NHS: Diabetes

Lord Prior of Brampton Excerpts

Thursday 26th May 2016 Lords Chamber

[Lord Harrison]

To ask Her Majesty’s Government how they intend to deal with the financial burden on the National Health Service of type 1 and type 2 diabetes.

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

My Lords, we want to ensure that the best possible care is provided for all those with diabetes, reducing the risks of complications and minimising the financial pressure on the NHS. Preventing type 2 diabetes—for example, through the Healthier You: NHS Diabetes Prevention Programme—and improving outcomes for all those with the condition, including through tackling variation in management and care and increasing take-up of patient education, are key priorities for this Government.

[Lord Harrison (Lab)]

My Lords, given that, currently, 10% of the NHS budget is absorbed by treating diabetes, which is set to quadruple by 2035, why is it that the prioritisation of diabetes foot care has been relegated below other objectives? The vast majority of amputations —135 every week in this country—are avoidable if attended to in time. Why have in-house specialist diabetes teams not been made regular throughout the country, given that they are shown to save three times their own set-up costs? Finally, on objective 2, can we hear what has happened to the obesity strategy?

[Lord Prior of Brampton]

My Lords, diabetes is a key priority of the Government and part of the mandate that was given to NHS England for this year. The noble Lord is right—the direct cost to the NHS of treating diabetes is actually about £5 billion every year. Variation is the critical aspect that we should focus on. Whether it is foot care or the incidence and treatment of diabetes, across the country there is a huge degree of variation. The work being done with Diabetes UK on a national audit for diabetes will play a big part in reducing that variation.

[Baroness Ludford (LD)]

My Lords, are the Government satisfied with the overall cost-benefit analysis of the provision of insulin pumps and continuous glucose monitors? I should mention that my own husband has those. NICE guidelines are quite restrictive, and only a fraction of those who qualify get them. Many people self-fund, yet the long-term cost savings to the NHS of good blood glucose control and avoiding organ damage are enormous. Will the Department of Health look again at whether the benefits outweigh the relatively small costs?

[Lord Prior of Brampton]

My Lords, there are clear NICE guidelines on the use of insulin pumps and blood glucose monitoring equipment. For type 1 diabetes, NICE does not recommend their use unless there is clear evidence that the patient will comply with such use at least 70% of the time. The advice from NICE is clear on the use of both.

[Baroness Gardner of Parkes (Con)]

My Lords, is the Minister aware of the very conflicting reports in the press at the moment about whether you should be eating more fat or less fat, or more sugar or less sugar? Does he not think it important for the Department of Health to bring forward some clear guidelines for people to avoid them having to go in for treatment? As regards treatment, will he acknowledge the very important part played by the specialist nurses?

[Lord Prior of Brampton]

Public Health England has clear guidelines, published under The Eatwell Guide, on what makes a healthy diet. However, I agree with my noble friend that the position is now quite confused following the report that was published earlier this week. Confusion is not something we want and I am sure that when we produce the obesity strategy later this summer, we will make it very clear what those guidelines should be.

[Lord Morris of Aberavon (Lab)]

My Lords, bearing in mind the tragic increase in types 1 and 2 diabetes each year, particularly among the young, will the Minister comment on reports of promising developments in this country and the United States in dealing with type 1 diabetes? Will he personally satisfy himself that enough funding is available for research into type 1 diabetes?

[Lord Prior of Brampton]

My Lords, I will certainly endeavour to do that. If the noble and learned Lord has a keen interest in research into type 1 diabetes, I am happy to meet with him outside and with anyone else who would like to join us.

[Lord Forsyth of Drumlean (Con)]

My Lords, does my noble friend agree that the considerable pressure on the National Health Service would be relieved if we were able to control levels of immigration into this country—we have shocking levels today—and if we did not have to make a net contribution of £10 billion to the European Union?

[Lord Prior of Brampton]

My Lords, I am not sure that that question has much to do with the original Question on the Order Paper. However, without the levels of immigration that we have had in the past, the NHS simply could not operate.

[Baroness Young of Old Scone (Lab)]

Is the Minister aware that one of the most cost-effective interventions in the care of people with diabetes is to educate them in how to manage their own condition in order to avoid progressing to the costly complications which constitute 90% of the costs to the NHS? Is he also aware that we are still bumping along with less than 10% of people with diabetes receiving any education whatever in how to self-manage their condition daily? What plans do the Government have to increase that figure stratospherically, to a point where all people with diabetes are not only offered education but are encouraged to take it up and use it?

[Lord Prior of Brampton]

The noble Baroness will know a lot about the diabetes prevention strategy that is being launched with the support of PHE and Diabetes UK, and about the DESMOND and DAFNE structured education programmes. The plan is to roll out the prevention strategy across the whole country by 2020, at which time we expect that at least 100,000 people will have personalised support, which will include structured education.

[Baroness Tonge (Ind LD)]

My Lords, in view of the fact that the Government are rightly worried about the obesity epidemic, will they do anything about the number of television and radio programmes that promote food, cooking, baking and gourmet meals? I find them disturbing and they make me very hungry.

[Lord Prior of Brampton]

As the noble Baroness will know, the Government will produce their childhood obesity strategy later in the summer. I am sure that advertising, particularly before the 9 pm watershed, will be addressed in that strategy.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I hope that “Bake Off” will not be removed from our screens as a result of the strategy. The Minister said that the strategy has now moved from being published in the summer to later in the summer. Will he say a little more about when we can expect to see it? Also, will it answer my noble friend’s original point? Will he crackdown on clinical commissioning groups that are making arbitrary decisions to cut foot care services, which are a short-term saving but a long-term disinvestment?

[Lord Prior of Brampton]

My Lords, on the first point, I think we can say that “later in the summer” means before the parliamentary Recess. I do not mean the Recess starting tomorrow, but the main Recess later in the summer. On foot care services, this goes back to the unconscionable variations we have across the country. These are being addressed in part by the diabetes audit and in part by the improvement and assessment frameworks that have been developed for CCGs, so that we can see the results of different CCGs around the country and take action accordingly.

Obesity

Lord Prior of Brampton Excerpts

Thursday 26th May 2016 Lords Chamber

[Baroness Jenkin of Kennington]

To ask Her Majesty’s Government what steps they are taking to tackle obesity.

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

My Lords, tackling obesity, particularly in children, is one of our major priorities. The Government are developing a strategy that will look at everything that contributes to a child becoming overweight and obese. We plan to publish it this summer.

[Baroness Jenkin of Kennington (Con)]

My Lords, I declare an interest as somebody who has been technically obese, so I am well aware how difficult is not only to lose the weight but to keep it off. Does my noble friend not agree that the solution is simple but not easy—that we should eat less and healthily and move more? If we do not do this and if the Government do not grip it, both the NHS and a substantial number of the population’s lives will collapse under the weight of the problem.

[Lord Prior of Brampton]

My Lords, can I say to my noble friend that she looks far from obese today? She looks positively svelte. I agree that obesity is a massive problem facing the country. The chief executive of the NHS even referred to it as “the new smoking”. It causes not just diabetes but cancers and heart disease, so it is critical that we address it—and it is critical that we address it with people at a young age as it is much more difficult to lose weight later on in life.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that some food manufacturers and supermarkets are delaying their reformulation programmes in anticipation of the strategy? Is he also aware that they would welcome mandatory industry standards for potentially harmful ingredients so that they do not lose competitiveness when they do the right thing?

[Lord Prior of Brampton]

My Lords, I think that the announcement of the sugar levy on sugary drinks has meant that that part of the industry has been forewarned of what is coming in the strategy. Already there are signs from some of the manufacturers that they are reformulating their products—which is the whole purpose of a levy rather than a tax.

[Lord Robathan (Con)]

My Lords, would my noble friend not agree that our noble friend Lady Jenkin is quite right to stress individual responsibility, which the Government must encourage? Of course there should be education, but individual responsibility will lead to people losing weight.

[Lord Prior of Brampton]

My Lords, of course my noble friend is right that individual responsibility is critical to this. But we have to make it easy for people to make the right choices by providing the right information. Particularly for children, we have to make it easier for them and their parents to make the right choice.

