PHSO’s report. In particular, it states:

“We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight … health and social care … have historically operated in silos”.

That is the issue on which we should be focusing.

[Baroness Pitkeathley (Lab)]

My Lords, I ask often in this House and elsewhere about co-operation between health and social care. Does the Minister agree that one thing we lack is a cohort of people, be they nurses or paid professional carers, who can work across health and social care in hospital and follow patients into the community? Will the Minister update the House on what is happening to encourage that kind of cohort?

--- Later in debate ---

[Lord Prior of Brampton]

The noble Baroness is right. Most well-run hospitals will have integrated discharge teams comprising people who work in the community, social care workers and people who work in the hospital. However, the fact is that over the last 20 years, with the benefit of hindsight, too much resource has gone into acute hospitals and not enough into primary care and community care. You cannot wish into being lots of district nurses overnight. There are some parts of the country—I will pick on Northumbria and Salford, for example—where serious integration is now going on, with hospitals also managing adult social care, GPs and community care.

[Baroness Butler-Sloss (CB)]

May I pick the Minister up on one point? He said that there were one or two examples, but my understanding is that this is right across the country.

[Lord Prior of Brampton]

The noble and learned Baroness is right, up to a point. I said one or two because the PSHO report focuses on nine individual cases. In so far as they are representative of behaviour across the country, they are important, but I want to put on record that the vast majority of hospitals the vast majority of the time are getting their discharge procedures right and are doing an outstanding job.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister has readily identified the problem of unsafe discharges. Why is there no explicit reference to this issue in the NHS mandate to NHS England for 2016-17?

[Lord Prior of Brampton]

I cannot give the noble Lord a reason off the cuff. It is very much a part of the better care fund. There is a CQUIN for 2016-17 that is focused on delayed discharges. One of the fundamental purposes underlying the STPs and the vanguards, which are a critical part of taking the Five Year Forward View into a serious plan, is to reduce delayed discharges and improve the relationship between acute care and social care.

[Lord Rennard (LD)]

My Lords, given that those nine cases were considered to be representative of the problem, does the Minister agree that it might be cost-effective to make greater use of voluntary sector organisations such as Age UK in better preparing people who are frail, elderly and on their own for going into hospital, and then looking after them when they are leaving, to avoid unnecessary, expensive and painful readmissions to hospital?

[Lord Prior of Brampton]

The third and voluntary sectors have a potentially huge role to play. I was talking this week to the chairman of the Chelsea and Westminster Hospital about the plans he had for involving the voluntary sector far more in discharge planning, particularly for frail and elderly people. I agree entirely with the noble Lord’s sentiments.

[Baroness Wall of New Barnet (Lab)]

My Lords, the Minister has referred to the STP, the sustainable transformation plan. Could he accelerate the way in which that plan is now going? We are into phase one, and some of the shocking things in the report that the noble Baroness, Lady Walmsley, has referred to could be remedied by using the STP properly. I wonder if we should look further and quicker at how we can achieve that.

[Lord Prior of Brampton]

My Lords, this is a difficult issue. You can lead a horse to water but you cannot make it drink. To some extent you have to rely on local people working together, and it is behaviour and culture that determine long-term sustainable improvement. If we try to force the pace beyond that at which local people are prepared to go, in the long run we may not make as much progress. In the first instance we hope that the STP process, involving all local people and giving them a framework for working together, will deliver the results we need. If it does not, we will have to revisit it.

[Baroness Watkins of Tavistock (CB)]

My Lords, could the Minister ask why the NHS has not considered funding nursing home places for people who are ready to be discharged for two or three weeks, so that they can have 24-hour care funded by the NHS while they prepare to move back home? People who live alone, in particular, are just waiting for financial assessments while reducing other people’s access to acute hospital beds, including young people who are routinely having standard operations cancelled.

[Lord Prior of Brampton]

My Lords, looking back over 20 years, the reduction in the number of what you might call step-down facilities—community hospitals and the like—has been a huge mistake. We lack step-down facilities. In America they are called skilled nursing units. The fact is that an acute hospital is not a good place to be for anyone once they are medically fit to be discharged; all the evidence suggests that it is more expensive but, more importantly, less good for the patient. I agree entirely with the noble Baroness that we need to explore avenues of discharging people earlier to nursing homes, community hospitals or, better still, back home with the right community support.

Carers over 80: Support

Lord Prior of Brampton Excerpts

Monday 13th June 2016 Lords Chamber

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

My Lords, we recognise the invaluable contribution carers make to society and that many provide long hours of wonderful care. We support wholeheartedly the implementation of the improved rights for carers established by the Care Act 2014, providing just over £186 million of funding to local authorities for these improved rights. We are committed to continuing to improve support for carers through the publication of a new national carers strategy by the end of 2016.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Research by Age UK, Carers UK and independent age charities shows that the older the carer, the more hours of care they tend to provide. That, surely, cannot be right. Many carers over 80 are providing as much as 50 hours of care a week, often without any support because they do not meet the new eligibility criteria and councils just do not have the money in their social care budgets. Will the Minister undertake to ensure that the new carers strategy tackles these high and increasing levels of unmet demand? With councils across the country having to cut back on carer support, what specific support and funding will the Government provide to help councils offer real support to carers?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. Nearly half a million people over 80 are providing more than 35 hours a week of care to their partner or loved one, which is a huge commitment and often has profound implications for their own health and well-being. We are all singing from the same hymn sheet on this and I am sure that the carers strategy coming out at the end of the year will address the particular requirements of that age group. The Government will continue to support carers’ rights. I mentioned the £186 million being given to local authorities to do that.

