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  • Apr 27, 2017:
    • Education (Student Fees, Awards and Support)(Amendment) Regulations 2017 - Motion to Regret | Lords debates

      My Lords, this is a terrible time for the Government to undertake a highly risky revision of the funding of student nurses. We are already short of nurses, as the noble Lord, Lord Clark, told us, and of course midwives, and the imminent Brexit has already made that worse with, as we have heard, a 90% drop in the number of applications from EEA nurses. In addition, we are losing nurses due to overwork and poor morale.

      The Government's so-called consultation focused only on implementation rather than looking carefully at alternative ways of funding nurse training to ensure both fairness and a stable increased supply of nurses. The excellent speech by the noble Baroness, Lady Watkins of Tavistock, clearly demonstrates that there are many different ways of doing that, and I am not convinced that the Government have taken all those proposals into account. They ought to stop in their tracks and look at all those alternatives before going ahead with this regulation. We are still waiting for information about how or whether the practice placements will be funded, wherever that is-in the NHS or in the care services. As we have heard, nurses have to do 2,300 hours in a clinical placement. This requires considerable resource input from the hospitals or care placements, and most hospitals are already in deficit. Without proper resources there is no way that the system can accommodate 10,000 extra student nurses, even if, as we all hope, the Government are right and universities do offer that many additional places.

      I understand where the noble Lord, Lord Willetts, is coming from. Clearly, the tuition fees and loans system has not put off students on most university courses. However, nurses are different from other students, so it is not a given that they would respond like students on other courses to the need to take out loans and pay fees. They are more predominantly from lower socioeconomic groups and have a higher proportion of mature students with family commitments. They spend nearly half their course time in supernumerary placements in hospitals and have a higher number of contact hours and weeks than other students. That makes it more difficult for them to get a part-time job to fund their living expenses, as other students can do. Indeed, because they are not highly paid, it has been calculated that the vast majority of them-I apologise to the noble Baroness, Lady Watkins-will not have paid off their student loans over 30 years, so they will be written off. It makes me sad to have to say that but it is a fact. Some even have other student loans from other courses that they have previously undertaken. So this strategy of the Government will not necessarily save much money in total but will simply shift the debt off the books, which I suppose was the objective of the exercise.

      The Government have been very hasty. Instead of arbitrarily removing the bursaries we need a thoroughgoing investigation into the factors affecting nurse recruitment and retention, because the latter is a very important factor. It is no use filling up the bucket if there is a great big hole in the bottom-and in this case there is. Retention of student nurses to the end of their course is poor, and retention of nurses and midwives beyond the first two years after qualification is also poor. Therefore, not for the first time I ask the Minister whether he will ensure that attrition data is collected in a consistent way so that we can identify those settings that are good at keeping their students, nurses and midwives and those that are not. We can then learn from the best practice and spread it.

      The impact of the Government's plans on admissions, student numbers and quality and on the stability of the qualified workforce is yet unclear, and the Government have not said how they intend to monitor the impact on the workforce. Without a solid evidence base this policy should not go ahead. I therefore support the regret Motion in the name of the noble Lord, Lord Clark, and call on the Government to think again.

    • Health: Electronic Patient Records - Question | Lords debates

      My Lords, given the continued revelations of data security breaches, along with the absence of a response to last year's report from Dame Fiona Caldicott, how do the Government intend to avoid a repeat of the fiasco several years ago over care.data? Does the Minister agree that it is vital that patients are given confidence in the security of their data so that they do not withdraw from allowing their data to be used for vital medical research?

  • Apr 25, 2017:
    • General Election: Voting Rights - Question | Lords debates

      My Lords, I thank the Minister for his reply, but I do not think that hundreds of thousands of disenfranchised British expats will thank him. The Government have been in place for two years now. Why have they not fulfilled their promise in the 2015 manifesto to give votes for life to these people? Is it not because the Government are afraid of how they might vote, given that the Government have ruined the lives of many of them who live in other parts of the EU by choosing a hard Brexit?

