House of Lords
Thursday, 25 June 2009.
Prayers—read by the Lord Bishop of Southwell and Nottingham.
My Lords, the Digital Britain report, published on 16 June 2009, sets out our plans for increasing digital participation, including for the over-60s, who make up a large proportion of those not online. Furthermore, there is our universal service commitment to ensure that broadband is available across the UK. Two megabits per second will ensure that virtually every household can have access, if it wants it. One of the key priorities for the work of the champion for digital inclusion and her expert task force, announced on 16 June, will be the 65 and over group.
My Lords, I thank my noble friend for his Answer. Does he agree that those without internet access in their 60s, and especially those over 70, who often come into a lower income group and who may be housebound, miss out on the advantages of cheaper rail fares, cheaper car insurance, choosing their own seats on flights, certain discounts and bargains on food and other retail items? According to the American Journal of Geriatric Psychiatry, internet activity boosts brain power in older people rather more than reading books, I am sorry to say. Is my noble friend aware that Age Concern runs 150 drop-in facilities which offer training in online use to people in their 60s, 70s and 80s?
Particularly crime novels.
My Lords, I hear what the noble Lord says. We are certainly aware of the numerous benefits and activities which older people miss out on because they are not online. They have much to gain. They miss out on keeping in touch with family and friends; organising household and personal paperwork, bills and direct debits; and they certainly miss out on some of the cheapest offers for air fares and train fares, enjoying interests, hobbies, education, employment, watching TV and listening to radio stations from all over the world. Research shows that using the internet—
My Lords, does the Minister agree that there is another reason why older people need access to the internet, which is that telecare in various forms and care services can be brought to the very frail if they have adequate access to all forms of IT? It is very basic and not difficult to learn how to use those services, which are essential to a lot of people and will be in the future.
My Lords, I agree with the noble Baroness about the potential for helping the elderly, for example, by telecare healthcare. That is why we are working closely with Age Concern, which runs computer literacy courses for older people, and we have announced our digital champion, Martha Lane Fox, who is going to focus on this area.
My Lords, the noble Baroness, Lady Rendell, mentioned that a lot of people are housebound. Does the Minister think there is a place for volunteers to help such people to make sure they know how to use the internet? Are we not extremely fortunate in this House to have PICT to help us when we come unstuck with the internet?
My Lords, I absolutely agree with the noble Baroness about the benefits we have—for those who are willing to take them up, of course—and the idea of targeted outreach to connect the vulnerable and elderly, introduce them to the online world and give them advice. One of the biggest drivers of getting people who are sometimes described as silver surfers online is the grandchild effect, which often persuades many of our more mature citizens to embark on the joys of cyberspace.
My Lords, would the Minister not agree that it is a question of encouraging access? There is a generation gap; the older generation feels that the internet is for younger people. Would the Government encourage a high-profile publicity campaign—we currently see Michael Winner promoting car insurance, although I think I would probably listen more to somebody like Joanna Lumley—linked with local provision in libraries, mobile libraries or wherever, to encourage people in the older generation to get the training and the chance to implement it?
My Lords, I try to go for a short response, but not that short. We agree with the need to do that. That is why we have appointed Martha Lane Fox, who started lastminute.com, as the champion for digital inclusion with a remit to speak up for the digitally and socially excluded. We are confident that she will do a good job. The £100 million People’s Network programme in public libraries is another successful part of reaching one part of that more mature generation.
My Lords, is my noble friend aware that, as a person over 60, I am continually bombarded with spam emails? They are always the same and are usually about penile extensions, Viagra or inkjet cartridges. Do I look like a man who requires inkjet cartridges?
My Lords, that was one of the conclusions in the Digital Britain report. It is a fairly modest contribution. We have to weigh it against the greater good. Extending internet access across the whole of the UK would give a benefit of something like £270 annually. The greater good makes it worth while.
My Lords, as I told the House on 8 October last year, usage of the defence estate is reviewed continuously. However, under current plans, Wellington barracks will remain the key location in London for the execution of state, ceremonial and public duties for the foreseeable future. There are no plans to dispose of Wellington barracks.
My Lords, I thank the noble Baroness for that reply. Is she aware that, with my noble friend Lord Lyell and the noble Lord, Lord Lee of Trafford, I visited Wellington barracks last year, following up on a visit the previous year? We were very well looked after. Is the noble Baroness further aware that someone said, “Last year it was very grotty and this year it is merely grotty”? Work is some weeks behind. Does she agree that the uncertainty about future funding is very worrying? Finally, is she aware that the basement area where the cars are kept is still flooding?
My Lords, I am aware of the visit and also of some improvements that have been made, which the group who visited has acknowledged. The drainage problems and major defects have been identified, the junior ranks mess has been significantly improved and there have been significant changes. There are still problems and there is still work to be done. Money is tight and it has been decided, as far as concerns the defence estates, to concentrate on living accommodation rather than band accommodation. I know that that disappoints some people, but it reflects a priority that most would accept.
My Lords, I will never forget my visit to Wellington barracks with the noble Baroness, because I got stuck in a lift with the top brass and officials, and it took a good five or six minutes to get out. The occasion is etched indelibly in my memory. Is not the problem with Wellington barracks indicative of the fact that the defence budget is in serious trouble? Does the noble Baroness agree that the nation now has to choose either to put more resources into defence and remain a premier military power, or to drop down to a superior, very effective but still second-division military power?
My Lords, I am aware of the fact that the delegation got stuck in a lift. Those who were present had—shall we say?—a little extended briefing. I have been assured that the flick relay component that caused the problem has been fixed and that the lift is now functioning. I am sure that that will reassure any Member of the House who visits in future.
As for the defence budget, I remind the House that we are spending £35.4 billion on defence, which does not include the significant cost of operations. By 2010-11, the defence budget will be 10 per cent higher in real terms than it was in 1997. As that marks the longest period of sustained growth since the 1980s, it should be reassuring.
My Lords, in relation to planning inquiries and the future of barracks, does the noble Baroness not agree that it is an outrageous abuse of his position for a member of the Royal Family to seek to influence another royal family in order to secure his preferred solution to a planning inquiry?
My Lords, I thank the Minister for her helpful comments. The noble Lord, Lord Lee, pointed out that there were considerable problems with the Ministry of Defence budget. The Minister is doing a great job but can she please push on with one of the last elements, about which I shall let her department know? I was very encouraged that she mentioned the figure of 10 per cent for the next financial year 2010-11. That will be a considerable help to the new arrivals at Wellington barracks. We thank her for that. Will she please keep us posted on the details?
My Lords, the 10 per cent figure was the total growth in defence budgets since 1997. I am sure that noble Lords who have visited Wellington barracks will keep a close eye on the situation. I know that, through the work of the defence group, the noble Lord, Lord Lyell, tries to get a good cross-section of visits. Perhaps he will consider some of the improvements that we have made, such as those at Woolwich barracks. It might be useful to see some of the spending that has gone into very successful projects.
As to the future, I am sure that the whole House will be aware that my honourable friend the Parliamentary Under-Secretary, Kevan Jones, announced earlier this week that there would be an advance of £50 million this year from the Treasury to improve service accommodation. Those funds will allow us to target improvements in accommodation for those returning from operations in Afghanistan and Iraq, which I think we would all welcome.
My Lords, the noble Baroness said that the flick relay mechanism had gone phut in Wellington barracks, thus causing a great deal of embarrassment for the senior staff and some of your Lordships who were guests. She says that it has now been repaired. What makes the noble Baroness think that it will not flick again causing equal embarrassment on some other occasion?
Olympic Games 2012: Shooting
To ask Her Majesty’s Government what plans they have to publish the paper presented by the Government Olympic Executive to the Olympic Board on 19 March on the issue of the suitability of Bisley as a venue for the shooting discipline at the 2012 London Olympic Games.
My Lords, I understand that there was a detailed discussion on Tuesday evening between the London Organising Committee of the 2012 Olympic Games and Paralympic Games, the Olympic Delivery Authority, representatives from the National Shooting Centre at Bisley and a number of noble Lords. At that meeting LOCOG and the ODA set out in detail the basis of the Olympic Board’s decision to confirm Woolwich as the venue for the 2012 shooting events. The Government are committed to securing a positive legacy from the shooting events in 2012 and will work with British Shooting, among others, to maximise the opportunities for the sport beyond 2012.
My Lords, I thank the noble Lord for that Answer. Will he confirm that the Government will encourage the Olympics wherever possible to undertake that type of briefing on any future issues? Will he also take this opportunity to confirm that it is the job of the Olympic movement to deliver a successful Games and to leave a legacy from those Games? The creation of white elephants would damage the idea and the spirit behind the Olympics, which surely must be the greatest legacy.
My Lords, I largely agree with the noble Lord. It is important that we have a successful Games, a major feature of which should be the legacy. However, the legacy is not just about bricks and mortar; it is about raising the profile of the sport. Having shooting close to the Olympic village and part, therefore, of the integrity of the Olympic Games will raise that profile, to say nothing of the fact that Woolwich barracks are both historic and located in a main urban area. We want to spread the appreciation of shooting as a sport and the venue will help in that respect.
My Lords, I was at that meeting with Members of this House and the other place. It was far from conclusive. Will the Minister urgently invite LOCOG to look again at the presentation shown by British Shooting on 16 February—it was seemingly dismissed as inaccurate information—that demonstrated that the Olympic shooting events can still be staged at Bisley, within existing boundaries, in time and on budget, if LOCOG now fully engages with British Shooting and its consultants? Would that not leave a much better legacy of a world-class centre for the next Commonwealth Games, international and national events and training, as well as military marksmanship?
My Lords, I do not accept my noble friend’s contention with regard to his last points. I was not present at the meeting, but I would be astonished if it had not been made definitively clear that Woolwich is the decision. The shooting is to be located at Woolwich for very good reasons, which have been explained. As I understand it, the purpose of the meeting was partly to define that situation.
My Lords, the noble Lord talks about legacy. As far as I am aware, the only legacy that is proposed is the kit to be used for the shooting event. With whom is the ministry in contact in the British shooting world to make sure that the kit that is specified and ordered is suitable for dispersal to local shooting clubs, or in some other way, to provide a legacy? That clearly must be a crucial decision. Following on from what the Minister said, has the ministry any other legacy proposals?
My Lords, as I have indicated, the most valuable legacy of the Games is to encourage people, particularly young people, to participate in the vast range of sports that the Olympics represent. I understand exactly the point made by the noble Lord. We consider the physical legacy from the shooting range at Woolwich to be at least as extensive as anything from Bisley. We do not see a great deal of legacy for the future in Bisley. That is one reason why this decision has been taken. However, I entirely accept that, as the noble Lord says, if the legacy is to be promoted effectively in terms of shooting kits and encouragement of the sport, the relationship between the Olympic authorities and British Shooting and all shooting groups must improve on what has obviously obtained in recent months.
My Lords, we will discuss with British Shooting the whole question of the legacy from Woolwich. We are optimistic that there will be a considerable one, including part of the range to be relocated. The House will appreciate that British Shooting has been strong in its view that Bisley ought to have been the location. The decision is final that Woolwich is the better option in the overall strategy for the Games. It is important that the Olympic authorities now relate closely to British Shooting and all those with the interests of the sport at heart to guarantee that this issue of legacy is promoted satisfactorily.
My Lords, Woolwich has a certain connection with shooting: it is the home of the Royal Artillery. I understand what my noble friend is saying about this sport. The same issue could be presented for the equestrian events, another contentious issue that we have discussed. Everybody knows the worldwide renown of Burghley and of Badminton. The decision that those events should be taken in Greenwich Park, close to the Olympic Village, is on exactly the same logic. These are the London Games. The integrity of these sports, which are often somewhat distant from the focal points of the Games, will be, in the London instance, closely related to the excitement round the immediate area of the Olympic village.
My Lords, there is always some sacrifice involved in concentrating the Games in an urban area. The Greenwich Park initiative involves some considerable change to the contours of the park. That is to be done sensitively. There is a clear obligation on the Olympic authorities to restore the areas and facilities that they command to their best, proper state after the Games are over.
Agriculture: Dairy Farms
My Lords, following the collapse of Dairy Farmers of Britain, the Government’s prime objective, shared with the industry and the receiver, is to find buyers for milk produced by farmer members. As a result, 96 per cent of the milk has been taken up by other buyers. The Government are optimistic that more of the remaining farmers will find buyers, but we must recognise that some might not be able to find a commercially viable outlet for their milk.
My Lords, the Minister will know that dairy farming is in crisis and that 46 per cent of UK dairy farmers have ceased production since 1997. The Milk Marketing Board, shut down by the Official Opposition when they were in government in the 1990s, had a contract obligation to every dairy farmer to collect all their milk however remote their location. The collapse of Dairy Farmers of Britain, referred to by the Minister, leaves 200 dairy farmers without guaranteed milk collection from their farms. Will the Government step in and ensure collection of this milk, underwrite these producers’ May milk cheques and bring forward a new milk marketing Act, as in the 1930s, to ensure that these dairy farmers get a fair price for their milk which is above their production costs? The 10p per litre currently being given to these 200 dairy farmers is a disgrace.
My Lords, we do not intend to interfere with the milk market to the extent that the noble Lord suggests. The milk market is a commercial operation and reflects the fact that the milk production industry in the United Kingdom and in Europe is suffering from the recession because demand has dropped. However, the Government are optimistic about the future of the British industry. If the noble Lord is using the recent collapse of Dairy Farmers of Britain as an instance of crisis, he may be exaggerating the point because, as I indicated in my Answer, 96 per cent of the milk being produced has found another buyer.
My Lords, do the Government have any idea of the implications of what has happened? It is all very well for the Minister to say that 96 per cent of the milk will be collected, but that does not necessarily mean that 96 per cent of dairy farmers are protected, because the milk that other buyers do not want very often comes from small, family farms. Will the Minister also comment on how much of the agricultural industry as a whole will be affected? We are talking not just about dairy farmers but about feed merchants, the transport business and the production—or at least the processing—areas. As for the Minister’s latest comment about the industry being in good heart, can he explain why it seems necessary to reopen intervention for butter and skimmed milk powder?
My Lords, certain areas of discrete intervention are always open and are necessary. I am saying that milk production in this country cannot be identified as being in crisis. It is no more in crisis than is the whole of the British economy in relation to the slump in world demand arising from the present recession. I marvel at the fact that, although noble Lords opposite continually advocate the free market, the moment they identify a stick with which to beat the Government they demand government subsidy and intervention.
My Lords, does the Minister appreciate that milk is a staple part of our diet in this country and that we should be very sure that we are self-sufficient in it? We were at one time self-sufficient, and we were exporting milk. We are now importing milk in the thousands of gallons from France. Is he satisfied that our milk industry is in good heart while we are importing from another country?
But, my Lords, we are also exporting milk as well. Therefore, I do not think that it will stand up to suggest that the milk industry is in crisis in those terms. There are certainly pressures on some small producers—we recognise that and we have sympathy for them. We are concerned. We called a meeting to analyse this problem and to give a reassurance that every mechanism would be employed to sustain as many of the small farmers concerned as possible. I am pleased to report that it was quite clear from that meeting that constructive action was being taken by all those concerned. However, we cannot extrapolate from that that the British milk industry is facing a bleak future, because it is not. What it is suffering from, in certain very exposed areas, such as the very small producers, is reduced demand, but we all recognise the reasons for that.
My Lords, it is proper that the Minister is made aware of the seriousness of the situation, but I am not sure that he has totally taken it on board. Is he satisfied that the Government can do no more as dairies close and jobs are lost? Has he considered the impact of government weakness and indecision on issues such as bovine TB and the huge cost to dairy farmers of NVZ regulations?
My Lords, both those last two factors are very important considerations that we need to address, and we are addressing them as very important problems indeed. I maintain, however, that the long-run future of the dairy industry and the milk-producing industry looks good. There are problems in the interim, but, as I indicated, milk production in this country will be reduced by a fraction of 1 per cent by the loss of these farms. The loss of production on these farms is a personal tragedy for each of the farmers concerned and their families—I am not underestimating that at all—but when considering the industry, which is what the noble Lord addressed his Question to, I do not accept that the industry is going through anything other than short-term difficulties with a long-run prosperity beckoning it.
My Lords, I am sorry, we have hit 30 minutes.
Arrangement of Business
My Lords, with the leave of the House, my noble friend Lord West of Spithead will repeat as an oral Statement an urgent Question allowed in the Commons and providing an update to the National Security Strategy, including policy for cyber security, immediately after the debate in the name of the noble Baroness, Lady Murphy.
Business of the House
Timing of Debates
Financial Services and Markets Act 2000 (Regulated Activities) (Amendment) Order 2009
Motion to Approve
My Lords, the average age of Peers in this House is 68, so I can tell noble Lords here today with some confidence that one third of us will die with dementia. It is us next. Dementia is the most feared illness of all. The writer AA Gill memorably described it recently as,
“the unspeakable plague of our medically privileged generation”.
Dementia is dying of the self, bit by bit. Not just memories go—indeed, that is often the easiest thing to cope with—but our speech, emotions, ability to reason, to retain social relationships and to participate in life; they all desert us.
I should declare my interest at this point. I am a psychiatrist, and for 25 years was professor of old age psychiatry at the University of London. That is a rather grand title but actually, much of my work was as a jobbing community psychiatrist for older people living in Lewisham and Southwark, working with the local authorities for patients and their families. Half of all my patients had one of the variants of dementia. I will spare noble Lords my well honed lecture on 150 different causes of dementia and, indeed, most of the facts and figures. Those I see around me here today are too well informed to need me to do this. I am also proud to be a vice-president of the Alzheimer’s Society, which has done so much in these past 25 years to bring this dreadful disorder into the sunlight.
When I was younger, I was often asked why I chose this field, which carried so much stigma for those who undertake it as well as the sufferers. Of course, one’s personal motivations are never straightforward, but mine owed much to growing up at home with my grandmother, who developed dementia in her mid-80s, and gradually becoming aware of the terrible stress that that imposed on my parents. Later I came under the influence of one of the truly great visionaries of his medical generation, Tom Arie, whose influence on service developments for older people, both here and abroad, has been remarkable. He taught me the fun, the fascination, the extraordinary personal rewards, that come from working in a highly professional multidisciplinary service with patients and their families.
The National Dementia Strategy has the potential to be one of this Government’s triumphs. It is a splendid piece of work, achieved under the excellent leadership of Professor Sube Banerjee and Jenny Owen, to whom I pay tribute. Its provisions are comprehensive and it is all good stuff. I do, however, worry about the £150 million notionally allocated from central funds to support its implementation; it will not be ring- fenced by primary care trusts, so we can assume that in some places even this small amount of pump-priming money will be rapidly diverted elsewhere the minute the expected NHS period of austerity begins to bite. How do the Government intend to monitor the spending and the progress of the implementation of the strategy?
There is still precious little understanding by health and social care services of the impact of dementia on families or on the economy. The £17 billion spent annually is the direct costs of care on those already diagnosed. Well over 80 per cent of the money spent on adult social care is spent on people with dementia, although most local authorities do not seem to have twigged this yet. We even waste £200 million or so in acute hospitals on inappropriate care.
If we are to begin to get services in to help families in the early stages, then diagnosis is the key, as the strategy recognises. Like any other neurodegenerative disease, dementia and its clinical precursor, cognitive decline, need to be diagnosed and treated. I used to rage at the NHS and local authority services which said my patients must be “assessed”, going direct for a social care package, when everyone else got a diagnosis for care and treatment. This does not happen to people with Parkinson's and motor neurone disease. Too often, people with this catastrophic disorder have been dismissed as a social problem to be tidied up. About half of all people with dementia will not get a diagnosis and there are some very perverse reasons for this.
The first is straight ageism—a false belief that dementia is senility, and that senility and ageing are synonymous. It is worth reminding ourselves that even at 95 you have a better than evens chance of being mentally fully intact, and the good news for the real stayers is that at 100, the odds are even slightly better. That is the survival effect. But one major disincentive to a written diagnosis is the funding arrangements for care. In theory, you cannot go into an ordinary care home if you have a label of Alzheimer's or one of the other named dementias. You can go in with “a little bit of memory impairment” and a smidgen of cognitive decline. So of course, we professionals pretend. But in reality no older person now goes into care unless they have serious cognitive impairment and dementia; we just call it by a euphemism.
If you have a nasty label such as Alzheimer's, you are supposed to go to an expensive EMI home rather than an ordinary one, which is probably of no better quality than an ordinary care home, and quite often worse. The family does not want that, the hospital waiting for a discharge will not want that and the local authority certainly will not pay the extra. We need to be honest about it and we will not be until the Government sort out this funding problem.
Dementia is a terminal illness—patients survive only two to three years in their final care home. Homes are, in effect, providing end-of-life care for patients with a neurological disease the way hospices provide care for terminally ill cancer patients. The difference is that you get hospice or hospital care free but if you have dementia you have to pay for your own care until your money has more or less run out. This is what the Alzheimer’s Society has called the “dementia tax”. For care at home, 26 per cent pay for it all themselves; another 42 per cent pay a significant proportion. More than half of those in residential care pay more than £300 a week towards the costs of being cared for. Can you imagine the outcry if the Government decided to charge hospital patients that amount?
I have never campaigned for social care to be provided free out of current taxation. I think rather it would be better if all health and social care was provided on a level playing field, with a mixture of state and personal investment. I am a fan of the minority report by the noble Lords, Lord Lipsey and Lord Joffe, on the Royal Commission on Long Term Care and very attracted to Sir Derek Wanless’s analysis, Securing Good Care for Older People, published in 2006. We still wait with bated breath for the social care Green Paper—I believe it is expected any day now. I hear a rumour about next Tuesday, but it had better be good as social care is in meltdown out there. There are so few services, and often of such poor quality, that these new dementia advisers, described so well in the strategy, are going to have a very thin time trying to put a package together. Some of the NHS and local authority commissioning practices have been disgraceful.
Joan Bakewell recently commented in the Times on the online e-auction system of tendering care for older people with dementia. Costs are driven down to rock bottom, meaning that authorities accept levels of care we would not tolerate in a well-run zoo. She is right. These were her words, not mine.
The training of both domiciliary and residential care staff is almost non-existent. They have no idea how to manage behavioural problems. We have a high turn-over of transient, migrant staff who often barely speak a word of colloquial English. It is time we insisted that staff learn to speak fluent English. It is time we learnt to value them too. Staff are extraordinarily poorly paid at minimum wage levels; we simply do not value sufficiently the vital work they do. The lives of the residents are often starkly empty as a result of this.
Once a person is in care they get less access to healthcare than at home—less nursing, less physio, less speech therapy, less chiropody, less doctoring, less mental health nursing. Often the primary care trust feels they do not need to access community health services because they are somehow being paid for as part of the private care package. Authorities pay far more for similar residential care for younger adults with disabilities. This is straight age discrimination and perhaps we will need to challenge this under the new equality legislation.
I know that after this speech I shall be inundated with letters from care homes proud of the quality of their care. It is true there are some reasonable ones but they are a minority and I would guess that there are many noble Lords here today who have tried to find a suitable care home for their own parents, only to be disappointed and disheartened by the quality of what they saw around them. Training is vital. Has the Minister had an opportunity to read the report of the All-Party Parliamentary Group on Dementia on training needs called Prepared to Care? That seems to me to be a good start on training requirements but we have to solve the workforce issue.
Turning to research, the Government are holding a summit in July with the great and the good, academics and funders, to talk about possibly having a plan. I hope it is a plan for a proper strategy for research development. There is more money than ever before in research programmes into the science of the dementias, about £32 million, but the Government invest eight times less in dementia research than cancer research and similarly less than in cardiovascular disease, even though economically, and tragically for families, the impact of dementia is greater. Furthermore, they do not invest in a long-term predictable way, but in sporadic bursts when pushed. How can the Government continue to justify that, given the economic and personal impact of this disease?
We have a science base in the UK that is world beating. All bar one of the genes that have been discovered to be predictors of the familial types of dementias have been discovered here in the UK. Here, we get far better bangs for our bucks investing in basic molecular science, and better quality outcomes for smaller investment, than does the United States. The NHS is well organised to do clinical research in this country and we also have university departments of social research that are set up to do the research—if only they could get the research funds.
Almost all the research undertaken at present is on the smallish younger groups of people: it is not focused on the everyday, common stages of dementia. We have no idea how that research will translate to older people. Of course, I should like to have a poly pill that we could all take at 40 that would prevent us developing this disorder, but the problem is that dementia and ageing are closely associated. There is no escaping the fact that one is 25 times more likely to develop it at 90 than at 60. It is likely that decreasing the risk of dementia with prevention strategies will lead to an increased ageing population and therefore the survival of the later cohort of dementia sufferers. Of course, it is very much worthwhile making it later, but the results of successful early treatment and prevention are not as clear as one would like on a population basis.
The Alzheimer's Research Trust, which provides something like £4.5 million of research money, and the Alzheimer's Society, which also provides some money for research, have talked together about how to pool their research-promoting energies. I hope that they will continue to talk because working together on this strategy would be helpful. Can the Minister assure us that the forthcoming summit will lead to a proper strategy for promoting research in this field?
I am greatly looking forward to the contributions of other noble Lords here today and have said quite enough, but I should like to end with my grandmother, Elizabeth Lawson. She was born a Geordie girl and was a key person for me as I was growing up. She told me wonderful stories of her dancing party days in Gateshead and sang Geordie songs, which I still remember. She confided to me that her first love, a soldier, died of typhus on the boat coming home from the Boer War, so you can guess what age she was born in. She later married my taciturn and brainy grandfather, who was a colliery engineer, who brought her south to Nottingham, where he joined the then brand-new Clifton Colliery and she raised a family.
On the whole, I think it was a good life, but after being widowed, my parents cared for her for many years as she developed dementia. She died—I was amazed to find this morning that it was 40 years ago—in an anonymous ghastly long-stay ward in Sherwood Hospital—a former workhouse infirmary—where regimented beds were so close together there was scarcely room to stand between them. It was such a horrible place that her son, my father, found it almost too distressing to visit.
Sherwood Hospital later became a superb example of really good care, curiously enough under the care of Professor Tom Arie, my mentor. But how much have we really improved the chances of good care in the community of a kind that we can all be proud of, which is not stigmatising? This strategy had better work, because it really is us next.
My Lords, it is a great pleasure and honour to follow the noble Baroness, Lady Murphy, and I congratulate her on securing this important debate. The House is indeed fortunate to have someone with her expertise and experience.
We are all living longer and that is good news. We are living in a world where one in four children born today will live to get their 100th birthday telegram from the monarch: I wonder if the Queen will have to rethink the number of telegrams she sends. In 2007, for the first time in this country, pensioners outnumbered children, and within 20 years, more than half of us will be over 50.This change in society is a great challenge but also a great opportunity. It is a cause for celebration that we have the chance to live longer, a time to take advantage of a range of prospects not afforded to previous generations and to share experiences across generations. However, while we celebrate, we must be clear that the incidence of dementia will increase with age as the noble Baroness has reminded us. In parenthesis we should perhaps remember that it is not always older people who are sufferers; there are many distressing instances of early-onset dementia given by the Alzheimer’s Society.
It is good news that this Government take the issue seriously and that they have published a strategy earlier this year. As someone who has spent many years working with carers, I was very glad indeed, and welcome most warmly, that the strategy recognises that families are an important resource—probably the most important resource—in providing care for somebody with dementia. The Government have recognised the heavy and difficult challenges that the carers of those with dementia often experience and the need to deliver better support.
The strategy sets out important steps in improving dementia awareness and information provision to help the public, carers and sufferers to better understand, prepare for and cope with the disease. In addition, there is a welcome recognition of the role that technology, like “telehealth” and “telecare”, can play in maintaining independence for dementia sufferers and flexibility for their carers.
No one could disagree that there should be better knowledge about dementia and that the stigma that surrounds the conditions should end. We should remove the perception that dementia is a natural consequence of ageing and that nothing can be done for people with this condition. In that regard, there needs to be much better education and training for professionals. This should not just be for people providing dementia services but for other people in the NHS too. Certainly, much more sensitivity about this condition is needed in general hospitals.