[Baroness Brinton (LD)]

My Lords, the Building Carer Friendly Communities research report for Carers Week last week reported that approaching half of older carers had not been offered an annual health check by their GP practices, and about half of older carers said that their GP practice had not told them where they could find help. What are the Government doing to encourage primary care to make sure that older carers get access to annual health checks and support?

[Lord Prior of Brampton]

My Lords, clearly it is essential that older people have access to at least annual check-ups from their GPs. A large part of the review that is being undertaken will be about how we signpost and inform people of the need to have these health check-ups. I am sure that will be a part of the strategy announced at the end of the year.

[Baroness Greengross (CB)]

Under the new legislation, the Care Act, carers have a right to an assessment of their needs. Will the Minister assure the House not just that those needs will be assessed but that enough resources will be put into the system so that they can be met?

[Lord Prior of Brampton]

My Lords, under the Care Act there is an assessment, eligibility criteria and a support plan. Clearly there is no point having a plan without the support.

[Lord Watts (Lab)]

My Lords, will the Government consider setting up an independent review to look at the sorts of budgets that local authorities will require to provide a decent service?

[Lord Prior of Brampton]

As part of the consultation that is being conducted in preparation for the publication of the strategy at the end of the year, the Government have called for evidence, looking at international comparisons as well as an economic review, which I am sure will take into account the issues the noble Lord raises.

[Baroness Farrington of Ribbleton (Lab)]

My Lords, in recognising the serious concerns about people over 80, and people under 80 with health needs themselves, will the Minister assure us that the review will have regard to the number of children who are carers for adult members of the family? The needs of the parent are assessed, quite rightly, but the needs of the child or children concerned are not always taken into account. Can we have an assurance that the new strategy will cover both my noble friend’s Question and concerns, and the needs of children?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. There are many tens of thousands of children who have very substantial caring responsibilities for their parents or grandparents. The impact on their education and future careers is certainly something that the strategy will want to take into account. Of course, the Children and Families Act sets out the rights of children. We need to assess them very carefully in the forthcoming strategy.

[Baroness Bakewell (Lab)]

My Lords, can the Minister tell us how much the group of people who are carers over 80 is saving the economy by offering their services?

[Lord Prior of Brampton]

I cannot give a specific figure for those over 80 but I think that, in so far as you can monetise something like this, the total amount for all unpaid carers is estimated to be around £1.3 billion a year.

[Lord Flight (Con)]

My Lords—

--- Later in debate ---

[Lord Flight]

Thank you. My Lords, does the Minister recognise that there are large numbers of older people who simply look after each other? This is at the heart of the institution of marriage and they may not be registered as a carer because they are of similar age and shape. This whole issue is about not just the carer situation but older people who happily look after each other in old age.

[Lord Prior of Brampton]

Yes, we are talking about not just people who are registered carers but in particular where older people are looking after each other reciprocally, whether that is within marriage or a long-term partnership. Again, you cannot monetise something like that. It is part of a loving relationship. One of the tragedies in this is that it can sometimes change that caring relationship of husband and wife to one of a carer and a cared-for person, which can have a quite difficult psychological impact on individuals.

[Baroness Manzoor]

My Lords, do the Government have any plans to provide respite care for carers, particularly where there are significant disabilities involved with the person being cared for?

[Lord Prior of Brampton]

Respite care is hugely important. I think that the better care fund provides about £130 million a year for respite care. Giving people time out is hugely important.

National Clinical Director of Adult Neurology

Lord Prior of Brampton Excerpts

Thursday 9th June 2016 Lords Chamber

[Baroness Gale]

To ask Her Majesty’s Government why the National Clinical Director of Adult Neurology post was ended, and what assessment they have made of the consequences of that decision.

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

My Lords, the reduction in national clinical directors resulted from NHS England’s review of its clinical advisory resource. This review sought to refocus capacity on areas where major programmes were being taken forward and in areas identified as priorities for improvement. NHS England will still be able to access neurological clinical advice in future. From 1 July 2016, clinical expertise will be provided by NHS clinical leads, the neurology clinical reference group, royal colleges and wider engagement.

[Baroness Gale (Lab)]

While I thank the Minister for his response, I am very disappointed. I am sure he is aware that there has been no transparency whatever, and no consultation on making this post redundant. He will be aware that the Neurological Alliance and the Public Accounts Committee have urged that this post should remain where it is. There was great rejoicing when the post was created three years ago and great disappointment that it has now been ended. Will the Minister agree to meet the Neurological Alliance so that we can have a full discussion and a full understanding of why this post was made redundant? Nobody seems to understand it, as it has all been done very quietly. I hope that this is not just a cost-cutting exercise.

[Lord Prior of Brampton]

My Lords, I am of course very happy to meet the Neurological Alliance with the noble Baroness. I just say this: if the medical director and board of NHS England cannot make decisions about where they should get their clinical advice, one is bound to ask what on earth the point of them is. There are certain decisions that must be made by NHS England and Bruce Keogh, its medical director, came to this decision. I think it is a decision that he should make, not politicians.

[Baroness Walmsley (LD)]

If three years has been long enough for NHS England to decide that the national clinical director and the regional clinical networks are not working well enough for neurology, how long is it planning to give the new system to prove that it is better for patients?