    • General Election: Voting Rights - Question | Lords debates

      My Lords, I beg leave to ask the Question standing in my name on the Order Paper and I declare an interest as the mother of an expat of more than 15 years.

    • General Election: Voting Rights - Question | Lords debates

      To ask Her Majesty's Government what plans they have to allow British citizens who have lived outside the United Kingdom for more than 15 years to vote in the forthcoming General Election.

  • Apr 5, 2017:
    • Health Service Medical Supplies (Costs) Bill - Commons Reason | Lords debates

      My Lords, I support the noble Lord, Lord Warner, in his amendment. I thank the Minister for how he has worked with your Lordships' House on all sides to improve this Bill; it is unfortunate that we remain with one point of disagreement. We certainly support the policy objective of the Bill in general and very much welcome the list of actions in the Minister's introduction to promote research and drug development in this country. But in listening to his outline of his particular responsibilities, it occurred to me that no policy area is ever an island; they always impact on other things. The Minister's responsibility to achieve best value for the NHS actually impacts on other responsibilities that he and his department have-in particular, in relation to this amendment, on the thriving life sciences sector, on which we all depend, and the access of patients to cutting edge medicines.

      Both those things are suffering from particular threats at the moment. One is Brexit, which I shall not go into now; we have discussed it on many occasions. The other is the recent £20 million affordability test that the Government are introducing. Although £20 million sounds like a very large amount of money, if it is applied to medicines where the population of those needing the medicines is very large, such as some of those mentioned by the noble Lord, Lord Warner-diabetes, breast cancer and other things-the individual cost to an individual patient does not need to be very high to be caught up by the affordability test. The Minister used the word "only"; he said that it would affect only one in five of medicines, but I think that that is an awful lot of medicines, and we should be very concerned about it. That is why we feel that it is important to press the Minister on this issue.

      I congratulate the noble Lord, Lord Warner, on offering the Government a compromise, which I hope would avoid what the Minister is clearly worried about: being taken to judicial review by a pharmaceutical company about efforts to push down the price of a medicine. I draw the Minister's attention to the word "sector" in paragraph (a) of the proposed new clause, which asks the Government to take account of the need to,

      "promote and support a growing life sciences sector".

      The word "sector" makes it unlikely that any pharmaceutical company trying to take the Government to judicial review would succeed if the Government had, in all other respects, promoted a thriving life sciences sector in this country. It is highly unlikely that they would do so.

      I therefore hope that the Minister will think again and not resist this amendment. It is essential, given the current threats to patients in this country-and very large populations of patients too, in particular those coming towards the end of life-to pharmaceuticals, to treatments and access to medicines. I therefore hope that the Minister will reconsider, and, if the noble Lord, Lord Warner, wishes to test the opinion of the House, he will have the support of these Benches.

    • NHS and Adult Social Care - Question | Lords debates

      My Lords, does the Minister recognise the logic of the committee's criticism of the cuts to public health funding? Will he go back and commit himself to promoting the prevention agenda and good health agenda, not just in his own department but across government, because so many other departments have an effect on the health of the nation?

  • Apr 4, 2017:
    • Children and Social Work Bill [HL] - Commons Amendments | Lords debates

      My Lords, my Amendment 12B is in this group. Today is a day of great celebration for me because ever since I came into your Lordships' House, I, along with the noble Baronesses, Lady Massey and Lady Gould, who is not in her place, have campaigned across party for this. I thank the Minister most sincerely for making it a reality for children. They have wanted it and demanded it; I hope they will now get it at a very high quality. The fact that it will be mandatory will mean that teachers will train specifically to give them the skills to deliver this sensitively and with an understanding of the young people.

      My amendment would remove subsection (2)(d). It is simply to probe the Government's intentions. The subsection says:

      "The regulations must include provision … about the circumstances in which a pupil (or a pupil below a specified age) is to be excused from receiving relationships and sex education or specified elements of that education".