[Baroness Finlay of Llandaff (CB)]

Has the Minister asked NHS England to tackle the problem of obesity among healthcare staff? It is very difficult for the public to get a public health message about losing weight from a member of staff who is, frankly, obese.

[Lord Prior of Brampton]

The noble Baroness makes a very important point. That is what lies behind the chief executive of NHS England’s decision to address the presence of unhealthy food and drinks on NHS properties, and to encourage staff to live a much healthier lifestyle.

[Baroness Wall of New Barnet (Lab)]

My Lords, does the noble Lord have a view on whether the sustainable transformation plans that are now in, joining all the services in a community, will make a difference to obesity when providers are working with the community and also with CCGs?

[Lord Prior of Brampton]

I completely agree with the noble Baroness. Integrated care organisations and accountable care organisations, although similar, will bring together in one pool the money for preventing as well as for curing disease—and will bring in social care as well. That should lead to a much better, more joined-up and more cost-effective way of delivering health and social care.

[Lord Lang of Monkton (Con)]

My Lords—

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[Lord Lang of Monkton]

My Lords, I wonder whether my noble friend can help me. We used to be told that we should not eat salt; now we are told we should. We used to be told that we should not eat fatty foods; now we are told we should. We used to be told that one glass of red wine a day was good for us; then we were told we should have none. Now we are being told we should have two. Will my noble friend tell us which of these items should exit our diet and which should remain?

[Lord Prior of Brampton]

My noble friend makes a very good point. He is as confused about this as most of us are in this House. A very important part of the obesity strategy, when it is announced later in the summer, will be to address this very clearly. All the evidence from more than 600 separate studies reinforces the advice that is already out there from Public Health England, but it has been very muddied over the last five days.

[Baroness O'Neill of Bengarve]

Does the Minister agree that this is not a matter just of individual responsibility? Many meals are eaten in places where people have no choice. They are provided by public institutions, including hospitals, hospital canteens, schools, prisons and the armed services. Should not all those meals be designed not to further obesity?

[Lord Prior of Brampton]

My Lords, I was not saying that it was exclusively individual responsibility, but we have to recognise that individuals must take some degree of responsibility for their own actions. Of course the noble Baroness is absolutely right. That is why we and the last Government introduced free school meals in all infant schools. It is why the proceeds of the levy will be ploughed back into increased sport and PE facilities in schools and why we have the fruit and vegetable scheme for schools. Of course we take diet and food extremely seriously, and where we have direct control, as we do in schools, we take action.

[Lord West of Spithead (Lab)]

My Lords, next week, when the House is up, is the centenary of the Battle of Jutland, where some 9,000 men from our two countries died. None of them was obese, I hasten to add, but the standard porthole was smaller than the size of the average man, so sadly many died able to see their way to freedom but unable to make it. Will the noble Lord pass the wishes of this House to all those commemorating the event and the 9,000 men who died bravely for their countries in a divided Europe?

[Lord Prior of Brampton]

My Lords, I certainly echo those sentiments. My history is not as good as the noble Lord’s. I had not realised that 9,000 men died in that action, which is a huge number of people. I certainly join with him and, I am sure, everyone in this House in commemorating those very brave men.

NHS: Bursaries

Lord Prior of Brampton Excerpts

Wednesday 25th May 2016 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they intend to halt plans to withdraw National Health Service bursaries.

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

My Lords, the Government do not intend to halt plans to withdraw National Health Service bursaries for nursing, midwifery and allied health students undertaking pre-registration training at university. The Government are currently running a public consultation on how to most successfully implement those reforms. The changes will affect only new students commencing courses on or after 1 August 2017.

[Lord Hunt of Kings Heath (Lab)]

But, my Lords, has the Minister seen the PAC analysis which says that, because of the loss of the bursary and the introduction of loans, there is a real risk that many people, particularly older people with children, will be dissuaded from applying to train as nurses and in allied health professions? Given that, and given the desperate shortage of nurses and other professionals, should not the Government take a little time to examine whether their original decision was justified rather than simply consulting on the way that it is going to be implemented?

[Lord Prior of Brampton]

My Lords, all the evidence is—not just from nursing but from other university courses—that loans have not reduced the numbers of people wishing to go to university: indeed, quite the contrary. The number of people going to university has gone up since student loans were introduced. The demand from young men and women who wish to go into nursing is very strong. The noble Lord will know that 57,000 people apply every year to become nurses and there are only 20,000 places, so we are confident that this will result in more, not fewer nurses.

[Baroness Walmsley (LD)]

My Lords, will the Minister say how much the Treasury will save by shifting this debt from the Government to low-paid nurses? Given the demographic of nurses, who are overwhelmingly female and, as I said, relatively low-paid, surely quite a lot of that student debt will never be repaid. Is this really such a good deal for the Government?

[Lord Prior of Brampton]

I think that it is a good deal for the Government—as the noble Baroness puts it like that—on a number of fronts. It is good for patients because there will be more nurses. It is good for the Government because there will be less need to recruit overseas nurses and agency nurses. Of course, the noble Baroness is right that for mature students coming in, the time to repay the student loan debt will be shorter than for younger people, but the Government will still make a return on that.

[Lord Clark of Windermere (Lab)]

Is the Minister aware that nursing students spend about 50% of their time on clinical placements? Given that there is no provision in the consultation document for extra financial facilities to be made available to hospitals providing those placements, how will they cope with the overstretch that is already in the hospital mentoring system?

[Lord Prior of Brampton]

That is a good question. Nurses spend 2,300 hours of their three-year course in clinical placements in hospitals. They are supernumerary. They are clearly supervised and mentored in that setting, but they also provide a fair amount of care in those hospitals as well. I am pretty confident that hospitals will work out an arrangement with universities to ensure that they create enough clinical placements for those nurses.

[Baroness Masham of Ilton (CB)]

My Lords, is the Minister aware that nurses used to have free accommodation and were also paid, but now they have these debts hanging over them? What is the view of the Royal College of Nursing?

[Lord Prior of Brampton]

My Lords, I think that the Royal College of Nursing, Unison and other unions have concerns about moving from bursaries to student loans; it would be idle to pretend otherwise. But we are convinced that the demand for young people to go into nursing is very strong and that the availability of more money through the loan system to nurses at university will therefore encourage more people to go into nursing.

[Lord Elton (Con)]

My Lords, I am sure that there is a simple answer to my question that everybody else knows. My noble friend said that there were 20,000 nursing places available for training and more than 50,000 people wishing to fill them. But we also read that there is a shortage of nurses such that there are very heavy demands made for agency nursing. What explains that discrepancy?

[Lord Prior of Brampton]

My Lords, the reason for the discrepancy is that at the moment the bursary system effectively caps the number of student places for nursing. One of the purposes of moving to the loan system is to remove that cap and our estimate is that by so doing an additional 10,000 places will be created between 2017 and 2020.

[Lord Turnberg (Lab)]

My Lords, if you go to any nursing graduation ceremony you will see lots of 30 and 40 year-old women who have been carers and who now wish to retrain as nurses. This is a very valuable asset for the health service, and yet they are just the people who may be disenfranchised by this policy. Is it not crazy to do this?

[Lord Prior of Brampton]

My Lords, the loan will be available to mature students as well as to students taking their first degree. The loan structure is such that if someone will not be working for as long as a younger nurse they will not in all likelihood repay the whole of the loan, which will be written off at the end of the period. I agree entirely with what the noble Lord says; we depend heavily on mature students coming into nursing. Our view is that this will not put off those people.

[Baroness Royall of Blaisdon (Lab)]

My Lords, was permission given by the Department of Health for the disgraceful use of the NHS logo on the side of Boris’s blunder bus? I would ask the Minister to look at the precedents. At one stage we asked to use the NHS logo and were told that we could not because it was political. I ask the Minister to look into this.

[Lord Prior of Brampton]

My Lords, I do not think that this has much to do with the Question on the Order Paper. Clearly, the NHS logo is a powerful and very strong brand and we should be very careful where we use it.

Health: Alcohol

Lord Prior of Brampton Excerpts

Thursday 12th May 2016 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what steps they are taking to alert the public to the dangers of alcohol and its causal links with hypertension, depression, Alzheimer’s and other forms of dementia.