[Lord Prior of Brampton]

I do not think that anyone is saying that the system was not working well enough. The argument that NHS England put was that it had to focus its resources on a smaller number of key national priorities—for example, mental health, cancer and learning disabilities—and that is what it is doing. It is poking the resource into a smaller number of well-focused and well-defined areas, but it can still get all the advice that it needs on neurology from the clinical reference groups and other sources.

[Baroness Finlay of Llandaff (CB)]

Do the Government recognise that the UK has only one-sixth of the number of neurologists that the rest of Europe has, which accounts for delays in diagnosis, poor outcomes for patients and wide variation in services? That needs to be addressed urgently for patients to have earlier diagnosis and better outcomes, and for their families to be better supported. Co-ordination of clinical and research efforts needs to be across the UK. I declare an interest at Cardiff University, where the amazing CUBRIC has just been opened by Her Majesty the Queen. It has the potential to transform neurological diagnosis in the UK, but there needs to be UK-wide effort.

[Lord Prior of Brampton]

Health is of course a devolved matter in the UK, but there is absolutely nothing to stop the devolved parts of the UK—Scotland, Wales, Northern Ireland and England—from working closely together on these issues. I do not think that the lack of a national clinical director prevents us in any way from doing that.

[Lord Polak (Con)]

I want to register a sort of interest: 28 years ago, almost to the day, I was given six months to live. I had a brain tumour and was saved by a team of neurologists at the Royal Free Hospital. I hope that, in listening to this, the Minister and the department will always remember that individuals and families are at the forefront of this. If there is a belief that somebody central is needed to ensure that the best treatment is given, maybe we could look at it again.

[Lord Prior of Brampton]

I do not want in any way to diminish the huge clinical importance of this and the suffering of many people with long-term neurological conditions. They are among some of the worst illnesses that anyone can have and I am delighted that my noble friend recovered from his. From everything that I have been told by NHS England and Bruce Keogh, I do not believe that the lack of a national clinical director will in any way detract from the resources that we are making available to neurology.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have enormous respect for Sir Bruce Keogh but, as my noble friend Lady Gale said, NHS England has essentially set out to decimate the influence of clinical advisers at the level of senior decision-making teams. When we set up national clinical directors, they were based in the Department of Health, had direct access to Ministers and were hugely influential. The current situation in NHS England is that they are often part-time appointments with virtually no support and limited influence. Is it not time that Ministers started to reassert control over services for which they are accountable to Parliament?

[Lord Prior of Brampton]

I do not think I agree with the last part of the question. We have set up NHS England as an arm’s-length body, and a key part of the reforms—the bit that probably everyone supported in the 2012 Act—was to get politicians more out of the day-to-day running of the NHS and to give more power to clinicians. It is better that clinicians rather than politicians should make these decisions. On what the noble Lord said about decimating the influence of clinical advice in NHS England, I just do not think that that is the case. In so far as he has raised it with me, I will have a meeting with Bruce Keogh and put that point to him and get his response.

[Baroness Masham of Ilton (CB)]

My Lords, is the Minister aware that there are many very complex neurological conditions? Surely there should be a co-ordinator and an adviser. It is really very difficult. Surely it should be upgraded, not downgraded.

[Lord Prior of Brampton]

My Lords, it would be a great mistake to think this was a downgrading exercise. This is NHS England deciding to get its clinical inputs from a clinical reference group rather than having a national clinical director. It has reduced the number of clinical directors by six. We are not talking about just neurology; five others have gone in different specialties—for example, pathology. It would be a great mistake if the House went away with the impression that NHS England was in any way decimating or downgrading the importance of neurology.

Learning Disabilities: Transforming Care

Lord Prior of Brampton Excerpts

Thursday 9th June 2016 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and to draw attention to my interests in the register.

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

My Lords, the data show a small but sustained reduction in in-patient numbers over the last year. Some 2,565 patients were recorded in hospital at the end of April 2016, compared with 2,800 at the end of March 2015. Forty-eight local transforming care partnerships have mobilised to deliver the three-year service transformation detailed in Building the Right Support, which was published in October 2015, with a national ambition of closing 35% to 50% of in-patient capacity and building community-based support.

[Baroness Hollins]

My Lords, I thank the Minister for his reply. Does he agree that this programme will succeed only if robust community support helps people to live in their own homes and prevents new admissions? Is the Minister confident that enough money is being provided to local areas to develop and commission the right support and services, as outlined in the NHS England service model, in particular to develop a trained and supervised social care workforce, which is currently seriously underdeveloped?

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, progress since the horrendous events at Winterbourne View some five years ago has not been as fast as we would like. Under the Building the Right Support programme, NHS England is putting in an extra £30 million, which will be match-funded by CCGs, and another £20 million for capital investment. That is a very significant commitment of extra resource, but the proof will be in the eating.

[Lord Hunt of Kings Heath (Lab)]

My Lords, as the noble Lord said, it is five years since “Panorama” exposed the scandals in Winterbourne View. Ministers’ responses at the time and since have been admirable in their expressions of concern and the action they require in the NHS. The problem is that very little has happened. Is the Minister satisfied that NHS England, which has been consistently charged with implementing the changes, understands what it is required to do by Ministers? So far there is very little evidence that it does.

[Lord Prior of Brampton]

It is very clear in the NHS mandate that it knows exactly what it has to do. It was NHS England that produced Building the Right Support. There is a lot more governance around the programme now. Every month we will see the numbers of patients in in-patient care settings. The noble Lord will be interested to know that over the last year 185 people who had been in hospital for more than five years have now left hospital and gone into the community. There are signs that things are happening, but I would advise the noble Lord that what is needed is constant scrutiny.