We must ensure that people with dementia are correctly diagnosed. Currently, I believe only one third of people with dementia ever receive a diagnosis. This puts excessive strain on the carers who do not get the support or information they need. Neither is their expertise recognised. I have lost count of the number of carers who have said to me, “I took him into hospital or to the day centre and nobody asked me about him, nobody asked me about how to deal with him and what his medication is and so on. They just said, ‘You run off now, dear, and have some good respite’”. For carers with a great deal of expertise in this area, this is demeaning. Certainly, we all understand that people with dementia, and their carers, should get easy access to care, support and advice, following diagnosis. I very much hope that the dementia advisers set out in the strategy will help this.
Much progress has been made with carers in recent years. I applaud the Government for the lead that they have given, as well as campaigning organisations such as Carers UK. However, they will only be adequately supported in this arena if we link the dementia strategy with the national carers’ strategy. The dementia strategy focuses mainly on the health and social care sector in supporting people with dementia. Carers also need a decent income, the ability to continue working, back-to-work support, health checks and better support from the health service for their own health. They need better information about housing and about their rights, and skills and confidence, too.
The dementia strategy says that support for carers needs to be delivered through the national carers strategy but it does not mention work or income. We need to ensure that the key professionals who are implementing the dementia strategy have a clear idea of their responsibility under the carers strategy and of how it can help carers. Conversely, we need those who are implementing the carers strategy to ensure that carers of people with dementia are better supported. If these two strategies do not work together, the outcomes for carers of people with dementia will be considerably weaker.
One example that was referred to by the noble Baroness is the £150 million that was given to primary care trusts to provide respite care. There is a great deal of confusion about this money. A few primary care trusts, we understand, have indicated that they will be spending all or some of their allocation on breaks. Many are confused and have not yet entered into discussions about what to do, and many acknowledge the extra funding but do not want to spend it on carers. I heard of one PCT which set up a planning group on how to use the money before realising that it was not ring-fenced. When it realised that, it said, “Ah. Well, we don’t need to spend it carers at all, then”. This is not satisfactory, so I hope that the Minister will tell us, while acknowledging that unpaid carers deliver the majority of care to people with dementia, what additional steps the department will take to ensure that carers of people with dementia benefit from the whole New Deal for Carers strategy and are better able to access not only funding but information.
The noble Baroness, Lady Murphy, mentioned the Green Paper, which we all await with baited breath. She thinks that it will come next Tuesday; funnily enough, I heard that it would be the following Tuesday—but never mind. Does the Minister agree that a long-term settlement for social care is essential to ensure full delivery of the national dementia strategy? People with dementia, as the noble Baroness, Lady Murphy, told us, are hardest hit by the system of charging for care. Will the Green Paper set out options for reform which will deliver a better deal for people with dementia and their carers? I have heard it said that what we are requiring and expecting from this Green Paper is nothing less than a new Beveridge.
In commending the strategy, I also point up its limitations; principally, that while it is very good that it sets out a plan of action that should benefit the half a million carers looking after somebody with dementia, it needs to be combined with good implementation of the national carers strategy if it really is to benefit those with dementia and their carers.
My Lords, I, too, thank the noble Baroness, Lady Murphy, for introducing this timely debate in such a brilliant and comprehensive way. Dementia is a national crisis and too little is being done to address an urgent need. I should declare my interest as a patron of the Alzheimer’s Research Trust and as the recently widowed wife of an Alzheimer’s sufferer.
I welcome the publication of a national dementia strategy; £150 million over the next few years, however it is spent, will certainly help. Nevertheless, as other noble Baronesses have said, it is woefully inadequate in the face of the problem facing us as a nation. Better training for GPs and a dementia specialist in every general hospital are welcome reforms which should have existed long ago. However, the fine words promising patients more involvement and control in their treatment and the additional help for carers do little to resonate with the reality of dementia for the thousands of sufferers and their families today.
The problem is indeed urgent, as the noble Baroness has said. More than 700,000 people suffer from this terrible affliction, involving untold distress and hardship for them and their families. But matters can only get worse. We have over the past century greatly increased life expectancy, but for more and more of us, our bodies will, in all meaningful ways, outlive our minds. It is estimated that by 2025, 1 million people will suffer from dementia.
I should like to reflect for a moment on the reality of the disease that we are debating. Dementia affects memory, orientation, thinking capacity, comprehension, calculation, learning, judgment and language. It is a progressive disorder for which there is, as yet, no cure. For many sufferers, it brings with it loss of emotional control, in social behaviour and in the ability to make even the most simple decisions. Although it can occur in early life it is strongly age-related; the number of cases roughly doubles for every five years past the age of 60. The personal grief which lies behind the statistics is incalculable.
The cost to the country is beyond imagination. Currently, as others have said, the cost is £17 billion per year, eased only by the massive contribution made by the partners, children and family members who act as unpaid carers.
I make an urgent plea to the Government, of any political persuasion, to make it a priority to address particularly three major issues: research; information and support for carers; and an improvement in the quality of residential care. First and most urgently, there must be investment in research. The Government still have no real research strategy for dementia, although there are many developments, in both genetic and stem cell research particularly, which promise a real breakthrough in preventing, curing or delaying the onset of this disease. The facts are stark—as many people suffer from dementia as from cancer, yet the Government are spending eight times as much on cancer research as on dementia. In 2007-08 the total government spend was £248.5 million on cancer, and only £32.2 million on dementia. The US Government wisely spend 13 times more than the UK on this research, and within Europe, our government spend is behind that of either Germany or France.
I believe that research should have been a major plank of the national dementia strategy. At present we must be thankful for the two charities, which, as the noble Baroness, Lady Murphy, said, support research to the tune of a further £6 million a year—£4.5 million from the Alzheimer’s Research Trust and £1.5 million from the Alzheimer’s Society. The national strategy does make proposals for increasing GP training and awareness, and that could lead to earlier diagnosis. However, without a breakthrough in research that delays the progress of the disease—or best of all, finds a cure—this will only marginally improve the lives of individuals or ease the lives of carers.
My second plea to Government is for better information and support for carers. Reluctantly here, I must tell my own painful story as an example. I do not know if it would have made any difference to my darling husband if we had known earlier what ailed him, but at least we could have discussed things with him while he was still able to take decisions about what he wanted, and made provision for the fate that was to overtake him. As it was, the diagnosis came late, and his descent into darkness was swift. A happy, loving and highly intelligent man, a former Oxford don with advanced degrees from both Oxford and Harvard, he soon lost the power to finish a sentence, to recognise his own home, his friends, and finally even to dress or feed himself.
Experts tell us that people with high intelligence and education are often not diagnosed until the disease is in an advanced stage—because they live at a level of mental performance above the average, they are able to function apparently adequately for a longer period of the illness. The consultant who looked after my husband in the last stages of his life told me a story that illustrates this phenomenon. A brilliant world-class chess player went to visit his doctor, saying, “Something’s wrong with me, I can only see six moves ahead”. Six moves being still more than the average chess player can see, no one else had noticed his problem. However, he was diagnosed with advanced Alzheimer’s and died within six months.
So it was for my husband, and as his sole carer, I found myself carrying the burden of physical care and of emotional grief over the loss of my beloved lifetime companion, with almost no help from outside. I pay the warmest tributes to my local interim care team in Wandsworth, whose care when my husband first came out of hospital after a bad fall, alas, lasted only six weeks. Without them—and their team incidentally has now been disbanded by the PCT—there would have been nowhere to turn for help or advice. I, with the help of my adult children, had to research the possibilities of care assistance and home adaptations on my own. I struggled to provide care and adapt our home, with the minimum of official advice or information. A reliable and identifiable source of such advice or support would be a huge advantage and should be addressed in the future strategy.
The worst, and most painful, decision, finally to opt for residential care, is where, more than at any other time, information is needed. For most of us, residential care seems a terrible last resort, but it was the therapist from the team—who remained an informal telephone adviser and friend—who bluntly told me that all I was struggling to do, and the care I could give at home, was not as good as a residential care home could provide. Like most of the population, I knew nothing about care homes and had no idea even where to start looking. Proper sources of information and support in the decision are the very least that should be provided. Most people avoid care homes, even when they live next door to them—so finding where they are and identifying the right place for a particular person is an impossibly daunting task, almost as daunting as wondering where to find the means to pay for it. I was lucky enough to be told about a website which gave brilliant assistance, and that was my introduction to the hidden world of residential care—a world which no one knew or wanted to know outside those who lived and worked within it, and those who love them.
That leads me to my third plea to government. Better staff and resources for residential care should be a priority. Behind the walls of care homes are real people, with real lives and personalities. Some have had distinguished careers. Many, as I was sadly to observe, are virtually abandoned by family and friends, and many are confused and disabled. However, those who care for them there are disgracefully poorly paid, and, although many are dedicated and caring people, they are under-trained and often poorly managed by equally poorly paid and under-educated senior staff.
I welcome the commitment in the strategy to better training and support for carers, and to an improved inspection regime. However, the quality and educational standards will improve only if the levels of pay attract a wider range of well educated people into the role of care workers and into the crucial role of managers.
If, as is projected and as has been said, one-third of us now over 65 are to end our lives with dementia, and many will need residential care, the betterment of this provision is a national priority. While we retain our voice and our capacity to argue the case, the over-65 age group should shout loud our demand for a civilised provision of residential care. We all hope that we will not need it, and we all hope to die in our own beds with our minds intact, but many of us will not achieve that good death, and those affected deserve the country’s promise of at least a measure of dignity in their final years.
My Lords, I feel quite shamed by that speech. I do not think that I shall be able to do quite as well but I am glad to take part in this debate.
Like many people, I have some experience of dementia in that I was the person most closely involved in the care of my mother as she gradually disappeared into the mists of the disease. I recall that one of her most frequent questions was, “Who is paying for all this?”. She was always reassured when I managed to say, “Well you are, darling”. That was one of the last questions that she asked me before she died. So the patient may be “demented” but that does not mean that they have lost all their good sense, their marbles or their customary behaviour. One of the other things that she used to say when I arrived to see her was, “Would you like a glass of sherry, darling?”. There was not a glass of sherry in the room but it was her habitual wish to offer refreshment to a guest that prompted her to ask that question.
Last year, I took part in the work of the All-Party Parliamentary Group on Dementia, which concentrated on the prescription of anti-psychotic drugs to people with dementia who are living in care homes and on the need for better trained and better paid staff, both of which have already been referred to. The all-party group’s recommendations reflected our serious concerns about the use and misuse of these psychotic drugs. It emerged that patients with mild behavioural symptoms were being given anti-psychotic drugs, often for long periods. Although the Mental Capacity Act requires care personnel to consult patients and their carers, the group found that this was not done, with the result that neither patients nor their carers understood the reasons for prescribing these drugs or what their effect might be on patients. At the same time, doctors prescribing anti-psychotic drugs often did not visit patients sufficiently to appreciate their effect on those with dementia. We concluded that better monitoring of patients by physicians might well lead to a reduction of doses or even to the discontinuation of the use of the medication for a patient.
More profoundly, we concluded that the rapid resort to anti-psychotic drugs for patients who might, for example, be distressed by the move to a different and unknown place was, in itself, a sign of underlying problems with respect to the training, recruitment, development and pay levels of those working within the care sector. The more recent report from the All-Party Parliamentary Group on Dementia—I did not take part in that—recommends that all care staff working with elderly people should receive dementia care training.
The Alzheimer’s Society supports these recommendations and is calling on the Department of Health to develop dementia-care-related skills in the workforce. In my opinion, it is of great importance that all care workers share a common training and a common understanding of the needs of Alzheimer patients. Equally, leadership of care home staff by the senior staff member can assist the staff to understand, and therefore serve, their patients more thoughtfully and sensitively. Good examples of that were brought to us during the work of the all-party group.
I make these points because they indicate the very precise targeting of proposed solutions to the practical problems encountered in care homes. Obviously a government strategy will be more comprehensive than what I am talking about, but we have to keep remembering that it is the high proportion of patients in private homes, and the high proportion of patients who are still not receiving proper care, who need to be encompassed in such a strategy, with the right protocols and training for staff and the right protocols for medical practitioners to ensure that, in things like the giving of drugs, the process is properly and correctly aligned to the needs of the patient and is not simply an automatic way of dealing with a difficult patient.
One of the problems about being in an old people’s home is that, by definition, you are vulnerable there. You are on your own; there may not be anyone in your family who can visit you on a daily or even a weekly basis. It depends where you are living in relation to the rest of your family. Cases where the nearest family members, who may still be at work or be looking after their own children, live far from their elderly relatives in their care home present particular difficulties.
The first advice that I would give any responsible family member is to ensure that any residential home chosen for the patient should not be far from the home of the person most likely to visit the patient. I made what turned out to be the stupid mistake of thinking that my mother would be better off in her own home town. That was not true; she would have been better off down the road from where I lived. That would have been much better for her and, obviously, much easier for me. Again, if I were advising a family on learning to cope with an Alzheimer patient, I would suggest creating a rota of visits in such a way that the entire burden is not left to one person and that the patient is helped to remember their grandchildren—and, in the case of my mother, their great-grandchildren—in other words, their true life outside the residential home.
The all-party group’s reports have made several important recommendations about the use of anti-psychotic drugs, the major subject of the report. They have dealt with the question of harm and the question of their not being kept under supervision by doctors. A recommendation was made that a new system for regular specialist assessment of vulnerable patients in care homes should be established, which would also involve the GPs responsible for day-to-day medical care. I am not sure whether any progress has been made in response to the recommendations of the previous report from the all-party group, rather than the most recent one. How much have the Government been able to do in response?
The group’s second report on this matter, the most recent, is concerned with the training for the care of people with dementia. It recommended that dementia training, including communication skills, should be mandatory for all care home staff; that dementia training should play a larger role in the training of GPs; that staff turnover needed to be reduced; and that local authorities should use their commissioning powers to drive up standards. Again, I am not sure whether the Government have responded to these suggestions. I am also not certain that any serious steps have been taken to create a recognised training programme for care home staff. The need for such a training programme has been mentioned by everyone who has spoken so far.
I apologise if this speech has appeared somewhat scrappy. Neither the document with which we have been supplied nor the subject lend themselves to this sort of debate; in other words, one needs more time to expand one’s thoughts. I have not been able to make any response to any of the excellent speeches made, for example, by those who spoke before me. I look forward to the Minister’s response and hope, for all our sakes, whether as sufferers or carers, that the new approach really will make the difference.
My Lords, I am glad to have the opportunity to speak today. I thank the Down’s Syndrome Association for its briefing in advance of today’s debate and of course the charity Mencap, of which I am the president. I also thank my noble friend Lady Murphy for introducing the debate, even though she once or twice frightened the life out of me with her statistics—I am now well into my 86th year.
I am delighted by the publication of the National Dementia Strategy and its wide-ranging aims of improved awareness, earlier diagnosis, intervention and a higher quality of care. This strategy is vital in light of the fact that people with learning disabilities have a significantly higher risk than the general population of developing dementia, at a much earlier age, particularly those with Down’s syndrome, such as my daughter, who displayed distressing symptoms for some years before she died.
I am glad to say that the awareness of dementia in people with learning disabilities, particularly in adults with Down’s syndrome, has increased significantly and is now well recognised in many parts of the country, with screening services either available or in development. However, I am concerned that there continues to be a mismatch between the services that are available and the ability of someone with learning disabilities who suffers from dementia to access them. In particular, delays in diagnosis are leaving people with a learning disability isolated. I would be interested to hear what plans the Minister has to help to speed up referrals to specialists so that the correct care and treatment can be made available as soon as possible.
I would like to take a moment to give a human face to our discussions today. Let me tell your Lordships about Sandra. She is 46, has Down’s syndrome and was in supported living in the south of England. When she began to show signs of deterioration, despite being allocated support workers, she worsened to the point of remaining in bed, soiling sheets, crying and shunning contact before she was taken into residential care. A further 12 months passed before the question of dementia was raised and she was eventually assessed by a psychologist. That report has never been finished. The psychologist left the service and Sandra is now waiting again for another assessment to take place. In the mean time, there is no diagnosis, no treatment and, of course, further deterioration. I am absolutely appalled by this case. Sandra may or may not have dementia, but until she gets an assessment of her needs she will get no treatment.
The Government could take a number of simple measures to assist services to improve and to meet better the needs of people with a learning disability. First, a baseline should be established for every adult with Down’s syndrome while they are healthy, as the detection of early signs of dementia relies on a good baseline. Secondly, assessment for dementia in any adult with learning disabilities should be readily available as soon as concerns have been raised. Thirdly, services might also consider prospective screening for dementia for adults with Down’s syndrome, conducted at intervals, say, from the age of 40 or 50. I would be grateful for the Government’s views, although it is very difficult to see how we can achieve improvements in assessment and diagnosis unless we invest in more resources.
The Government also need to recognise the increasing possibility that people with learning disabilities will be living in a range of accommodation: independently, with family, supported by other services such as social care or healthcare, or in residential care. It will be essential to ensure that services such as those for dementia reach the target audience.
The Government have said that they intend to ensure that all health and social care staff involved in the care of people with dementia have the skills needed to provide the best quality care in the roles and settings where they work. This is welcome. However, we must have such training for all those who work with people with learning disabilities throughout the health and social care sectors in order to prevent further cases such as Sandra’s or our hearing once again those dread words, “Lessons have been learnt”.
The social care funding crisis, where resources have not kept pace with the increasing numbers of people with a learning disability requiring them, is also having a major impact on the lives of people with a learning disability who experience dementia. Many are being excluded from appropriate support or are reporting cuts in their services. Indeed, a report published last year by the Learning Disability Coalition found that 34 per cent of respondents had experienced cuts. These reductions in care mean that there is less chance that symptoms of dementia will be identified or recognised.
Next month sees the publication by the Royal College of Psychiatrists and the British Psychological Society of guidance for the assessment, diagnosis, treatment and support for people with learning disabilities who develop dementia. It highlights the specific issues that people with learning disabilities and dementia present and identifies the key elements of an excellent service that would lead to a high-quality, safe and person-centred lifestyle as the dementia progresses. I would be interested to hear what the Government plan to do to promote this guidance.
I am afraid that this inequality in care facing people with a learning disability echoes throughout the health service, as evidenced by Mencap’s campaign for justice for the families of people with a learning disability who died unnecessarily in the care of the NHS after they were treated differently because of their learning disability. Indeed, one of the six cases highlighted by Death by Indifference was that of Ted, who did indeed suffer from dementia. An ombudsman’s investigation published earlier this year found that the NHS trust in charge of Ted’s care was guilty of service failure.
Too often medical professionals cannot see past someone’s learning disability through to his physical health needs. With regard to dementia, that means that the condition is often misdiagnosed as being behavioural and those in need miss out on treatment and pain management. I certainly took forward to hearing the Minister’s response to the points that I have raised today.
My Lords, I am grateful to my noble friend for allowing your Lordships to take part in this important debate. I must disillusion Members of the House about the telegram from the Queen. You already have to write and send your driving licence and your passport if you are to get a telegram from the Queen. I know this because I have a sister who has just passed her 100th birthday and has neither a passport nor a driving licence, not having been able to drive for some years. However, she got the telegram in the end because I rang up and said that I would vouch for her identity, so you may get a telegram, but you do not get one automatically.
I was very interested in the strategy and glad that the Government published it. The word “stigma” was used in the document and by some noble Lords who have spoken. I do not think that it is quite the right expression. I do not think that there is a stigma attached to dementia; rather, I think that it is a taboo subject, which is rather different. It is taboo because it is so extremely horrible and people are not willing to talk about it. This is an important distinction.
In a recent paper from the University of Wisconsin-Madison, two doctors demonstrated statistically how beneficial, both socially and financially, was early intervention with dementia. They recommended that drugs should be given at an early stage to lengthen the life of sufferers. I do not know whether these were anti-psychotic drugs. There must be more research, as everybody has said, and much better knowledge about the effects of whatever drugs may be given—I hope that we may hear more about this later—to slow down the progress of what is a terminal illness, albeit one that may last for years.
The doctors from Wisconsin showed that, for early intervention to work—and this is common sense—early diagnosis is essential. However, I do not underestimate the great difficulty of early diagnosis. The noble Baroness, Lady Perry, has pointed out that sometimes the most intelligent people are diagnosed latest, because not only have they had a very active and interesting life, but also they are capable of developing strategies to disguise what they know are defects—even defects in their chess playing, but certainly defects in their social behaviour. The story told by the noble Baroness, Lady Thomas, about her mother offering sherry, is typical. Many people with severe and far-progressed dementia retain a very agreeable social manner for a long time and will always be polite to visitors, even if they do not have the foggiest idea who they are. I always find touching the stories from people with direct experience of dementia. They are also difficult to bear when one thinks of one’s own possible future.
The trouble with early intervention is partly that people develop strategies and partly that they are in denial. We know that the older population dread the onset of dementia far more than they dread cancer or heart disease: it is the dread of everybody’s life as they get older, which is why the subject has been taboo. We should therefore be grateful for the publication of the strategy.
However, I was particularly alarmed to detect in the strategy—optimistic and useful though it is—an assumption that most people who develop dementia will have someone living in their house to look after them. Everything that was said seemed best fitted to the case of somebody with a spouse who will heroically take charge and become a carer. Early diagnosis is especially difficult in the case of people who have no one living with them. Huge numbers of people live by themselves as they get older—a fact that is seldom noticed by people who want to deliver parcels, or expect there to be someone at home to welcome the plumber. People who live by themselves are often in denial—they will not notice changes—and their family who come to see them do not live with them, so may not notice the early signs of dementia.
This brings me to something that is terribly important. The possibility of early diagnosis rests with the GP. Most GPs, when people go to see them, understandably attend to the problem that the patient has gone with, which may be anything. They do not have time to assess the general state of the patient. This is partly because they have five minutes or less to talk to them, but partly also because so many GPs now do not know the patient well. They know their case history, but they do not know the person and cannot see signs of deterioration in the way that, in the old days, the family doctor would have done. There is an enormous responsibility on the medical profession, in particular general practitioners, to be alert to possible signs of dementia and to question the older person who comes to see them about how their life is going and whether they have any worries. That is not often done, but it would help early diagnosis if doctors learnt, first, the signs of dementia and, secondly, the necessity to probe when making their diagnosis.
The main reason why I feel so strongly about early diagnosis is that, when the disease is diagnosed, the person should be allowed to talk about their future and make a specific advance decision about how they want their life to end. This seems to be of the greatest possible importance. What I seek from the Minister is the assurance that, if someone has been diagnosed with dementia, that will not in itself constitute a diagnosis of mental incapacity. If it did, the advance statement would be of no use. I would like to see a situation where we can make an advance statement about our own death before the steep decline that comes at the end of dementia has set in. I would like the Minister to say something about that.
My Lords, I congratulate the noble Baroness, Lady Murphy, on securing this debate. It is a matter that should be aired. I disagree slightly with the noble Baroness, Lady Warnock. Her distinction between taboo and stigma is interesting, but ordinary people still think that a stigma attaches to dementia. Many have adopted the word “Alzheimer’s” for all forms of dementia, because they feel that it is more acceptable to society than “dementia”, which is a much older word. However, in some ways the noble Baroness is right—I agree absolutely that for most people the dread of dementia is very worrying.
Dementia is no respecter of persons. My mother was a very early graduate from Sydney University—one of only 100 women at the time. She was a bright young woman. When I went to see her in Australia in 1958, she had had a stroke, mini-strokes and was suffering from early dementia, from which she never recovered. She went on to become quite childlike and lived for a number of years. Fortunately, I was one of nine children and the other members of the family were able to look after her, but she was in residential care. She lived to quite an age.
Another interesting case is that of Iris Murdoch—many of us have seen the film. Years ago, I was asked to meet Iris Murdoch when she was signing books. Her latest book was The Sea, the Sea. I met her in Marylebone library, where the reading and book signing was held. She was such a clever woman—I was very impressed, and the book was very complicated, too. A few years later, when I moved to the country, I found that my house was immediately opposite hers. I had no idea that she lived there, but we met again in the village street. She was still quite well, but not very well. She remembered clearly having met me before, and welcomed me to the village—she was charming. We all know that she deteriorated very badly. I used to see her when her husband took her for walks in the village. They moved out of the village altogether when they needed to be closer to medical care. Again, she was a very clever woman in whom we saw a lot of changes. I pay tribute to my noble friend Lady Perry. George was a most brilliant man and I know how much she did to look after him in his last years.
When I was chairman of the Royal Free Hospital, we had a special section of the hospital that had been the home of Sir Thomas Lipton, the famous man from the days of the America’s Cup who was going to win it back for Britain. This home was converted into a special place for the care of dementia cases. It was a huge Victorian home, on to which the hospital had built a lot more. Every year we had a garden party for everyone, including the relatives, and I went every year while I was chairman of the hospital. Many relatives told me that the problem with dementia is that it is a living bereavement and I agree with that. Early onset dementia is uncommon, but it happens, and can occur in people as young as 30. One man came every day to see his wife who had been in a bad state from the age of 40. It is hard when people are old, but it is more anticipated. It is rare in young people, but it is very upsetting.
I was given a marvellous book, Alzheimer’s at your Fingertips, which was written by Dr Nori Graham, a consultant at the Royal Free Hospital, Harry Cayton and Dr James Warner. It was published in 1997. It is so good because it answers the practical problems of the people who have so much to do with caring for people, particularly in the early stages of Alzheimer’s. It answers questions, such as who will get Alzheimer’s disease. It says that it is uncommon in younger people, but it can affect them, and that it occurs more in some groups. Alzheimer’s is the most usual occurrence of dementia. After that comes vascular dementia, the type that my mother had, which is due to a stroke. We all know many people who have had a series of mini-strokes. Often they make a partial recovery between the strokes, then they have another one and they go a further step downhill.
I rushed to read this book when my wonderful godson was diagnosed with Pick’s disease. Unfortunately, that is not good. The book sets out the details of the forms of dementia, which people do not understand, and explains that the causes are not fully understood. It refers to the importance of seeking a diagnosis, which so many speakers have emphasised today, and I could not agree more. The book covers practical care, general questions and the different situations in which people find themselves. Non-recognition is very distressing for loved ones who find that they are not known.
The book is written in the form of questions and answers, for example:
“My wife often says to me ‘When are you going to take me home?’. Then she packs some things into a bag—pictures, ornaments, etc. How can I explain that this is her home?”.
Another example is:
“Sometimes, in the evenings, my husband looks at me and asks me when am I leaving. He then hands me the telephone and says ‘Tell my wife to come home, so that you can go back to your home’. What can I do?”.
People find themselves in these types of situation all the time. The answers are reassuring and it is comforting for people to know that others suffer the same situation. The book then gives answers to the questions.
Another interesting question is:
“My husband, who has Alzheimer’s disease, often gets angry, and sometimes hits me. He never used to do this. What can I do to calm things down”.
I have met many people who find themselves very distressed by a husband who has always been a calm and loving person suddenly becoming quite violent. Restlessness, agitation, wandering, anger, aggression and bitterness are all problems that people face. Knowing that others face the same problems consoles them and helps understanding.
However, there is a need for a greater public awareness. People often know nothing about it until they find themselves in that position. Public awareness changes attitudes and means that people are more supportive in general. I support the view that diagnosis is undoubtedly the key. I was rather pleased to meet a young German doctor at an Alzheimer’s function here. He told me that he had come to England to do research into this because he believes that our research is probably further ahead than that of most other countries. What we all want to see is not research into either prevention or cure, but research into both. The strategy is excellent, but we should deal with this matter in such a way that we do not have this distressing number of cases.
My Lords, I congratulate my noble friend Lady Murphy on securing and introducing in such a brilliant way this important and urgently needed debate. The speeches I have heard have also been moving. When dementia hits, it is a tragedy for everyone, not just for the patient but for their family and friends. Therefore, the National Dementia Strategy is extremely welcome. Much of it is excellent and gives us hope for the future. Sadly, the promised review of anti-psychotic drugs has been delayed and, as has been pointed out, research is not an integral part of it.