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

My Lords, the new UK Chief Medical Officer’s advice on low-risk drinking helps people understand how they can reduce their risks from alcohol consumption. Public Health England has recently launched One You, a marketing programme providing personalised feedback on alcohol and other potentially harmful behaviours. In primary care, alcohol-risk assessments are offered to all patients registering with a new GP and 3.5 million people have had one as part of their NHS health check.

[Lord Brooke of Alverthorpe (Lab)]

I am grateful to the Minister for his Answer and for the efforts which I know he makes on this topic. Is he aware that we now have 9 million people suffering from hypertension, that the number of people with depression has doubled since 2005 and that the evidence now quite clearly shows that 62 illnesses are related to alcohol? Given the amount of money which the drinks industry spends on advertising seeking to persuade people to drink more, is it not time that the Government start to undertake some important work with a publicity campaign gently to persuade people to drink less and live a better, longer and happier life?

[Lord Prior of Brampton]

My Lords, the new guidelines published by the CMO are very clear about how much alcohol should be drunk and the implications it has for health. I do not know whether the noble Lord has been on to the One You website or has downloaded the drink tracker app. The information is out there. A campaign is being conducted by Public Health England, and we are making some progress.

[Baroness Hollins (CB)]

My Lords, does the Minister agree that introducing the evidence-based minimum unit price for alcohol would send a strong message from the Government about their concerns about the health dangers of alcohol? I should draw the attention of the House to my interests shown in the register.

[Lord Prior of Brampton]

Public Health England is conducting an evidence review of the harm done by alcohol, and minimum unit pricing will be an aspect that is addressed. To express a personal view, if we are going to address alcohol consumption by increasing the price, is it best that the benefit of that should go to the drinks companies through charging higher prices, or is it better that it should go to the Government through taxation? That is a question that the House might want to ponder.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that compelling public information is key? Does he recall that the last time we talked about the sugar tax I recommended that manufacturers of sugary products should label them showing how much exercise would be required to burn off the contents? Is he aware that that is exactly what the Drinkaware website does? Would it not deter noble Lords, when considering ordering a glass of wine in the Bishops’ Bar, if they knew that they would have to run up and down Whitehall for 16 minutes in order to burn it off?

[Lord Prior of Brampton]

I am sure we will all be following in the noble Baroness’s wake when we do that. It is worth making the point that one of the benefits that came out of the responsibility deal, which I know not everyone in this House thinks was successful, is that the labelling on alcoholic products has got much better.

[Lord Lansley (Con)]

My Lords, my noble friend will be aware that the risk of dementia in later life is now one of the public’s principal concerns, and of course it is established that there is a relationship between harmful alcohol use and the risk of alcohol-related dementia and Korsakoff’s disease. The One You website does not readily click through to give that information so that people’s concern about dementia is something that they understand can be related to the harmful use of alcohol.

[Lord Prior of Brampton]

My Lords, that is an interesting point, which I will draw to the attention of Public Health England. If that click-through is not clear, it should be. Since the Blackfriars Bridge agreement, PHE has been working with Alzheimer’s UK to do more research into analysing the impact of alcohol on dementia.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I commend the Minister on his courtesy in answering Questions in your Lordships’ House. Perhaps one or two of his colleagues might learn from that example. The logic of the Chief Medical Officer’s position is that essentially all alcohol is harmful. Is that the position of the Government?

[Lord Prior of Brampton]

Thinking very quickly, my Lords, our position is that alcohol is not safe but it is low risk depending on how you drink. It is a low-risk activity at a level of about 14 units spread evenly across the week. I am sure that the noble Lord will adhere strictly to that guideline.

[Baroness Finlay of Llandaff (CB)]

My Lords—

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[Baroness Finlay of Llandaff]

In the review to which the Minister referred, is the cost of accidents through alcohol-related driving and road accidents being costed? Is consideration being given to lowering the drink-driving limit, perhaps even to almost zero, as in some countries?

[Lord Prior of Brampton]

My Lords, traffic accidents caused by alcohol have been costed. I cannot give the noble Baroness that figure today but I will write to her with it. I do not believe that we are currently reviewing the alcohol limit for driving, although I know that in Scotland it has recently been reduced.

[Lord Watts (Lab)]

My Lords, have the Government considered using the tax system to encourage people to drink lower-alcohol drinks?

[Lord Prior of Brampton]

That is a very good question. I do not have the answer to hand but I would like to think about that and write to the noble Lord. As part of the responsibility deal that was done with the industry in 2010, there has been a significant increase in lower-alcohol drinks, but I will have to come back to the noble Lord on that issue.

National Health Service Trust Development Authority (Directions and Miscellaneous Amendments etc.) Regulations 2016.

Lord Prior of Brampton Excerpts

Tuesday 10th May 2016 Grand Committee

[Baroness Walmsley (LD)]

My Lords, I have no intention of detaining the Committee, as I agree with everything that the noble Lord, Lord Hunt, has said. I look forward to hearing the Minister’s reply. I am particularly concerned that a very complex system of governance will not produce transparency and accountability, and I look forward to reassurance on that score.

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

My Lords, that was a short intervention from the noble Baroness. I was very struck by the noble Lord, Lord Hunt, saying that, when the 2012 legislation went through Parliament, it took 85 days and 85 of the Bill’s clauses dealt with Monitor alone. I am afraid that that is part of the response that I shall give him today. We did not have 85 days—or maybe 165 days, if we take into account the TDA and the restructuring—because matters are too urgent. However, the noble Lord is right to bring this issue up today, because I do not think that there has been enough scrutiny around Monitor, the TDA and NHS Improvement.

Responding to the points that he raised about foundation trusts will perhaps in part answer both questions. The distinction between foundation trusts and trusts has been eroding over time—there is no question about that. The roles of Monitor and the TDA were becoming more duplicated over time. It is interesting that, when David Bennett was at Monitor, he saw the need to develop an improvement agency within Monitor, almost mirroring the TDA. Simply being a financial and economic regulator was clearly not enough at a time of such huge stress and pressures within the system.

However, there are two other important factors that I should mention. At the time, I agreed that the principle of foundation trusts—I think it was called “earned autonomy”—was absolutely right, as was the governance structure, with clear accountability through locally elected and appointed governors to the local population. But when the King’s Fund says that what we now have is the end of competition and autonomy, it is partly right. Using competition as a means of driving improvement through the NHS has been tested almost to destruction. It started back in 2005-06, with the new Labour Government and ISTCs, foundation trusts and the like. Increasingly, we are of the view that competition has a role to play but a pretty limited one, and we cannot rely upon competition—or the market, if you like—to drive the kinds of improvements and change that are needed within the system.

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[Lord Hunt of Kings Heath]

I thank the noble Lord, Lord Prior, for his response. I certainly understand the need for speed and the erosion over time of the distinction between foundation trusts and non-foundation trusts. I also agree with the Minister on the issue of competition. The past years have shown that while it can play a role, that role should be limited, and I have no objection to that, nor, indeed, to the extended remit of improvement. That is something which has been missing from the regulatory apparatus and it is to be welcomed.

I would like to make a couple of points. First, the Minister said that we are moving locally to system-level leadership and development. I am sure that that is right, but I hope that local accountability will be borne in mind. I have just had responses to a number of Questions for Written Answer that I tabled about accountability in the sustainability and transformation plans. As the Minister knows, they have to be in by 30 June. We know that they will all say that the acute care footprint will be reduced by so many hundreds of beds—to be honest, this has all been done before—and they will then say that there is going to be heroic demand management and, somehow or other, there will be miraculous developments in the community. But they will not have ownership locally because, essentially, they are being top-down led. At some point, they will have to go through formal consultation procedures and I believe that, unless there are some powerful forms of local accountability, they will run into trouble.

[Lord Prior of Brampton]

I think that the noble Lord has put his finger on it. If the STP process is just another top-down-led system redesign, it will not have any teeth to it. But what has happened in Manchester, for example, is that there is clear local leadership and accountability, which mean that some of the really difficult decisions that have not been taken for generations are now being addressed. There must be effective local accountability and governance around the STPs.

[Lord Hunt of Kings Heath]

The other area, which I have raised with the Minister before, is in relation to clinical commissioning groups. First, the creation of federations of GPs makes the model unsustainable in the long term, because in some parts of the country the electoral body for the GP members of CCGs will be almost coterminous with the federations. Clearly, there is a conflict of interest in that. Secondly, there is still an issue about the accountability of CCGs. If ever one needed a governance structure that made them somehow locally accountable, the foundation trust model would provide some answers which I hope that the Government will look at.