[Baroness Emerton (CB)]

My Lords, I thank the Minister for reminding us how many patients have been removed from hospital, but I declare an interest that goes back to the 1970s, when I was responsible for transferring 1,500 and then another 1,200 patients from hospital through a joint working party involving social services and the health service. It seems that we have discharged patients. The Royal College of Nursing demonstrated in a recent report that, from the nursing point of view, never have so few nurses been trained in mental handicaps. People with learning disabilities have physical and mental requirements, as well as environmental ones. Safe staffing is the issue here. Following on from what the noble Lord, Lord Hunt, said, will the Minister please consider getting out an edict on the importance of looking not just at hospital staff but at community staff?

[Lord Prior of Brampton]

The noble Baroness raises a very important point. It is worth saying that an assurance board monitors the national transformation plan on a monthly basis and comprises local authorities as well as CCGs and others. On the workforce front, which is obviously crucial, it is no good putting money into a system if you do not have the right people to deliver the care. We expect the number of whole-time learning-difficulty nurses to increase from around 3,000 to more than 5,000 over the next five years, so there should be more resource going into this very important area.

[Baroness Jolly (LD)]

My Lords, I declare my interest as chair of Hft, a learning disability charity delivering such services across England. It is really very difficult to plan at the moment. We anticipate an element of growth, but we are not sure where or when that will come. The Minister outlined issues such as that. Could the NHS learn from some local authorities that are charged with managing their markets so that when they are ready to discharge such patients they have already established settings for them?

[Lord Prior of Brampton]

All the transforming care partnerships will comprise both CCGs and local authorities, so all the experiences learned by local authorities should be paid into the process.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister agree that when such in-patients leave in-patient care, much of the responsibility for looking after them actually lies with their families? As this is Carers Week, would the Minister update the House on the Government’s attitude to this with the revision of the carers’ strategy?

[Lord Prior of Brampton]

I think we have a direct Question on carers next week. We are absolutely committed to supporting carers. Where people who have been in hospital for more than five years are discharged back into the community, as it were, the CCGs will provide them with a dowry to cover their costs. It will be very clear that the funding of those patients will stay with the CCGs.

[Lord Pearson of Rannoch (UKIP)]

My Lords, will the Government encourage village and intentional communities, which have proved so successful for those covered by this Question and are in great demand by their families, a demand that cannot be met at the moment? I declare an interest, as my daughter lives in such a community.

[Lord Prior of Brampton]

Yes, I am very happy to do that. There are some concerns about changes in social housing and rent caps, which might have the unintentional consequence of making it more difficult to build new houses that can accommodate these kinds of people. That is very much under review by the Government. We absolutely support what the noble Lord says.

[Baroness Gardner of Parkes (Con)]

My Lords, is the Minister aware that some of the establishments of the type just described by the noble Lord, Lord Pearson, are closing? The Camphill communities are an example of that. I was disturbed to see that, because we cannot afford to lose those facilities. Is he aware of that, and can anything be done to help?

[Lord Prior of Brampton]

I am not aware of the specific case of the Camphill communities, although I know about Camphill. Certainly, the preference is to have an environment where there are not too many people, with houses containing between, say, five, 10 or 15 people, rather than large organisations with sometimes many hundreds of people. I believe that Calderstones Hospital in the north-west, for example, has 223 in-patient beds. The intention is to close that and reprovide those facilities in the community. The key thing that we should always bear in mind is the best interests of the individual.

[Baroness Royall of Blaisdon (Lab)]

My Lords, the Camphill Village Trust is an excellent organisation that provides small family units. May I ask the Minister to visit the excellent Camphill Village Trust in the Forest of Dean?

[Lord Prior of Brampton]

This is an area of healthcare about which I am least informed, so I would very much like to do that.

[Baroness Brinton (LD)]

My Lords, Sir Stephen Bubb’s update report also said that the review was going forward very slowly. The Minister has also referred to this. What is the new timetable for the full implementation of the Bubb report?

[Lord Prior of Brampton]

It is a three-year timetable. The intention is to reduce the number of in-patient hospital beds by between 35% and 50%, as I said. There will be a review at the end of the three years to see whether that can be taken further. The truth is that progress seems painfully slow until you look back to where we have come from. We have come a long way over the last 20 years, but nothing like far enough or fast enough. An old Chinese proverb says that it is better to light one candle than curse the darkness. We are making progress, but it could be quicker.

NHS England: Pre-exposure Prophylaxis for People at Risk of HIV

Lord Prior of Brampton Excerpts

Tuesday 7th June 2016 Lords Chamber

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

My Lords, with the leave of the House, I shall now repeat in the form of a Statement the Answer given by my honourable friend the Minister for Public Health to an Urgent Question in another place on pre-exposure prophylaxis. The Statement is as follows.

“HIV can be a devastating illness. We know that PrEP can make a difference to both those at risk of contracting HIV, and those who are already HIV positive. However, it is crucial that we have a full understanding of all the issues surrounding PrEP. As with any new intervention, PrEP must be properly assessed in relation to clinical and cost effectiveness. That is why we have today asked NICE to conduct an evidence review of Truvada for pre-exposure prophylaxis of HIV in high-risk groups.