I agree with the noble Baroness, Lady Gardner, that dementia is not quite as much of a taboo subject as it previously was and that it is now recognised. We have heard that funding for research is just over 2 per cent of our total research spend. As the noble Baroness, Lady Murphy, said, that is eight times less than is spent on research into cancer and heart disease, but we know that the incidence is far greater than both of those. I still think it is shaming that in the United Kingdom, we spend £13 per person on dementia research per year, whereas in the United States the spend is £121 per person. I hope that the Minister can assure me that the forthcoming research summit, led by the Government with the Medical Research Council, will lead to a comprehensive research strategy. Cross-sectoral and cross-disciplinary collaboration are essential. We need a really broad research strategy, including a reversal of the totally inadequate number of trials to ensure that prompt translation of scientific developments into new drugs and treatments can be assured.
We also know that apart from the huge scale of suffering, the economic consequences of dementia are enormous. In the UK, we already have 750,000 people with the disease and 53,000 new cases are diagnosed every year. The demand for care will increase exponentially and we know that at present only 30 per cent of people suffering from dementia are in care homes. Most are in the community. As the noble Baroness, Lady Pitkeathley, pointed out, most are cared for by family and friends.
We cannot guarantee that that situation will continue; that people will be able or willing to continue to do that job. Certainly, many people are hindered by a lack of support. A lot of the paid carer support services are often not fit for purpose. Families and other carers face a huge number of disadvantages, even in getting adequate advice and guidance. The dementia strategy must remedy that situation. The strategy does not adequately address the challenges and possible opportunities presented by the personalisation agenda. I hope that the Minister can reassure me on that as well. As we have heard, the development of our workforce must be prioritised and training must be a mandatory part of care through commissioning. Again, I hope that the Minister will reassure me that this will happen.
People who work in the field of dementia are low paid and invariably poorly qualified. We know that low pay and poor qualifications lead to a skills shortage. It is better and more socially rewarding to get a job at the Tesco cash till than working in many homes. People leave when they can. Care in people’s own homes is often bought by the care companies and agencies by the hour or even by the minute. This has to be reversed. Care needs to be based on achieving quality of life. It has to be outcome-driven, not task-driven. That is another priority.
We have heard that there is a problem in care homes with the overuse of anti-psychotic medication. I was part of the All-Party Group on Dementia inquiry report that pointed this out. Similarly, we have to look at the use of restraint in homes and hospitals, which can be both overt and hidden. Restraint can easily slip into abuse. Only adequate training can prevent that happening.
On pharmaceutical treatments and prevention, Professor Ballard commented earlier this month that the use of cholinesterase inhibitors and amyloid cascade interactors has been delayed by poor prioritisation and funding. We need to consider that seriously.
We have heard from noble Lords about the discrimination against older people that still persists. Otherwise, 50 per cent of patients would not be without a formal medical diagnosis. Labelling the care they need as social care is proof of that discriminatory prejudice against older people. The National Audit Office found that GPs are also not sufficiently trained to recognise early symptoms or to manage the disease. It is difficult, but people should be made aware of their diagnoses. For that to happen, GPs—apart from training—have to know that some treatment and support will be available. Otherwise, they are not going to add to the distress of their patients by diagnosing them when nothing will be done to help them. The widespread introduction of memory clinics across the UK in this strategy should enable earlier diagnosis and treatment.
We have to pay more attention to those people in the final stages of dementia who need palliative care. There are other worrying trends. The noble Lord, Lord Rix, has mentioned one. The Social Care Institute for Excellence reported recently on a growing incidence of younger people suffering from one type of dementia, Korsakoff’s syndrome, through the overuse of alcohol. We have to watch for new types of dementia that are emerging.
The dementia advisory role in the strategy is a welcome development. It should provide a point of contact and support. At present, in spite of the huge amount of work done by the charities—they do a wonderful job—people and families often wait for up to three years before seeking help.
We can learn an awful lot from other countries and we should not resist doing so. The French have produced their third national Alzheimer’s plan and there are points in that we could learn from. In the Netherlands, there are specialist care home physicians.
We need a set of goals to which we aspire. Let us aim to have real improvement in diagnosis, treatment and care for dementia patients within the next five years, and immediately integrate health and social services in this field while developing specific skills and training at all levels. For this we need a major public awareness campaign that places dementia in the forefront of public priorities. We probably also need a dementia tsar or champion—I know this is being considered—to lead our country in awareness of dementia and acceptance of the challenges it brings.
One of our leading care home providers has called dementia the “silent epidemic”—an adequate description. We have to remove any remaining stigma and lack of interest that leads to this sort of discrimination. We must be determined to give dementia the priority it deserves. We need a national framework together with local and enforced standards in care. The role of the Care Quality Commission will be critical in looking, for example, at healthcare in residential homes, where so many people with dementia live.
People with dementia are among the most vulnerable in our society. Action and total commitment are needed now. It is the least we can expect.
My Lords, I also thank my noble friend Lady Murphy for this debate and her excellent introduction to it.
In 1999, just after my retirement from chairing the Broadcasting Standards Commission, I was asked to be one of the judges for ITV’s best documentary of the year. It turned out to be an interesting assignment. It was also my personal introduction to the subject of today’s debate. The film that made by far the most vivid impression on me was “Malcolm and Barbara: A Love Story”, created by Paul Watson. Malcolm and Barbara were husband and wife and Paul Watson their long-standing close friend. When Malcolm, a talented musician then in his early 50s, was diagnosed with Alzheimer’s, they reacted to the bad news by agreeing that, however horrifying the developments, Watson would film the disease as it developed over the years ahead. It was indeed horrifying and distressing to watch the stages of the disease unfold on film, and, at the same time, to observe the lack of appropriate support for Barbara that occurred along the way.
If anything was needed to alert me to the huge sums that carers save the national budget in this area, as well as to wake me up to the need for a totally different national approach to dementia, it was to see just how much Barbara was able to—indeed, had to—achieve, by coping so heroically with fearful mood swings, not excluding violence, from her distressed husband. It is therefore no wonder that I was particularly glad to see that Barbara featured in a recent Honours List—a more than well-deserved recognition of the love and dedication that she and so many other carers in these situations provide. Currently 500,000 family carers are providing, unpaid, some £6 billion worth of care.
In the 10 years which have elapsed since I first saw that documentary I think that we have all become increasingly aware that we are indeed an ageing population, and increasingly aware of the many implications that this has and will have for our own and for our children’s future. I am certainly aware that I am 10 years older, and I am beginning to recognise my own moments of tell-tale forgetfulness. So, against that background, it is more than fitting that I should congratulate the Government on their decision this year to publish and roll out a National Dementia Strategy. I hope that that way forward will include the contribution that employers also can make by retaining for as long as possible the valuable skills of dementia sufferers via means such as flexible working.
We should all give considerable priority to the Government’s plan because it is clearly in everyone’s interest. In its 2008 report The Dementia Tax, the Alzheimer’s Society predicted that the number of people with dementia will rise rapidly from 700,000 today to over 1 million by 2025. I know that different people will quote different figures but another of its reports predicted that one in three people over 65 will end their lives with a form of dementia. Bluntly, the financial cost of all this will be unmanageable if we continue as we are now.
As the Alzheimer’s Society points out, dementia is the UK’s biggest health and social care challenge. So the more I read about the strategy, the more important four aspects of it seem. Other noble Lords have already mentioned many of these. The first and most urgent aspect is the Government’s commitment to a national public awareness campaign. It is essential that the stigma—indeed, the fear—that dementia engenders must be confronted and changed.
The second aspect is earlier diagnosis. It is good to know that the Government believe that with earlier diagnosis, more effective and well-researched medication and, above all, improved training and awareness among doctors, nurses and all those involved with the care of these patients, “living well with dementia” can be achieved. That is particularly important for end-of-life care, which is manifestly inadequate at present. This whole area needs to improve, as currently only 31 per cent of GPs believe that they received sufficient basic and post-qualification training in diagnosing and managing dementia. Only this week I heard from an Australian friend that every GP in that country is already required to test all their 70 year-old patients for dementia. So we are clearly behind other countries.
Thirdly, for those with dementia and for their carers, the crucial need which they themselves identified in the consultation process was to have,
“someone with them on their journey”.
In other words, they need a local, knowledgeable contact who, from the moment dementia has been diagnosed—and, equally important, before then—can give support, information, advice and access to the services needed.
One important feature to bear in mind is the evidence showing that people want to stay in their own home and, preferably, ultimately, to die there. In many ways that is so much the better—not only do they fare better out of hospital; another tangible benefit is considerable financial relief for the NHS budget. As we have heard, 70 per cent of acute hospital beds are occupied by older people receiving inadequate care. That does not make any sense.
However, if dementia patients are to be able to stay at home while at the same time enjoying the benefits of companionship, they will ideally need to find themselves in a diverse as well as comprehensive community. Most people—patients and carers alike—would prefer access when wanted to personalised social activity, from bingo to bridge, and short breaks for carers within a peer group with whom they can share activities and compare experiences.
Fourthly, dementia is a disease. I was glad to hear a number of other noble Lords say that it is quite wrong for its treatment effectively to be classified as social rather than medical care and therefore means-tested. For dementia patients, that is all too often the practical consequence of the present system of charging for care. This fundamental point is most clearly spelt out by the Alzheimer's Society in its report The Dementia Tax. And what a value we have in the Alzheimer’s Society—without it, I do not think that we would not know half of what we know. I look forward most to the Minister’s reply on this point. Is the treatment and care of dementia likely in future to be managed and financed on the same basis as any other disease tackled by the NHS? If not, why not?
My Lords, this has been a singularly well informed and at times extremely moving debate. Only those who have witnessed and experienced the progressive deterioration in intellect and personality of a family member can recognise how immensely distressing, even agonising, that experience can be.
Alongside obesity and type 2 diabetes, dementia stands now as one of the greatest public health challenges of the age. As Members of your Lordships' House have said today, it is likely that by 2025 the number of people with dementia in the United Kingdom will almost have doubled. As the Alzheimer’s Society has made clear in its excellent briefing, the cost of dementia will rise from £15 billion today to more than £23 billion by 2018.
One of the problems is early diagnosis, to which many noble Lords have today referred. I propose to spend a little time on that, because it is crucial. My noble friend Lady Murphy said in her excellent introduction that there are about 150 causes of dementia, many of them exceptionally rare. More than 80 per cent of patients with dementia are suffering from Alzheimer’s disease, but there are other, not uncommon causes—as the noble Baroness, Lady Gardner of Parkes, said, multi-infarct dementia resulting from repeated minor or major strokes is an important one. So, too, is Lewy body dementia. It is less common, occurring in association with, but not invariably so, Parkinson’s disease, because of the deposition of Lewy bodies throughout the cortex of the brain. Fronto-temporal dementia is also quite different.
It is crucial to get the diagnosis right because research is progressing in many parts of the world which is bringing within sight the prospect of a more effective treatment for the various dementias, particularly for Alzheimer’s disease, which may be a crucial development alongside the improvement in the standards of care to which many noble Lords have referred.
Unfortunately, there is no precise diagnostic test for Alzheimer’s disease. CT scanning and magnetic resonance imaging may help to show shrinkage of the brain. There are other tests, such as those for memory. More recently, a precisely defined test-your-memory test has proved to be extremely valid. It has been designed to minimise operator time and to be suitable for non-specialists to use. However, as a recent editorial in the British Medical Journal stated:
“Diagnosis requires consideration of the person’s education, culture, and circumstances; dementia presents when a person’s cognitive abilities are no longer adequate for them to cope with their environment. A high flying executive may experience problems early in the … process, whereas a resident of a care home may have no difficulty with his or her routine until pronounced changes have occurred”.
Many years ago, when I held a chair of neurology in Newcastle-upon-Tyne, I was involved with Professor Roth, Doctor Blessed and Professor Tomlinson in studying the changes in the brain occurring in patients with Alzheimer’s disease. We all recognise, as several people have referred to today, that, as we get older—I am approaching my 87th birthday—we often find problems with the memory, particularly memory for proper names. It is extremely embarrassing when you encounter somebody whom you know extremely well and suddenly find that their name has gone—you can call that selective nominal aphasia, benign cognitive impairment or benign senescent forgetfulness. In a way, Alzheimer’s disease is a rapidly progressing, advanced form of that kind of impairment, as the work of Blessed, Roth and Tomlinson showed, because, even with normal ageing, there is an increase in the number of senile plaques in the brain cortex. That number is vastly increased in patients with Alzheimer’s disease.
What about research? The Newcastle scientists, helped by the biochemists, the Perrys—husband and wife—found a serious reduction in the concentration of acetylcholine in the brain cortex. Acetylcholine is a neurotransmitter which carries messages from one nerve to another. That finding led to the introduction of drugs which inhibited the enzyme which degrades acetylcholine. Those are the drugs called donepezil, and many of its other derivatives, which have proved to be helpful in delaying to some extent the progression of the disease. However, that is symptomatic treatment; it does not strike at the root cause of the disease. In these senile plaques, which are so characteristic, and the neurofibrillary tangles which appear throughout the brain cortex, chemical substances have been identified, not least beta-amyloid and its precursor, but also a substance called phosphorylated tau, which appear to be markers of the process occurring in the cortex in these conditions. Work is now in progress in a number of centres in the UK and abroad where individuals are attempting to introduce techniques to reduce the level of those substances within the brain cortex.
A few years ago, an attempt was made to produce a vaccine and the vaccine against beta-amyloid was shown to be, in some ways, effective. Unfortunately, in clinical trials, it also produced unacceptable degrees of brain inflammation and the trials had to be discontinued, but other methods are now being explored.
Although, as a number of noble Lords have said, the amount of money being spent on dementia research in the UK is much less than in other countries, we do have centres of excellence—I was talking yesterday to Professor Martin Rossor, who is a leader in this field at the National Hospital for Neurology and Neurosurgery, Queen Square. He commends, incidentally, as do I, the National Dementia Strategy, though he feels—and I ask the Minister to comment upon this—that though the dementia strategy is excellent in what it plans and proposes for the elderly patient with dementia, it is less suitable for those who develop dementia at a relatively early age, in their 40s and 50s. The Minister may wish to comment on that point, but it is an excellent document.
These centres of excellence are in London, in Oxford and at the outstanding Centre for Brain Ageing and Vitality, led by Professor Tom Kirkwood, in Newcastle-upon-Tyne, funded by the Medical Research Council and the Wellcome Trust, where some outstanding work is going on. I stress these points because I genuinely believe that, within the next 10 years, we will see mechanisms introduced whereby forms of treatment for Alzheimer’s disease will become much more effective than those available now. That kind of treatment must stand alongside the crucial improvements in care and the other objectives so clearly set out in this dementia strategy. I think we have considerable optimism for the future.
My Lords, it is a privilege to begin to sum up at the end of what has been a highly informed and at times very moving debate. I pay particular tribute to the speeches by the noble Baronesses, Lady Murphy and Lady Perry, and my noble friend Lady Thomas of Walliswood. I should declare an interest as one of the 18 per cent of Members of your Lordships’ House who does not qualify for a bus pass. In response to the noble Lord, Lord Walton of Detchant, with every passing year, I become more inclined to think that I ought to carry a card that says, “in case of an emergency, please note, she has never been any good at remembering people’s names—do not assume that she has got Alzheimer’s.”
In thinking about this debate and reading this document today, I was trying to place this disease in its historical context. I think we have moved from an age in which Alzheimer’s, or dementia, was a thing of such fear and dread that it was locked away and ignored. Dementia has become something which people talk about in euphemism. When I talk to older people, something I do quite often, and they talk to me about other older people they know, they will say things like, “She is really losing the place”, or “You know Mrs So-and-so? She doesn’t know her husband any more.” Recently, I was talking to some younger people and they were telling me that one of them is practising for his driving test. They said, “It is really good, because his nan lives with them and she’s got Alzheimer’s and one thing that calms her down is that she loves being driven around in the car, so he is driving her around all over.”
The point is that Alzheimer’s and dementia are beginning to become part of family and community life. The thing that is missing from this document, good though it is in many ways, and the thing that restricts it as a strategy, is that it does not really address the key issues about how this disease becomes part of community and family life, with effects way beyond the narrow confines of health and social care. I think that that is the point my noble friend Lady Thomas of Walliswood was making when she talked about the disparate nature of this debate. This document, laudable and welcome though it is, is a series of unconnected points. That is unfortunate, when we are going to be looking at its implementation at a time of severe restrictions in public expenditure.
If the department had been bold, this would have been a strategy to enable individuals and communities to manage what the noble Lord, Lord Walton, rightly called one of the biggest public health developments that we have. It would have acknowledged, for example, that this is a disease with a greater incidence in areas of affluence. It is a disease that happens when people are sufficiently well and are not affected by other co-morbidities, so that they live longer. It is a disease the incidence of which is a manifestation of other health inequalities, or what I would call health poverty. It is no surprise that people who have had very distinguished careers get this disease more than others, because they have not been affected by other things.
At the beginning of setting out a strategy, we on these Benches ask, how is it that we can enable individuals, families and the state to deal with this issue as it grows? There is no doubt that responsibility for care will rest on a partnership between individuals and the state for a very long time to come.
I want to talk briefly about a strategy for research. A lot of people have talked about research into early diagnosis. Noble Lords who listened to the Reith lecture on Radio 4 will have noted the very interesting point made by this year’s Reith lecturer that much of the commercial investment in this sort of research is about early diagnosis. This is in order to produce drugs which not only help people who have dementia, but people who are beginning to go through those very early forms of forgetfulness and who wish to maintain their brain performance. The noble Baroness, Lady Murphy, said in her introduction, that there is going to be a research summit. Will the strategy for research be about discovering treatments and mitigations for early onset of the disease, which will enable people to remain economically active for longer, or will it be about research into treatments and mitigations for those who are significantly older and will therefore live longer with other co-morbidities? Will the research be about improvements in quality of life for people who have this disease and their carers, or about prevention for a younger group?
Noble Lords listening to Radio 4 this morning will have heard what has been happening with the cancer strategy and the cancer plan. I agree with the noble Baroness, Lady Greengross, that it was interesting to note that the cancer strategy has not worked as well for older people. Having said that, the cancer plan and the way the cancer plan has worked, bringing together academic research, the NHS, charities and principally to focus the involvement of sufferers is exemplary. For breast cancer, for example, it has led to the establishment of centres of clinical excellence in research and treatment, but it has done so in a way that has enabled those who have the disease to make improvements in their social care.
It was very interesting that when Professor Mike Richards was tackled recently about the cancer plan and how our cancer survival rates are not as good as those of other countries, he defended the plan, saying that any plan had to address cancer prevention and treatment as well as early diagnosis and care, and there has been an all-round improvement. If we were to have a strategy for dementia that worked in that way, it would be worth investing a very great deal of money in it.
I echo the point made by the noble Lord, Lord Rix—I never repeat his points, as he makes them far more eloquently than I do. There is a growing need for people throughout the whole of health and social care to understand dementia as it affects their discipline. Dentists, for example, need to know what to do when somebody with dementia presents to them. I would go much further and say that in the commercial world, smart companies will recognise that dementia will have a huge impact on family life. When housebuilders start building houses again, will they build very small boxy units or will they actually build houses into which three generations will at some stage move, as families with younger children will be looking after people with dementia? I think that it could go much further.
The noble Baroness, Lady Murphy, referred to the comments made by Joan Bakewell. I have been saying for some considerable time that the process of tendering for social care is wreaking a great deal of havoc, particularly upon specialist services. It is increasingly the case that a service—information and advice, domiciliary care, or whatever—is commissioned not on the basis of need or of client groups but of all people over the age of 60. I think that in future there will be many fewer specialist agencies around, particularly in the voluntary sector, to help implement some of the worthy but at times very unrealistic ambitions of this document.
My Lords, I, too, thank the noble Baroness, Lady Murphy, for initiating this debate and introducing it so comprehensively.
The National Dementia Strategy is an excellent report, and I was especially pleased that one of its objectives is to address the stigma associated with dementia and reduce social exclusion and discrimination. I have always found it rather surprising and disappointing that so many apparently intelligent people can make disparaging remarks about those with mental illness. Making comments such as, “He’s nutty”, or “He’s bananas”, or “He’s away with fairies” is totally inappropriate and, in psychiatry, might be described as “incongruity of affect”.
Age Concern and Help the Aged wanted a stronger emphasis on research in the report, as the noble Baroness, Lady Murphy, and my noble friend Lady Perry have emphasised. They want the same level of investment in dementia research as currently exists for research into cancer and heart disease. The Alzheimer’s Society compared research papers on chronic disorders and found that since 2002, 23 per cent were devoted to cancer, 17 per cent to cardiovascular disease and only 1.4 per cent to dementia, to which my noble friend Lady Perry alluded. More research is needed into preventing dementia and slowing down the development of the disease. There is always a need for more emphasis on training doctors and nurses in this subject, especially as one-third of the people in hospital beds are elderly, with mental health problems in addition to the illness that brought them into hospital in the first place.
As the noble Baronesses, Lady Thomas of Walliswood and Lady Barker, have said, there is a great need for a much more comprehensive approach to the whole problem. I think that the report might usefully have emphasised what millions of carers can do right now, without any extra expenditure, to improve the quality of the lives of these patients.
An exciting recent development in the management of dementia is the widespread adoption of the SPECAL method, which stands for specialised early care for Alzheimer’s. It is based at Burford in Oxfordshire and was developed by Penelope Garner. It has been validated in the past by the Royal College of Nursing and the Care Consortium of the Alzheimer’s Society. I am grateful to the clinical psychologist Oliver James for a tutorial on this subject. His book, Contented Dementia, describes the method which is now used all over the country, with carers and professionals now able to provide 24-hour well-being. It is the only management method which seems to confer contentment. A 2005 review published in the Journal of the American Medical Association shows that none of the conventional methods is very helpful, which is presumably why there is such a heavy use of antipsychotic medication for these people.
There are now dozens of centres throughout the country which train carers in this SPECAL method. In cost-benefit terms it has massive implications: it reduces the need for emergency care, eliminates the necessity for antipsychotic medication and relieves the stress of carers. Without any impetus from Government, coming up from the grass roots, SPECAL is rapidly becoming the best accepted way of managing dementia.
Penny Garner, the founder, uses the analogy of a photograph album. If you think of the individual photographs as memories, then in a healthy individual the album is full. But in Alzheimer’s sufferers, many new experiences fail to get stored as photos in the album at all. The recent pages of a sufferer become increasingly blank, while the earlier ones remain intact. Suppose your husband tells you at breakfast to book some cinema tickets and you agree to do so. Unbeknown to you, your dementia means that this discussion has not been stored in the album. When asked about the tickets in the evening, you have no record of the original plan. You may get annoyed at being “wrongly” accused of having failed to carry it out. You become angry, then confused and scared.
Penny argues that the distress is compounded by well meaning attempts to remind the sufferer of what they have forgotten. Nellie, aged 81, was creating mayhem by wandering around the house and garden. In response, her fiercely loyal, military-trained husband, Richard, was providing detailed lists of what she had to do that day to “get the old girl sorted out”. This is the standard response, known as reality orientation. But it usually results in the sufferer thinking, “Why is this person constantly telling me my name? Are they mad?”. Instead, Penny Garner gets alongside the sufferer by finding out what used to be in their album. Extensive evidence from brain scans now proves that although short-term memory is damaged, the long-term memory is largely or completely intact. So Penny ferrets out from the family members the emotional places where they liked to be, stored in the long-term memory. Using this as a context, and taking the lead from the sufferer, Penny enables them to live almost all the time in a happy place. She “makes a present of the past”, as she puts it.
Gardening was Nellie’s happy context. With SPECAL’s help, Richard provides clues from her album which remind her of pruning flowers, so secateurs were placed all around the house. Soon she stopped drawing blanks; instead, she would wander around the house on the way to the garden to do some pruning. Mostly, she never got there, waylaid by discussions about the best implements for pruning, moving from one pair to the next. Living this happy way her mood improved dramatically. By finding benign, historical context, SPECAL creates a lifelong sense of well-being, rather than the rage and confusion that are triggered by the conventional responses to dementia. Oliver James states that dementia does not need to be hellish as it is possible to create a sense of well-being for the rest of the patient’s life. The person with dementia can no longer reliably store new facts but does continue to store feelings in the normal way.
The noble Baroness, Lady Gardner of Parkes, drew attention to the value of practical advice. Penny Garner found that the following advice is helpful. First, it is important to realise that people with dementia find it difficult and frustrating to answer questions. This is due to their impaired ability to remember. The solution therefore is to avoid asking them questions. Secondly, as their long-term memory is usually intact, one should concentrate on their long-term memory and celebrate it. Thirdly, always agree, never argue should be the policy at all costs. It does not really matter if they believe that a dead relative is alive or if they think that they are at the airport when they are actually shopping in the supermarket. Fourthly, when the short-term memory deteriorates further it is quite usual for the patient to ask the same question over and over again and it is very easy to become exasperated. The best thing is to be hesitant in answering the question, so when the repeated question is, “What day is it?”, one says: “Well, let’s see, um,” then look at the watch or the calendar and say, “it’s Wednesday”—actually it is Thursday. One does all this without appearing to be patronising in any way. We need to identify pleasurable themes from the past to help them make sense of the present. For example, it is possible to spend much of the day planning to watch a favourite old film. Routine, based on life well before the dementia developed, is very important and, if at all possible, once established should not be altered.
In conclusion, may I repeat that Alzheimer’s disease does not need to be hellish as it is possible to create a sense of well-being for the patient. The methods advocated by the charity, SPECAL, are much better than smothering the patients with excessive drugs.
My Lords, I congratulate the noble Baroness, Lady Murphy, on securing today’s important debate on the National Dementia Strategy. There can be no doubt that dementia is one of the most challenging issues we face as a society today. This has been a classic debate in your Lordships’ House and there has been enormous expertise as well as enormous compassion in many of the contributions. It has been a privilege to listen to the debate and to answer it.
The scale of the problem has not been underestimated by the contributions of noble Lords. It is a devastating illness with major consequences for the people who develop the condition and for their families. The noble Baronesses, Lady Perry, Lady Thomas and Lady Warnock, spoke with enormous eloquence about the painful nature of this disease. As a society, because we are living longer, it increases the likelihood that we, or someone we care for, will be affected by dementia at some point in our lives.
Dementia is one of the main causes of disability later in life, ahead of some cancers, cardiovascular disease and stroke. It is estimated that there are already around 700,000 people with dementia in the United Kingdom, a figure that is set to double in the next 30 years. The direct costs of dementia to the NHS are approximately £3.3 billion a year. The overall annual economic burden is estimated to be £14.3 billion a year, or £25,391 per head. The estimated prevalence of dementia in people aged over 65 living in nursing homes is between 66 per cent and 80 per cent, with similar rates in care homes. To deal with this growing problem, it is right that we develop the services to deal effectively with dementia while ensuring that people with dementia and their carers are treated with dignity and respect and receive the support that they deserve.
The publication of the first ever National Dementia Strategy this February was an important milestone in raising dementia up the agenda and giving priority to improving dementia services and raising the quality of care. The content of the strategy was welcomed by a wide range of the stakeholders involved. I am glad to say that it has received support across the political spectrum. The praise it received is a direct consequence of the extensive and detailed consultation that took place in preparing the strategy.
The shortcomings of existing dementia services have been well documented and mentioned today. It should be recognised that many people with dementia do receive wonderful support from dedicated health and social care teams who provide high quality care. A good example is the Croydon Memory Service, which the Minister for Care Services will be visiting shortly. We are working to ensure that this sort of provision becomes the norm rather than the exception that it is at present.
The National Dementia Strategy provides a strategic framework within which local services can deliver quality improvements to dementia services and address health inequalities relating to dementia. The strategy has 17 key objectives and we do not apologise for that number of key themes. I very rarely disagree with the noble Baroness, Lady Barker, but on this occasion I will as I think the strategy hangs together rather well. It does address many of the issues that were raised by the noble Baroness and by other Members of Your Lordships’ House.