My final point is on what legislation will be in the Queen’s Speech. Clearly, from all that the Minister has said, much of the 2012 Act is defunct in practice. We are moving to a planning model, and the Act is very different from that. The longer that this goes on, the more need there will be at some point for some legislative change, because at the moment people in the health service are at risk. They are essentially being asked to develop a system-led planning model, but that is challengeable because the Act is very different from that. I believe that at some point it will be challenged. The Government may not want to have core health legislation debated, but at some point that will have to be done. I also remind him that we still have a draft Law Commission Bill and I am hoping that, at the very least, we will see a short form of that announced in the Queen’s Speech.

This has been an excellent debate and I am very grateful to the noble Baroness, Lady Walmsley, and the noble Lord, Lord Prior.

Tobacco and Related Products Regulations 2016

Lord Prior of Brampton Excerpts

Tuesday 10th May 2016 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, this has been a great debate and I am grateful to the noble Viscount, Lord Ridley, for once again bringing our attention to this matter. It is a pity that we are in Grand Committee and not in the Chamber, but I can understand the reason for that. I should declare my presidency of the Royal Society for Public Health, which has of course produced documentary evidence on electronic cigarettes.

It is tempting to debate Europe—and I look forward to the view of the noble Lord, Lord Prior, on that, as it clearly seems to be part of our debate—and it looks as if we have quite a long time to wait this evening. I am in favour of remaining in the EU, but I would remark that this directive does not seem to show much evidence of the Prime Minister’s claim to have negotiated a new concordat and relationship with the EU.

I am very doubtful about the argument that, if we were outside the EU, we would not be doing this. The fact is—I speak as president of the RSPH—that some elements in the public health world were prejudiced from the start against e-cigarettes. That clearly influenced the Department of Health and is the reason why it has taken such a mealy-mouthed approach to e-cigarettes, which is simply not based on evidence at all. It is interesting that, if you look at some of the papers produced by public health bodies, there are some weaselly words around this issue: “We still don’t know and we need to be very careful”. They are really trying to find a legitimisation for the initial very negative reaction, which I am afraid has laid the foundations for where we are today, because this is bonkers. It is simply madness. Here we have a product which is clearly of benefit to smokers and there is no evidence whatever that it will be used by non-smokers, which is where all this nonsense has come from. Why would a non-smoker take up these e-cigarettes?

The noble Lord, Lord Stoddart, and I have debated tobacco issues for many years, and he will know that I have been strongly in favour of very strong legislation. I moved the amendment to ban the smoking of tobacco in cars with children only a year or two ago, so I am not at all worried about being very tough on smoking, but e-cigarettes are completely different. I do not understand why they are part of the directive at all or classified in the same way.

The evidence is abundantly clear that e-cigarettes are almost wholly beneficial. My concern is that it is also clear that the public are, at the moment, confused. RSPH research revealed that 90% of the public still regard nicotine itself as harmful. Going back to September 2015, Public Health England issued a joint statement with other UK health organisations, saying:

“And yet, millions of smokers have the impression that e-cigarettes are at least as harmful as tobacco”.

It seems to me that one of the real adverse consequences of this is that, as it becomes known that there are going to be major restrictions on the promotion of e-cigarettes, all that will do is emphasise the belief that they are harmful. I have seen the RIA, but I could not see there any analysis of the impact that that could have on reducing the uptake of e-cigarettes among smokers. However, it is a very important point.

I want to put three points to the Minister. First, the noble Viscount, Lord Ridley, asked him what would happen to the investment in smoking cessation services. My understanding is that, as a result of the Government’s cut to the grant to local authorities for public health, smoking cessation services investment is going down. Will the Minister confirm that and say what he is doing to reverse the pattern?

The second point is that, clearly, this directive will go through, because there is no Motion to stop it. What monitoring will take place, and how soon will the Government undertake an assessment of the impact? Assuming that we are still in the EU, is the Minister prepared to go back to the EU if evidence becomes clear that this is having an adverse impact on smokers giving up smoking? I hope he can give some reassurance on that.

The third issue relates to enforcement. In the statutory instrument, regulation 53 makes it clear that:

“It is the duty of each weights and measures authority in Great Britain and each district council in Northern Ireland to enforce these Regulations within their area”.

What guidance is going to be given to the weights and measures authorities about taking a light-handed approach to enforcement?

It is quite clear that these provisions are not supported. It is pretty obvious that the Government themselves do not support them because of the amelioration that they have attempted in transposing the directive. At the very least, one could expect a message to be given to weights and measures authorities that the Government expect enforcement to be proportionate, minimalist and certainly light touch.

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

My Lords, I do not know whether to thank my noble friend Lord Ridley for bringing this debate here today or not. The arguments that have been put have been very powerful and it would be obtuse of me to say otherwise.

Perhaps I can start by going back to the opening words of my noble friend Lord Ridley, who said that there are three ways of trying to influence the behaviour of people doing things that do harm: you can punish them; you can hector them; or you can try to offer safer alternatives. In the article he wrote in the Times some time ago, he used the example of methadone as something that is not desirable in itself but is used as a means of treating people with heroin addiction.

In the case of tobacco we have tried all three things. We have penalised people through taxation, we have hectored them incessantly for years, and having tried nicotine replacement therapies, in a sense vaping is a way of encouraging people to use something that is considerably less harmful than smoking. Actually, most people would agree that we have been hugely successful in reducing the consumption of tobacco in England. I was asked for a statement of the Government’s view on vaping; I think I can say unequivocally that we are in favour of it as a means for people to come off smoking cigarettes. There is absolutely no question about that. The reports produced by Public Health England and most recently and very powerfully by the Royal College of Physicians entirely endorse that view. The president of the Royal College of Physicians, Professor Jane Dacre, said in response to the report:

“With careful management and proportionate regulation, harm reduction provides an opportunity to improve the lives of millions of people”.

I pick that out because she used the words “proportionate regulation”, and that is really what we are discussing today. It is not about whether we are in favour of vaping or not, it is about what kind of regulation should be around it.

On the European element, given that the noble Lord, Lord Hunt, could not resist throwing that in as one of his questions, I am not sure whether if we had been left to our own devices we might not have come out with something far worse several years ago. The noble Lord was kind enough to mention the original views of PHE and the MHRA, so we may well have brought in a licensing system or even have banned them altogether. I am not sure that one can lay this at the door of Brussels or indeed our own Government. We have been far too quick to resort to regulation in many areas and as a rule I am wholly in sympathy with less regulation. That is the best place to start. What we are discussing today is whether this regulation is proportionate, what damage it could do or what the directive’s unintended consequences might be.

I should just mention while I have it to hand, to put the concerns of my noble friend Lord Brabazon of Tara to rest, that the concentration which he is taking it at will not be affected. It will not have to be licensed by the MHRA, but sadly I cannot say the same to my noble friend Lord Cathcart, who at 2.4% is higher than 2%, which is the cut-off point for licensing. But I shall come to that in more detail in a minute, if I can.

Perhaps I may pick up on a few of the fears that noble Lords have expressed about the directive and see whether I can allay their minds today. It has been said that the directive will ban flavourings in e-liquids. I should make it clear that it will not do so. What it does say is that flavourings which pose a risk to human health should not be used; we could probably all agree that that is a sensible rule. There is an additive called diacetyl, which I think is also used in the making of popcorn, and there are other flavourings where there is some evidence that airways can be inflamed. The noble Lord appears to be questioning that, but I think the RCP report cites evidence that some flavourings can cause damage.

It has also been said that the directive will ban all advertising and prevent shop owners communicating with their customers. It does not do that. The new rules do not prevent information being provided to customers either online or in physical retail outlets, nor does it ban online forums, independently compiled reviews or blogs. Some advertising will also be allowed, such as point-of-sale, billboards and leaflets, subject to the rules set out in existing advertising codes to ensure that these do not appeal to people aged under 18 or non-users. There will therefore remain a wide range of information on the products available to smokers who wish to buy these products.