This evidence review signifies the next step forward and will inform any subsequent decisions about commissioning. It will look at the evidence for effectiveness, safety, patient factors and resource implications. The NICE evidence summary will run alongside a pilot scheme in which we are investing up to £2 million. Public Health England is currently identifying the most effective places for the pilot to take place.

It is also important to remember that the drug used for PrEP, Truvada, is not yet licensed for this use in the UK. That is why, as well as the pilot scheme, the Government want to see an evidence review, which will help inform future commissioning decisions about PrEP.

PrEP is only one of a range of activities to tackle HIV. Our £2.4 million national HIV prevention and sexual health promotion programme also gives those at highest risk the best advice to make safer choices about sex. The UK has world-class treatment services. The UK is already ahead in reaching two of the three UNAIDS goals of 90% diagnosed infection, 90% of those diagnosed on treatment and 90% viral suppression by 2020. In 2014, 17% of those living with HIV had undiagnosed infection but 91% of those diagnosed were on treatment, of whom 95% were virally suppressed. We are determined to continue to make real progress to meet these goals and are considering carefully the role that PrEP can play in helping us get there”.

[Lord Hunt of Kings Heath (Lab)]

I am grateful to the Minister but this decision by NHS England not to commission and fund PrEP is a matter of great regret. In the UK there are more people living with HIV than ever before. Without any need for an evidence review, it is absolutely clear, without any uncertainty whatever, that PrEP has the potential to be a game-changer. It is proven to be effective in stopping HIV transmission in almost every single case. There is no need for an evidence review. It is simply a delaying tactic because of this absolutely disgraceful decision not to fund this drug. The Minister mentioned our record in relation to other countries. It is a matter of shame that this drug is being used extensively in other countries but is being denied to NHS patients without any justification whatever.

At some point the Minister will pray in aid the cost of new drugs. On a number of occasions I have asked him this question but he will never answer it—because, I suspect, the answer is too embarrassing. He knows that he is in the middle of a five-year agreement with the branded drug industry through which, if the cost of drugs goes over the base level plus a small allowance for inflation, the department receives a refund every three months. That agreement should enable new drugs to be funded, but that money is not being used to invest in those new drugs. If he says that this cannot be done because of cost, that is simply not true. I very much hope that the Government will reconsider this decision. It is utterly indefensible.

[Lord Prior of Brampton]

My Lords, I am not going to proffer the argument that it is too expensive, because that is not the issue today. The issue today is that NHS England feels that it does not have the power to commission this particular drug. Whether or not it has that power may well be judicially reviewed, so I cannot comment on the outcome of that judicial review.

The PROUD study produced strong evidence of the effectiveness of Truvada as a preventive drug. The work that NICE is going to do, and the pilot scheme to look at the effectiveness of this drug—it will cost £2 million and will be funded by NHS England and PHE—will ensure that when the question whether NHS England has the power to commission this drug is resolved, there will be the evidence on which to make that decision.

[Baroness Walmsley (LD)]

My Lords, are the Government simply delaying until Truvada comes out of patent and becomes cheaper? Can the Minister say whether NHS England has taken into account the protection from HIV infection of the whole community that would result from a reduction in infection of high-risk groups? Can he also explain why the Government see infection prevention as a local authority responsibility in this case, given that other forms of prevention, such as vaccination, are the responsibility of the NHS nationally? This is not consistent.

[Lord Prior of Brampton]

As I said in response to the earlier question, this is really not about the efficacy of the drug. There is evidence that it is very efficient; that will be confirmed or otherwise by the extra work done by PHE. It is purely a question of the independent legal advice given to NHS England that it does not have the power to commission this drug.

[Lord Fowler (Con)]

The independent advice seems extremely curious and the Minister should go into more detail, because surely we are past the stage of needing a pilot. The international evidence on PrEP is overwhelming. Is not the underlying fear here that policy on HIV has gone off the boil, in spite of the fact that prevention measures such as this are good in both human and financial terms?

[Lord Prior of Brampton]

All I can say in response is that NHS England has had independent legal advice that it does not have the power to commission this particular drug for this particular purpose, and for this purpose the drug itself is not yet licensed. It is not to do with any decision made on efficacy grounds for this drug; it is purely that they have received independent legal advice.

[Baroness Finlay of Llandaff (CB)]

Can the Minister confirm that that legal advice, as I understood it on reading it through, points out that there is weak evidence that NHS England does not have the power to commission PrEP? It says that NHS England does not have the power to fund PrEP but points out that under Section 7A, the Secretary of State has the power to delegate the commissioning of PrEP. Can the Minister therefore explain why, in the face of the evidence that has come through from the PROUD study and internationally, the Secretary of State has not used Section 7A to support NHS England? Is there a dispute going on between NHS England and Public Health England, and is this a fallout from the Health and Social Care Act?

[Lord Prior of Brampton]

I do not think that it is a fallout from the Health and Social Care Act. It is purely that the NHS specialist commissioning committee within NHS England has received clear independent legal advice, as I understand it, saying that it does not have the power to commission this product. That position may well be challenged legally, in which case it will be resolved one way or the other.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, I am sure that the Minister will be aware that for those of us who are not experts in this field but know a little about it, this is an extraordinarily puzzling thing to be confronted with. It just sounds plain daft, frankly. But will he confirm that there is very little prospect of vaccination or immunisation against HIV being developed any time in the foreseeable future and that PrEP is therefore a vital tool in preventing the spread of this infection for the next generation, and probably for subsequent generations? If this legal tangle has to be untangled, can he also say how long he anticipates that will take?