The first theme is one that was referred to by many noble Lords—raising awareness amongst professionals and the general public alike. It is a vital component if we are to make progress. If we are to challenge the stigma and the taboo that was mentioned by the noble Baroness, Lady Warnock, we need to improve people’s understanding, remove the level of stigma that exists and tackle the misconception that dementias are untreatable. The Department of Health has already provided funding of more than £500,000 to support the Alzheimer’s Society’s “Worried about Your Memory” campaign. A range of materials has been issued to all GP surgeries in England to help raise awareness of dementia in the general public and better to inform those concerned that they may have the early signs of dementia. A further £1 million is to be made available later this year for more work on raising public awareness.
The second theme of the strategy addresses early diagnosis and intervention, mentioned by most of the noble Lords who contributed to the debate. The lack of early diagnosis, and services to deliver it, is a major problem and one where action clearly needs to be taken. Only one third of people with dementia ever receive a formal diagnosis. That is unacceptable. A core aim therefore of the dementia strategy is to ensure that effective services for early intervention are available on a nationwide basis.
The third theme is improving the quality of care, again mentioned by many noble Lords. We are at the beginning of a process of implementing the National Dementia Strategy over a five-year period. It is backed by £150 million of initial funding. I stress that this is initial funding as £150 million would not be adequate if it was all that was there. The Government’s aim is for services to transcend existing boundaries between health and social care, as well as between service providers and people with dementia and their carers. We will be addressing the vital issue of training and development for NHS and social care staff who come into contact with people with dementia. I take the point that one noble Lord made that this does not just concern people working in social care or who nurse people with dementia, but includes most health professionals—dentists and so on.
There are already examples of good local training in dementia taking place across the country. We need to standardise this and ensure that everyone working with people who have dementia is aware of the signs and symptoms of the disease. We will be working with the royal colleges and professional bodies to ensure there is appropriate training on dementia in undergraduate and postgraduate training in both health and social care courses. The noble Baroness, Lady Thomas of Walliswood, and my noble friend Lady Pitkeathley particularly mentioned the training of home care staff and carers. I absolutely take their point.
We have made headway in terms of vocational training for social care staff. Skills for Care has produced guidance on what care workers need to know and the skills that they should possess to provide good-quality dementia care. Similarly, the General Social Care Council has recommended that all domiciliary care workers should gain a relevant qualification on entry to the social care register. That will help to drive up standards and ensure that staff working with dementia sufferers are properly trained. The noble Baroness, Lady Greengross, was concerned that that should happen, and she is absolutely correct.
We will make extensive use of national levers, such as the Joint Strategic Needs Assessment, local area agreements, the NHS operating framework, the commissioning framework for health and well-being and the world class commissioning programme, to ensure that the strategy is fully implemented locally and that services improve as a result. I hope that that addresses the question asked by the noble Baroness, Lady Murphy, at the very beginning of this debate about how we would ensure proper implementation. We intend to use the levers that we have established to drive that forward.
Improving dementia services is not just a matter for central government—it is a matter for local government, NHS managers, frontline practitioners and, vitally, those who use health and social care services. Neither is it just a matter of funding for dementia services. It is as much about how all the players involved can learn from best practice better to meet the needs of those suffering from dementia and their families. We must recognise that, in practice, the pace of change brought about by the implementation of the strategy will vary, depending on where services are at present. Some areas will have achieved all the strategy’s aims and objectives within the five-year implementation period. Those starting from a low base may take longer. Our job is to drive that forward, monitor it and ensure that we are giving local services the right kind of support so that they can deliver the right services. We have every intention of ensuring that that is the case.
To help make the changes needed, we have already set up a nationwide support programme with expert regional teams working closely with the NHS and local authorities in implementing the strategy. Their particular focus will be on supporting those services that are starting from a lower base and need most help and guidance. I should also mention that the department is currently setting up demonstrator sites to provide evidence on the role of dementia advisers and peer-support networks. Bids from more than 100 PCTs and local authorities were received to run these sites. This work is progressing well, and we will be announcing the chosen demonstrator sites in early July. I am pleased to be able to tell the noble Baroness, Lady Murphy, that we are addressing the important area of research into dementia, looking at our future need for research relating to the causes of the illness, potential cures, treatment and care for people with dementia. I hope that that partly addresses the issue raised by the noble Baroness, Lady Barker. I was recently able to attend an enormously helpful round table discussion on this chaired by the noble Baroness, Lady Greengross, and I am very glad that she has also agreed to chair the Government’s dementia research summit taking place on 21 July.
The summit will involve key researchers from all the relevant aspects of research, from the UK and abroad, as well as people with dementia and their carers. We believe that it will provide us with a better picture of the current body of research, where there are gaps in our knowledge, and what the priorities should be in focusing on research effort. The noble Baronesses, Lady Murphy, Lady Barker and Lady Greengross, asked whether I could assure them that the dementia research summit will provide a future strategy. I promise that that is our intention. The Medical Research Council, which is jointly running the summit, will produce a framework for the future of research and will take account of the conclusions reached at the summit and the gaps that are identified.
National clinical leadership for the strategy is of course of huge importance, and will be provided in future by a new National Clinical Director for Older People and Dementia. The post has recently been advertised and we expect it to be filled in the autumn. I should stress that there is much that needs to be done locally in terms of leadership to drive forward implementation. The strategy makes very specific recommendations on the need for better leadership in hospitals and care homes. We want to see the identification of a senior clinician in all general hospitals and an appropriate member of staff in care homes to be given the specific responsibility of ensuring good quality dementia care.
I now turn to some specific points raised by noble Lords. I will try to address them all in my remaining time, but if I do not address everything, I promise to go through the debate and write to anyone who has not had their question answered. The noble Baroness, Lady Murphy, raised the issue of how the Government intend to monitor spending and implementation. I think that I have addressed that point, but Objective 17 of the strategy calls for good quality information to be made available on the development of dementia services, so it is definitely integrated into the strategy. The noble Baroness also asked about the All-Party Parliamentary Group on Dementia report on training. I know that we are not allowed to use visual aids, but I read this report as part of my briefing and we know that improved training for all those involved in dementia care is a core part of the national strategy. Our challenge is of course to change the undergraduate and postgraduate curriculum for professional and vocational training, as I have already mentioned.
My noble friend Lady Pitkeathley quite rightly made the link between the National Dementia Strategy and the Carers Strategy. It is of course essential. Family carers are central to the National Dementia Strategy and I can confirm that those developing the strategy worked closely with those working on the Carers Strategy and will continue to do so as we enter the implementation stages of both those strategies.
My noble friend and the noble Baroness, Lady Murphy, both referred to the Green Paper. I will repeat exactly what my right honourable friend the Secretary of State said in another place:
“In early July, we will publish a Green Paper setting out options to reform the care and support system”.—[Official Report, 23/6/09; Commons col. 656.]
I suspect that the date will be nearer that mentioned by my noble friend and the noble Baroness, Lady Murphy, but I am not allowed to mention any date specifically.
My noble friend continued to make the point about carers and I should like to add to my remarks that the £150 million available to PCTs in addition to the £25 million available to councils to help them to provide short-term cover in emergencies may help to reassure them. By March 2011, we will have invested £1.7 billion to councils to support carers.
The noble Baroness, Lady Perry, made a most moving speech and I felt privileged to listen to it. Most eloquent in terms of the description of her husband's dementia was the plea for information. I completely agree. We are determined that that is part of the strategy and that we need to deliver it. I am completely at one with the noble Baroness about that.
The noble Baronesses, Lady Thomas and Lady Greengross, both raised the issue of anti-psychotic drugs. The Government agree that the potential overuse of anti-psychotic drugs for people with dementia is a serious issue. The department is undertaking a review of the over prescribing of anti-psychotic drugs for people with dementia in care homes. That follows emerging evidence that such drugs were being prescribed excessively and inappropriately. The review remains a priority and we will publish the results shortly.
The noble Lord, Lord Rix, raised the issue of dementia and people with learning difficulties. He was completely correct about the need for the dementia strategy to explicitly include those with dementia who have learning difficulties. Indeed, it does. Of all the people who present problems, it is very important that early diagnosis and appropriate care is there for people with learning disabilities. The noble Lord quite rightly pointed to the shortcomings. The National Dementia Strategy is designed to change that and good quality care for people with learning disabilities and dementia will quite clearly require joint working and a specifically tailored approach. We are discussing that, as advocated by the royal college. The implementation strategy will provide some of those solutions.
The noble Baroness, Lady Warnock, raised an interesting issue about stigma and taboo. It was a point very well made. The noble Baroness also raised the issue of early diagnosis. She is completely correct. Our strategy is clear about the need for early diagnosis for all those with dementia. One of the reasons is that this gives people the ability to make choices themselves while they have the capacity. It gives people with dementia the chance to discuss their future care and to record decisions about their future care. I can assure the noble Baroness that the diagnosis of dementia does not mean that a person lacks the capacity to make such advanced directives for information about their future care. In fact, that is extremely important.
I always love listening to the speeches of the noble Baroness, Lady Gardner of Parkes. They are always informative; they always make a pertinent point; and they are always very human in what they relay to us. She was completely correct, and illustrated it with the points that she made, that early diagnosis is absolutely the key.
The noble Baroness, Lady Greengross, referred to money for research. We know that it is not sufficient and that there is much more work to do on that. I am extremely pleased that the noble Baroness is chairing the summit on science and research. I very much enjoyed the round table that she organised the other day, particularly when the group was discussing GP diagnoses. It is an issue that is being raised by many noble Lords. I was very struck by the remarks made by Professor Steve Iliffe about the problems that GPs themselves face in making the diagnosis.
The noble Baroness, Lady Howe, made an important point about the role of employers in this matter. She was the only person who made that point. I agree with the noble Baroness about the value of the Alzheimer’s Society and the work that it does. As ever, the noble Lord, Lord Walton of Detchant, gave us a master class in the research and the science of research. I really appreciated the message of hope that he left us with at the end of his remarks. I thank him very much for doing that.
The noble Baroness, Lady Barker, made a very pertinent point about the cancer plan being a very good model and about how one takes this forward in terms of research. As ever, the noble Lord, Lord McColl, had something unusual to say. I remember reading about the programme in a Sunday newspaper and being very struck myself about the imaginative nature of that programme.
We have had an excellent debate today. I thank noble Lords very much for their contributions. I congratulate the noble Baroness again on giving the House the opportunity to discuss this important issue. The National Dementia Strategy is an excellent document that spells out the full range of changes that need to be made. These changes will not happen overnight. However, the Government are fully committed to their implementation. An excellent start has been made in creating the dementia services that we can all be proud of in the future.
My Lords, I thank the Minister for her very helpful response. With that little hint of more money to come, I feel even more optimistic. I am very grateful for the wise contributions that have been made to the debate today. The personal story of the noble Baroness, Lady Perry, has moved us all and reminds us that we cannot take away the personal tragedy for the people who love those who suffer from this condition. We can, however, hope to improve it substantially with good care treatment and proper research. I beg leave to withdraw the Motion for Papers.
National Security Strategy
My Lords, my right honourable friend the Minister of State for Crime, Policing and Terrorism answered an Urgent Question earlier in the other place. With the agreement of the usual channels, it is being repeated in this place as a Statement, as is the practice. The Statement is as follows:
“Mr Speaker, at 10 o’ clock this morning my right honourable friend the Prime Minister made a Written Ministerial Statement, laying before the House this year’s update to the national security strategy. Accompanying the strategy update is the first national cybersecurity strategy for the United Kingdom. Last week, the Government presented to the House the Digital Britain strategy. This country is well placed to take advantage of the opportunities of the digital age. However, we can seize these opportunities only if people are confident that they can operate safely in cyberspace.
Every day, millions of people across the UK rely on the services and information that make up cyberspace. The internet is accessible in 65 per cent of United Kingdom households, a figure that is growing by about 8 per cent per year. Plastic transactions, which depend on wired or wireless communication, make up 90 per cent of our high street purchases.
The national security strategy, published for the first time by this Government last March and updated this year, sets out an honest and transparent appraisal of the risks that we face, including the threat that organised crime poses to our country. Organised crime costs this country £20 billion per year. We have a duty to the British public, and to British industry, to take all measures to reduce dramatically this cost. The Government also need to assess the threat from terrorist organisations and other states and prepare our response to that. The public would expect no less.
All these threats can arise in cyberspace. As the director-general of the Security Service has said,
‘a number of countries continue to devote considerable time and energy trying to steal our sensitive technology on civilian and military projects, and trying to obtain political and economic intelligence at our expense. They do not only use traditional methods to collect intelligence but increasingly deploy sophisticated technical attacks, using the internet to penetrate computer networks’.
We know the importance that terrorist groups—notably al-Qaeda and its affiliates—place on the internet and cyberspace. This is particularly important at the moment for propaganda. We know that terrorists would like to be able to operate more effectively in cyberspace. This Government are not in the business of scaremongering. We do not assess at present that terrorists have the capability to mount such an attack imminently but we must prepare as terrorists become more sophisticated.
These threats from states or terrorists could affect critical national systems. There is a real threat to millions of ordinary citizens, their transactions and the businesses that they work for. Online fraud generated £52 billion worldwide in 2007. The average cost of an information security incident for a small company is in the range of £10,000 to £20,000. For a large company, it can be more like £1 million to £2 million. As the UK’s dependence on cyberspace grows, so the security of cyberspace becomes ever more critical to the health of the nation.
So, today, the Government are publishing the first cybersecurity strategy. As a result, we will establish the office of cybersecurity in the Cabinet Office, to lead on cybersecurity issues, and a cybersecurity operations centre, a multi-agency body based alongside GCHQ in Cheltenham. This organisation will also examine the operations and technical capabilities needed.
As a result of the new strategy, we will develop a cyberindustrial strategy for critical UK cybersecurity needs, in the same way as we have a defence industrial strategy. We will develop a cybersecurity skills strategy for the UK, plugging existing gaps and creating more high-tech employment opportunities. We will make critical systems in the public and private sector more resilient and enhance our ability to detect attack. We will develop the international law and doctrines of national defence in cyberspace, working with other countries. We will better advise business and citizens about the cybersecurity risk picture and the steps that they need to take to address it. We will develop new strategies for tackling terrorists’ and criminals’ use of cyberspace with our colleagues, in line with the ACPO strategy for law enforcement on cybercrime due out shortly. We will also plan emergency response. The new centre will test the UK’s ability to respond to a major attack, as we do for terrorism, in setting up a strengthened analysis function for cyberthreats.
As with all our national security activity, it is important that government powers are used proportionately and in a way consistent with individual liberty. So we will set up an ethics advisory group to advise on this. I will update the House on its membership when it is formed. The centres will be operational in September and new funding will be announced before then, building on the existing resources allocated largely to intelligence agencies. I will report back to the House.
On the wider national security update, the Government have taken forward the good start made last year. We look across the broad range of national security threats. We have set out an updated analysis of the threats that we face and made new commitments on tackling what drives insecurity in the world. These are conflict, energy shortages, poverty and, looking to the long term, the impact of climate change.
Keeping Britain safe depends on the dedicated and professional work of the Armed Forces, the intelligence services, the police and other services. I pay tribute to them all”.
That concludes the Statement.
My Lords, as always, I thank the Minister for repeating the Statement. We agree with the Government that there is no more important responsibility for government than national security, so we find it extraordinary that this Government have published the country’s first cybersecurity strategy and the 2009 update to the national security strategy by way of a Written Ministerial Statement.
These have come after the strategies had first been trailed in the press in an extraordinary way. Indeed, I understand that in another place yesterday Mr Speaker made a Statement, his first after being elected, pointing out the importance of Ministers presenting to both Houses of Parliament changes in policy on important matters before trailing them in the press. It is only as a result of an Urgent Question from our Benches in another place that the Minister is before our House today and we have this somewhat limited opportunity to debate the strategies. By using a Written Ministerial Statement, the Government were, in effect, trying to ensure that both Houses of Parliament did not have the appropriate opportunity to discuss or debate the strategies.
The Government are making much of their new cybersecurity strategy. Action in this crucial domain is due—indeed, long overdue. And what does it amount to? It includes the establishment of an office for cybersecurity in the Cabinet Office and the upgrading of an already existing unit in Cheltenham, which is to be called the cybersecurity operations centre. It is impossible to know, however, how significant these changes are, because we are not told what funding is being made available to enhance our ability to tackle cyberthreats. The Government’s special supplement on cybersecurity contains some figures as to the costs of cyberinsecurity to the nation, but we will have to wait until the autumn to know how much money the Government will devote to the tasks set out in the Statement.
The Government also tell us that they are now giving leadership to this issue. But how does that square with using the gag of a D notice to stop us knowing who the new director is? I understand that, regardless of that, the name has been leaked.
Cybercrime proceeds apace in the absence of cybersecurity. There is significant cybercrime in the United Kingdom. Many in this House will have had experience of it in relation to bank accounts, but the strategy has virtually nothing to say about the response. It simply tells us that the Association of Chief Police Officers will produce an anti-e-crime strategy later. I might say that at present the Metropolitan Police has a unit of 12 officers devoted to national e-crime. It is hardly surprising that it is difficult to get action when an e-crime is committed. We have a long way to go on this matter.
There is some confusion about the way in which these structures will work and whether or not there is overlapping and overbureaucracy in all of this. Can the Minister assure this House that the Government have not set in place structures that will duplicate existing work on cybersecurity and information assurance? There seems to be a real risk of duplication, since other units appear to continue to do work in this area without being tied properly into the new structures. There are no efficiency savings here, it would seem. What do the Government mean when they say that the office for cybersecurity will be based initially in the Cabinet Office? What are the longer-term intentions?
Clearly, the Government have missed an opportunity here to review more widely and make sense of the very muddled security structures that exist across Whitehall. The need to produce a substantial update to the national security strategy just over a year after publishing the first version is an admission that the Government’s first attempt was not actually a strategy, as it did not adequately set long-term direction for different departments and agencies.
It remains to be seen what effect this update will have in the absence of a proper national security council with a dedicated staff and a proper national security budget. Indeed, we are also left waiting for a lot of detail on organised crime, maritime security and energy security, which are promised for later. Instead of saying what will be announced later, as the Minister repeating the Statement made clear, and coming back to the House again and again on other matters, the Government should have done the work first and should have been be able to tell us now how we are to proceed. Will there perhaps be a third update next year? In particular, will the Minister be more specific on when the energy strategy will be published? Will he say when the reviews of the organised crime strategy and the maritime threat will be completed and whether they will be published?
In this House we have the opportunity by way of a Statement to have a few more minutes than were available in another place. It was regrettable that this matter could be debated in another place only by way of an Urgent Question, which is all too brief. I should be grateful if the Minister could indicate that the Government would welcome an approach from the usual channels to ensure that there is a fuller opportunity to debate these matters on another day.
My Lords, we on these Benches, too, find the process by which this Statement has been made extremely regrettable. The Minister will remember that, on the Second Reading of the Policing and Crime Bill, I raised at some length the issue of cybercrime, because we felt that it was a very much more serious issue than those dealt with in some of the unnecessary parts of the Bill. It is particularly surprising and regrettable that, if the Minister had in mind the fact that there would be this big revelation on cybercrime, we could not have considered something in this House in a more structured way.
This Statement is a lot more about headlines, because there is actually not much action in it. I shall give the Minister a few examples of the action that we would have been pleased to see. However, perhaps he can first tell me whether we have ratified the European Convention on Cybercrime. Particularly important is Article 25, which enables us to co-operate properly, have mutual legal assistance, respond to requests for help from other countries and make the best use of all the international provisions. This is because a lot of e-crime is perpetrated in countries such as Brazil, China and so on. Without a proper co-ordinated international effort, we will not get very far. Perhaps the Minister could also confirm that, where serious e-crime is perpetrated in third countries, the extradition arrangements are satisfactory, because the tariffs have been so low for these offences that they were not extraditable.
The Minister talked of the ordinary citizen. Another enormous problem for the ordinary citizen on whom e-crime impacts heavily is that, according to a Written Answer that the Minister was kind enough to send me earlier this year, the Government do not collect central figures on e-crime in any case, so we do not know its scale. It would be interesting to know from the Minister whether the liability of banks for losses suffered by people as a result of e-crime when the banks’ security systems are not efficient is underpinned by legislation, because that area remains dependent on just the Banking Code. Will the Government look at strengthening that?
The public need a lot more help in getting safe online. Will the Government, as a result of this new effort on cybercrime, launch a much more targeted and satisfactory effort on helping the public to get safe online? They should start by running an advertising campaign, obliging retailers to offer a “get safe online” package every time they sell a new computer and encouraging colleges to offer short courses on exactly what is necessary. There is an awful lot to be done in this area. Most people who are fairly computer literate are still astonishingly illiterate when it comes to how to get safe online. I admit that it is quite difficult to know all the things that you should be doing. In the parliamentary system, we are somewhat helped by having it done for us, but that cannot be said for the ordinary citizen and that needs to be addressed.
The Minister spoke of an ethics advisory committee, which may offer some reassurance when we look at the centre that is to sit alongside GCHQ. However, a more practical step was suggested in this House last Friday, which was that there should be a Joint Committee, as recommended by the Constitution Committee of this House. However, the Government said in their response that they had no intention of pursuing that idea. That is a big gap. There is a lack of parliamentary oversight of this area. It is falling in a gap between the Home Office and other departments, so a Joint Committee—a considered suggestion from the Constitution Committee—would be a very good first step. If we are going to have a cybersecurity operations centre, doing all the data mining and interception of web traffic that that involves, we surely need proper parliamentary scrutiny, starting with the Joint Committee. Finally, will the Minister tell me whether he still feels, in the light of the new cybersecurity operations centre, whether RIPA is fit for purpose? I hope that we have the opportunity to debate this at greater length, because there are an awful lot of questions that we need to ask about it.
My Lords, first, I thank the noble Baroness, Lady Anelay, for raising a number of points. It was good to see her at the start of the debate. I have noticed that a colleague of hers has appeared on every media channel in the past two hours, talking about this national security strategy, and I must say I am impressed by the speed with which she had managed to read it and absorb it all. I apologise for the fact that there was an error in a department with a D Notice that went out quite normally. We try to protect people who have been working in very sensitive areas, but I am afraid that department put in a D Notice rather earlier than it should have done, and that led to a couple of articles. I wrote a letter to the Speaker and to the honourable Crispin Blunt in the other place, explaining that. I apologised for that having happened. The department that did it realised the error of its ways—there are some people walking on stumps—but I will not go into any more detail on that. The way we have issued this, with my right honourable friend the Prime Minister producing this as a Written Ministerial Statement, with two documents, was absolutely right.
I agree with both speakers so far—I absolutely hope that there will be a debate on these really important issues. However, I had hoped that we would have the debate after people had read the documents in detail, because they are highly complicated. We could then have a deep and meaningful debate. I am aware, because of happenstance and this unfortunate D Notice, that this has all happened in rather a gallop. I certainly want to have a proper debate later, and I thank the noble Baroness, Lady Anelay, very much for the noble way she has pushed this forward today. It is unfortunate that people are talking about this without actually really knowing very much about it, and I am a little disappointed about how that has been done.
The noble Baroness talked about duplicating various things, but I think the document merits considerable attention. Far from duplicating things, we are actually co-ordinating and pulling together all the work that goes on. We have been aware of these threats now for some time. When I was Chief of Defence Intelligence, back in 1997, I was aware of various threats, but of course we were not so well joined-up and so close together. When I took over this job in 2007, it became very clear to me that we needed a co-ordinated strategy. A lot of very good work was being done in the CESG in Cheltenham, in other centres of excellence, and in many of the financial institutions, but the people who were getting at us were getting cleverer and cleverer at doing it. However, we were getting more and more interconnected. There is always an extraordinary balance in which all of these lovely things we have now—these amazing computer capabilities, hand-held sets, the ability to transfer data and to use satellites—are designed to be as open as possible to let us share data. That is great for business, globalisation and for lots of things, but it is of course a huge vulnerability when there are nasty people who want to get at it. Steadily, it has got more and more complex and people have got cleverer and cleverer at actually attacking us in those areas. Therefore, it became very clear when I took over in 2007 that we needed to co-ordinate all the very good work that was going on.
The noble Baroness mentioned the amount of funding involved here, and of course we will look specifically at funding. My honourable friend in the other place gave a specific commitment to come back to Parliament to look at the funding available for training people and for another work stream, which I have forgotten at the moment. He will come back with evidence on those two areas. Lots of money is being spent, and I want to co-ordinate this better. It is too easy, and it is wrong and old-fashioned, to just try to throw money at something. We need to get it co-ordinated, use all the money that is there and get this efficiency and use it properly. That is what I am trying to do within this strategy, and I think that will be achieved.
The first national security strategy was a huge step forward—we had not done something like that before in this country. We looked at it across the board, for all threats, and we thought of it in terms of the citizen. We said we would develop and build on that, and that is what we have done. We are still building it around the citizen, so that we can relate this to the citizen in every single area. One of the great successes of the last strategy was that out of that I pulled a National Risk Register, which goes right down to the various local areas, to the local risk forums. In that, we said that pandemic flu was probably the most likely and most dangerous risk, and so we started making preparations. There is now a pandemic—although luckily it does not seem to be really virulent at the moment—and when it began the World Health Organisation said that Britain was the most prepared country in the world. That was because we had identified it in our national security strategy.
We have now covered more areas, and are working through this in a much more structured way. There is a logical sense to the way we have gone about the strategy so that people can follow it. The average citizen can read it, work it out, and say, “Oh yes they’ve done that”. The strategy looks at various domains, which is why cyber is such an instant success as a domain that we need to work in. A lot of work is going on in the maritime area, but it leapt out at me as one where there are so many fingers in the pie that we need to co-ordinate it better. That is what we will do. Within 12 months, we will actually have an answer and a proper, tied-up strategy stopping things like the attack on Mumbai coming from the sea, and piracy. We will know what is around our coast. Space was another area that we had not really addressed properly. I have said we need to co-ordinate it, and we are now doing that. However, you cannot do everything instantly—there is only limited resource in terms of brains and people. However, we have done a remarkable amount—we are delivering these things and we now know very clearly which way we are going. The cybersecurity strategy is just one chunk of that, another domain rather like maritime—it is a new domain and one we need to work in.
The noble Baroness, Lady Miller, mentioned that she has talked about cybercrime for some time. I have touched on that—it has been growing and we have been aware of it. The reason we have gone about it the way we have is that the connectivity increased and the capability of attacks got bigger. We needed to co-ordinate it more, and that is why we are where we are. However, it is a complex thing, and to get all these people to work together is complex and difficult. We are very lucky in this country—we have some remarkably capable people, and we need to grow more of them. We need to become a centre of excellence in the world, because we are ahead of anywhere else. We worked really closely with our American cousins and there are very close links between GCHQ and the NSA. But of course they are in a far worse place than us because they were connected up long before we were. They were using computers and talking to each other when we were still on quill pens—not quite, but you know what I mean. But as we came into that computer age later, our government net, for example—the gsi.gov.uk net—had a very restricted number of portals. It is quite difficult for people get in, and we know the number of attacks. The American system has more than 8,000 portals in its government network. We know from some of our pointy-headed hackers how easy it is to get into it, and therefore the Americans have a real problem to resolve. We are working very closely with them on this, and in fact we were doing this work at the same time, if not before, them. Therefore, it is rubbish when people say that President Obama has grabbed this, that he has jumped ahead of us and that we are not catching up. We have been working with the Americans and I think that we have delivered a great deal.
The noble Baroness, Lady Miller, mentioned the EU convention. We are still working on that, as there are complexities and difficulties within government. The ethics part is for individuals but aspects of law are also involved. We have to get all these things right. We are still working on that and we hope that it will be completed fairly soon.