[Lord Stoddart of Swindon]

I take it that they will not be allowed to advertise on television—am I right about that? I see television adverts from the pharmaceutical companies for Nicorette and that sort of thing, so why on earth should these products be treated differently?

[Lord Prior of Brampton]

What the directive is trying to do, though it may not be doing it well, is to differentiate between smokers and non-smokers, particularly non-smokers under the age of 18. It wants to encourage information being given to smokers but does not want to risk the unintended consequence of normalizing vaping so that people who do not smoke start doing so. That is the purpose behind it.

The noble Viscount, Lord Ridley, asked how much money would be spent on public information. If there is evidence that the impact on advertising is such that smokers are not getting the right information about switching to e-cigarettes or vaping then there will be a strong case for a public information campaign to correct that, but we will have to wait and see what impact the directive has. It has also been said that the directive will ban certain types of products and make those that are available less effective. No current type of e-cigarette will be banned. In addition, it is worth noting that this is a fast-growing, highly disruptive and innovative market—I read somewhere that Goldman Sachs has put vaping down as one of the eight most disruptive products being marketed worldwide at the moment. Although we do not know how many products there are in this new and dynamic market, there may be as many as 25,000. Officials are persuaded that after this directive comes through there will still be many products on the market.

Concerns have been raised about the cost of notification for products that are below 20 milligrams per millilitre. The MHRA has announced that the fee for notification will be £150 per product and has been leading work with our partners in other member states and UK industry to develop and publish pragmatic guidance on the reporting requirements to minimise the burden on business. So, we will have to wait and see but I do not think it is right to assume that there will be a significant diminution of the number of products in the market.

Lastly, concerns have been expressed that the limit of 20 milligrams per millilitre will not meet the needs of smokers who are most addicted and that they will be unable to benefit from the harm reduction potential of these products. Again, this is not the case. Higher strength products can still access the market after 20 May, but they will need a medicines licence. Indeed, the Government would welcome a wider range of applications for licensed products. The noble Viscount, Lord Ridley, said that there is only one at the moment—which is true—and that it has not been properly marketed. But the Government would welcome more products in this space so that they can be made available to those such as the noble Earl, Lord Cathcart, who need and would benefit from them.

We know that the most commonly purchased products are below 20 milligrams per millilitre, though we do not know the exact number above that limit. We also know that at this strength or below, it meets the demands of the majority of current users and balances the risk of exposure of nicotine to children with the needs of users. Last week the European court agreed with this assessment, ruling that the provisions set out in the tobacco products directive, including those limiting strengths, were proportionate and valid.

It would be a massive unintended consequence if, as a result of this directive, fewer people gave up smoking.

[Lord Lawson of Blaby (Con)]

It may well be unintended. I would not know the intentions of the curious people who devised this measure, but it is certainly an inevitable consequence, and it is the consequence that matters, not the intention.

[Lord Prior of Brampton]

The intention of the regulations is to make vaping safer and less variable than it currently is. The intention of the directive is to make it a better product and to cause more people to use it. If it does indeed result in smokers not giving up smoking, then it will have achieved the reverse of what the Government wish to do. The Government’s view is clear: we wish people to quit altogether but if, as a way of quitting, they can give up smoking and take up vaping, that is something that we wish to encourage. Of course, I understand that nothing I can say today will satisfy my noble friends and other noble Lords, but I have done my best to put our case forward.

[Lord Hunt of Kings Heath]

The Minister is very gracious to keep giving way. It is interesting that he used those terms. There is a reluctance to promote vaping. Even in the words that he used there was a qualification. The Government would prefer everyone to give up smoking but it sounds as though they are half-hearted about this. I understand why they are in that position but the issue that I raised with the Minister is that the evidence is that the public are confused. My concern is that if weights and measures authorities enforce this in a heavy-handed way, it will confirm the public’s view that there is something wrong with vaping. For goodness’ sake, if we could persuade all smokers to vape, it would be a fantastic public health movement. Why is there this hesitation? I do not understand it.

[Lord Prior of Brampton]

I think that the hesitation comes because for a number of years the evidence around vaping was not clear. Many distinguished scientists felt that it was potentially harmful; it was not just the tobacco lobby. It is now absolutely clear, as I said earlier—I am unequivocal about this—that vaping is far more preferable to smoking. That does not alter the fact that quitting altogether, either smoking or vaping, is probably the best outcome.

[Lord Snape]

The noble Lord, Lord Callanan, and I mentioned the “heat-not-burn” products. I know that strictly speaking they are not covered by the SI but, as I understand it, they are covered by the legislation emanating from Brussels as a whole. As the Chancellor mentioned in his Budget that he was looking at an alternative to cigarettes, I wonder whether the Minister can comment on the Government’s future intentions.

[Lord Prior of Brampton]

If that is on the taxation point, I am not aware of any intentions to tax these products. I will find out more about that question and write to the noble Lord but, as things stand, I am not aware of any intention to do so.

[Earl Cathcart]

My Lords, the noble Lord, Lord Hunt, has twice mentioned weights and measures authorities enforcing this in a heavy-handed or a light-touch way. Can the Minister comment on which he thinks they will do?

[Lord Prior of Brampton]

I certainly hope that enforcement will be more Italian than traditionally British, if I may put it that way.

[Lord Stoddart of Swindon]

I am obliged to the Minister for giving way yet again. I understand that he has no power over taxation but, as a member of the department, he has the opportunity to make recommendations to the Treasury. Would he be prepared to ask his department to recommend to the Treasury that it should not put any tax, other than VAT, on this product?

[Lord Prior of Brampton]

My Lords, I am not responsible for public health in the Department of Health but I will talk to my honourable friend Jane Ellison, who is the Minister for Public Health and will put that view to her very strongly.

[Viscount Ridley]

My Lords, I will be brief because I know that other noble Lords are waiting to start the next debate. I am most grateful to all those who have spoken in the debate: my noble friends Lord Brabazon, Lord Callanan and Lord Cathcart; the noble Lords, Lord Stoddart, Lord Hunt and Lord Snape; the noble Earl, Lord Erroll; and my noble friend Lord Prior. I say to the noble Lord, Lord Snape, that he looks in extremely good shape. He did not get the advice he was looking for about his health and I am not medically qualified, but he looks fine to me.

Care Quality Commission (Fees) (Reviews and Performance Assessments) Regulations 2016

Lord Prior of Brampton Excerpts

Tuesday 10th May 2016 Grand Committee

I believe that this approach can be developed further to increase the efficiency and effectiveness of the regulation and inspection in health and social care. It can also demonstrate the CQC’s commitment to an “intelligence-driven approach to regulation” that is at the same time robust and credible. Such an approach would offer the very real prospect of easing both budgetary pressures and regulatory fees in the future.

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

My Lords, I first acknowledge the fact that any increase in fees, at a time when providers of adult social care, the NHS and elsewhere are going through a very tough time, is clearly very unwelcome. So perhaps it was not surprising, in a sense, that in the consultation when given the choice of spreading the increase over four years or two years, everyone voted for four years rather than two. I think everyone knows that, over time, it was the intention of the previous Government, as well as this one, to have full cost recovery. In the end, that must be right, but it is a question of how long it takes to get from where we are to where we need to be.

Most people will understand why the scope of the CQC’s work has developed over the past three or four years. The origins of the new CQC lay in what happened in Mid Staffordshire, Morecambe Bay and Winterbourne View, and a feeling that those tragedies could not be allowed to happen again. A much more comprehensive, expert-led inspection regime was the right way to try to unearth those awful things.

I totally understand what has been said by my noble friend Lord Lindsay and the noble Baroness, Lady Walmsley, about moving towards a more risk-based form of inspection. In the CQC’s strategy, which will be announced in a week or so, I hope there will be some reference to it having a more risk-based inspection regime. Of course, that has to be based, as my noble friend Lord Lindsay mentioned, on good intelligence. Over the past three years, the CQC has been able to collect intelligence, particularly on NHS trusts, where there are much better data—we are also using soft data as well as hard data—and that does enable one to put in place a more risk-based system of inspection. It has already said that it will re-inspect institutions that have a “Good” or “Outstanding” rating after a longer period of time than the ones with “Requires improvement” or “Inadequate”. But we will see when it produces its strategy next week exactly what it is planning to do.