[Lord Prior of Brampton]

I do not know how long a judicial review will take. I guess that it will be months rather than years, but I simply cannot answer that question as I do not know the answer to it. Again, this is a legal issue, not an efficacy issue. This is a question not of the Government saying that we do not want to fund this prophylactic, but of NHS England simply saying that it has been advised it does not have the power to do so.

[Baroness Howarth of Breckland (CB)]

My Lords, can I ask a simple social question? If there are to be trials, how will the decision be made as to who gets into a trial and who gets left out, as that could be a matter of life and death for some HIV sufferers?

[Lord Prior of Brampton]

My Lords, NHS England and PHE are consulting on how those trials should be constructed. Clearly, they will be focused on high-risk individuals but choosing who goes on to the trial will be up to PHE and NHS England.

[Lord Paddick (LD)]

My Lords, there has been a lot of misunderstanding over the use of PrEP and an increase in the prevalence of other sexually transmitted infections. Will the Minister meet me, and other noble Lords who may be interested, to discuss these issues? I declare an interest as a participant in the PROUD project.

[Lord Prior of Brampton]

I would be very happy to meet with the noble Lord. It may be better for him to meet with my honourable friend in the other place who is responsible for public health, but either one of us will be very happy to meet with him.

[Lord Scriven (LD)]

My Lords, the UK now has the worst HIV epidemic of any large western European country, having overtaken Spain, France and Portugal, and every day, seven men who have sex with men are diagnosed with HIV. In the light of the legal argument and of what the noble Baroness said, the Secretary of State, under the legal advice that was given to NHS England, has the power under Section 7A to delegate who gives these PrEP pills. Could the Minister please ask the Secretary of State to do that until the legal issue is resolved, so that lives are saved, rather than our arguing about who funds this and who has the legal ability to do it?

[Lord Prior of Brampton]

I am not briefed on Section 7A and am not sure what the powers of the Secretary of State are. After this debate, I will research that and find out what powers he has.

Dental Health: Children

Lord Prior of Brampton Excerpts

Tuesday 7th June 2016 Lords Chamber

[Baroness Benjamin]

To ask Her Majesty’s Government what is their strategy for keeping children’s teeth healthy.

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

My Lords, Public Health England is leading a substantial programme of work and NHS England will test new ways to improve children’s oral health in 10 high-need areas. The Department of Health is working with NHS England to test a new NHS dental contract focusing on improving oral health. We also expect that measures to reduce sugar consumption will have a positive effect on reducing tooth decay.

[Baroness Benjamin (LD)]

My Lords, this is all excellent news, because shocking reports by the LGA, dentists and surgeons warn that the growing lack of children’s oral health practice, especially in deprived areas and communities, is costing the NHS millions. Huge numbers of hospital admissions for tooth decay and painful extractions are affecting children’s education, well-being and mental health. But this crisis is preventable with early intervention, co-ordinated strategies and funding. How will the Government’s new preventive programme to improve children’s dental health work, how soon will it happen and where will the funding come from?

[Lord Prior of Brampton]

My Lords, I think that the obesity strategy, which will be announced later in the summer, will answer part of the noble Baroness’s question. The new contract for dentists, which will have prevention at its core, is being piloted and will be introduced in 2018. This is a very high government priority.

[Lord Colwyn (Con)]

My Lords, my noble friend talks about the dental contract. Will he tell us when the Government will complete the long-standing delay on dental contract reform? Will they ensure the new contact works for both dentists and patients?

[Lord Prior of Brampton]

My Lords, the new dental contract is under discussion as we speak. Prototypes will be tried in a number of areas over the next two years, I believe. It will be heavily weighted towards prevention, with a high degree of capitation in the contract. It will be very much outcomes-based. I believe that we expect the new contract to be introduced fully in 2018.

[Lord Maxton (Lab)]

My Lords, will the Minister agree that the quickest, easiest and cheapest way to ensure that children do not get and suffer as much from tooth decay is to ensure that all water supplies have the right levels of fluoride in them?

[Lord Prior of Brampton]

My Lords, there is no doubt that fluoridisation is a critical part of good oral hygiene. This is up to local authorities. Public Health England will assist local authorities that wish to introduce fluoride into their water. I add that 3.5 million children in 2014-15 received a fluoride varnish. It is not the same as putting it in the water, but it is fully recognised that fluoride is a critical part of good oral hygiene.

[Baroness Gardner of Parkes (Con)]

My Lords, is the Minister aware that Manchester, which has had reports about hospitals being completely blocked by young children requiring full clearance under general anaesthetic, has no fluoride in the water? Australia has it pretty well everywhere, unless you live in the country, where there is only rainfall and a river. Birmingham, which has had it since the 1960s, has no difference with Manchester in its general health pattern except for the dental difference between the two. I have asked questions on this repeatedly and had Written Answers. Does he think that when Manchester has this new super-authority it might do something about this at last?

[Lord Prior of Brampton]

I agree with my noble friend. Fluoridisation has a huge and direct impact on oral hygiene. It will be up to Manchester to make that decision in due course. To pick up a point made by the noble Baroness, Lady Benjamin, social deprivation also plays a big part in the variation in the quality of people’s teeth. Interestingly, 75% of all children have no tooth decay now, but in some parts of the country—Blackburn, for example—the figure is as low as 40%.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that a healthy diet, including milk, fruit, vegetables and enough vitamin D, is as important to the development of children’s teeth as not eating too much sugar? The Healthy Start programme provides those eligible with free vitamins and vouchers to buy those healthy foods but I understand that the uptake is poor. What are the Government doing to improve the uptake of this programme and to ensure that the lessons learned by those authorities that choose universal distribution of vitamins are spread throughout the country?