The noble Baroness is absolutely right about individual members of the public. Although I have now been made the Minister responsible for cybersecurity, I sometimes feel like an ingénu? in this area. It is quite daunting and horrifying to see how people who want to get money out of you or cause damage can fool you into giving up data. Part of this whole package is intended to teach our people so that they are aware of the risks. Very often, the weakest link in any net is the human being. People are sent something, they open it up and are then asked a question in a clever way. They answer and—bang—every bit of their computer is suddenly available for others to use. I will not mention some of the clever things that these people do to get information because we do not want to let other people know about them, but I can say that they are quite terrifying. Our aim is to teach people about these things. We will set things up to let people know about these matters and train them, letting them know the right things to do and putting in place mechanisms within the system to make things safer.
As I said, far from this being done somewhat late and in a bit of a rush, I think that we have acted in a timely and sensible way. There is no confusion or duplication; we are tying things together. Very shortly, the Home Office will produce something on serious and organised crime. We are addressing every one of these areas and pulling them together. I think that what we have done is rather impressive, but I had better stop now and allow more questions to be asked.
My Lords, I thank the noble Lord for his Statement. However, does he agree that measures to address the threat to states from cyber attack have to be global and all-inclusive? I hope to heaven that he does agree with that. If he does, is it not quite extraordinary that the only short passage in his relatively long Statement referring to the global impact and the global measures that are needed is where it says that the Government will,
“develop international law and doctrines of national defence in cyberspace, working with other countries”?
That is only a tiny fragment dealing with the essential urgency of a global approach to these matters. One cannot help but come to the conclusion that the Government’s approach to this, once again, is all talk and no action.
The Minister has been boasting about what the Government have done but perhaps I may ask him two questions. First, if the Government regard this massive threat as urgent, why has the Council of Europe’s Draft Convention on Cyber-crime, which the United Kingdom signed seven and a half years ago in November 2001, not yet been ratified? What could the reason be for that? Secondly, NATO’s Cyber Defence Management Authority has been operative since April last year. The United States has signed up to it but the United Kingdom has not. All this adds up to the irresistible view that the Government have spent these past years half asleep in relation to these matters. What are they going to do to harness the serious threat of cybercrime on a global scale?
My Lords, we have a set of work streams and one that the office for cybersecurity will tackle relates to international engagement. We are engaged internationally. As I said, we are almost joined at the hip with the US, and that stems from the agreement signed in the late 1940s between the NSA and GCHQ. We are working very closely with the US on its huge project to sort out the problems that it has in this area. Indeed, at times the US has used us to help in finding out what some of the problems are. We are working with the US very closely, as we are with the French and a number of European allies. Therefore, an international engagement work stream is part and parcel of this whole issue.
I mentioned to the noble Baroness, Lady Miller, that we are working on the agreement with Europe, which we hope to have ready soon, although there are complexities in these matters. I agree entirely about NATO, and I think that we will have to put in more effort there. That is why I want an international engagement stream, because I believe that we need to be closely involved. It is a global issue, although I think that there is a difference of equity among people. We have a greater understanding with the US by a quantum amount than we do with almost any other country. However, that does not mean that we do not need an international work stream, and that work will be done.
My Lords, my locus in this is that, when I was in the position of my noble friend Lady Miller, I worked on the pre-legislative scrutiny of the Communications Bill and the RIPA legislation. I listened to the Minister and heard his passion for co-ordination. Perhaps I may ask him to think again and not just to give an off-the-cuff reaction to the idea put forward by the Constitution Committee and my noble friend for a Joint Committee to look at these issues. The more he spoke, and the more enthusiasm he expressed, it seemed that the bit of co-ordination missing from the puzzle was parliamentary oversight. Therefore, that suggestion for such a committee bears re-examination.
When we carried out pre-legislative scrutiny of the Communications Bill, we took a conscious decision to leave the internet out of the scope of parliamentary legislation. It was felt that it was such a wonderfully dynamic opportunity that it was wrong to encumber it with legislation. However, should the amazing growth of technology be revisited or should the internet still be free?
Linked to that, I also worked on the RIPA legislation, where it was often a case of the blind leading the blind. I make no comment about the noble Lord, Lord Bassam, but certainly some of the technology went way above my head. I remember that we built in quite strong safeguards for civil liberties. My noble friend asked whether the RIPA legislation was still fit for purpose in term of developments in technology.
Finally, I went to a very interesting briefing by Vodafone the other evening, where, again, the convergence of technologies was explained—the phone as a computer with access to the internet and so on. To make this work, we will have to have an active buy-in by private companies with commercial considerations as well as national and international obligations. Is the Minister sure that we can get the buy-in from the private sector for the objectives that he has set out?
My Lords, the noble Lord raises a number of very important issues. As noble Lords will know, we are looking at the RIPA legislation because we are not convinced that it is being used by, for example, local councils in the right way. That was never intended and we want to ensure that that is resolved and that there is proper guidance. Without a doubt, we need to look at the legislation in that context.
As regards ethics and the Joint Committee and the question of parliamentary oversight, there is of course the committee for the national security strategy. I thought that it would have been named already, as I know that it is being talked about in the other place with the Speaker and so on. It will have some oversight of the national security strategy. I undertake to look at cybersecurity on its own and see whether the committee will cover that, or whether we need, with the ethics committee, some other joint aspect. So I commit to that, but I would not want to give an off-the-cuff answer on it. The matter is too complicated; some of it will be the business of people within the other place as well as here, and to say more would be beyond my remit.
One feels at times that the internet is a bit of an ungoverned space. The noble Baroness, Lady Miller, has often mentioned the issue of deep packet inspections and the like, and I have some concern about that. We have managed to get a lot of voluntary agreement on things such as child pornography, which is super, and I am pleased that we have achieved that. However, it proves more difficult in some other areas, and the internet is now so all-pervasive that we will have to think about this. At the moment, though, there is nothing planned, and we would have to think about how to move forward in a very broad, all-party context. So we are not doing anything, but it is a nagging concern at the back of my mind.
Some of the CSPs and ISPs have been very good about working with us. BT, for example, has been fantastic: it has engaged with us and helped us in saying, “We’ve had this many attacks; this is happening; what about trying this?”. It works closely with us, as generally these companies do, but some are better than others. All of them, though, are beginning to understand that, given the state threats, the threats from serious and organised crime—£50 billion a year or so is lost around the world, and that amount is getting bigger all the time—and the threat to each individual, such as identity theft or bank account attacks, it is in all our interests to work together, and I think that generally they will.
My Lords, the United Kingdom has a proud record of achievement in medical research. It has received more Nobel prizes for physiology and medicine than any other country of comparable size, and it stands high in the world in the citation indices of peer-reviewed publications in medical and scientific journals. In this debate I shall concentrate on medical research and teaching and upon the vital contribution of the NHS, and I shall leave my noble friend Lord Mawson to discuss how the NHS contributes to social enterprise and cohesion.
In the 64 years since I became a doctor, advances in medical and scientific knowledge have been astonishing, and my theme today is to convince your Lordships that today’s discovery in basic medical science results in tomorrow’s practical development in patient care. This is translational research, meaning that basic scientific discoveries are translated into new methods of management of disease and its prevention. For anyone practising medicine before the NHS, as I did, the vast range of new and effective drugs has been phenomenal. Serious diseases which I saw as a young doctor, like diphtheria, poliomyelitis and scarlet fever, are rarely, if ever, seen, due to effective vaccination, while rubella, which may damage the foetus in a pregnant woman, and mumps are now controlled. Measles, too, should have virtually disappeared in the UK, were it not for the misguided campaign, based on flawed research, that caused the MMR vaccine scare.
With new antibiotics emerging, many bacterial infections have been defeated, but antibiotic resistance has caused the emergence of strains like MRSA and drug-resistant tuberculosis, while AIDS, still a major challenge, is now more effectively controlled by appropriate medication. Methods used when I was a young neurologist to identify the cause of strokes and to locate brain tumours, for example, often involved great discomfort and potential risks, but new methods of imaging, such as CT and ultrasound scanning, magnetic resonance imaging and its functional variant, have given us information about abnormalities in the body’s internal organs undreamed of a few decades ago.
Admittedly, there are still some incurable diseases, not least in neurology, even though developments in molecular biology, including gene identification and the discovery of the missing or abnormal proteins resulting from such gene defects, have raised hopes of new treatments for many such conditions, perhaps by gene therapy or other variants. The prospect of the repair of damaged tissues, so-called regenerative medicine, sometimes using adult stem cells but more often using the highly effective pluripotential embryonic stem cells, which can readily be converted into nerve cells, liver cells, kidney cells, heart cells and indeed many cell types, brings within sight the prospect, if not of immediate cure, certainly of amelioration.
As I always told my students, though, while there are still many incurable diseases, none is untreatable. All can have their effects modified by pharmacological, biological, physical or psychological means. I quote as an example the improved care of patients with the most severe form of muscular dystrophy, the Duchenne type, affecting young boys, who have progressive difficulty in walking and are confined to a wheelchair from about the age of 10. When I first began research in the 1950s, many such boys died in their mid-teens from heart failure or respiratory infection, having become grossly deformed through neglect of supportive measures. Now, in specialised centres such as London, Oxford and Newcastle, where ventilatory care is available, the average age at death of these boys is in the 30s, whereas in the south-west of England it is still in the late teens. As a result of a detailed survey by an All-Party Parliamentary Group and the Muscular Dystrophy Campaign, improvements in services for these patients and their families are pending, while the discovery of the responsible gene and of the missing product called dystrophin has led to major research initiatives in Hammersmith, Oxford and Newcastle, where clinical trials of exciting new techniques designed to circumvent the primary genetic effect are now in progress.
I must mention briefly the issue of stroke. This country has been lagging in its introduction and development of stroke units and in introducing new and improved methods of treatment. We know now that if one can recognise stroke and one regards it as an emergency—the public, the paramedics and the medical profession need to be much better informed about this—and if a patient is admitted within the three-hour deadline and can have an immediate scan to demonstrate whether the stroke is due to an infarct, as the result of the blockage of a vessel or a haemorrhage, then, if it is an infarct, clot-busting drugs and thrombolysis can improve the condition greatly. At the moment only 1.5 per cent of patients with ischaemic stroke in the UK are receiving thrombolysis. This is unacceptable, and measures must be taken to improve that position.
Many years ago, as a member of your Lordships’ Select Committee on Science and Technology, I chaired an inquiry into research in the NHS. Our report was endorsed by the then Conservative Government, who accepted that while much research and many treatment trials were being conducted in the NHS, there was no dedicated line of funding for health service research. Concerns then about the freezing of clinical academic posts in universities, appointments that involved not only teaching and research but also patient care, led to a major decline in recruitment. That inquiry led first to the Culyer report on NHS research, the Richards report on clinical academic medicine and, several years later, the outstanding Cooksey report on NHS research. Dame Sally Davies now presides over a National Institute for Health Research, supporting much research in the NHS.
The Conservative Government responded to our report by agreeing that 1.5 per cent of the NHS budget should ultimately be devoted to R&D, but the figure has never yet exceeded 0.9 per cent. While that is substantial, in view of increased NHS funding, what plans do the Government have to increase this figure to somewhere nearer the agreed target? Might additional academic health science research centres be established in places that narrowly missed out in the first tranche? As the recession bites, may we also hope—recent government statements are encouraging—that increased government spending on science, especially in the annual grants to the Medical Research Council and the BBSRC, will be maintained?
We must also acknowledge the massive support of research funding provided by the Association of Medical Research Charities, of which the Wellcome Trust is pre-eminent, although the disease-oriented charities have also made crucial contributions. In my view, it was a sad day when, some 20 years ago, the Advisory Board for the Research Councils removed infrastructure funding from the University Grants Committee, funds specifically allocated under the dual-support system to provide well-found university and hospital departments and laboratories, and passed that money to the research councils, fearing that the new universities, the former polytechnics, might seek such support, diluting resources available for the old-established universities. As a result, confusion arose about overheads to be paid by research charities. Under the UGC, overheads were not paid but now universities are acquiring full economic costing.
The Charity Research Support Fund, introduced by government and providing infrastructure funding for charity-funded research, is, I fear, inadequate, and I would welcome the Minister's comments. A recent survey by a notable charity found that only 5 per cent of 245 researchers funded by charities considered that fund adequate. One-third of those researchers found that universities were becoming increasingly reluctant to support applications for charities for research grants for that reason.
The NHS does, of course, play a vital role in the undergraduate and postgraduate education of doctors, nurses and other healthcare professionals. I was disappointed that education was not highlighted in the NHS Constitution. I shall be interested to hear from the Minister how the proposed health innovation and education clusters will nurture such education. The doctors and nurses of tomorrow are dependent on the facilities of the NHS for their undergraduate and postgraduate training. Do the Government accept that we must maintain the opt-out from the European working time directive for young trainee doctors? The restriction on working hours will have an adverse effect on training, and surgeons in particular are deeply concerned that, under the restricted hours now proposed, the training of surgeons will suffer.
Has the MTAS scheme proved a disincentive for young doctors wishing to take time out from training to undertake research? When I was head of a department, many young men and women came to the department in the course of training—as registrars and senior registrars—before moving on to apply for consultant posts, but a very large number of them took a year out from their formal NHS training to undertake a programme of research. I am informed by many heads of departments that, because of the MTAS scheme, that is becoming increasingly difficult for many young doctors to do. In my view it is crucial to recognise that a period of time spent in research nurtures the development of young doctors who benefit from that, and in the end it improves their ability to undertake practice and clinical care.
Happily, the NHS continues to fund many clinical academic posts in our universities, recognising the crucial role that such individuals play not only in teaching and research but also in patient care. Initiatives of the Academy of Medical Sciences and the Wellcome Trust in supporting clinical academia have been admirable, so that academic medicine is now in better heart. However, there are storms on the horizon as some health service trusts and even foundation trusts have questioned the need for such posts to be funded by the NHS. Does the Minister agree that the vitality of clinical academic medicine is essential if high quality research, teaching and patient care are to be maintained?
Finally, the NHS offers an ideal environment for clinical trials of new forms of treatment, trials often expertly assessed by the National Institute for Health and Clinical Excellence. Has the European Union directive on clinical trials had any adverse effect? Are the Government satisfied that seeking ethical approval of research protocols, especially for multicentre and multinational trials, where unacceptable delays have often occurred in the past, is now satisfactory? Can we be confident that research ethics committees contain a majority of scientifically literate individuals able fully to appreciate and to consider the scientific content of such research programmes?
For more than 40 years I was stimulated and inspired by my responsibilities in clinical academic medicine, involving teaching, patient care and research. I firmly believe that those three branches of academic activity are interdependent and mutually beneficial, and that the NHS is probably the finest clinical laboratory that exists anywhere in the world for the pursuit of clinical and translational research with the objective of improving disease prevention, treatment and cure. May it continue to flourish. I beg to move.
My Lords, I congratulate the noble Lord, Lord Walton of Detchant, on obtaining the debate today and on the typically informative and vigorous way in which he has introduced our discussion. I pay tribute to him for his distinguished medical and academic career in this area. As a non-medic, among a number of distinguished medics who are to address your Lordships this afternoon, I shall speak with some humility about the issue of quality. To set the scene, I shall talk about quantity. Ninety-three per cent of patients requiring admission to hospital are admitted within 18 weeks; not many years ago the waiting time was two years. In quantity terms there has been a real improvement.
When I was an MP, 30 years ago, I got to know someone in my constituency who had cataracts in both eyes. He was a working-class man who was quite poor and could not afford private treatment. He was virtually blind but he never received treatment in the health service before he died. Now there are 250,000 cataract operations a year and the average wait is 10 weeks. I often think of that man when I consider that statistic.
As regards hearing, I declare an interest in that one of my granddaughters was born profoundly deaf. Under the National Health Service, she had cochlear implants on both sides and, thank goodness, she is a very vigorous and energetic four year-old. Hearing is a very big problem for a lot of people: 400,000 people a year are referred to audiology departments. They are not the big glamour operations for many people but they are very important to people's lives. That is the quantity issue and I now turn to the issue of quality.
The noble Lord, Lord Darzi, led the NHS Next Stage Review which was published last year entitled High Quality Care for All. It said that we need to move from an NHS which is rightly focused on increasing the quantity of healthcare to one which focuses on improving the quality of care. If quality is to be at the heart of everything done in the NHS, it must be understood from the perspective of patients. That is quite a change in many parts of the NHS. Patients are concerned with both clinical outcomes and their experience of the service. If you go to a restaurant you tend to go back to one where perhaps the food is not always good but the overall treatment, including courtesy, is good.
Improving the quality of service has to involve everyone. It requires a true team effort, with everyone committed and everyone proud of the achievements. The noble Lord, Lord Darzi, was right to say that change is most likely to be achieved if it is led by clinicians. I agree with that. The emphasis should be on teamwork and inclusiveness. In many hospitals, still too large a proportion of staff feel undervalued and in some—I do not say all—major hospitals senior medical staff are still viewed with awe or fear rather than as lead partners in achieving high quality outcomes and patient experience.
The NHS is a large and daunting structure for patients, and I wonder whether we do enough to integrate the patient’s needs and experience through primary, secondary and tertiary care. People often go through all those. Is enough done to take people through that on a continual basis, avoiding cancelled appointments, missing or out-of-date information, so that they have to go back again to see the consultant, and all the things that we know can go wrong?
A few years ago, I suffered from an underactive thyroid—I still do, of course—and I went to see many NHS consultants, until I found one who knew what it was, although it was not his specialisation. I had an appointment to see one chap and, as noble Lords would expect, I arrived for the 12 o’clock appointment at about three or four minutes to 12 o’clock and discovered eight people waiting. When I asked the secretary whether the specialist was on time, she said, “Yes, but you’re eighth in the queue”. Twelve o’clock did not mean 12 o’clock; it meant that that was when a group of people turned up. I had to cancel the appointment because I had a number of other things to do that were extremely important, more important than my health. I cancelled the appointment and felt very bad about that. In that little microcosm, that NHS cost itself resources and money, it did not do the patient experience any favours and left me feeling very frustrated. Nobody gained, and nobody got a grip on it.
Raising quality does not mean increasing costs or reducing productivity, far from it. In my view, raising quality is about addressing the whole process of delivering a health requirement and means finding ways to deliver more for less, provide more time to improve the patient experience, review outcomes and seek further improvements. My view, speaking with a business school background, is that the message that improving quality will cost more and reduce productivity so that we cannot afford to do it is far from the truth. We can have more for less if it is seen as a process, not in isolation. Times are going to be tough for the NHS in the next few years. There will be plenty of people saying that they cannot afford to have meetings to discuss these things because they have enough on as it is, but I believe that it can be achieved.
When I was in the United States not long ago, talking about the health industry and the role of medically qualified people, I discovered that in some of the states that I visited up to 50 per cent of chief executive officers are medially qualified. I came back to this country and asked for the figure and it is about 2 per cent. The difference is staggering. I ask the Minister to consider whether there is a serious career structure for medically qualified people who want to add value to the NHS on that basis. In my view, that is critical to improving quality and performance. Is the financial reward structure adequate? My guess is that it is woefully inadequate. My message is that quality matters and is not something that cannot be afforded when times are tough. Quality improvements are even more important when times are tough, and getting the right people leading teams and making a real team effort requires an improvement in the way in which medically qualified people are involved in the senior management running the health service.
My Lords, I greatly welcome this debate and listened to the speech of the noble Lord, Lord Walton, with pleasure and close attention. I am wholly a layman and I speak as a patient about one niche of concern. Eight years ago, I had a stroke. I was very lucky; there was no apparent physical damage, but my reading, writing, speaking and comprehension were severely affected, and I had two and a half years of speech therapy. I raised this matter in the House in a debate three years ago, and I have since had two similar opportunities to discuss stroke.
Initially, I was critical of the NHS, and particularly Health Ministers, for neglecting, over many years, the causes, consequences and treatment of stroke, which had an unacceptably low profile among major diseases. These shortcomings were set out in a devastating report by the Comptroller and Auditor General in 2005. More recently, there has been substantial progress, as the noble Lord, Lord Walton, said. The Stroke Association called its recent document Getting Better, which is just about right. I should add that I am a member of the All-Party Parliamentary Group on Stroke, which is ably chaired by Andrew Lansley MP, the Conservative health shadow who has recently been having a rather tough time.
Today, I am looking at stroke again, on this occasion in the context of the new National Sentinel Stroke Audit published by the Royal College of Physicians in April, and at the role of stroke research. I have already warned the Minister of my particular interest, and I hope she will be able to respond. In sum, I am disturbed that the new sentinel audit report shows that there remains a serious gap between what is actually happening and what should happen. There have been significant improvements. Twenty-nine per cent of patients are now admitted to a stroke unit on the same day and 57 per cent are admitted either the same day or on the following day. That is a major step forward since 2006. There have also been marked improvements in the speed of assessment by therapists after admission. All this is good.
However, the headline of the sentinel audit is that a quarter of stroke patients are still not given the best treatment. It refers to,
“unacceptable variations in the quality of care between hospitals with some parts of the country still failing to provide anything approaching an acceptable service”.
There is even a group of hospitals,
“that appear to have deteriorated - a few by very significant amounts”.
I regard that as alarming.
Professor Roger Boyle, national director for heart disease and stroke, the so-called tsar, has commented on the audit. He said:
“The national stroke strategy is a ten-year plan, and there are no simplistic quick-fixes ... But, by making stroke a number one priority for the NHS, providing extra funding and establishing the Stroke Improvement Programme and local stroke networks, we are now firmly aiming at the revolution in stroke services”.
I have great respect for Professor Boyle and admire his commitment. However, will the Minister confirm that the 10-year plan is on target, that the extra funding is in place and that it will remain undiminished with no delay or redesign, which is a familiar euphemism for setting something aside?
Within the national stroke strategy, there is yet another strategy, the stroke research network or SRN. The health department says that:
“The SRN provides a world-class health infrastructure to support clinical stroke research and remove barriers to its conduct”.
I should say that three years or so ago, I agreed to become a patient representative on the Thames Stroke Research Network and, later, played a very modest role in its launch in April 2007. I am concerned about the stroke networks and whether they have been established on time and are achieving their preliminary purpose. I should be grateful if the Minister would confirm that that is the case and that the department intends to make them a permanent feature within the continuing national stroke strategy
I have said that strokes have been the poor relation—if I may put it in an awkward way—of other diseases. This has been reflected in inadequate research funding. According to a Written Answer in the House of Commons, the aggregated expenditure on stroke research in 2006-07 was £9.87 million—a tiny sum. I find the Answer confusing, because it adds that comparable information in respect of the department’s centrally managed research programmes is not available. I ask the Minister why not, and, in particular, where can I find the costs of the Stroke Research Network?
I come briefly to the current outlook, taking into account the national financial and debt crisis and the prospects for public spending, especially on health and health research. In a long political life I have become familiar with such crises, to which I have been uncomfortably close. Ministers of the day have admitted the quantum of lower expenditure, but tried to hide the damage. They have concealed the consequences by discreetly scaling down plans, delaying capital investment and using expenditure figures in cash rather than real terms. They have talked about huge sums in unspecified efficiency savings, making everything stronger, leaner and fitter. However, I am afraid that much of what has been called painless has been cuts by stealth.
Until a few weeks ago, there was a remarkable silence about public expenditure cuts beyond 2011. The King’s Fund says that the NHS could face drastic cuts as the service moves from years of significant growth in its real terms funding to very low, zero or negative growth. Will the Minister say in plain terms whether the Government agree with the King’s Fund or whether, to the contrary, they intend to preserve fully and ring-fenced, as I have previously understood, the current level of spending on the NHS, as well as other government health spending, direct or indirect—for example, spending by the Medical Research Council? If the latter is the case, I am reasonably reassured about stroke research, such as it is. If not, I am deeply concerned.
My Lords, it is a privilege to share this debate with my noble friend Lord Walton. I begin my contribution to the debate on the future of the NHS by addressing my remarks to the opportunities presented by social enterprise for the future of health and, in particular, primary care.
In recent months, many of us have listened with growing concern to the unfolding story of Baby Peter in Haringey—one of the tragedies that point to the lack of joined-up working between health and social care services and to an insufficient focus on people. Despite years of talk about joined-up working and putting people first, this is still very patchy in practice. While we have moved some way down the road to co-locating services in primary care buildings and to recognising the role of social entrepreneurs in health, we still have a way to go in making greater use of community and integrated approaches to health and in using the talents and ingenuity of local people.
I was interested to hear my noble friend Lord Laming, in a Radio 4 interview, describing how difficult it was for Ministers to get the words about joining up health and social care off the pages of glossy reports and into reality on the streets of our towns and cities before yet another crisis erupts on to our television screens. I suggest that putting people before structures is the only practical way of joining up services and implementing a truly integrated approach to primary healthcare in this country. We need to use the innovative skills of social entrepreneurs and organisations that have a proven track record and to back such people by giving them the resources and freedoms that they need to transform the health and well-being of the communities that they serve.
Many of these people are doctors—I have worked with some of them. Many others are individuals working in third sector organisations and leading teams of dedicated people committed to improving health and social care services in their local communities. These people seldom appear on the NHS radar and, even when they do, are rarely valued for the contribution that they make. The tragedy is that despite the years of commitment to new commissioning structures—third sector compacts, social enterprise initiatives and the like—there is still little widespread procurement of local holistic services from social enterprises or the third sector. The true meaning of “third sector procurement” seems to be in the name itself. Successful third sector organisations and social enterprises often feel that they are the third choice—that the bits that the public sector might not want to deliver get passed down the line. Second in line is the private commercial sector and, finally, at the end of the queue, we have the third sector patiently waiting its turn for the crumbs from the table.
The poor souls in the third sector are no third-rate choice. The third sector is like any other sector—better in some places than others. Our approach to procuring health and social care services is ignoring some of the most talented and innovative individuals and organisations—people who have been working tirelessly in their communities for far longer than the perennially reconstituted PCTs and health authorities.
This is my experience over 25 years in Bromley-by-Bow in east London. Over the years, rhetoric around the holistic integrated model has never been matched by an integrated commissioning structure that delivers a Bromley-by-Bow-style approach to public service delivery, community regeneration and social enterprise.
I am afraid that I see little room for optimism in the latest polyclinic initiatives. The noble Lord, Lord Darzi, and his team have produced a programme for primary care that will produce wonderful new buildings and a new level of integration that has never been seen before. However, I have a profound problem with the scheme. At its heart it is still a biomedical model of healthcare that focuses on delivering clinical interventions for patients. Important as this is, it is only one dimension of a multidimensional problem. We are building not polyclinics but monoclinics.
I am sure that the Department of Health recognises the multicausal nature of chronic ill health in our communities. However, after all these years of rhetoric, we still seem unable in this country to create commissioning structures that cut across the departmental silos of government and focus on the customer. Why should that be? In my view, there is a problem at the core of our understanding of integration. Many in the public sector still think that this is about only traditional bits of the public services working more closely together.
We need holistic approaches to public service delivery that use social enterprises to deliver better services and better value for money across a range of measures. Where better to start this approach than in primary care? These solutions are particularly relevant today when the financing of the medical intervention model has been put under severe strain as a result of the financial crisis. However, I fear that despite the rhetoric the Government—and perhaps a future Government—still do not understand how practically to use entrepreneurs in the delivery of health services. I know that it works because in the past few years I have had the privilege of seeing and working with such entrepreneurial health organisations across the country. These organisations put people first because they understand and are part of their communities. They bring together health and social programmes. They are trusted, not because they engage in elaborate consultations but because they have a track record of delivering services that local people need.
There is of course no shortage of action by the Government. A multiplicity of programmes for the provision of integrated health services by the public, private and social enterprise sectors has been initiated. My concern as I travel across the country is that these initiatives, while well intentioned, by and large do not rely on the ingenuity and talent of entrepreneurs and local people but continue to use the old bureaucratic and paper-based mechanisms. Bureaucracies like talking to bureaucracies and doing many of the same old things that they have always done. We are putting old men in new clothes. The rhetoric has changed but in practice it is still difficult for social enterprises to win APMS contracts to run GP surgeries, despite that being possibly the best way to spread entrepreneurial talent in the health sector, as my friend Dr Michael Dixon of the NHS Alliance has suggested.