      If the programme of study is designed as the Bill intends it to be, there should be no need for any parent to want to withdraw their child. However, the current situation-and it is hard to believe, I know-is that a parent can withdraw their child from sex education up to the age of 18 if they stay on at school in the sixth form. In this day and age, that is downright ridiculous. I understand that the Government intend to look at that and come back with regulations which bring the situation much more up to date. When they do so, I hope that they will bear in mind that for 25 years we have been signatories to the UN Convention on the Rights of Child. A proper course of PSHE and relationship and sex education will give a child the right to life-saving and life-enhancing information that will enable them to work towards a healthy body, a healthy mind and healthy relationships in their future life. If they have all that, they will become productive members of society.

      It is also important that we bear in mind the "best interests of the child" principle, which I think was introduced in 1945. It is in the best interests of the child that they have all the information about these issues that they need to keep them safe and help them to be healthy and happy. Whatever they hear from their parents, they will then be in a position and have the tools to make their own judgments and choices, which is vital.

      I will be honest about the fact that I do not feel that parents should have the right to remove children from this life-saving information at all, but I am not pressing that point today. I want to ensure that the consultation will be wide enough-I hope that I will be able to contribute to it-and that the Government bear in mind those principles to which we are already signatory and look at examples such as Gillick competence, which relates to children's ability to make decisions for themselves about things such as contraception and privacy of their medical records. We need to look at the child's ability to understand the issues and make the decisions for themselves. Under the UN Convention on the Rights of the Child, they have a right to do that. This is just a probing amendment. I look forward to hearing what the noble Lord will tell us about the Government's approach to the regulations.

    • Children and Social Work Bill [HL] - Commons Amendments | Lords debates

      My Lords, I add a few words to those of my noble friend Lady Pinnock. I particularly thank the Government for the amendments to Clauses 4, 5 and 6, which were in response to a promise made to the noble Baroness, Lady King of Bow, and me during the Bill's passage through your Lordships' House. They will certainly improve the position of children in this country adopted from abroad, but, as you would expect, the amendments can only bring those children within the scope of the measures in the Bill.

      The battle is not over for the parents of those children, because many of them are now coming to the age where they transfer from primary to secondary school and are having difficulty getting into the school which their parents feel is most suitable for their particular needs. Is the Minister aware that some parents and I have spoken to Mr Edward Timpson about the need to extend priority admissions and pupil premium plus to those children? We are waiting to see whether the Government will make those changes. Will the Minister agree to meet me and some of the parents of those children so that he may hear for himself their concerns? Having said that, they asked me to say that they thank the Government and very much welcome the changes that they have made.

    • Hospitals: Patient Transport - Question | Lords debates

      My Lords, according to the NHS website, there are some areas in which patient transport services are not available. I want to ask the Minister two things about that. First, what should patients in those areas do if they need transport? Secondly, are the Government going to hold to account the CCGs that are not commissioning these services?

  • Mar 30, 2017:
    • Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) (Amendment) Regulations 2017 - Motion to Approve | Lords debates

      Sorry to spring this on the noble Lord but there was something that I forgot to ask him. He mentioned the accessibility of school nurses. The fact is that if a school nurse is looking after five schools they are not terribly accessible. I wonder if he might write to me as to whether there are any plans to increase the number of school nurses, because that is part of increasing the child's health right the way through the age range.

    • Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) (Amendment) Regulations 2017 - Motion to Approve | Lords debates

      My Lords, I am delighted to support these regulations because I am an enormous fan of a universal health visitor service, and in particular the healthy child programme. Our economy is never going to keep up with the demand for health services unless we pay more attention to the issue of prevention. That really is the public health agenda. Any doctor will tell you that you really must lay the foundations for a healthy body, lifestyle and habits in the early years or you will get illnesses later on. The review of the programme so far has been very positive. As the noble Lord, Lord Hunt, said, there have been significant improvements in the populations reached. However, we will not see the true benefit of this programme until we are years down the track and find that those young children who have been given a healthy foundation grow up to have fewer of the terrible but preventable chronic diseases that are costing the country so much.