[Lord Prior of Brampton]

My Lords, there is no question but that a low-sugar, healthy diet is good for people’s teeth. The noble Baroness will have to wait until we produce the children’s obesity strategy later in the summer, in which we will reveal the full strategy.

[Baroness Lister of Burtersett (Lab)]

My Lords, I am glad that the Minister focused on the question of social deprivation. What will the government strategy do about that?

--- Later in debate ---

[Lord Prior of Brampton]

The best way of addressing social deprivation is to have a strong economy. As I am sure the noble Baroness will agree, the Government have the perfect economic strategy to address that issue.

[Lord Elton (Con)]

My Lords, my noble friend emphasised the fact that sugar is bad for teeth and that the Government are trying to reduce the intake of sugar by private individuals. What is the effect on teeth of the substitutes that will be introduced into many products to replace sugar?

[Lord Prior of Brampton]

I am afraid that I cannot answer that question as I simply do not have the knowledge. I will research it and write to my noble friend.

[Baroness Howarth of Breckland (CB)]

My Lords, this used to be picked up through schools and nurseries, where most children are seen. What happens now in education establishments, particularly academies, where children’s teeth are found to be poor and action needs to be taken?

[Lord Prior of Brampton]

Schools clearly have an important role to play. Interestingly, in Bradford the Building Brighter Smiles programme involves not just a community-based fluoride varnishing application but also supervised tooth-brushing in schools and nurseries. I am sure that that has a very important role to play.

[Baroness Jenkin of Kennington (Con)]

My Lords, the number one reason for primary school children to be admitted to hospital is for multiple tooth extraction as a result of poor diet and the other things that have been mentioned. These are children who generally do not drink water; they drink juice and fizzy drinks. Can my noble friend please confirm that the Government will give this a priority in the obesity strategy later this summer?

[Lord Prior of Brampton]

My noble friend will be aware that a part—only a part—of the obesity strategy includes a levy on fizzy drinks. That will be a levy on the manufacturer not the consumer. That is a very important part of trying to improve the diet of young children.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I should remind the House of my presidency of the British Fluoridation Society. I come back to the issue of fluoridation. The noble Lord has been rightly positive about its impact. The real problem is that the law gives responsibility to local authorities but local authority boundaries do not always fit with the way that water is produced by the water companies. Given that, does the noble Lord agree that there is a role for the Government, working in partnership with those local authorities, to give impetus to water fluoridation? Will he also pick up the point raised by his noble friend and work with the Greater Manchester Combined Authority to see whether Manchester could be brought up to the level of the health of people in the West Midlands?

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, of course Public Health England has a role to play here and works with local authorities that wish to introduce fluoridisation schemes. The noble Lord is quite right that this is not always co-terminous with local water supply. Public Health England agrees entirely with the sentiments of the noble Lord. I assure him that it will work with Greater Manchester or any other local authorities considering water fluoridation.

Mental Health: Ensuring Equal Access to Mental and Physical Healthcare

Lord Prior of Brampton Excerpts

Thursday 26th May 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 Brinton, for tabling the debate. It is a pity that it is right at the fag end of this sitting because it is a hugely important issue. Whether it is once or twice a year, we ought to be held to account. It is so important. At a time when the health service is going through very difficult financial times, it will be easy to fudge some of the numbers. It is important that we are held to account for what we say will do. I thank the noble Baroness for bringing the debate here today.

The noble Baroness said that this was a funding issue and of course it is—up to a point. We have won a big argument over the last few years that preceded the funding issue. We should not underestimate how far we have come in this debate about mental health. It was very moving to hear the personal story of the noble Lord, Lord Oates. Society has come a heck of a long way since Section 28 of the Local Government Act, or whichever Act he referred to. The gender issues are largely behind us—but not fully so. The noble Lord, Lord Crisp, said that there was still prejudice around not just race but also homophobic issues. We should not be complacent about this but society has moved a heck of a long way over the last 20 or 30 years. We are slowly winning the argument that mental health care should be treated truly with parity with physical health care. Although I subscribe to the old saying that fine words butter no parsnips, fine words made a difference in this area of healthcare.

All speakers have shown just how important mental health is. As the noble Baroness, Lady Brinton, said, nearly all of us have someone very close to us—it may be as close as ourselves, as in the case of the noble Lord, Lord Oates, but it might be members of our families, children or friends—who have suffered the devastating consequences of poor mental health. The story of the 16 year-old girl kept in a police cell for 48 hours having committed no crime except that she was mentally ill is just one indication of that. But this is in part no longer a taboo subject because of the bravery of people such as Alastair Campbell and Stephen Fry. Some noble Lords will have read the obituaries of Sally Brampton in the papers last week; she took her own life after a lifetime of struggle with depression. I was particularly struck to read in one obituary that she had said that when you are depressed you do not know if it is your nature or your biology. That goes to the fundamental essence of depression. You do not know whether you are a bad person. Of course, it is often a question of biology and genetics, and of the environment you are in. The noble Lord, Lord Oates, talked about the strength of his family and friends that got him through a really difficult time.