As I have listened to debates in your Lordships’ House in recent months, Ministers, including the noble Lord, Lord Mandelson, have highlighted in public conferences the virtues of social enterprise. Yet in the health sector basic conversations are still not taking place. I have spent the past five months since the publication of our report on social enterprise and health—here I must declare an interest—attempting to bring Ministers to the same table as colleagues from NHS LIFT and the Big Lottery Fund in order to bring new joined-up investments to support an integrated approach to health.
What the Government have done to date is commendable, but the NHS now needs to change its paradigm from the expensive clinical model to one based on networks and more modest-scale and sustainable initiatives that can be private, public or social enterprise—it does not matter. What matters is that entrepreneurial leadership and organisational culture put people, not systems, first.
If this Government—or a future Government—are serious about the future of the NHS and about social enterprise and community cohesion, I humbly suggest that a first step might be to do the following. First, they should ensure that their programmes are led by individuals with a strong track record of enterprise and appropriate risk-taking, as well as delivering innovation in mid-sized organisations. These should be people who understand the challenges of growth businesses; this is a job not for academic civil servants but for social entrepreneurs. Secondly, the Government must stop being fixated on new health initiatives and focus on making sure that the basic framework is in place to support communities in the delivery of their health services. Thirdly, they should move from a generalised support for social entrepreneurs to an informed support, which understands in detail how an entrepreneurial approach helps to deliver efficient services in the health sector. As always, the devil is in the practical details. Fourthly, they must start to assess health interventions not through reports and targets but through a focus on the health of patients and their care. Too often you get what you inspect and not what you expect. Fifthly, we need to ensure that all procurement opportunities by the Government are open to social enterprises and that procurement is not biased against small organisations. This applies very clearly to the procurement for GP surgeries under the APMS arrangement. Finally, we need to ensure that different interventions by the Government and actors talk to each other. This is not happening at a very basic level across the country. This is the road to enterprising healthcare and social cohesion.
My Lords, I, too, congratulate the noble Lord, Lord Walton, on introducing this important debate in such a characteristically lucid way. No one seems to deny that medical research is vital for our future health and healthcare, least of all me with my interest as scientific adviser to the Association of Medical Research Charities and as a past clinical researcher. If anyone needed convincing, they had only to listen to the debate introduced earlier today by the noble Baroness, Lady Murphy, to realise the enormous personal and economic costs of dementia and Alzheimer’s disease and the potential benefits that could accrue from successful research in that area. I make no excuse for focusing heavily on research, to which this Government have shown a clear commitment. They have put more into general and medical research in particular than ever before. The Prime Minister has reiterated his strong support in giving research high priority, as have my noble friends Lord Darzi and Lord Drayson on our Front Bench.
I focus my remarks on two topics that are seen to be major inhibitors of research in the UK. First, there are the difficulties posed by the multitude of regulatory bodies that have to be satisfied before research can go ahead. Secondly, there are the hurdles that have to be jumped before research can be done not on the patients themselves but on information and data about them.
I return to the subject of regulation. Despite valiant attempts at bureaucracy-busting by many, including my noble friend Lord Warner when he was the Minister, researchers are still faced with a rising tide of form-filling required by innumerable bodies that seem to take for ever to respond. A recently appointed lecturer, funded by the new and welcome investment from government and charities, will often spend the whole of his or her first 12 months waiting for approval to do the research that they were appointed to do. What a terrible waste of time and money. The pharmaceutical industry is also looking to other countries in which to do its research because of the long delay before it can get approval here.
No one denies the need for careful and thorough regulation of research on patients—certainly not the researchers themselves. They gain funding through a rigorous peer review, against considerable competition. They have to gain the approval of the Research Ethics Committee, which is entirely appropriate and necessary. Yet sometimes they have to go through several ethics committees if patients come from different trust areas. We can run into problems where different ethics committees come to different conclusions on whether they should approve the same research. There is a bit of a postcode lottery.
Yet it is the multitude of other bodies that need satisfying where the main difficulties arise. We have the local trust R&D committee, the Medicines and Healthcare Products Regulatory Agency, the Human Tissue Authority—where tissues are to be used—and several other bodies depending on what type of research is proposed. All require their own forms to be filled in, which are often long—up to 80 pages for some—and they all have different timeframes and dates at which they will consider submissions.
Paul Stewart, a distinguished researcher in Birmingham, writes that the current bureaucracy placed on investigators,
“is poorly coordinated, lacks consistency at all levels, and at times is completely illogical”.
This is no way for the UK to keep up with the competition. Our patients, the ultimate beneficiaries, deserve better. I am afraid that I have asked this before, but will the Minister have another go at bureaucracy-busting and rationalise the number of different bodies involved in this confusing array of regulators?
Secondly, there is the need to do research not directly on patients themselves but on information or data that already exist about them in the NHS. The NHS is an enormously valuable repository of information about patients, their diagnoses, treatments, cure rates, causes of death and so on. It is the envy of the world in the completeness of its information about the whole population. It provides an extremely fertile resource for research. The problem lies in trying to balance the need to carry out that research with preserving patients’ confidentiality and trust. Questions of data protection and definitions of what constitutes informed consent or anonymisation—a horrible word—remain difficult to resolve.
There is usually little problem where patients can give their consent and understand the nature of the research, the consent of an ethics committee has been obtained and there is the knowledge that those conducting the research have a professional responsibility to maintain confidentiality. Yet there are many situations where research is needed on stored data where patients are no longer accessible. They may have moved, died or be otherwise untraceable—a seeming Catch-22 situation. Similarly, where a researcher is gathering data from large populations with whom he or she has no direct contact, he has to rely on others to seek their consent even to be approached to obtain consent.
There are ways through this difficulty. One that I hope can be actively pursued is that proposed in the Walport-Thomas data-sharing review of last year, which involves the depositing of patients’ data in a databank under the control of a regulated controller. He or she may then agree access to elements of the data to bona fide researchers who have an ethically approved and rigorously reviewed research project. This would have to be entirely dependent on the patients’ approval to place their data in such a bank. For that to happen, the NHS needs to inform patients so that they are aware not only of the uses to which information about them may be put and are comfortable with that but also of the value of the research to them and to future generations. These are the bones of a system which could work and which I believe Dame Sally Davies, director of NIHR, and Harry Cayton, director of the National Information Governance Board, are striving to achieve. I am not sure how much of a push they need to achieve it.
Earlier this week I was at a meeting of the organisation DIPEx, a charity of which I am a trustee and which funds the website healthtalkonline. It is a wonderful organisation that takes interviews with real patients in which they describe their illnesses—breast cancer, rheumatoid arthritis and so on. It has gathered about 50 of those interviews online for patients to gain an inside picture of what it is like to have their illness from others suffering from the same thing. The website gets lots of hits every week. The interviews are enormously valuable, too, for medical students in training. I mention this organisation now because its latest offering is on clinical trials, which gives a picture from a range of patients of what it is like to be involved in clinical trials directly or indirectly using their data. I hope that, in the PR exercise that the NHS should engage in about the importance of research and the need to use patients’ data, the department will make use of this resource and information to help to get its message across.
My questions for my noble friend are, therefore, whether she will give us some encouragement that the regulatory burden on researchers will be eased by rationalising the number of bodies that have to be satisfied, whether she will ensure that the use of patient data for research will be put on a more rational footing and, finally, whether she will look at the DIPEx website, healthtalkonline, and see whether she can make more use of this marvellous resource.
My Lords, I, too, thank my noble friend Lord Walton for initiating this important debate. I shall follow on from the subjects mentioned by the noble Lord, Lord Mawson.
It is now a year since we celebrated both 60 years of the existence of the NHS and the publication of the report of the noble Lord, Lord Darzi, High Quality Care For All. The report provides an exciting challenge for the NHS to provide a world-class service. The areas to be addressed are set out within the report and many are on the way towards implementation, but in the short time available to me I should like to explore the challenging issues relating to integrating services in the community.
I shall focus on three paragraphs from section 5 of the report, entitled, Freedom to focus on quality. The first is paragraph 24, which begins:
“This transparency must not be limited to acute health services”.
The second is paragraph 30, which states:
“We will empower clinicians further to provide more integrated services for patients by piloting new integrated care organisations (ICOs) bringing together health and social care professionals from a range of organisations – community services, hospitals, local authorities and others, depending on local needs”.
The third, paragraph 31, headed, Fostering leadership for quality, begins:
“Greater freedom, enhanced accountability and empowering staff … making change actually happen takes leadership”.
The patient pathways have been welcomed, but many gaps remain on the patient journey, as both the noble Lords, Lord Woolmer and Lord Rodgers, mentioned. Paragraphs 24 to 25 indicate that the measurement of quality care is not limited to the acute sector alone. Therefore, during 2009, a quality framework to develop services will also be completed, with a standard but flexible contract to enable commissioners to hold community health services to account for quality health improvement. That will take account of local populations, including the most vulnerable or excluded people with complex needs. It will be managed by the strategic health authorities and include annual associated health outcomes, competencies and governance. PCTs will have started to implement the system in March 2009, and first results will be formally published in March 2010.
These are admirable targets, but we know that patient pathways are not entirely NHS managed. Immediate families, carers and other statutory or third-sector agencies need to be involved, as was clearly set out by my noble friend Lord Mawson. This requires empowering NHS staff and can best be described as “learning and doing”. There is a need to restore passion combined with experience to ensure that holistic, high-quality care is delivered against the important backcloth of theory, statistics and policies arrived at from evidence-based practice, but always taking account of the prevailing needs of the individual and immediate family or carers and local community environment. Will the Minister indicate the progress being made in implementing the integrated care organisations, illustrating that patient pathways are not limited in access and that integrated services are the overall aim?
That brings us to the requirement for leadership skills to ensure that these implementations can successfully take place. Leadership is central to ensuring the delivery of high-quality care. In the words of the report:
“Leadership has been a neglected element of the reforms of recent years”.
It is acknowledged that there are many routes to effective leadership, but what is required here is for people to hold meaningful conversations that transcend organisational boundaries. The core elements of any approach to leadership towards change in the NHS are, first, vision; identifying what improvements need to be made. Secondly, method; how will they make the change happen? Thirdly, expectations; what difference will the necessary behavioural change make to people?
I too listened to the radio report by my noble friend Lord Laming following the Baby P case and I summarise his words. It seems to be generally agreed that the current policies, legislation and practice guidance is fundamentally sound. The problem is the gap between the written word and the day-to-day activity at the front door of each of the key services. The challenge is to get the written word off the page and into the bloodstream of each of the services. Failure to do so has resulted in a marked reduction in the confidence and willingness of health visitors, paediatricians, GPs and accident and emergency departments, as well as the other front-line services, to become involved in the safeguarding of children. The gap between theory and practice is great; similarly the gap between the claims of senior managers and the experience of front-line staff is too great. Yet the vulnerable depend, not on brave words, but on practice skills. Now is the time to address both the competence and confidence of front-line staff and to ensure that the performance of senior managers is judged against the quality of services delivered. The focus must be on better outcomes for service users. That being so, there must now be a major review of the quality and content of training. I suspect that many trainers are more comfortable debating different theories rather than focusing on practice skills. Now is the time to ensure that in future courses should be assessed on their ability to promote the highest standards of good practice.
I can identify with this very erudite statement, having had, during my career, experience in teaching a course correlating theory and practice and as a manager leading the closure programme of two large mental handicap hospitals and five large mental hospitals, a programme that I am sure the noble Lord, Lord Warner, will identify with, as one of the directors of social services involved. Leadership skills were needed to cross the boundaries between the NHS and social services in an unprecedented way during that 10-year programme, which involved patients, families, communities, housing associations, and third-sector organisations. However, that was 20 years ago and there are still lessons to be learnt. Not all barriers have been eradicated and gaps do still exist in many places, but in others, high-quality services are in place or are being developed. I declare an interest in that I am one of the 20 commissioners appointed to the Prime Minister’s Commission on the Future of Nursing and Midwifery. Within the terms of reference, there is an opportunity to progress the work already in hand following the recommendations of the High Quality Care for All report, but also to explore and recommend innovative ways of closing the gaps in patient pathways and overcoming the boundaries that prevent the holistic, seamless care that we all know is necessary in order to deliver world-class quality care to the communities we serve. These communities differ according to their locations and range of populations, but the three key requirements I began with are fundamental—transparency not limited to the acute sector; empowerment of staff through appropriate education, training and support; and leadership of front-line services by accountable boards, able to cross boundaries and not confined in silos.
I hope that the commission will be able to make recommendations that allow for innovation and for the entrepreneurial skills so eloquently demonstrated as necessary by my noble friend Lord Mawson. These issues need to be addressed, so that patient pathways can be complete and holistic care of high quality received by patients and families.
My Lords, like other noble Lords, I thank my noble friend Lord Walton of Detchant for initiating this debate. I intend to follow up on one of his chosen themes of social cohesion and focus on that factor. In particular, I want to look at the role of the NHS in maintaining social cohesion in Northern Ireland during the Troubles.
At a time when it is commonplace to read in the media about former terrorists travelling the world and giving advice about conflict resolution to other countries, and to see them receiving much applause for so doing, it is an appropriate moment in this House—it is thanks to my noble friend Lord Walton that we have this chance—to talk about some of the real heroes of the Troubles. In Northern Ireland, more than 3,500 people out of a small population of 1.5 million were murdered through political violence. Tens of thousands more were mutilated and suffered the most horrible injuries. That placed an extraordinary burden on the NHS over a 30-year period, a burden it met in an absolutely remarkable way.
I declare not an interest but a bias in that I am a child of a Belfast medical family; both my parents worked as doctors in the NHS all their lives, apart from when they were in the forces during the Second World War. I think it is important to acknowledge the role that the health service played.
Let me begin by presenting a general picture: doctors experienced serious difficulties going about even daily work; regular bomb hoaxes led to massive traffic jams in which nurses and doctors would be stuck in frustrating positions, trying to reach their hospital or their place of work. That was almost the easiest part of the Troubles. Illegal checkpoints at certain points during an occasion such as the UWC strike in 1974 led to health officials negotiating with strikers to get permits so that doctors and nurses could be let through. It may have been a necessary and, indeed, a pragmatic adjustment, but it was undoubtedly felt by doctors and nurses to be humiliating.
Things became even nastier. Staff were murdered at the Royal Victoria Hospital site, which also witnessed a gunfight in the main corridor. Musgrave Park Hospital was bombed. Three hospitals in Belfast—the City, the Mater and the Royal Victoria—suffered the ultimate insult of having patients shot in their beds.
During the hunger strike movement of 1980-81, again the medical profession was thrust into the forefront of the crisis and emerged with its status and professionalism enhanced. Throughout the entire time of the hunger strikes, it acted under previously agreed protocols but at the price of stepping back from the requirement to save life. So it was not a moment without ambiguity.
From the standpoint of medicine, novel forms of injury arising from the Troubles presented themselves. Expertise in the treating of gunshot and bomb wounds emerged, and a new expertise was gained in running a hospital under the pressure of an influx of the severely wounded and dying. This was learnt the hard way—almost an anodyne phrase. One nurse interviewed about this recently said that when the casualties came in from the Abercorn bombing, she felt that she was actually at the gates of hell.
One doctor quoted in Candles in the Dark, the forthcoming Nuffield Trust study of the impact of the Troubles on the NHS, said something which summarises the ethos of the NHS during this period:
“I don’t remember very much about ethics training but I do remember a very strong informal ethos which was that we were doctors, we were Health Service and we would treat everyone with respect—regardless of who, why, where, their involvement, non-involvement and what part of the community they came from”.
This quotation expresses a profound truth and in its way is the best possible tribute to the work of the NHS during the Troubles. It is a tribute which should also embrace those pharmacists who kept open their dispensaries when riots were going on nearby and often under very difficult circumstances.
Having said that, I do not wish to end by giving a purely panglossian picture of the NHS and how it works in Northern Ireland. In his very fine book, Minority Verdict, published in 1995, Maurice Hayes, a distinguished Permanent Secretary at the Department of Health and Social Services in Northern Ireland, and a most eloquent defender of the core principles of the NHS, none the less admits that it was hard to defend, for example, a level of prescribing in Northern Ireland which was 25 per cent to 30 per cent above the UK average. It reminds us also of another unsung hero of the Troubles, the unknown British taxpayer. Dr Hayes adds in his fine book:
“A more basic question was whether the NHS was adequately funded and properly managed. The answer on both counts is, I think, no”.
Dr Hayes’ book was published 14 years ago. At that time, NHS expenditure was 5.6 per cent of GDP. Since then, expenditure has risen markedly, but there is still, in certain quarters, and for reasons already listed by the noble Lord, Lord Walton, and other speakers, disappointment with certain outcomes; certain key issues which have to be resolved. That is the core subject of our debate—whether we are talking about Northern Ireland or the United Kingdom as a whole.
My Lords, when I saw the title of this debate about the National Health Service and the words of the Motion, I am afraid that I did what many of us do—I picked out the bits that I like in order to get across the message that I want to send. So I will not be talking much about scientific research but will be discussing the possibility for the NHS to drive the agenda.
Will the NHS be an engine of lobbying within government to achieve certain objectives in other departments? The noble Baroness will not be terribly surprised that I am talking primarily about encouraging greater physical activity and exercise—an issue which has lately received a greater degree of push primarily because of the Olympics, which have upped awareness not only of sport generally but of healthier lifestyles. There have also been revelations about this becoming an increasingly obese society.
There are many things you can do, but much of what we hear about from the Department of Health and the NHS is about dealing with those who are already morbidly obese. What we do not hear as much about, and very little until very recently, is how we can stop people getting obese. One of the most important things we can do is to get the NHS to lobby to make sure that it is easier to take exercise.
Much can be said about food and overeating. Eating for many of us is at least partly a leisure activity—something that is pleasant. Very few of us eat purely for fuel. Eating is something we do when we are sitting down. It is something to do with our hands when we are watching television—probably the great driver of obesity is watching television and snacking. If we encourage people to take physical activity and exercise in other ways, they will probably not spend as much time sitting down, doing nothing and snacking, and they will be burning off calories.
Your body is designed to be used. It is designed to have a degree of physical activity to function properly. We also get obsessed with the idea of weight. I will not give the House another diatribe on how useless I think the body mass index is as a description of health. When Steve Redgrave won his last Olympic medal, he was not obese; he was merely very heavily overweight, according to the index. It does not refer to the fact that muscle per volume is incredibly heavy compared with fat. You can carry a lot of fat and it weighs less than a smaller amount of muscle. In fact, you can get much fitter and gain weight in many cases.
Will the NHS have some form of input into the rest of government, including local government, to make sure that it is easier to take exercise, so that exercise can be a fun activity? Will it use its huge political power to make sure that it does this job? You cannot cut the NHS, or say that you will cut it, without paying a price in the press. If it were, for example, to ask other parts of government, including local government, for the provision of parks that were pleasant to walk in and that children could play sports in, with properly maintained swings and playgrounds, that would do more to move the rest of government than would action by almost any other department. It could put pressure on the rest of government to ensure that we deliver something beneficial to health.
Physical activity was recently described to me as a wonder drug—it prevents the problems of being overweight and can act as a cure. However, not everyone wants to give up a huge chunk of their life to play sport—I did not for many years; that is the fact of the matter. If you do not have what is effectively an addiction to give up one day a week for eight months of the year to play a sport, and a number of other days for training, you will not get a buzz from it and you will not do it. But if it is light exercise and a pleasant activity, people will do it. We can encourage them to walk dogs and go out for a walk themselves. A journey by foot that you would have had to make anyway can be a pleasant way to exercise.
We could get away from the need for such measures by getting rid of half the technology in our lives, but we are not in a hurry to do that. How can we make sure that the NHS drives this on? It could save considerable sums by getting involved in some of the acute problems for which there is no easy preventive solution. How can this investment be used? What thinking is going on? How does the NHS see its involvement in pressuring the rest of government to achieve this? That is the question that we should be asking today. If we do not have an answer, it is probably because the NHS has been warned off. The Department of Health has warned it off. Unless the NHS is prepared to interfere and make itself thoroughly unpopular with one or two people by changing their plans, it will not happen. Achieving consensus is all very well, but occasionally you have to make one or two enemies to make one or two friends.
My Lords, I, too, am grateful to the noble Lord, Lord Walton, for providing us with this opportunity for a debate today. I want to talk about the ability of the NHS to learn from known weaknesses in healthcare delivery in order to improve significantly its productivity and efficiency. I want to follow up some of the points made by my noble friend Lord Woolmer and the noble Lord, Lord Mawson. I first declare my interest. I no longer have any appointment with NHS London, but I advise two companies with health interests—the General Healthcare Group and Perot Systems.
Since 1991, the NHS has had real expenditure growth averaging 5.5 per cent a year. That growth has been even higher under this Government. Never in its history has the NHS had such a sustained improvement in its resources and we have of course, as a number of noble Lords mentioned today, seen many improvements. However, now it faces a period of considerable retrenchment. How it conducts itself as a £110 billion a year business over the next year or so will influence significantly the available resources for research, translating research into clinical services and even medical education itself.
I do not intend today to get into a debate over which party will best protect public services, other than to say that being straight with the public is likely to pay better political dividends. I will take as my starting point, however, a quotation from the recent annual report for 2008-09 by the NHS chief executive, David Nicholson. I commend the report to the House. On page 47 of the report, Mr Nicholson says:
“We should also plan on the assumption that we will need to release unprecedented levels of efficiency savings between 2011 and 2014—between £15 billion and £20 billion across the service over the three years”.
I have a question for the Minister and, indeed, for the opposition Front Benches. Do they and their colleagues agree with the chief executive’s assessment of the scale of NHS retrenchment likely to be needed between 2011 and 2014? I suspect many people in the NHS would like to know where the political parties stand on that particular issue.
One of the best predictors of future behaviour is past behaviour. Applying this principle to NHS productivity and efficiency is not, however, reassuring, as the Office for National Statistics has shown. Despite NHS revenue nearly doubling in the past decade, and an investment of nearly £30 billion in capital assets, ONS data show NHS productivity falling consistently from 1995 to 2004. Only in 2005 and 2006 did it rise, a period when Patricia Hewitt and I were winning friends and influence in the NHS and getting into a considerable amount of trouble for energetically pursuing NHS reform and control over NHS finances and pay deals. After this period of challenging vested interests the NHS appears to have reverted to its old ways of falling productivity.
We are approaching a difficult time for public expenditure for whoever is in government, with high expenditure on debt interest, falling tax revenues and higher recession-driven transfer payments. Now is the time for the critical friends of the NHS to push for a bit of action on its flabbier parts, a kind of anti-obesity campaign with the NHS management of services. I start with another item from Mr Nicholson’s annual report on page 40. He says:
“While the NHS has had a good year, can we say we have done our best when 25 per cent of patients in hospital beds don’t need to be there and could be looked after by NHS staff at home?”.
It seemed to me, when I read it, a rather good question to which we need some answers before pouring too much extra cash into the NHS coffers.
Let me offer a few suggestions in my final remarks. The key to driving productivity and efficiency is for there to be a huge improvement in the quality of commissioning by concentrating the activities in a much smaller number of larger, more competent, bodies. It would also help to streamline the processes for changing unsustainable, often unnecessary, and sometimes downright dangerous, local hospital services. Simply buying more of the 35 per cent of spend that currently goes on fixed-price tariff items in local hospitals keeps services in those hospitals unnecessarily and will not remove unnecessary beds.
We have to drive the provision of healthcare outside acute hospital beds, more in line, I suggest, with the rather neglected 2006 White Paper, Our Health, Our Care, Our Say, which was based on a massive consultation with the public. Consolidation of specialist acute services, especially with the final stage of the European working time directive, which has already been referred to, is essential if we are to make services safe and effective for patients. I notice that my noble friend Lady Wall will be speaking. We need look no further than north London to see a large area with too many hospital services on too many sites consuming NHS resources that should be used for other health purposes.
I share the views of the Health Select Committee’s strong reservations about primary care trust commissioners. I remain unconvinced by the Government’s response to that report on this issue. It is not possible, or even, I would suggest, worth the effort, to try to produce 150 world-class commissioning PCTs. We simply will not get to the end of that journey.
To reduce our dependence on inappropriate hospital services, we have to improve significantly primary care and community services. From some of the work I initiated in London, I suggest a hefty dose of performance management and market testing on primary care trust community services. It could produce something in excess of a 25 per cent efficiency gain over time. The management of these services needs to be scaled up and improved, integrated better with GPs, social care and other services—as the noble Lord, Lord Walton, said—and far more effectively managed. I suggest that that could be done by using greater competition and new entrants to local markets. Personally, I do not care whether those new entrants come from the public sector, the private sector or from social entrepreneurs. I strongly suggest that the public do not care that much, either.
This approach is more likely to deliver the kinds of changes that the noble Lord, Lord Mawson, and others are looking for. I could mention other cases—pathology services come to mind, as do the management of estates, facilities and buildings in the NHS. The NHS has a footprint that is too big for the services it needs to provide. All these areas need to be looked at.
I end on this note. If we do not start to tackle these issues more energetically, as the NHS chief executive seems to be suggesting, it will be difficult to strengthen those areas that we probably all know need to be strengthened, such as the new dementia strategy, end-of-life care and adult social care. They have not had anything like the generosity of funding that exists in the NHS. All these Cinderella areas will be neglected if we do not tackle the issue of resources going unnecessarily into the acute hospital sector. I wish to finish with a quote from President Obama’s Chief of Staff. He said,
“it would be a shame to waste a good crisis”.
My Lords, I thank my noble friend Lord Walton of Detchant for introducing this important debate. But it is the patients who come top of my list of priorities, and their safety should be foremost.
Good quality of care, the correct diagnosis and safety at all times while in hospital are what all patients desire, and they need the same quality when they rely on their care being given in the community. First-class medical training is vital, and with many complicated conditions specialised training is essential. When the specialised units are linked with universities, this enables research to expand. There should be good communication and co-operation between the universities and hospitals.
A cousin of mine, Dr Tim Inglis, became frustrated when he found that this was not happening. He did not have enough time and freedom in the UK to do his clinical research for improving patient treatment. He is a microbiologist and is now working in Australia. He has undertaken interesting research and enjoys life. It is so important that we do not lose too many of our dedicated clinical researchers.
The noble Earl, Lord Howe, and I opposed the closure of community health councils. The Government, instead of building on them, set up the health forums in their place as a patient voice and support, only to close them down after two years. The Government then set up LINks, and this is the current situation. I quote from what they have said to me in an e-mail:
“Many of us have made supreme efforts to make the new LINks model work. LINks are now 14 months old and many have managed little at all of active oversight of health and social care. They have become bogged down in processes rather than outcomes and the so-called support from the Government has been passed from pillar to post, adding to the confusion and demoralisation. Events at Stafford have since come to light and there is real concern that other Staffords out there will go unnoticed in the current situation”.
I declare an interest as a vice-president of the Patients Association, which has been supporting the friends and relatives of the 1,200 people who may have died as a result of the poor care at the Mid Staffordshire hospital. Like many others, the association has been asking for a public inquiry.
Senior doctors who speak out against dangerous practices are being frustrated, or even bullied into silence, according to new research by the British Medical Association. Doctors and nurses claim that the current law is inadequate, and that whistleblowers need much greater legal protection if they are to prevent another patient safety disaster. An NHS trust has been accused of victimising an eminent paediatrician, who claimed that a baby’s death and at least 28 botched operations on children were caused by unskilled doctors. The consultant’s concerns were ignored by hospital chiefs—who then suspended him, saying they were concerned about the state of his mental health. However, his colleagues at the University Hospital in North Staffordshire say that the surgeon—a former adviser to the Healthcare Commission—was suspended for blowing the whistle over children’s safety. There must be better protection for patients, and for these people, who try to protect them from unsafe practices. I should be grateful to hear a response from the Minister. Or would she agree that there should now be a public inquiry into all hospitals in Staffordshire?