On the comments of my noble friend Lord Lindsay, we did have some discussions when I was at the CQC, but I have to accept that they did not get very far. However, I would encourage him to meet the new chairman of the CQC, Peter Wyman, as well as David Behan, whom he already knows, to see whether or not there is any way that UKAS accreditation can help not just in adult social care but in aspects of clinical care as well.

On the points made by the noble Lord, Lord Hunt, about the consultation, the consultation period did go from 21 December 2015 to 1 February 2016. There was a reasonable period of consultation, but I accept that the implementation of the increase was much quicker. I also know that, although it did not sound very much in the context of the whole, for individual trusts this was just another cost increase that they had to bear. It is worth noting that the total cost of the CQC as a proportion of the whole that is expected for adult social care and the NHS is around 0.19%—very similar to the cost of Ofsted in education. So it is not as though it is expensive; it is just that the level of cost recovery has been ordained to be over a shorter time.

It is also worth noting that, for domiciliary care, the period of time is over four years and not two years. For GPs, where it was felt that the cost increase was the straw that might break the camel’s back, the baseline funding has been increased to allow for the extra increase.

[Baroness Walmsley]

My Lords, am I right in thinking that the help for GPs will be over just one year?

[Lord Prior of Brampton]

I believe that it has gone into the baseline funding of the GP contract, but if I am wrong about that I shall write to the noble Baroness.

More generally, the CQC’s scope and the way that it does its inspections is just much broader than it used to be. They are done in more depth and detail. This statutory instrument was introduced to Parliament so that it would reflect what the CQC is now doing and recognise its enlarged scope. The regulations do not extend the remit of the CQC’s activity or the scope of reviews or performance assessments to additional providers or services; neither does it change the fees actually charged.

The CQC, like every other aspect of the NHS, is going to have to save a considerable amount of money over the next five years, which the noble Lord, Lord Hunt, referred to in his speech. This means that the kind of inspections which we have seen in some NHS trusts, where a large number of very expensive people descend upon a trust, will have to be scaled back to some extent. As the noble Baroness intimated, I think that we will see a more risk-based inspection model—a bit more like the Ofsted model. I suspect that we will see more unannounced inspections as well, because a large part of the cost of the CQC is not just its direct cost but the indirect costs on the trusts preparing for the inspections. Sometimes the degree of preparation undermines the validity and insightfulness of the actual inspection.

I take on board entirely the strictures of the noble Lord, Lord Hunt. This is another expense when times are extremely hard, but it reflects the fact that the scope of the CQC is now broader than it was three years ago, and the need to have full cost recovery over a fairly limited time.

[Lord Hunt of Kings Heath]

My Lords, again, I am grateful to all noble Lords who have spoken in this debate and to the Minister. I have no problems whatever with the wider scope of the CQC’s responsibility, which inevitably has an impact on its cost base. Nor do I object to full cost recovery as a principle, because that has obviously been accepted by Governments over many years.

My complaint is that it is hugely insensitive for the Government to insist, which is essentially what has happened, that the NHS and parts of the care sector had to move to two-year full cost recovery. I note the alleviation given to GPs and domiciliary care, but I am puzzled that residential care was not given the same amelioration, given that, as we know, the care sector is in such a parlous state at the moment. We obviously look forward to the CQC strategy; I am sure it is right that it should be more risk based.

I very much welcomed the intervention of the noble Earl, Lord Lindsay. The United Kingdom Accreditation Service does its role very well. I also recently met RDB Star Rating, which is based in Sussex although it covers a number of institutions nationwide. It also made the point to me that, if you have a strong accreditation system, not only is there greater ownership by the bodies being accredited—because they have volunteered for it—but it ought to tie into the CQC process. The Minister has encouraged the noble Earl to meet the CQC; I hope that he might encourage the CQC to meet the noble Earl to see whether further progress can be made, because we clearly ought to take up the offer in relation to accreditation, if at all possible.

This has been a good debate. It is not at all a criticism of the CQC but of the Government and their approach, and it has been useful to raise those issues.

Junior Doctors: Contract

Lord Prior of Brampton Excerpts

Thursday 5th May 2016 Lords Chamber

[Baroness Symons of Vernham Dean (Lab)]

My Lords, I beg leave to ask a Question of which I have given private notice.

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

My Lords, my right honourable friend the Secretary of State for Health will write to the Academy of Medical Royal Colleges later this morning explaining that we are willing to pause the introduction of the new contract for five days from Monday should the junior doctors’ committee agree to focus discussion on the outstanding contractual issues: namely, unsocial hours and Saturday pay.

[Baroness Symons of Vernham Dean]

My Lords, I am not sure whether I am entirely happy with the Answer, but it is rather more hopeful than I was expecting and I am grateful to the Minister for it.

This dispute is of enormous importance to everybody. If there is no resolution, what will the Government do when thousands of young doctors refuse to sign contracts later this year and instead opt to become locums?

[Lord Prior of Brampton]

My Lords, given that we have the opportunity over the next five days to try to find a resolution to this dispute, it is probably not helpful now to talk about the “what ifs”. My experience of these situations is, the least said in public, the soonest mended. If the noble Baroness does not mind, I will not answer her question directly today.

[Baroness Walmsley (LD)]

Does the Minister accept that what he has said this morning, welcome thought it may be, is really rather too late? Trust is the most important element when it comes to the provision of medical services. The Secretary of State has already lost the trust not only of junior doctors but of a very large percentage of the general public. It has to be said that the BMA has also lost the trust of a certain percentage of the public. Trust is also important in political matters. We all accept the Government’s intention in their manifesto to provide more services seven days a week—of course, most junior doctors work seven days a week anyway—but does the Minister accept that imposing this contract at the end of the pause period is not the only way of achieving the Government’s objective? Further discussions with those who provide the services may very well find an even better way of providing these seven-day services to patients.

[Lord Prior of Brampton]

My Lords, I am not sure where that question ended up, to be honest. All I will say for today is that we have an opportunity over the next five days for the BMA and the Government to find a resolution to this issue. If we can, it will make the implementation of seven-day working across the NHS much easier.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Government’s approach has been cack-handed throughout the process. It would have been much better if, instead of initially rejecting this proposal and now setting out some new conditions, the Government had accepted it. Obviously, we hope the outcome will be successful and the situation will be resolved. At the end of this process, we are left with thousands of junior doctors disengaged from the service because of the circumstances of the dispute and the alarmist statements issued by the Secretary of State. Will part of the discussions look at how the junior doctors are to be brought back into the fold and given the support they so richly deserve?

[Lord Prior of Brampton]

My Lords, I think there is general recognition that many of the issues that lie behind the dispute over the contract are not actually involved in the contract itself. It is about how junior doctors are trained, valued and integrated into hospitals and the workforce. These are much broader issues than just the contract, and I assure the noble Lord that the Government are fully aware of that. Once this dispute has been settled, we can start to resolve those bigger, deeper and more fundamental issues.

[Lord Patel (CB)]

My Lords, I am surprised but delighted at the news this morning that the Department of Health has agreed to enter into discussions with the junior doctors. I hope that both sides will enter into them in the spirit of finding a resolution, rather than finding faults. I am sure that the talks will resolve the issue, because as far as I am concerned striking is not the answer. Anything that prolongs the exercise is detrimental to patient care.

[Lord Prior of Brampton]

My Lords, I wholly, 100% agree with the words of the noble Lord.

[Lord Naseby (Con)]

Is my noble friend aware that the public will greatly welcome the magnanimity of Her Majesty’s Government in willingly moving forward and having further discussions over a short period? At the same time, though—I can only speak from having talked to some of my former constituents in Northampton—the public want to know what the benefit is to both the public and the junior doctors from this new contract. Maybe the time has come to publicise, through the standby agency of the COI, in an advertisement, exactly what the benefits are to both parties.

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, rather than getting ahead of myself and addressing that issue, I would just say that we have five days to talk and for the Government and the BMA to try to come to an agreement. All our efforts over the next five days should be focused on that.

[Baroness Corston (Lab)]

My Lords, during the five-day process, will the Minister guarantee to revisit the department’s own equality analysis of the effect of the contract, given that it has expressly accepted that the contract discriminates against women in terms of unsocial hours and caring responsibilities but makes the amazing suggestion that this is a legitimate means of achieving a purpose? That is not fair to a profession that is becoming feminised, about which we should be pleased.