I was struck by the comments of the noble Baroness, Lady Tyler, about health inequalities. She referred to Michael Marmot. Frankly, many of these issues go way beyond the NHS. We spend all our time talking about the NHS and so many of our health inequalities stem from poor housing, a lack of family support, unemployment, poverty and so on. It is interesting how much time we spend talking about the NHS when so much of what needs to be done in healthcare lies well outside the health system.

The noble Lord, Lord Crisp, made the fascinating point that globally mental health attracts 1% of funding but causes 25% of disability. He asked whether DfID could look at parity of esteem as well. That is a very interesting point and we should look at that. He made three other points, including on out-of-area treatment. That point was also mentioned by other noble Lords. When you have ill people being transferred not just for very specialist treatment but for general acute treatment—as he put it—that is a highly unsatisfactory situation. First, people may be admitted into an incredibly busy A&E department of an acute hospital. Often the situation in the A&E department is chaotic and people do not get the kind of one-on-one special support that they need. They then get put on a ward, where there is general chaos as well. They are just not kitted out to deal with people going through a psychotic interlude. The staff desperately ring round for beds in the county the patient happens to be in but they cannot find any. Then they find a bed somewhere else and by the time the patient gets there, that is taken and they end up in a bed somewhere else.

Meanwhile the patient’s family is at home, wherever that is, while the patient is transferred from one place to another. When he or she finally gets a bed, sometimes they are not assessed for days. Sometimes people can buy their way out of this. One noble Lord talked about CAMHS. Someone with money who has an eating disorder, for example, can sometimes buy their way out of reliance on state provision, but, of course, that is not available to many people. One of your children or friends may be being treated many miles away from where they live—that is, if they get a bed in an eating disorder unit.

The foreword of Paul Farmer’s report states:

“For far too long, people of all ages with mental health problems have been stigmatised and marginalised, all too often experiencing an NHS that treats their minds and bodies separately. Mental health services have been underfunded for decades, and too many people have received no help at all, leading to hundreds of thousands of lives put on hold or ruined, and thousands of tragic and unnecessary deaths”.

That is the background to this issue. We have to recognise and be realistic about how long it will take us to get from where we are to where we need to be. It will not happen in a couple of years but over a longer period than this Parliament, I suspect.

I was very moved by the words of a patient, as cited by the noble Lord, Lord Crisp. So often it is the patient’s story that makes the argument. I also cite the words of a patient, as follows, “I returned to hospital from leave but there were no beds available so I had to sleep in a common room. There was little privacy, no lock on the door, no frosted glass. People often just wandered in, thinking it was a public room and I had to create my own makeshift curtains. The room stank of cigarettes. The floor was dirty and the only storage place I had was a small bedside table. Despite constant complaints from me regarding the room, I was expected to put up and shut up. I would have had better treatment in jail”. That is just one person’s experience of the mental health system.

So we are a long way away from parity of esteem, if we are honest, and it will take us a long time to get there. But that is no excuse for not trying as hard as we can and no excuse for not holding this Government to account for the promises they make. Before I come to the commitments that we have made, I will refer to the eight principles that Paul Farmer thought should underpin reform. Decisions must be locally led. Care must be based on the best available evidence. Services must be designed in partnership with people who have mental health problems and with carers. Inequalities must be reduced to ensure that all needs are met across all ages. Care must be integrated, spanning people’s physical, mental and social needs. Prevention and early intervention must be prioritised. Care must be safe, effective and personal and delivered in the least restrictive setting, and the right data must be collected and used to drive and evaluate progress.

Getting the data was referred to by the noble Baroness, Lady Tyler. She has made that point before. It is a black hole because without the data you do not know where you are. One thing that has absolutely come home to me over the past year is that if we are going to address the unwarranted variation that exists across the country, which is as true for physical health as it is for mental health, we have to have the data. If we are going to have waiting times enshrined in the constitution or legislation or anywhere else, we have to have the data —and, frankly, we do not have the data at the moment. So getting the data has to be an absolute priority.

Turning to the commitments we have made in support of parity of esteem, the 2015-16 planning guidance made it absolutely clear that CCG allocations must increase by at least the amount of the overall allocation, which was 3.74%. Half way through the year it looked as though that was growing by about 5.4%. The planning guidance for 2016-17 is that commissioners must continue to increase investment in mental health services each year at a level which at least matches their overall expenditure increase. Your Lordships must hold us to account for that. That is what we have said we are going to do in 2016-17. If the money is not getting through to providers, as the noble Lords, Lord Crisp and Lord Tunnicliffe, said, then it should be getting through to providers and we have an obligation to make sure that it does.

I will write to noble Lords about the tangible commitments we have made. The noble Baroness, Lady Tyler, said before the debate that she would prefer me to write, and I do not think there is any point in me giving the figures now. I have got the annual figures but rather than read them I will write to everyone who has contributed to this debate, setting out the figures on a year-by-year basis. In summary, we are committed to spending £1.4 billion on children and young people’s mental health and eating disorders over five years. Of that £1.4 billion, £150 million is earmarked for eating disorders. In January this year the Prime Minister made a commitment to spend £1 billion over the period to improve perinatal mental health, mental health liaison services and 24/7 crisis care. In the Five-Year Forward View for Mental Health, Paul Farmer’s recommendations totalled £1 billion by the end of the period. I will write to noble Lords setting out clearly what those figures are. What they will show is that at the end of the period, we should be spending more than an additional £1 billion and another £300 million a year, I think, on children’s mental health.

In conclusion, we are absolutely committed to delivering better mental health care over the next five years, but your Lordships will have to have some patience with us: it will not happen overnight.