I must mention a very serious problem, which is the increase in the number of antibiotics becoming resistant to infections. There is an urgent need for new antibiotics—we have become reliant on them, and we do not want the infections to win. There is a desperate need for research and development on new antibiotics, which the Government may have to take the lead on. Could there be legislation to encourage investment for the pharmaceutical industry? This is beginning to happen in the USA—could the Government set up a working group to help this to happen here? It will be a disaster for future generations if they are without antibiotics.
A strong message came out of a seminar on diabetes that I attended last Thursday, with many experts present—that specialist nurses are an essential part of the best treatment and follow-up for patients with diabetes. One consultant from Ipswich had lost his specialist nurse, to his and his patients’ dismay. Specialist nurses are also as valuable a part of a team for treatment of stroke patients, as are physiotherapists and occupational therapists. Also the specialist nurses are so important for patients with epilepsy, dermatological problems, Parkinson’s disease, cancers and many more. They are an investment—not only do they support patients in hospital and the community, they teach other nurses and junior doctors, who so often do not understand the treatments of such patients.
Dehydration in ill and elderly patients is putting them at risk when they come into hospital, and so often one hears of neglect of these vulnerable patients. If one watches hospitals at five o’clock on a Friday evening, one will see staff pouring out of the doors. Over the weekends, patients are left with only essential staff, and little goes on. If only hospitals could keep fully working for seven days a week, so much more could be achieved, and patients would not be put at risk by getting dehydrated, if they cannot drink unaided. This can also be a problem in care homes, when residents are fearful they will be scolded by staff if they drink and then have to go to the lavatory. So they restrict their fluid intake, making them dehydrated, and that makes them confused and unwell. This area needs more research and guidelines. Perhaps this is something that CQC members could check in both hospitals and care homes so that patients and residents are kept contented and safe.
My Lords, I, too, thank the noble Lord, Lord Walton, for the opportunity to take part in this very important and wide-ranging debate. Like other noble Lords, I pay tribute to his career, which, when you listen to it being described, is astounding.
I declare an interest as chair of Barnet and Chase Farm Hospitals NHS Trust, which delivers healthcare across north London. I think that I am grateful to my noble friend Lord Warner for mentioning me and my contribution to the debate. He is always thought-provoking and controversial but very often right.
The NHS is a huge organisation with many facets and it is charged with maintaining the health of the nation—a huge responsibility. It is an organisation that is continually changing and adapting to new challenges. These range from new exciting treatments to the way in which healthcare is delivered, ensuring that the focus is on the patient, as referred to by my noble friend Lord Woolmer. Innovations such as same-day or short-stay surgery, minimally invasive surgery and major developments in the treatment of cancer have all come from the service’s ability to learn from research and experience and from feedback from the patients and their families and our staff.
My trust is a partner member of the NHS Institute for Innovation and Improvement and is actively engaging that organisation in a range of development initiatives aimed at improving patient care, such as the Productive Ward programme, Lean thinking, No Delays Achiever, patient safety and the Delivering Quality and Value strategy—all things that I think we would applaud.
An acute trust such as Barnet and Chase Farm has a major responsibility for providing safe and timely care to our patients. This is rigorously monitored to maximise the efficiency of the organisation in terms of access by patients into the system and I am pleased to say that the patient experience and the quality of care are increasingly being monitored. I say that I am pleased because that is exactly why we are there. The whole range of clinical governance tools are employed to do this, but listening to what patients and their families tell us is crucial to the ability of the organisation to learn from this experience.
The national patient survey feeds us with important information on how our service is viewed by patients. Their views may be very subjective, but we have to remember that their perception of the service is vital to our understanding and our ability to make changes to improve their experience. This, of course, may be in the form of a complaint, to which our organisation pays utmost attention—it views the whole process as a learning experience. Much work goes into training our staff in the handling of criticism and using that knowledge to improve our service.
In my view, one of the health service’s huge strengths is its total commitment to training and education. The term “lifelong learning” is embraced within the service for all grades of staff in both clinical and non-clinical areas. Through the process of appraisal, the potential of our workforce is identified and nurtured to the benefit of the service and of those who receive our services. There is a well used phrase—that our staff are our most important asset—and we should not dismiss that easily.
It also has to be remembered that the service trains the vast majority of staff who go on to work in the private sector and in many other settings both at home and abroad. It should be recognised that training goes on in virtually all healthcare settings and not just in teaching hospitals, although sometimes general hospitals worry that that may be the message that goes out. The challenge and debate that that brings to individual departments are very healthy in that they introduce innovation and change to enable the service to be fit for purpose. Training also develops the trainers in such a way that they examine their knowledge and practice regularly and keep abreast of modern developments.
Research and development has a key role in the service. Since the early 1990s, money has been identified within the NHS budget to foster and promote research. The Culyer report in 1994, to which the noble Lord, Lord Walton, referred, paved the way for research to become embedded in most NHS trusts, including my own, which is a necessary tool for the service to develop.
The nature of research in our organisation spans all disciplines, with some focusing directly and immediately on the delivery of healthcare. This system has recently been superseded by a network system of research-active organisations. They will promote the links between primary and secondary healthcare, along with academic institutions.
My trust plays an active part in our local network; indeed, it receives an income in recognition of the research activity undertaken, which helps to support the process and develop the culture of research. As I said when referring to education, research raises the quality of an organisation, enabling a culture that embraces change and innovation, which can only benefit the future of healthcare.
My noble friend Lord Warner will not necessarily agree with this, but the local hospital is an essential component of the local community. In my area of north London, which is populated by many cultures, religions and economic groups, it plays an important role. The equitable access to our service for all has a large influence on communities living together. We must now work hard to ensure that the services that patients need are the services that they get. We will continue working with local clinicians, residents, our patients and other partners to ensure that all improvements to local healthcare are sustainable, delivered smoothly and effectively and in the best interests of all patients.
In conclusion, the NHS is an overarching organisation that continually learns from its experience and its research to deliver the safe and appropriate care for which it was created.
My Lords, I am grateful to the noble Lord, Lord Walton, for initiating this debate and to be able to contribute, albeit with a great deal less knowledge than he has but with equal concern that, despite the relentless march and associated benefits of modern technology, healthcare delivery and social enterprise and cohesion are not as sophisticated or effective as they could be or should be.
Over the past year or thereabouts, I have had the privilege to chair an independent review of autism services for the Department of Health in Northern Ireland. My review team found that, despite a wealth of knowledge acquired, mainly by and through the voluntary sector organisations that have done some wonderful work over the past 20 years, throughout the entire period of direct rule in Northern Ireland there had been virtually no co-ordination, no command and control hierarchy and no structured pathway for autism. I believe that this deficit is overall of national proportions and I shall concentrate on this issue.
It appeared to me that the Hall and Elliman report, specifically the one known as the “Hall 4” report, in its conclusion that there was no foolproof method of screening for autism, was able to allow off the hook those who direct within the health service. Well, things have moved on. The team of professionals that I chaired has concluded that effective assessments of developmental progress are possible from around two years of age. That means in effect that, from January 2010 in Northern Ireland, 22,000 children aged two to three years will be screened each year.
One may ask whether that will be a massive and costly exercise, but that will not be the case. We already have in place—I assume that it is the same in Great Britain—a health visitor system, which over the past 60 years has successfully and willingly adapted to changing demands. It is eager to adapt and embrace up-training with regard to early identification of autism tendencies, which will be achieved at acceptable cost with the voluntary sector and departmental agencies working in partnership. Much of this is about efficiency gains.
In line with an expectation that roughly 1 per cent of the population is on the autism spectrum, we have calculated that 3 to 4 per cent of two years-olds will be queried, some 750 children per year in Northern Ireland. By assessing on the basis of population and with simple primary school maths, it will surely not be difficult to plan—largely, if not entirely, on the basis of the existing consultant provision—what is required to provide immediate early assessment and diagnosis. Each healthcare trust will know exactly what to expect and consultants can plan ahead, up-training themselves where necessary. They will refine the initial 750 children identified down to 1 per cent, which will probably be 200 to 250 children each year, who will from that early age be able to benefit from early interventions.
I come back to costs for a moment. We will be using almost the same professional practitioners, but in a way that is planned and structured better. Extra costs will occur but mainly in up-training, and those updated skills can be built into training programmes for those planning to enter the medical and associated professions.
Of course, that cannot be the simple end to my thesis. Children with autism spectrum disorder have to face transition to primary school and to secondary school and then they have to adapt to adolescence and so on. But is it not better to begin to learn to cope in the vital learning years between two and eight than for us to find a confused eight year-old with behavioural problems falling behind his peers and unable to adapt?
Here is the opportunity for progress, but it is not the end of the story. That is a matter for further adaptation and joined-up government. The Department of Health can break down the front door but every other department has to smooth the path that lies ahead: teacher training, police training, the Prison Service, sports clubs, the workplace and so on. I believe that each stage can be dealt with as effectively as we plan in Northern Ireland for the two to eight year-old phase. We do not have to reinvent the wheel; we do not have to tear down and replace existing administrative structures. We have to adapt to a reality that does not put our nation into and take it out of a series of disassociated stages. Life, especially for those with any disability, should be a gentle stream, not a series of waterfalls.
I conclude by asking the Minister and her noble colleague, the noble Lord, Lord Darzi, who has contributed so much, if they would look at the Answers that their department gave me on 20 May over the signature of the noble Lord, Lord Darzi, at col. WA 312, regarding the plight of those on the autism spectrum who find themselves in prison—perhaps up to 30 per cent of our prison population. It was simply not good enough to have an Answer that implied, “Prisons and autism we don’t do; we don’t provide; we don’t really want to go there”. Given the Minister’s diligence and given the noble Lord’s industry since he came into this House, I do not believe that that it is what either of them would want.
My Lords, I, too, congratulate the noble Lord, Lord Walton, on securing this debate and on his excellent speech—not a speech, a tutorial—on the benefits of and need for medical research. I am sure that the House appreciated it. It was ably backed by the personal story in the speech of my noble friend Lord Rodgers. I thank my noble friend Lord Addington for reminding us that we should be thinking about a national health service. He reminded us that prevention is better than cure. I would add that my noble friend is not overweight; it is all muscle.
The National Health Service today is a strange organisation. It is neither totally planned from above, nor does it free its patients to obtain treatment and care from any health facility, public or private, that they wish. It is something of a muddle and rather confusing. It is leading to a lot of fragmentation and confusion. I shall illustrate the law of unintended consequences in some of the things that are happening in the health service, especially in medical education and research. Teaching and research used to be done primarily by the academic workforce in medical schools, medical faculties and the teaching hospitals, often in collaboration with doctors and physiologists in the non-teaching hospitals and using all the extra clinical material in those places. However, between 2000 and 2007, there was a fall of 27 per cent in the medical academic workforce. There are now only 2,937 academics working in our hospitals, medical schools and universities. Despite that, there has been a huge increase in the number of undergraduates: a 50 per cent increase in the number of medical students in the past 10 years, which is hugely welcome. The student population is currently 30,000, excluding all the postgraduate students, but that means that there is only one medical academic working in this country per 100 undergraduate students.
As a result of the decline in academic staff, there is more pressure on clinical staff in hospitals to teach and do research, but managers of those hospitals are often interested only in data collection, patient throughputs, targets and waiting lists. Teaching and research are very low on their radar screens and we heard from the noble Lord, Lord Warner, that PCT commissioning is questionable at times and does not always consider research and education.
We also need to look at a few other reasons for the demise of medical academics. The noble Lord, Lord Turnberg, mentioned bureaucracy. One would expect a Government that managed to deregulate the City in such a dramatic and fantastic way to be able to do something about deregulating medical research. We must remember that there is not pay parity between clinical and academic staff. Newly qualified doctors have huge debts. Medical students have a longer training and it is full time, so they cannot take part-time jobs to help pay their fees and debts when they qualify, so they are more likely to want to go into medical and clinical training and get on the ladder quickly to earn a decent salary as clinical staff than to spend time doing academic work or research.
I raise the question also of women in medicine. I am delighted that most medical schools now take in more women students than men. This is excellent news for women, who are eminently suited to a medical career. However, they, too, may be in a hurry to get their higher qualifications. They may want to earn money not only to pay off their debts, but also perhaps to pay for childcare in future; so they may reject medical research and get on with clinical work to earn a higher salary. Is the NHS doing any research to analyse the hopes and aspirations of the women doctors who are qualifying and are their circumstances being taken into consideration for properly planning the workforce in future?
Another factor is the private finance initiatives. Polyclinics and new health centres were mentioned by one noble Lord. The noble Lord, Lord Mawson, mentioned the integration of social care—how I wish that we could have integrated health and social care. Polyclinics would be an ideal place. However, no private developer will want to waste money on facilities for teaching and research. He will want a return on his money, and it will be much more difficult to make a profit if there is social care as well as teaching and research going on in an establishment.
I read something interesting about contracts with the private sector and commissions for routine surgery that are often taken out by PCTs. I read about a gastroenterologist who had his entire endoscopy list taken away from him without being consulted by his managers. The endoscopies were to be done by a private hospital, away from the main hospital. Most of his research and teaching of students was based on how endoscopies should be done and what he was discovering. When that sort of thing happens, it is crazy and counterproductive.
In conclusion, in the past 10 years the National Health Service has improved beyond recognition. Many new facilities have been built and a great deal more equipment supplied, along with more doctors and nurses—I do not have to recite the Government mantra for them. Everything has improved hugely. We know that quality is an issue, but the noble Lord, Lord Darzi, is addressing that. Surely the challenge now is to make sure that medical education and research go on being the best in the world, as they have always been. They must not fall behind because we are concentrating on profitability, efficiency and patient throughput. We must remain the best in the world for medical research and education.
My Lords, I, too, thank the noble Lord, Lord Walton of Detchant, for initiating this important debate and for introducing it in such a lucid and informative way.
The report Best Research for Best Health stated that the objective of Her Majesty’s Government is to ensure that patients benefit from clinical research, that areas of unmet needs are addressed and that the health of the people is improved. Bearing in mind these worthy objectives, I will examine how they relate to the greatest hazard that threatens millions of people in the UK. I refer to the obesity epidemic, which is increasing all the time and represents a dangerous threat not only to the nation’s health, but also to the NHS and to the economy as a whole.
Evidence-based medicine is quite rightly the best basis for the practice of medicine, but sometimes lobby groups position themselves between science and good evidence-based practice. The food industry has concentrated on the lack of exercise as the cause of obesity, which of course suits it very well because, understandably, it does not want any reduction in its trade. The science is clear: if one wants to take a pound of weight off by exercise, one has to run a mile; whereas simply reducing the number of calories eaten or drunk is guaranteed to reduce weight. Exercise is very good for the integrity of the cardiovascular system and is effective in reducing the wrong sort of cholesterol. There is also evidence that exercise helps in reducing the amount of fat in a patient’s body, rather than a reduction in muscle. But that is when exercise is combined with a reduction in the number of calories, as the noble Lord, Lord Addington, knows well. It should be emphasised that one can put on weight just by drinking fluids. Let us take, for instance, the cocktail, Mai Tai: three such cocktails provide 1,000 calories.
In a predominantly sedentary population such as ours, it is clear that exercise is not an efficient method of weight reduction. In fact, many obese adults are precluded from exercise by problems such as arthritis, heart disease and respiratory inadequacy. The emphasis on physical activity has political supporters, however, as there are fewer commercial interests opposing the message and it fits with the promotion of events such as the 2012 Olympics. The alternative message, which proposes a move towards healthier diets and reducing the consumption of energy dense foods, such as fatty snacks, confectionary, soft drinks and so on, is much more sensitive politically. A man who was confined to an electric wheelchair and therefore could not exercise decided to reduce his weight by two stone, or 13 kilograms, which he did in a rather revolutionary way. He simply ate less and quite soon he came down to the size he wanted.
There are a number of red herrings in this subject, including brown fat, big bones and hormones, but at the end of the day we are what we eat. An overweight man consulted me about his excessive weight and he assured me that he had tried every diet in the book, but without any effect. He asked whether I could help. I noticed that his wife was quite thin—perhaps I should say she was a normal size. So I suggested that he ate the same quantity as his wife. He saw the danger of that and was somewhat reluctant, but he agreed to give it a try. Three months later when I inquired of his wife how successful this regime had been, she said, “It has been a disaster because I’m putting on weight”.
Danish doctors have reported that a British formula- based diet was successful in reducing the weight of their patients by more than 12 per cent, which gave very good symptom relief in obese men and women with arthritis of their knees. One hundred and ninety two of them followed a 500 calories a day or an 800 calories a day diet for eight weeks and were maintained on a stabilising diet for about six years. On average, the patients weighed 16 stones and lost two stones in 16 weeks, and 60 per cent had a significant improvement in relieving their symptoms, especially pain in their knees.
Professor Bliddal from the Parker Institute, Frederiksberg Hospital, commented that obese patients have very bad knees and if they exercise before losing weight they almost certainly wear the knees down and make things worse. In his programme people lose weight first and when they are a lighter weight, they usually regain their former activity. He ends by saying that bad knees are no excuse for failure in losing weight.
Those who insist that exercise is the solution to the problem of obesity give obese patients just the excuse they need to say that they cannot exercise to lose weight. They remain in their morbid and eventually fatal outcome. Yet there is some comfort for those obese people who find it difficult to lose weight. A strange mechanism in the brain is relevant in weight control. As one’s weight increases, a complex brain regulatory system adapts to lock in to the new, heavier weight. It becomes the new level which the appetite and activity control centres then try to maintain. This explains why some people have difficulty in reducing weight. Even so, they can still lose weight if they diet.
I have so far dealt with adult obesity. As the noble Lord, Lord Addington, mentioned, we need a different approach with children, one combining a reduction in calories with increased activity and counselling. At the same time, all children have to be encouraged to be much more active: walking or cycling to school, plenty of games and reducing the amount of TV and computer pastimes. Prevention is much better than trying to cure the obesity when it occurs. The culture has to change radically if the nation’s health is to improve.
Life today is such that we need to eat 500 calories less than was the case. The food industry has got to produce new, mainstream foods with far lower calorie densities. At the start of the last war, one-third of the British people were either underfed or ill-fed. The introduction of food rationing changed that within a few weeks. That was the greatest public health experiment ever. We cannot put the clock back but we must have voluntary change. This can be helped if Her Majesty’s Government in particular and politicians in general accept what research has already revealed: we are what we eat and there are no mysteries.
I have forgotten to declare an interest. When a person tells me that I am lucky to be thin, I am tempted to say “Actually, I am normal”. As that might be construed as a criticism of his obesity, I explain that I cannot claim any credit for being the size that I am. It is all due to a patient of mine 40 years ago. I was on my way to a black-tie dinner wearing the black-tie outfit belonging to my father-in-law. It was 50 years old and green round the edges. I was called out to St Bartholomew’s Hospital to see a lady who was bleeding to death from a tumour in her groin. I went up to the bedside. To my amazement she seized hold of my jacket and said, “That jacket is very old”. I said, “It is 50 years old”. She said, “It looks it.”
I did not quite know how to cope with this. There was this lady dying yet joking away. She said:
“Now, look. I know I’m dying. I know there’s no hope and it’s inoperable. But I want you to take me to the operating theatre and have a go. Take a risk and try to remove this tumour. You will have to put a new artery in”—
she knew her medicine.
“I am in the cloth trade in the East End and if I survive I will make you a new black-tie outfit”.
I was amazed to hear this. I operated all that night and because she was indestructible she survived eight years. During that time she made me a new suit.
As a tribute to her, I have to stay the same size. As I am Scot I do not want to buy a new suit. We are what we eat.
My Lords, it is a pleasure and privilege to be responding for the Government to this debate. I am grateful, as other noble Lords clearly are, to the noble Lord, Lord Walton of Detchant, for initiating it. If nothing else, it has been wide-ranging—a veritable potpourri of contributions. I hope I will be able to address all the themes and individual issues. I confess that I have a large pile of notes in front of me and it may be necessary to write to some noble Lords, for which I apologise in advance. I will do my best.
I turn first to health research. The Government fully recognise that a vibrant and well-organised health research sector is of enormous importance to our healthcare system, to our economy and to countless individuals and their families. That is why we have the radical and ambitious health research strategy that the National Institute for Health Research is delivering. That is why funding for all aspects of research has been increased to the highest-ever levels and why the place of research within the NHS has been given renewed emphasis. We hope the combination of our strategy and the growth in funding is powerful. No one can fail to be struck by the progress that the NIHR has made or by the efforts being made under Sir John Bell and the Office for Strategic Co-ordination of Health Research in invigorating translational research.
What we are beginning to achieve through that research—through what the OSCHR partners are doing together—is, as several noble Lords have mentioned, unequalled anywhere else in the world. We are doing it by building on, and in no way diminishing, our strengths in basic science. That much and a great deal more are clear from the progress report that the chairman of the OSCHR published last November.
Progress is unquestionably what the NIHR—I apologise for using initials—has achieved. The energy and determination which so many people in the Department of Health and the NHS have put into implementing Best Research for Best Health has enabled enormous strides to be made. The evidence is clear in the positive impact that the new funding regime is having on all parts of the research community and across the NHS. It is clear from the impact of the clinical research network on the numbers of trials taking place in the NHS and the scale of patient recruitment to them. It is clear from the effect of bringing together and supporting the people who conduct research in the NIHR Faculty.
We want a research-intensive NHS. It is good for patients and, as the noble Lord, Lord Walton, rightly said, it is good for clinical teaching at all levels and across disciplines. The quality improvements and innovation that lead to productivity gains and better patient outcomes depend on the new ideas that research generates and evaluates. We recognise the need for vitality, which was mentioned by several noble Lords, including the noble Baroness, Lady Tonge, who correctly said that we have to remain at the top. Clinical fellowships and lectureships provide research, exposure and experience for academically gifted medical and dental trainees. We are moving to the stage where there will be some 750 academic clinical fellowships and 400 clinical lectureships in the NHS, which is equivalent to more than 2 per cent of all hospital doctors in professional training.
We are uniquely placed in this country in the scope the NHS offers as a base from which to conduct clinical trials. We and our research partners in industry and the charitable sector believe that we have the right policies and right structures to capitalise on that potential. There are of course challenges internationally and at home to the full realisation of that objective, but I do not believe that the European clinical trials directive—mentioned by several noble Lords, including the noble Lord, Lord Walton of Detchant—is one of them. The total number of clinical trials in the UK has remained stable since the introduction of the directive and we continue to be at the top end of the European league table in our sponsorship of both commercially and non-commercially funded trials. If we are to remain there, and to face the international competition, we need efficient, robust and, above all, transparent ethical and governance systems. I shall return shortly to the points raised by my noble friend Lord Turnberg on those issues.
Real and considerable effort is being made in this area. We are making our research ethics committee structure simpler and stronger and integrating it more closely with other aspects of research regulation. We are simplifying and streamlining the administrative and regulatory procedures governing trials and other studies and updating our research management systems.
The noble Lord, Lord Walton, mentioned research charities and their excellent umbrella organisation. The support we give those charities is as important to them as it is to us. The clinical research network now provides automatic infrastructure support for all eligible trials, and the 2004 science and innovation investment framework committed the Government to underpin the charity-funded research undertaken in our universities. This investment is made through the Higher Education Funding Council for England through its quality-related funding stream and will rise to £194 million in 2009-10.
The noble Lord, Lord Walton, also raised the issue of the European working time directive. There is no evidence that greater numbers of trainees are failing in their end of year assessments where 48-hour working has been introduced. No junior doctor can become a consultant until the appropriate royal college has issued a certificate of completion of training. This is an essential safeguard ensuring that medical training remains of the highest standard. Given the concerns raised by some professionals, we have listened and acted. The former Secretary of State for Health announced a review on the impact of the implementation of the European working time directive on 20 May. This review will consider concerns that the introduction of a 48-hour working week may have a detrimental effect on junior doctors’ training, particularly on the training they receive while at work. It is important that there is an independent and objective assessment of whether the introduction of the directive fully into the NHS will necessitate changes to the current system of postgraduate medical training.
I shall address the issue of social enterprise as part of these remarks and then return to the individual points raised by noble Lords. I feel that I should declare an historic interest, as it were, as the founding chair of the Social Enterprise Coalition and as someone who has been working with social enterprises and co-operatives almost all my working life. I believe that social enterprises can make a big difference to the lives of the people and local communities they serve. We agree entirely with the noble Lord, Lord Mawson, that they are able to transform the way services are delivered and to improve health outcomes. Innovative and flexible solutions to transform health and social care can be found in social enterprises and they have strong potential in other sectors, such as housing, leisure and transport. That is why encouraging social enterprise in health and social care is a key part of our patient-led reform of services.
The department is actively promoting social enterprise in health and social care through the Social Enterprise Investment Fund and by supporting the next stage review commitment for the staff’s right to request. The Social Enterprise Investment Fund has so far provided £20 million of funding to 200 social enterprises and the new fund manager is working to build on this success to support even more. The fund offers a range of financial services, including grants and loans, as well as providing business support tailored to the needs of social enterprises in various stages of development.
In addition to evaluating the impact of these investments, the department is working with the Office of the Third Sector to pilot the social return on investment. We are working with six social enterprises delivering mainstream health and social care services, to measure the social value that they are bringing to their local communities. The department’s investments include funding for several healthy living centres, such as Well UK, Community Docs for All and St Luke’s Healthy Living Centre. These centres address local health inequalities and improve access to services for the local population, making a real difference to local communities. The right-to-request commitment in the next stage review is enabling clinical staff in primary care trusts to use their entrepreneurial and leadership skills to develop innovative services to improve service provision for their patients and their local communities and we are very committed to that programme.
The noble Lord, Lord Mawson, raised the issue of social enterprise and expressed his frustration. He is correct that we have yet to crack the need for holistic commissioning and he knows that I am a great champion and supporter of this issue. He knows that it works and there is no doubt that we still have to crack the issue of rolling this provision out. We are committed to encouraging commissioners to grasp the opportunities offered by this sector. For example, Manchester PCT has commissioned the Big Life Group to run the Kath Locke Centre, a primary care centre in Moss Side. The centre allows local people to access services and to help deliver them. We have published two documents that we hope will help local commissioners to crack this.
I take issue with the noble Lord about polyclinics being based on a biomedical model. One of the largest community-owned health organisations is Local Care Direct. It was set up to provide out-of-hospital care to 2.5 million patients in Yorkshire and Humber. Being a Yorkshirewoman, I am particularly fond of this organisation. Local Care Direct was the first organisation to open one of the new GP-led access centres nationally in December 2008. These services complement existing GP and out-of-hours services in the area and demonstrate how a social enterprise can help transform primary care.
I pay tribute to the noble Lord, Lord Mawson, for the work he has been promoting on healthy living centres and I hope that I can help him to crack the bureaucracy. He is quite right that getting bureaucrats to be entrepreneurial and to recognise the benefits of social enterprise is a major challenge, and that is clearly what we have to crack. He is absolutely right to make that point.
The noble Lord, Lord Walton of Detchant, mentioned academic health science centres. These bring together a small number of health and academic partners. The aim is to help speed up the process of translating developments in research into benefits for patients and the local community, and to promote the adoption of their discoveries within the NHS and across the NHS and the world. Designation is awarded for a period of five years and the successful centres will be subject to review. The international panel of designation recommended that there should be a reapplication process. The Secretary of State has accepted this recommendation and he also reserves the right to suspend or remove designation if that is deemed necessary.
The noble Lord asked about the 1.5 per cent research spend. The Government have made unprecedented increases in funding for health research. Total government investment in health research will be £1.7 billion by 2010-11, an increase of more than £290,000 in the three-year period covered in the 2007 Comprehensive Spending Review. There is no evidence to suggest that a particular proportion represents a right level of support to aim for. We need to aim to make that investment work for us and to make it as effective as possible.
The noble Lord raised the issue of MTAS. Since the old system was abolished the Department of Health has worked with the medical professions at various levels to design the best possible recruitment system for doctors in training. Nearly all the deaneries use the same IT system for their local recruitment. National recruitment has continued to improve. The establishment of Medical Education England represents a unique opportunity to work with professions and get the right number of staff in the NHS, at the right level.