[Lord Prior of Brampton]

My Lords, I think we recognise the huge and vital role that women play. Some 60% of all medical students qualifying now are women. If we do not take care of women, we are not taking care of over half our workforce. Again, I do not think anything is to be gained from my making statements on this in public at the moment.

[Lord Wallace of Saltaire (LD)]

My Lords, does the Minister remember the EU working time directive, which a few years ago was touted as being disastrous for the training of junior doctors? It was said that it would make it completely impossible for them to be trained. Now that the Government are trying to push our junior doctors to work longer hours over more days, does that mean that all the fuss over the EU working time directive was a myth, or is this in an entirely different category?

[Lord Prior of Brampton]

No; the noble Lord has misunderstood the contract. The number of hours are coming down, not going up.

[Lord Watts (Lab)]

My Lords, the Government are pursuing a policy which is not evidence-based and is driven by dogma. Would it not be better to seek arbitration to get us out of the mess they have got us into?

[Lord Prior of Brampton]

My Lords, we now have a pause for five days. This is not dogma; we have two parties who have different views about a small part—about 10%—of the existing contract. Over the next five days we have a chance to resolve that.

[Lord Ribeiro (Con)]

My Lords, while the whole House welcomes this pause, I hope that, whatever happens, there will be an opportunity for an independent review to look at the very points that were made earlier about the lack of appreciation of and support for junior doctors. If there is one thing last week’s dispute has shown, it is that when consultants man the front door of a hospital, services are very much better. Will the Government consider having an independent review after this dispute to look at the future workforce?

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, my noble friend will know that Dame Sue Bailey, the president of the Academy of Medical Royal Colleges, has been asked by the Secretary of State to look at these more profound issues outside the contract, and we must do that as a matter of urgency. However, we cannot do that constructively until we resolve the current dispute.

National Living Wage: Social Care

Lord Prior of Brampton Excerpts

Thursday 5th May 2016 Lords Chamber

[Lord Oates]

To ask Her Majesty’s Government what assessment they have made of the effect of the national living wage on providers of social care.

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

My Lords, across the sector higher productivity, staff retention and better-quality care will benefit employers and care home residents. The national living wage rewards the valuable contribution made by care workers. Out of an estimated 1.52 million adult social care jobs in England, up to 900,000 people are expected to benefit. The department continues to work in collaboration with care providers and commissioners to support effective commissioning, recruitment and retention in adult social care.

[Lord Oates (LD)]

I thank the Minister for his response, but it is a response rather than an answer. Is he not conversant with the BBC research published yesterday, showing that there are 5,000 care homes at risk of closure over the next three years, the recent Moore Stephens report, showing a 34% increase in care home insolvencies over the past three years, or indeed the LGA estimate of a £2.9 billion funding gap in adult social care by the end of the decade? In the face of these figures, why do the Government continue to assert the incredible proposition that it is possible to increase wage costs and regulatory burdens but not increase real-terms per capita funding? When will they end this dangerous fantasy and start addressing the serious crisis in adult social care?

[Lord Prior of Brampton]

My Lords, the increase in the minimum wage from £6.70 to a living wage of £7.20 has been universally welcomed, I think, including by most Members of this House. Care workers and people who work in care homes do an incredibly difficult job and £7.20 does not seem a small fortune to pay them. It will increase the costs for people in the care sector and there is some evidence that some care homes are closing. The figures I have are that in the past two years 2,000 beds have closed in the care sector, but during that time 600 domiciliary care agencies have opened—so I think that there is going to be a switch in the way that care is delivered from residential care to domiciliary care.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I must say, it is very difficult to know sometimes what planet Ministers live on. That was an extraordinarily complacent answer. The survey yesterday showed that a quarter of all care homes are facing closure because of the financial squeeze. The Minister’s Government decided unilaterally to postpone—probably for ever but certainly for four years—the introduction of the Dilnot care cap. This proved massively disappointing to many people. The Government have put £6 billion into forward programme spending plans. Why not use some of that money to help the viability of the care home sector?

[Lord Prior of Brampton]

My Lords, if I sounded complacent, I did not mean to. I recognise that there is tremendous pressure on many providers of adult social care, particularly those funded by local authorities. It is for that reason that—disappointingly, frankly—Dilnot has been postponed. We wanted to bring in Dilnot but we decided that the cost of bringing it in was too great for local authorities to finance in the short term, although we are committed to doing it in the long term. The Government have allowed local authorities to raise a 2% precept and will be increasing the better care fund by £1.5 billion at the end of the period, bringing the total to £3.5 billion. It is a tough settlement—no one is making any bones about that—but tough choices have to be made.

[Baroness Buscombe (Con)]

My Lords, related to this is the whole issue of the better care fund. I think that Ministers will accept that while the better care fund is quite right, the delivery of it has not been properly thought through. In which case, what steps are the Government now taking to ensure that the better care fund is directed towards innovation in social care provision, to stimulate more cost-effective care in the community?

[Lord Prior of Brampton]

My Lords, the better care fund should be seen in a longer-term context of bringing together health and social care. The sustainability and transformation systems that are now being developed are the logical extension of the better care fund. Until prevention, healthcare and social care are brought together in a single budget, it will be extremely difficult to ensure the right allocation of resources.

[Baroness Greengross (CB)]

My Lords, if a huge number or even a fairly large number of care homes close down—we have been reading about this in the papers—there will be huge pressure on the NHS. That will be the effect. What plans have the Government put in place to deal with what might be a really big crisis in the NHS?

[Lord Prior of Brampton]

My Lords, the Government are putting £10 billion of new money into the NHS over the five-year period. Clearly, if there is a crisis in social care, that will have a direct knock-on effect on the NHS. We fully recognise that. The CQC has an obligation to keep a very close eye on this and to produce early warnings if a major, hard-to-replace provider looks as if it is getting into financial difficulty. It is an area that we are acutely conscious of and are keeping a very close eye on.

[Baroness Bakewell (Lab)]

My Lords, when these situations have arisen before and there has been a crisis with care homes, there has been a lack of response which has resulted in old and frail people being virtually turned out of the door. This is a crisis and there is going to be a crash—the care sector has warned us that it is coming. The Government have made concessions—the precept and so on—but will they put contingency plans in place so that when the crisis actually hits, old and vulnerable people are not suddenly thrust into a crisis that they do not know how to deal with?

[Lord Prior of Brampton]

The noble Baroness is absolutely right. Our whole focus must be on the residents of these homes rather than the owners. There are a number of very highly leveraged providers in this sector, which have high levels of debt—often very expensive debt—for historical reasons. The CQC is keeping a very close watch on them. When there are early-warning signs of difficulties, the CQC and the local authorities will put in place alternative plans.

[Baroness Smith of Newnham (LD)]

My Lords, talking to a charity recently I was told that some care homes have already raised fees by £100 a week since the introduction of the national living wage in April this year. What plans do the Government have to look at the relationship between the cost of care homes and the cost to the individual of the economic viability of care homes, in light of the fact that the target for 2020 is to have a national living wage of £9? We need social care and care homes to be economically affordable.

[Lord Prior of Brampton]

The living wage will go up over this period of time. The better care fund and the social care precept will of course go up, too, over this period. Clearly there will be some fee increases. Local authorities have an obligation under the Care Act to have a sustainable and diverse market in their area. There will be fee increases to private providers but the main squeeze—the main concern which we in this House should have—is over local authority-funded care.

Southern Health NHS Foundation Trust

Lord Prior of Brampton Excerpts

Tuesday 3rd May 2016 Lords Chamber

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

My Lords, with permission I shall repeat as a Statement the Answer given to an Urgent Question in another place by my right honourable friend the Minister of State for Community and Social Care on Southern Health NHS Foundation Trust. The Statement is as follows:

“The whole House was profoundly shocked by the Mazars report into the failings at Southern Health NHS Foundation Trust following the tragic death of Connor Sparrowhawk in July 2013. The first duty to patients and their loved ones is to keep them safe. This applies to all of us with a role to play in the NHS, from the front line to this House; and the Government are therefore clear that we must learn the lessons of this report for the NHS as a whole. We must ensure that the trust itself continues to be scrutinised and supported to make rapid improvements in care. If that means intervention from the regulators, they will not hesitate to take the necessary action, and we will not hesitate to back them.