      I am very proud of the coalition Government's vision of improving the health outcomes of children, young people and their families. Transferring the responsibility to local authorities was part of that: it gives them the chance to combine services, right up to the age of 19. However, as the noble Lord, Lord Hunt, said, there are serious questions to be asked. The first, of course, is about resources. Although these services are mandated, and although the Minister may say that the money has been ring-fenced, budgets have been cut and are going to be further cut. Local authority councillor friends of mine tell me that it is getting more and more difficult for local authorities to provide even those services which they are mandated to provide because things are getting so tight financially. I hope the Minister can give us some encouragement on that, although I somehow doubt it.

      The other question on resources is about people. We have heard from the Minister about the number of health visitors in training. Are they going to be enough to serve rising demand? We have a rising population and a lot of additional young people and families who require services. A universal service is terribly important because you do not just get health problems among the most deprived. However, there is a great deal of poverty in this country and the need for these services is growing. How confident is the Minister that we will have enough sufficiently trained nurses, given the stresses on all health service staff and given that so many people are leaving and retention is getting more difficult? Are we going to have enough people?

      Are there any plans to extend these services a little further up the age range? I am particularly concerned about the large number of children who are starting school between the ages of four and five already overweight, obese or with poor eating habits. So, although the healthy child programme and the reviews that are mandated here in these regulations go up to the final check at two to two and a half years, it is really important that we do it again just before the child goes to school, because at that point they are already at a disadvantage. Many of these children are from a disadvantaged background and sadly these problems occur more frequently in those backgrounds. They get to school and they are already developmentally a good deal behind children from more advantaged backgrounds. I think the proof that we have had over the few years that this programme has been in place is sufficiently convincing to tell us that perhaps we ought to extend it a little bit further.

  • Mar 28, 2017:
    • Medical Research - Question for Short Debate | Lords debates

      My Lords, I congratulate my noble friend Lord Sharkey on introducing this debate, which has actually been quite worrying for those of us who believe that unless we maintain the UK's position in medical research, UK patients will continue to lose out. Only this morning we heard in the news about how our performance in diagnosing and treating cancer is well behind that of our neighbours in Europe, so this is no time to be imposing further restrictions on the availability of new oncology medicines for UK patients.

      My noble friend Lord Sharkey has outlined his concerns, which I share, about NICE's new affordability cap. As the noble Baroness, Lady Morgan, said, 20% of all medicines would fall within the £20 million cap-these are proven, effective drugs-which makes me think that the cap is far too low. Have the Government assessed the impact of this on patients who have already waited too long for medicines that could benefit them? I am very concerned about patients dying while they wait for NICE to decide to allow them the medicines they need. The current 90-day accessibility obligation is reasonable but is to be increased to three years and, given all the delays in the application process and 12 weeks for consultation, it could easily turn out to be four years.

      It is the most innovative medicines that would have reached the new price threshold if it had been in place in the past, and it is those same cutting-edge medicines that will be affected by it in the future. If companies inventing and developing these medicines cannot find a market in this country of a size to make it worth licensing them here, they will just go to other markets and UK patients will lose out.

      This is yet another example of rationing in the NHS, and we are getting to the point where patients' rights under the NHS constitution are being breached. But instead of being honest about it and having a national debate about what should be funded, the Government are hiding behind NICE and restricting its freedoms. Only this morning we heard about banning prescriptions for gluten-free foods and other medicines, which will affect the poor and vulnerable, who normally get free prescriptions. This is arbitrary rationing.

      The UK currently gets a disproportionate amount of the EU's R&D and clinical trials, and Brexit threatens that. I agree with every word my noble friend Lord Sharkey said but, since I have said the same words myself in your Lordships' House at least five times since last June, I will not bore your Lordships by repeating it. He expressed it much better than I could, anyway. But is this really the time to be putting in place further deterrents to companies making cutting-edge medicines available here? The industrial strategy said a lot of the right things about the Government's intention to promote scientific research, yet their actions do not match their words.