Last week’s CQC report followed a focused inspection announced by the Secretary of State in December 2015. The report from the CQC set out a number of concerns, including: a lack of robust governance arrangements to investigate incidents; a lack of effective arrangements to identify, record or respond to concerns about patient safety; and a need for immediate action to address safety issues in the trust environment. The report also found that the senior management and board agendas were not driven by the need to address these issues.

I would like to set out for the House the action that NHS Improvement has taken in recent months to address the issues at the trust. NHS Improvement has been working closely with the CQC and the trust over recent months. On 24 March, NHS Improvement, which was operating as Monitor at the time, appointed an improvement director to the trust. On 14 April, following a CQC warning notice on 6 April, NHSI placed an additional condition on the trust’s licence, asking it to make urgent patient safety improvements to address the issues found by the CQC. This condition gave NHS Improvement the power to make management changes at the trust if it does not make progress on fixing the concerns raised.

On 29 April, following the resignation of the trust chair, Mike Petter, NHS Improvement announced its intention to appoint Tim Smart as the chair of the trust. As chair, Mr Smart will have responsibility for looking at the adequacy of the trust’s leadership. Given the centrality of issues of governance to the CQC’s report, I welcome the action taken by NHS Improvement. The direct appointment of a new chair by a regulator is a relatively rare step, and reflects the seriousness of the issues at the trust.

NHS Improvement will continue to monitor the situation closely in the coming weeks and months. I understand that the CQC is considering the trust’s response to its warning notice and the risks it highlighted before deciding whether to take any further enforcement action. The notice required significant improvements by 27 April. NHS Improvement is working closely with CQC and the trust, and there are monthly progress meetings between NHS Improvement and the trust.

In addition to the action we are taking on Southern Health, it is vital that we learn the wider lessons for the NHS as a whole. First, I hope the whole House can agree that it is right that we have robust, expert-led inspection from an independent CQC that provides an objective view about issues of safety and leadership, and that this is backed with action from NHS Improvement when that is required. Only by facing problems in care can we hope to solve them.

Secondly, it is vital that we ensure that we take the issue of avoidable mortality as seriously for people with learning disabilities and mental health problems as we do for other members of our society. To that end, the learning disability mortality review programme has been put in place by NHS England to ensure there is a continual cycle of learning about the causes of premature mortality in people with learning disability. In addition, the CQC will be leading a review of how all deaths are investigated, including those of people with learning disabilities or mental health needs. There can be no question that the CQC report makes for disturbing reading, and that it demands action at local and national levels. We owe our most vulnerable people care that is safe and secure, and I am determined that we do all we can to learn the lessons and make the necessary improvements in the weeks and months to come”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Baroness Tyler of Enfield (LD)]

My Lords, I, too, thank the Minister for repeating the Statement. The original Mazars report highlighted two profoundly shocking issues: the tragic and preventable death of Connor Sparrowhawk and the fact that too many unexpected deaths among those of learning disabilities and older people with mental health problems were even being investigated. Why did a full three months elapse after the Mazars report was published—and, indeed, only after a BBC investigation covered it—before Monitor finally appointed an improvement director to go in to work with the trust on urgently needed improvement? Why the delay?

Secondly, despite a series of national reports—we have just heard about the CQC report—warning notices, monitoring and progress meetings, all referred to in the Statement, nothing has been said about the precise changes that have happened or improvements that have taken place in Southern Health Trust. When can we hope to hear about specific and tangible improvements to the care provided by Southern Health Trust to some very vulnerable people?

Thirdly, it is crystal clear that new leadership needs to be in place if the trust is to retain any credibility, particularly among the people and families who use its services. Why have there been different responses to Mid Staffs and Southern Health? Both are about the neglect and death of vulnerable people in NHS care. There have been serious consequences for those in leadership positions in Mid Staffs, but not so at Southern Health. What does that say about the value placed on the lives of people with learning disabilities and older people with mental health problems?

[Lord Prior of Brampton]

My Lords, a number of serious questions have been asked. I shall make a personal observation. This trust is the result of the merger of three trusts: a mental health care trust, a community trust and a learning disabilities trust, three very complex businesses being brought together as one. They have 250 separate locations with over 1 million patient contacts every year. The risk inherent in that kind of business at this time is huge. In putting in a governance structure, we have to be very careful that we do not just draw up such structures in a boardroom or come up with strategies that cannot be implemented.

In the report, I was very struck by the fact that now there is almost a tick-box approach to the duty of candour; you tick the box to say that you have done it. Culture is usually important in this. What is the culture in the trust? That is one of the big issues that the CQC report is trying to get at. In response to the question of whether we can give guarantees about patient safety: this is inherently a very risky activity. Putting in strong governance structures is very important, but much will depend on the culture within the trust.

I turn to some of the particular points. I, too, was struck by the fact that there were still problems with ligature points in some of the facilities, as had been pointed out by the CQC some time ago. I was struck by the fact that the epilepsy protocol for those being bathed or showered had not yet been approved two and half years after Connor Sparrowhawk’s death. Clearly, there were very significant problems at the trust. On the question of where accountability and responsibility lie, the chairman has resigned. The principal job over the next three or so months will be assessing the capability of the executive management. That seems the right way to approach this.

It is always tempting to call for a public inquiry; I understand that temptation. We have an independent regulator, the CQC. The inspection team was led by mental health professionals and is fully transparent. We now have to give the trust the chance to respond to the CQC’s report and watch for serious improvements.

The noble Baroness asks if there have been any improvements. There are some illustrations and examples in the CQC report of where there have been some improvements, but putting in a new governance structure, changing the whole culture about raising concerns about those kinds of issues, will not happen overnight. Of course, I appreciate that for Connor Sparrowhawk’s family this happened two and a half years ago, and one must never lose sight of that.

A question was asked about NHS Improvement. It put in an improvement director. These people do not grow on trees. If we are honest about the NHS, we are very short of highly qualified and highly skilled senior management, and it sometimes takes time to find the right people.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, the history of people with learning disabilities and mental health problems and the institutions in which they live goes back a long way. Many appalling situations have taken place, and I do not want to belittle this deplorable situation. However, did the report also identify areas of very good-quality care and professional standards? The danger is that vilifying an institution—and even going on to a public inquiry, which prolongs the agony even further—does not give it the opportunity to build on its strengths and provide the quality of care that the hundreds of people working there wish to provide and wish to be proud of doing.

[Lord Prior of Brampton]

I am grateful to my noble friend for those comments. There are many examples in the CQC report of good care. In one of the domains that the CQC inspects, which is caring, it is clear that the vast majority of people who work for Southern Health are deeply caring, committed people. We have to be careful. I am afraid it is a question of the curate’s egg; the report is good in parts. I go back to what I said originally: an organisation this big is incredibly difficult to manage. That is one of the learnings that we need to take from this. The temptation to merge organisations to get centralised cost reduction, or whatever, is very tempting but leads to serious issues around governance.

[Baroness Masham of Ilton (CB)]

My Lords, where does Healthwatch come in? Should there not be far more openness and participation by the public to stop such things from happening? It is all very well having management, but one wants caring people from the community who will speak out on behalf of these people.

[Lord Prior of Brampton]

My Lords, this goes back to the culture of the trust. It is important that members of the public or Healthwatch have a right to go in and visit facilities, and that they are welcomed there, but that they do not go native at the same time—that they are truly independent, looking at it from the patients’ perspective. Healthwatch has an important part to play, and the relationship that it has locally with the CQC inspection team is very important.

[Lord Foulkes of Cumnock (Lab)]

My Lords, I am slightly perplexed. Why is it that, once again, it is only because an Urgent Question was tabled and agreed by the Speaker that Parliament knows all the details and is able to hold the Government to account? If, as the Minister says, the Government are so concerned about it, why did they not volunteer a Statement?

[Lord Prior of Brampton]

My Lords, the CQC report is in the public domain, as are all the CQC reports. To be honest with your Lordships, I am not technically sufficiently aware of the procedures of the House to know why it did not automatically come to the House but, as I say, I am here today.