      So I ask the Minister: how soon does the DoH plan to assess the impact of the new NICE cap? I have heard that the Government plan to leave it for three years, which is far too long. I suggest that an impact assessment should be carried out on the first five medicines affected to ensure that the impact on patients is no greater than the Government predict. Will the Minister agree to do that?

  • Mar 27, 2017:
    • Gene Editing: Agriculture and Medicine - Question | Lords debates

      My Lords, given the potential of gene editing of non-reproductive cells for treating HIV, sickle cell, haemophilia and, as the noble Viscount said, cancer, what plans do the Government have to ensure continued research in this important and valuable area after Brexit?

  • Mar 23, 2017:
    • EU Membership: UK Science - Motion to Take Note | Lords debates

      My Lords, the tone of our debates at Question Time this morning was more subdued than usual for obvious reasons, but in this debate we have rightly returned to a considerably more forthright tone. We have heard words such as "idiocy", "derisory" and "carelessness", so if I continue in that forthright tone, I hope the Minister will accept it in the spirit of returning to business as usual as soon as possible.

      No scientist in her right mind would think of Brexit as being anything other than the worst challenge we could impose on UK science. Why would we want to lose access to major sources of funding, put at risk valuable international collaborations, deter top scientists from coming here and leave our biggest market for the outputs of science that make our lives better, healthier and longer? The committee's report does its best to be optimistic, but it expresses very clearly the serious downsides of the choice this hard Brexit Government have made. As someone who is particularly concerned about the effect of Brexit on our life sciences, UK patients' access to cutting-edge medicines and treatments, and the survival of our health and care services, I welcome the committee' report, which highlights many of the concerns I have felt ever since 24 June last year, and it proposes some solutions to mitigate the worst of them.

      One of the first effects I heard about, within a week of the referendum, concerned a research scientist I know who was in the early stages of a collaborative research funding application to the EU with scientists from elsewhere in Europe. He was asked to withdraw on the basis that his presence in the team would reduce the chances of the application being successful. So, while the committee states that there is a scarcity of hard evidence for this effect, it accepts that there is anecdotal evidence of discrimination in ways that may never be documented. I know that to be true.

      A great many of our research projects are funded by the EU. The UK has benefited more than any other member country from EU money for science, partly because we are very good at spending it well, so the Government's commitment to underwrite Horizon 2020 funding with new UK money is very welcome. However, what happens when Horizon 2020 comes to an end? It would be better if the Government tried to negotiate continued access for UK scientists to Horizon 2020, its successor and other EU funding, given that other countries outside the EU already have such access. The Prime Minister may not have the stomach to try to negotiate continued access to the single market, but surely our negotiators can have a try at this one, given its importance to our economy.

      Harmonised regulations are particularly important to the development of medicines and medical technologies. While I agree with the noble Viscount, Lord Ridley, on the issue of GM crops, I find myself more in agreement with the remarks of the noble Lord, Lord Hunt of Chesterton, about regulation. Regulation is not necessarily a burden, and if it was faulty we could have tried to improve it from within rather than walk away. We have the freedom to sell and the confidence to buy when our regulations are identical to those of our major customers. It is therefore not surprising that most of the submissions to the committee called for UK regulations in the scientific domain to remain harmonised with the EU.

      In the medical domain, UK scientists have played a major role in the European Medicines Agency, and we have here in London a great deal of the expertise in medicines licensing and regulation. Where will that expertise go after Brexit? Professor Dame Jocelyn Bell Burnell pointed out that if we wish to trade with Europe, we are going to have to abide by the European regulatory system. But of course, that system will not remain static; it will change over the years, so I ask the Minister, how are we going to keep up? If the Government decide to set up our own system it will be very expensive, as pointed out by Mr James Lawford Davies, a solicitor and partner at Hempsons, in his submission to the committee. The UK would have to set up its own infrastructure and administration, with no additional benefit to us. It looks to me like a classic example of shooting yourself in the foot. The Government tell us that it will be all right but I am afraid that, based on their record to date, I doubt it.

      Have the Government assessed the cost of setting up such a system, and if not, why not? The Government appear not to have heard of the phrase "plan B". Will the increased trade we are supposed to be expecting post Brexit be in excess of the costs of this system? The committee recommends that such an assessment be made and published prior to the introduction of what my noble friend Lady Ludford calls, "The not so great cut-and-paste Bill". Can the Minister assure us that that will happen so that we can assess the damage? Of course, the costs of an independent system are a fact, while the potential for increased global trade is speculation. No sensible business person exchanges facts for speculation, and neither do they take on unnecessary costs. That is why much of business is against Brexit, although as we know, big business is very flexible and resourceful and will survive.

      UK science depends not just on international collaborations but on attracting top-flight scientists and student scientists to the UK. Here, the committee expresses serious concerns in its report about the Government's approach to immigration. On the one hand, Jo Johnson MP stated,

      "We remain fully open to scientists and researchers from across the EU",

      while on the other hand, the Home Secretary, Amber Rudd, told the Conservative Party Conference that she would,

      "look again at whether our immigration system provides the right incentives for businesses to invest in British workers"-

      a not so veiled threat that is to be followed up by action. In two weeks' time the immigration skills charge-a charge of £1,000 per year for workers brought in from abroad on a tier 2 visa-will be implemented. There are exemptions for PhD chemists, physicists, social scientists, research and development managers and so on, but there are no exemptions for health and care employers bringing in essential doctors and nurses to fill the gaps in our health service. When we discussed the regulations two days ago, I demanded an exemption for the NHS and social care, and I repeat that demand today. The tax will cost front-line services £7.2 million per year and add to the black hole in funding, at a time of severe Brexit challenge to the health workforce. It is a very short-sighted thing to do. The committee pointed out that the Government are also being "less than helpful" in refusing to exclude international students from their immigration targets, rightly described as "idiocy" by the noble Earl, Lord Selborne. The financial viability of many of our universities depends on being able to attract international undergraduate and graduate students and staff, so no wonder they are concerned about the Government's intransigent attitude.

      There are other avoidable threats. When the Health Service Medical Supplies (Costs) Bill went through the House, we passed an amendment to ensure that when the Government use their new powers in the Bill, they have to take account of the need to promote a thriving life sciences sector and access for UK patients to new medicines. Considering the challenges outlined by the committee in the report we are debating today, I am surprised that the Government overturned the amendment in another place. I hope that noble Lords will stand their ground on this when the Bill comes back to your Lordships' House in a couple of weeks' time.

      I end by congratulating all members of the committee on their forensic examination of the threats of Brexit to British science, and I congratulate them on their valiant effort to be optimistic. I hope the Government will accept the committee's helpful recommendations.

    • Education: Nursery and Early Years - Question | Lords debates

      My Lords, the early years sector is very diverse in relation to types of governance. We have the state-funded sector, private settings, and not-for-profit and voluntary settings. Can the Minister ensure that the money to employ qualified early years teachers is easily available to all kinds of settings?

  • Mar 20, 2017:
  • Mar 14, 2017:
    • End of Life Care - Question for Short Debate | Lords debates

      My Lords, as the King's Fund report Understanding NHS Financial Pressures commented yesterday, terminally ill patients have very little political voice. Therefore, I am delighted that the noble Baroness, Lady Finlay, has spoken up for them this evening. Indeed, I am very grateful that I live in Wales and will probably die there.

      Over the last five years, we have seen several reviews of palliative and end-of-life care with multiple recommendations. Therefore, I hope that, at the end of this debate, the Minister will be able to provide us with an update on progress towards meeting those recommendations. For example, the Government's response to the review of choice made two commitments that are particularly relevant to the topic we are debating today-namely, to,

      "engage with clinical commissioning groups and Health and Wellbeing boards on improving end of life care provision through local strategic planning and commissioning";

      and,

      "to provide commissioners with data, tools and palliative care currencies to help identify palliative care needs in local areas and the best ways to commission services to meet those needs".

      I hate jargon, so I looked up what "palliative care currencies" means. I found that it refers to payment models for palliative care. As the Minister will know, the majority of community palliative care providers in England, which are largely in the voluntary sector, are currently commissioned by block contract, and a lot of hospices in particular have been working within the same cash envelope for many years. Indeed, yesterday's report from the King's Fund commented that one of the factors that make some services particularly vulnerable is that block contracts have not been adjusted to match rising demand, and that demand is continuing to rise.

      In 2010, Marie Curie's review of funding recommended that the NHS move to a per-patient funding model, defined by phase of illness, so that providers would be paid more for patients with more complex care needs. One of the major difficulties encountered was the fact that most voluntary sector providers have a mixture of NHS and charitable funding, so it was difficult to identify which aspects of care were NHS-funded and which were charitably funded. Therefore, moving every provider to per-patient funding has its problems. Can the Minister now confirm that NHS England will provide a number of different palliative care currencies so that commissioners can choose which method is right for their locality? If that is the case, how will value for money be audited and by whom?

      We have heard that palliative care in this country can be the best in the world. However, successive national care for the dying audits have found wide variations in the quality of care in different hospitals. I welcome the fact that end-of-life care is now a key area for assessment in the Care Quality Commission's inspections of hospitals, but can the Minister update us on the plans in place for those that perform badly to learn from the best?

      However, poor patient and family experiences are often due to poor commissioning, planning and co-ordination, as well as insufficient provision for family support, rather than poor delivery. Clinical commissioners have a vital role in co-ordination because it is increasingly rare that individuals' needs will be met by one service alone and they often need to be moved from one location to another as their needs change. Co-ordination is particularly crucial when terminally ill patients wish to die at home. Last year I spoke in your Lordships' House about a particularly distressing case that I know of where that all went wrong. Obviously it makes sense to get services right in the community rather than have the patient admitted to hospital when the family can no longer cope.

      Despite the numbers needing these services, according to Marie Curie, just over half of health and well-being boards in England made no mention of palliative care in their strategies, only a third had comprehensive plans, and 30% of STPs made no mention of end-of-life care at all. Given that NHS England says that it requires local leaders and professionals to ensure that a strategy for end-of-life care is in place, this is pretty disgraceful, and, having made that statement, it does not audit what is in place, so there is no accountability. Therefore, I ask the Minister how CCGs and health and well-being boards are being held to account for this state of affairs.

      Finally, I want to raise clinical training. A professor of palliative care who is a friend of mine told me recently that some medical graduates have no more than one day of training in end-of-life care. In other places, such as Royal Liverpool University Hospital, students spend three weeks in local hospices, which equips them much better. Although we need palliative care specialists, we also need generalists with enough knowledge of pain management and other issues linked to end-of-life care, including how to help the bereaved. I understand that Health Education England's end-of-life care core skills education and training framework-what a mouthful-is soon to be published. Can the Minister say how soon it will be implemented?

  • Feb 28, 2017:
    • Nursing and Midwifery (Amendment) Order 2017 - Motion to Approve | Lords debates

      My Lords, midwives have a very special role in the local medical and nursing team. They should be seen as an integral part of that team; their role should not necessarily end at the point of birth. I know from many cases that the personal relationship built up between a mother and her designated midwife during the antenatal period can be enormously valuable at a time when she is very vulnerable. The mother often has the confidence to confide in the midwife if she has any health or personal security worries. I am talking here about domestic abuse, which so often occurs when a woman is pregnant. It is important that this relationship is nurtured and nothing gets in the way of a midwife adding all the value of which she or he is capable. I would hope that in future there would be more integration between the midwife, the health visitor and the district nurse. There is a lot of potential for that.

      No debate about midwives and nurses is complete without talking about numbers. The noble Lord, Lord Hunt, mentioned rates of attrition. A couple of weeks ago, at Oral Questions, I asked the Minister how data are collected on the rate of attrition. It is not consistent. It makes it very difficult to know which areas of the country are good at keeping their midwives and nurses and which are not, so that we can see and spread best practice.

      We have an enormous number of nurses from EU countries and, indeed, from other parts of the world. Brexit is looming and there is uncertainty-which we debated in this House yesterday and on other occasions-over the status of people from other EU countries working here. At the same time, we have a Government who are trying to reduce their immigration rates to a maximum of 100,000 a year, which could affect midwives coming from countries outside the EU. This is a big concern and we must not ignore it when we are talking about regulation.

      I turn to the order before us and the amendment in the name of the noble Lord, Lord Hunt. We on these Benches are broadly supportive of the order, which will bring more flexibility into the regulation of nurses and midwives, in line with the way in which the GMC and other medical regulators are able to carry out their fitness-to-practise processes. It is right that the regulator should be able to deal more proportionately with cases where there is a finding of "no case to answer" and where the person concerned accepts that the practice in that case falls short of what should be expected. There is currently no power for examiners to consider alternative ways of resolving these cases. However, the Secondary Legislation Scrutiny Committee raised some questions about the new power to issue a warning. It accepted that this power is permissive but felt that, if examiners are to use the power to give a warning, and guidance is intended to direct users as to how terms should be interpreted, then the detail of the threshold for issuing a warning should either be in statutory guidance or in the order. What is the Government's response to the committee's suggestion?

      Turning to the role of midwives in the governance of the NMC, it is important that the particular role of midwives is both recognised and catered for. However, if you are taking away the role of development support and supervision, and separating it from regulation, you do not necessarily need the existing structure of the midwifery committee. It is important and right that regulation and supervision are separated. I understand that there is to be a new midwifery panel which should be consulted and that supervision is to be replaced by new support and supervision structures in the four countries of the UK. There is also to be a new senior midwifery adviser. I take the point of the noble Lord, Lord Hunt, about status, which is important, particularly to the morale of the midwifery profession. Concerns have been raised that the new structures for support and supervision will not be ready in time for the changes at the end of March. I understand that, of the four nations, only Wales is ready to take over. What can the Minister tell us about the state of readiness of the other three nations?

      I recognise that the new structures that the Government are proposing present a challenge to the midwifery profession. This is right, in response to the reviews discussed earlier. There are concerns that the new structures within the NMC cannot, for example, put midwifery matters on the council's agenda. Can the Minister assure us that specific midwifery issues will be appropriately dealt with under the new structures?

      The effectiveness of the proposed new structures will take a while to be demonstrated, so it is right that we seek these reassurances at the outset. In the end, patient safety must be at the forefront and that depends on the quality of development, training and supervision of the midwives. It is a challenge for the profession, and it is only right that we give midwives the opportunity to demonstrate that they can rise to that challenge. However, it is right that the powers and structures of the regulator are up to date and able to cope with the workload in an appropriate manner at a time when, as the noble Lord, Lord Hunt, said, the demand is rising.

  • Feb 23, 2017:
    • Health Service Medical Supplies (Costs) Bill - Third Reading | Lords debates

      My Lords, we on these Benches are also happy to support the amendments. Like the noble Lord, Lord Lansley, I have no intention of detaining the House with long-winded thanks. However, I want to voice my recognition that the Minister, in his new role, has both understood and responded to the issues raised on the Opposition and Cross Benches about the shortcomings of the Bill, which had been through the House of Commons without anybody noticing or trying to amend its unintended consequences, rather like the Article 50 Bill that we debated in this House on Monday and Tuesday.