My noble friend Lord Woolmer was correct to mention the next stage review and made a good point about patients’ needs and experience and how they should inform how services are organised. I will address funding issues in a moment. He also made the point about more clinicians in leadership roles. Clinical leadership is key to the future success of the NHS and the National Leadership Council has been established to support the service delivery in this.
The noble Lord, Lord Rodgers, raised the issue of stroke, as did several other noble Lords including the noble Lord, Lord Walton of Detchant. He was right to point out that we have a new national framework for stroke and we are endeavouring to give it the right kind of emphasis and prioritisation that stroke requires. I can confirm that the 10-year plan is on track, that the stroke strategy acknowledges that the networks are of great benefit and that all the stroke services in England now fall within one of the 28 networks. The work of the stroke improvement programme, including the networks, will be evaluated over the next year, after which future work plans will be considered.
The noble Lord also asked about research. The NIHR clinical research network is building on the extraordinary success of the cancer research network to maximise the potential of the NHS to support clinical trials and involve more patients in them. The stroke network, to which the noble Lord referred, is one of six topic-specific networks and well over 200,000 people were recruited into studies across the whole network last year. Among other things, the result is an increasing integration of research and patient care, about which the noble Lord was concerned. The noble Lord asked where he could find out about the cost of the stroke research network. Improving the level of quality of research provides new opportunities for stroke research in the NHS and the integration of research within the delivery. There is a commitment of £20 million over the next five years that has been made to support the UK stroke network. That does not answer the question about where you find that information and I undertake to write and tell the noble Lord. It says that we are doing it, but not where you find the information, for which I apologise.
My noble friend Lord Turnberg talked about regulation, data sharing and the DIPEx website. He asked whether we could have another go at bureaucracy busting. We are redoubling our efforts to reduce bureaucracy and are fully aware of his and other concerns. We are working with Professor Paul Stewart in Birmingham on these issues and others and taking practical steps to include the creation of an integrated research application service. This is transforming the application process. Single application forms are necessary and we want to move towards a much simpler way of proceeding. We are doing our best to do that and my noble friend makes a very good point. On DIPEx, the NIHR is the main funder of the DIPEx database that the noble Lord mentioned enthusiastically and I undertake to look at it myself.
The noble Baroness, Lady Emerton, as usual made a very well-informed speech about the importance of building community cohesion—High Quality Care for All being the beginning of the revolution not the end. I am pleased that the noble Baroness is serving on the commission that the department has established. The former Secretary of State announced a review of the impact of the implementation of the European working time directive on 20 May, which is an issue that the noble Baroness mentioned, and I hope that I have answered that question.
The noble Lord, Lord Bew, gave an important and eloquent description of how the NHS coped during the Troubles and I join him in paying tribute to NHS staff at all levels during that period.
The noble Lords, Lord Addington and McColl raised the issue of obesity, which we have discussed in your Lordships' House within the past week or so. I would say to the noble Lord, Lord Addington, that we are working across government. Change4Life and the Olympic legacy show that we are fully aware of the need for people to walk, cycle, swim, dance in their bedrooms and take exercise. We have policy documents to deal with that and they are rolling out across government. The noble Lord, Lord McColl, gave us an important master class of good sense on the prevention of obesity. The only thing that I would add is that we are leading development in obesity research strategy across government, with a strong emphasis on prevention.
I need to deal with the issues raised by my noble friend Lord Warner. He asked about a speech made by the head of the NHS. That text was agreed and cleared with the then Secretary of State. It started with what we know: that PCT allocation will grow by an average of 5.5 per cent each year 2009-10 to 2010-11. It then sets the scene that although we do not know what the spending review settlement for April 2011 will be, we at least know that total public spending will slow significantly and large productivity gains will be needed to cope with the rising demand for health and social care systems. The argument is that unprecedented productivity gains can be made only by improving quality.
My Lords, I was not quoting from the speech. I was quoting from page 47 of the NHS chief executive’s annual report. I was asking whether the Government had endorsed that. If my noble friend says that the Secretary of State approved the text, I will be reassured.
My Lords, he did indeed. My noble friend will know from his own experience that that would certainly be the case.
We know that we need to get better care delivering better value. There will be great efforts within the NHS to tackle, for example, healthcare associated infections. We estimate that we have already saved £75 million in reduced bed days and drug costs, while improving outcomes for patients. I have quite a large amount of information about the costs and savings that we are seeking to make, so I will write to the noble Lord because I am probably running out of time.
The noble Baroness, Lady Masham, raised the importance of the patient’s voice, the issue of Mid-Staffordshire and whether we should be having a public inquiry. We are unconvinced at this time that a public inquiry would add anything to our understanding of what went wrong in that hospital and what needs to be done to prevent such events happening again.
My noble friend Lady Wall again pointed to the importance of listening to patients and the use of patients’ feedback to inform change and progress. Her remarks were relevant and supportive. The noble Lord, Lord Maginnis, raised the issue of autism. I pay tribute to the noble Lord’s pioneering work on autism. We have discussed this in your Lordships’ House in the past. I hope that we will see the noble Lord participating in the forthcoming discussion on the Private Member’s Bill on autism which is about to come to your Lordships’ House.
The noble Baroness, Lady Tonge, made a wide-ranging speech, which included a pop at some of the issues that she is concerned about. She recognised that there has been significant improvement. I undertake to write to the noble Baroness about women doctors and their aspirations.
We have run out of time. I hope that I have at least nodded in the direction of all the issues raised by noble Lords. This is the last Thursday of debates in your Lordships’ House before we enter the time of trying to complete the Government’s legislative programme before Parliament rises in the autumn. It is entirely appropriate that the Cross Benches chose these subjects for debate and that they were of such high relevance and interest. I thank noble Lords for their contributions.
My Lords, I am extremely grateful to the Minister for that remarkably comprehensive and detailed analysis of the speeches that we have heard today in this very wide-ranging debate. I became a Member of your Lordships’ House 20 years ago. Not long afterwards, I was successful in obtaining a Cross-Bench debate, surprise, surprise, on the National Health Service. At the end of that debate, I tried, valiantly, to comment upon all of the contributions that had been made during the debate. As I attempted that I was roundly rebuked by the Minister on the Front Bench and told that was not appropriate in these circumstances. I have learnt that lesson. Hence, I am not going to say more, except to thank everyone who has contributed to a debate that has covered an enormous range. It will repay reading because so many invaluable points were raised in the many contributions today. I beg leave to withdraw the Motion.
Europol (EUC Report)
Motion to Take Note
My Lords, the subject of this debate is a report that was prepared following an inquiry by Sub-Committee F of the European Union Select Committee between March and October last year. It is good to see the noble Lord, Lord Roper, in his place after recent surgery. We are delighted to see him back in full harness as chairman of the EU Select Committee. We took oral evidence between May and July, and I will come to some of that in a moment. For the present, I want to say how grateful we are to all the witnesses who gave oral and written evidence. The bulk of our report gives testimony to the evidence that we received.
I pay tribute to the work of our outstanding clerk, Michael Collon, who did so much to make this report the success which I believe it is. He was ably assisted by Anneliese Baldaccini, our committee specialist. I pay a special tribute to Kevin O’Connell, our specialist adviser who brought all his expertise to assist us in drawing up this report.
Noble Lords may recall that a year ago I asked the House to take note of another report by our sub-committee, of which I was the chairman, on FRONTEX, the European borders agency. In that case, I had cause to complain that the Government’s response, signed by Mr Liam Byrne, who at that time was a ministerial colleague of the Minister at the Home Office, reached the committee well outside the mandatory two-month period and only five days before your Lordships debated the report. I have to say that the removal of Mr Byrne from that position did not cause any tears to be shed by members of our committee, because we had a most unsatisfactory relationship with him.
I am, therefore, very glad to be able to thank the Minister for the fact that the Government’s response to this report, signed by Mr Vernon Coaker—another erstwhile colleague—was received within the two-month period. I am only sorry that circumstances have conspired so that a further five months have elapsed before we could have this debate. I hope I am not to blame for the fact that the Minister who gave evidence to the committee for this inquiry, Mr McNulty, is a third erstwhile colleague. I am delighted that the noble Lord who will answer in this debate—I have already had a go at him this morning—seems to be the one fixed point inhabiting the Home Office ministerial universe. I shall try not to say any more rude things about the Home Office, but the Minister probably knows that I have a satchel full of them if I am provoked.
All of your Lordships know that Europol, the European Police Office, is a vital weapon for co-ordinating the European fight against serious organised crime. However, when in the early 1990s it was first proposed to set up a European police office, there was no legal basis for this to be done under the treaties. The member states therefore concluded between them a convention for establishing Europol. Since the entry into force of the Treaty of Amsterdam, a legal basis has been available. A decision was negotiated allowing Europol to be reconstituted as an agency of the EU; it was signed at the Justice and Home Affairs Council in April this year—six months after it was first on the agenda of the council for signature—and on 1 January 2010, Europol will be reconstituted as an agency of the European Union. This was one of the factors which influenced the timing of our inquiry.
At the same meeting, the Council of Ministers unanimously agreed on the appointment of a new director for Europol. Thereby hangs a story. We took evidence from the Serious Organised Crime Agency, SOCA, on 4 June last year. We were told that its deputy director, Mr Rob Wainwright, was to apply for the post of director when it became vacant. This was news to us, and I have to say it was also news to the director of Europol himself, who first learnt of this when he was reading Mr Wainwright’s evidence. I do not suppose it was particularly good news for the director, but to us, it was certainly good news because we felt that Europol could do with new and vigorous leadership, although we did not say as much in our report. I think we were sufficiently tactful—and as it transpired, rightly tactful—fearing that we might prejudice Mr Wainwright’s candidature if we drew attention to it in our report. Now that Mr Wainwright has been appointed to take up this post, I should like to take this moment to welcome his appointment very strongly, and to offer him the committee’s congratulations. He has got a difficult job ahead of him, and we wish him well in that work.
In its report the committee reached a number of conclusions and made a large number of recommendations, which are currently before the House. I want today to concentrate on three of them: first, the exchange of information; secondly, the governance and management of Europol; and, thirdly, the relationship between SOCA—the Serious and Organised Crime Agency—and the United Kingdom police forces, which supply SOCA with most of its information.
I start with the first of those, which is the exchange of information. After all, that is what Europol is all about—passing information about serious cross-border crime to police forces of other member states, and, conversely, obtaining such information from them. This is not the same as giving other forces information that they have requested. Information is put on the Europol database, to be available to the forces of any other member state which may find it of use. If therefore the information does not reach that database, it will not be available—and this unfortunately is exactly what happens. The national liaison officers at Europol headquarters in The Hague exchange four-fifths of this information between themselves, without putting it on their database. Access to information is thus greatly reduced, and it may be that crimes could have been prevented or solved, and criminals deterred or caught, if this information had been made more widely available.
We concluded that the reason for that was basically a lack of trust—much of this information is highly sensitive, and could lose all its value if it was disseminated too widely. However, once on the database, it is available to all forces of all 27 member states, and to anyone to whom they please to pass it. That of course is the objective, but it is also the reason why liaison officers are reluctant to make sensitive information available, if the liaison officers of even one of the other member states are not thought to be trustworthy. That is one of the problems we face. We did not wish to discourage bilateral exchanges between liaison officers of two member states—far from it, but we did feel that any information exchanged between them should also be put on the database. The Home Office told us in its written evidence, that it was prepared to take the lead, and we invited it to tell us how it proposed to set about doing this. In its response, it told us that SOCA had reviewed its procedures and would routinely copy details of bilateral exchanges to the Europol database. This would be excellent were it not qualified by two words which were inserted in the original small print. Those words were “sensitivity permitting”, which precisely illustrates the point that the committee has been trying to make. We would like to see the structure and make-up of Europol to be such that sensitivity is no obstacle. I should like to hear what the Minister thinks can be done to increase trust at Europol between all officials who are posted there, not just some.
The exchange of large volumes of information depends on the data being uploaded. We were told that SOCA was not yet in a position to use the systems for the automated uploading of data on to the Europol information system. The response told us that the Government viewed the upgrading of SOCA’s information technology systems as a priority and that they hoped this would be achieved “by 2010”. I hope that the Minister will be able to tell us what exactly that means. I hope that, when the Government talk about 2010, they do not mean the end of 2010, 18 months away. I hope that, rather, they mean the beginning of 2010, six months away. That is important.
I turn to the second point that I want to discuss—the governance and management of Europol. An organisation based on trust needs an executive that can help to foster that trust and a structure that can allow it to be developed. This is not what we found. The management board which supervises the director has a chairmanship rotating with the presidency, and the result was that Mr Max-Peter Ratzel, the then director from whom we took evidence, had in nearly four years worked with eight different chairmen of the management board. He can hardly be blamed for finding it difficult to build and retain trust between the chairman and the director, and indeed trust within the organisation.
We should have liked to see a system similar to the one to which I referred earlier in my remarks about our FRONTEX report a year ago, where the chairman is elected by and from the members of that board. Instead, under the decision, a chairman will be appointed by and from the three members who happen to be those appointed by the three member states holding the current and next two presidencies. This is scarcely better. It scarcely increases the likelihood of the best man or woman being appointed as chairman. It means that the chairman will serve for 18 rather than six months. That is an advantage only if the chairman chosen from among the three presidencies is better than the one chosen from a single presidency. There is really no guarantee of that in the system.
In their response, the Government, to give them credit, agreed entirely with our view and said that they had proposed an open competition for the selection of an individual who would hold the chair for at least two years. Apparently, a significant number of member states refused to agree to this. Apparently, too, there is no prospect of their changing their minds once the decision is in force. I ask the Minister why that is. Who are these people? Are they doing it just for political reasons? Are so many member states afraid that choosing the best man or woman for the job will mean that one of their national members will never be chosen to do it? Does the Minister not agree that the fight against international crime is far too serious a matter to be left to political bickering? If he does agree, which I feel sure he does, is this not something that should be raised at the highest levels? Perhaps I might suggest that it would be a start if it could be agreed by the Interior Ministers of the G6 at their forthcoming meeting in Birmingham, about which we had some correspondence with the Home Secretary—or perhaps I should again say the erstwhile Home Secretary.
As it happens, I know that we have already experienced political bickering of this type in the appointment of the new director, which I mentioned earlier. Mr Wainwright was agreed on all sides to be the best candidate put forward by any state, so why were there problems and delays about his appointment? If, to take a random example, the best candidate had been a Hungarian, it is scarcely conceivable that the United Kingdom would have objected to his appointment on the ground that it was not Hungary’s turn. I hope the Minister will agree that as the EU moves increasingly into the areas of crime and police co-operation, it is time for member states to show a bit of maturity about such matters.
I turn to the relationship between SOCA and the United Kingdom police forces that supply SOCA with most of their information. As I have said, Europol’s co-ordination role is based on the exchange of information. Those who gather that information are the police forces of the member states. Without the information that they supply, there would be nothing for Europol to do—we should understand that—but the police forces must be told what is happening. From the evidence we received from the Association of Chief Police Officers, it was clear that too often police forces passed information to SOCA without knowing what was going to happen to it; they did not know if it went to Europol; if it did, they did not know if it was useful; and if they received information back from SOCA, too often they did not know if it was information from Europol rebranded, or information originating from SOCA itself. They can do their job properly only if they know these things. If they know, they will have a proper incentive to do better.
We were glad that, in their response, the Government accepted that more could and should be done. They told us that SOCA would act on our recommendations, that it would indicate to police forces which channels of international communication were being used and that it would inform them of the outcome of their inquiries. Does the Minister think that if the Committee took evidence today from ACPO, nearly a year after we last did so, we would be told that things really had improved, that Europol now had a higher profile among UK police forces and that they were now aware of what happened to the information they were dutifully passing on? I hope that he will be able to expand on that when he replies.
Few things are more important than the fight against international crime. Europol is an important weapon in our armoury but it could be much more effectively used, and we think that it would be if our recommendations were implemented. Although we had criticisms of the Government, we applauded much of what they had done and were doing. Our main criticisms were reserved for the international stage. Much of what needs doing requires the agreement of other member states, but that is all the more reason why the Government should use the considerable reputation of this country in the fight against international crime to persuade our partners that things can be improved, if only they can find the will to do so.
I commend the report to the House, and I beg to move.
My Lords, first I reiterate the interests that I declared in the sub-committee’s report as chairman of the Security Industry Authority and president of the Association of Police Authorities. I want to pay my tribute to the committee’s chairman, the noble Lord, Lord Jopling, for all his hard work and his clear focus on ensuring that the inquiry into the changing nature of Europol was conducted thoroughly and rigorously and that the report was comprehensive. I reiterate the thanks of the noble Lord, Lord Jopling, to our committee clerk, Michael Collon, for his help, advice and considerable drafting skills, to the other specialists who served the sub-committee and to our specialist adviser, Kevin O’Connell, for his invaluable insight and practical knowledge of policing issues.
I will speak about some of the issues covered in chapter 4 of the report, on intelligence-led law enforcement and the organised crime threat assessment, and to speak briefly about information exchange and analysis before finishing up with a mention of accountability.
Over the past few years in Britain, the phenomenon of intelligence-led policing has gathered pace. I witnessed its development from my vantage point as chairman of the Lancashire Police Authority and of the Association of Police Authorities. In Britain, it finally resulted in the implementation on a national scale of the national intelligence model to which all forces signed up, under the watchful eye of the police inspectorate. The national intelligence model has been extremely important in the United Kingdom in enabling forces to target their resources on particular areas of activity or on individuals or locations identified by the crime data that they collected and the trends and patterns that have clearly emerged. The adoption of the national intelligence model has also enabled forces in the United Kingdom to work together more effectively, as they are now sharing a common methodology and approach.
Under the United Kingdom presidency of the EU in 2005, there was a drive to establish intelligence-led policing as a concept and as a methodology across member states. That led to the adoption of the European equivalent of the national intelligence model—the European criminal intelligence model. We investigated that as part of our inquiries. It is clear that not all member states in the EU were equally enthusiastic about that move or paid it more than lip service to start with. It has to be said that the doctrine of “not invented here” is not just a United Kingdom phenomenon. To be fair, policing is delivered through very different structures and in quite diverse ways across the European Union. None the less, the concept of intelligence-led law enforcement at EU level has been endorsed and welcomed by the council and has in recent years been an important development from the perspective of enhancing the effectiveness of Europol.
In the course of our inquiry, differences of view emerged about how firmly this new approach has, in practical terms, taken root in different member states. There has clearly been some dragging of feet and some reluctance on the part of policing agencies in some countries to sign up to it in practical terms or even to profess to understand what the term “intelligence-led policing” actually means. Thus the committee felt that renewed energy and focus need to be directed to establishing among member states’ police forces a common understanding of what intelligence-led policing entails and the methodology and approach that underpin and drive it.
We believe that Europol is in a good position to undertake this important task and that it should work with the heads of national units and the European Police College to organise training to encourage the adoption and use of intelligence-led policing as the common working method across Europe. Just as great benefits flowed in the United Kingdom from the establishment of the national intelligence model, so similar benefits are surely there to be obtained from its adoption across the EU. I now understand that the Europol draft work programme for 2010 contains an objective to embed the principles of intelligence-led policing in Europol’s decision-making processes.
I agree with the Government’s assessment, in their response to our report, that there is a role for SOCA in promoting this initiative at the level of heads of Europol national units and for our National Policing Improvement Agency to use its influence at the EU police training college. I look forward to hearing how successful Europol is able to be in relation to that initiative in the next few years.
The organised crime threat assessment was first introduced in 2004 under the Hague programme. A year later, one of the United Kingdom’s presidency objectives in the area of justice and home affairs was to ensure that good intelligence and its analysis would feed through into good-quality threat assessment, which had not existed in this form at EU level before. Europol therefore drafted the first organised crime threat assessment by the end of 2005 and now publishes them annually, giving an overview of the principal threats faced across the EU, allowing Europol to facilitate joint operational responses by member states. According to evidence that we took from SOCA, this is helping to usher in a new phase in the development of Europol and is,
“establishing the agency as a central intelligence base in the EU supporting a range of subregional initiatives around the EU”.
This has clearly been a very important development in the effectiveness of Europol’s role, resulting in the establishment of a centralised knowledge base and information systems to deliver effective operations. We must pay tribute to the British Government and to United Kingdom officials for exporting across the EU and to Europol the concept of the organised crime threat assessment. However, it now needs to be further developed alongside intelligence-led policing. I hope that in time it will bring about important results as well as closer liaison arrangements between prosecuting and investigating officials, improved information exchange and more accurate communication.
Europol also has an important role to play in providing a general information exchange service to enable member states to search a central EU repository for data relating to serious and organised crime. However, as we heard from the noble Lord, Lord Jopling, there is not, at present, enough data coming into Europol. One reason for this is that only five member states are currently using the automated loading system to feed in the large quantities of data involved. I reiterate the point made by the noble Lord, Lord Jopling, that it is imperative that SOCA’s information technology systems are upgraded as a matter of urgency so that it can take advantage of the automatic data-loading facilities available. I also welcome the planned introduction of a direct link to police forces in England and Wales via the police national network system. That, again, will facilitate data access and exchange, which is a central function of Europol’s role.
Europol has also developed a number of analysis work files to which member states have access. The UK certainly values the high-quality service of data analysis offered by Europol on issues such as drug trafficking, financial and property crime, forgery and, increasingly, terrorism and organised crime groups. However, while our report supports Europol’s role as an intelligence co-ordinator, we would not want to see Europol facilitating investigations. We make it clear in the report that its role should be to support, facilitate and co-ordinate investigations but not to initiate them. In their response, the Government agreed with that view.
I end by raising the important issue of the accountability of Europol. Europol is an important and growing resource for member states, but it needs to be scrutinised effectively, not just by the European Parliament but possibly by national parliaments in some way. Its work needs to be regularly and systematically evaluated. We need to know exactly where it is adding value, what the obstacles are to its further development and how they can be removed. I know that some of this will begin to happen in the next four years, but I urge the Government to do everything that they can to support a move towards ensuring greater accountability of Europol to the European Parliament and, in some form or other alongside European Parliament scrutiny, to national parliaments.
My Lords, I join the noble Lord, Lord Jopling, in saying what a great pleasure it is to see the noble Lord, Lord Roper, back in his place. I thank the noble Lord, Lord Jopling, for such an excellent introduction to the report. The report is very useful, not least because it lays out some of the issues that we have heard about this afternoon from the noble Lord, Lord Jopling. It also dispels some myths, the first of which is that Europol is a European police force. That is clearly a dangerous myth and the report makes it clear that Europol is a resource for national police forces. The issues that Europol addresses, and on which it facilitates much closer working, were touched on by the Minister in his Statement this afternoon. They are some of the most serious issues that we face. Cross-border crimes such as terrorism, money-laundering and the trafficking of people and drugs are serious crimes that require cross-border co-operation to deal with.
Surveys show that, even if UK citizens are sometimes unclear about the benefits of Europe, fighting crime is something that they are keen on when it comes to European co-operation. According to Eurobarometer in December 2007, 70 per cent of British people believe that decisions on terrorism should be taken jointly with the EU. The report says a number of things about co-operation against terrorism. It highlights the fact that Europol does not get systematic information on terrorist cases. Although the committee rightly urges caution on intelligence sharing, it is clear that there needs to be, as the report highlights, a lot more discussion on the matter in Brussels and, indeed, here.
I was interested that the report highlighted the two-country rule, under which at least two European countries must be involved before the 2005 decision applies. That seems quite arbitrary when terrorism can take so many forms. Cross-border crime is costing the EU in the order of £20 billion a year. That is the figure quoted, but it must be hard to estimate. Europol is one of the most needed aspects of co-operation in Europe, because criminals regard the constraints on domestic police forces of national boundaries as a great help, so everything that can be done to diminish those constraints is essential.
The report is timely. In January 2010, Europol becomes an EU agency, funded by the Community budget. With this in mind, it is especially important to address the matter of democratic accountability raised by the noble Baroness, Lady Henig, which remains unresolved. We were disappointed that the reform treaty did not address the matter of Europol in as much detail as it should have done. Europol should be subject to full democratic and judicial scrutiny, both by the European Parliament and the European Court of Justice. The decision to strengthen Europol should have gone hand in hand with the reforms introduced by the treaty of Lisbon. Nevertheless, we support strongly the concept of Europol.
We are worried about the Conservative position; I will be interested to hear from the Conservative spokesman in a moment. I know that the Conservatives have a number of reservations, including about Eurojust, the body that helps to co-ordinate prosecutions across Europe and recently led the successful prosecutions following Operation Koala, which broke up a paedophile ring and resulted in the arrests of 93 people and the rescue of 23 victims. Conservative MEPs voted against the EAW, which slashed extradition times between Britain and other EU countries from an average of 18 months to just 43 days and resulted in 920 criminals being swiftly extradited from British prisons to face justice in Europe. Not only is it streamlining the system, but it is also saving British taxpayers’ money. I hope that the Conservatives will feel more enthusiastic about European co-operation.
The noble Baroness, Lady Henig, mentioned the European criminal records information system, which again Conservative MEPs voted against. That was surprising, because it standardises the format of criminal records in Europe and allows streamlining and more efficient exchange between police forces and between employers such as airports. We see that sort of thing as essential to fighting crime.
I thought that the report was particularly interesting on data. It contains a number of lessons. It is essential to recognise that a sloppy, weak or unclear policy on data is not acceptable. While we accept that data exchange is invaluable in the fight against crime, it is immensely important that the corresponding safeguards for those data are excellent. Of course, we have this debate a lot about domestic data and we know how easily data can be lost. We have to be confident that the European system will be sufficiently strong not to undermine public confidence in any country, especially ours, in the operation of Europol. EU countries are now exchanging the data, but the report has some reservations about the adequacy of protection. I believe that the arrangements for transferring data were agreed behind closed doors under the Prüm treaty, which possibly weakens them, as they were not open to adequate scrutiny at the time.
As Europol becomes an EU agency, two aspects concern us most: accountability must be addressed and data safeguards must be adequate. Overall, we see this as a positive move. The report highlights for the Government some helpful areas but, because they were not within its remit, the report did not address a couple of things that should be addressed at the same time. I mention them now because they are critical issues as regards crime and security: the European border security force and a database on illegal immigration. The Minister may want to comment on those.
My Lords, I, too, thank my noble friend Lord Jopling for initiating this debate and congratulate Sub-Committee F on this comprehensive report. Perhaps I may also associate myself with remarks made by other noble Lords about how pleased we are to see the noble Lord, Lord Roper, back in his place.
Let us first look at Europol’s successes in the 17 years of its existence. They include the disruption of a network of people smugglers which spanned six countries, the dismantling of a large international cashpoint skimming operation and, impressively, Operation Koala, which resulted in customers ordering videos showing child abuse being arrested in 19 countries following an investigation which began in Australia.
I am sorry that the performance of my Conservative colleagues in the European Parliament has drawn criticism from the noble Baroness. Had she given me prior notice, I might have been in a position to address that. But let us give credit in this debate to Europol for what it has achieved; that is, real, tangible successes. However, the report has highlighted a number of shortcomings, which have been addressed in this debate. The sub-committee concluded that attempts to tackle crime across Europe are being hampered because police intelligence is not being shared effectively. In the early years of its existence, there was a lack of trust and fear of leaks, which is understandable where matters of intelligence are involved. But we hope that these are lessening as the agency matures.
A subsidiary, although important, but more easily rectifiable, problem has been the SOCA IT system, which is not compatible with that of Europol, as my noble friend mentioned. In comparison with other problems, this surely can be addressed with reasonable dispatch and we hope that the end of 2010 does not mean what he suspects it might mean. We will welcome the Minister’s assurance on this point, with my noble friend’s trenchant comments ringing in his ears.
A more fundamental problem arises from the system of liaison officers from member states. This again has been highlighted by the sub-committee and by my noble friend. These liaison officers are, I understand, housed in the same building as Europol. It is hardly surprising that much of the intelligence is shared in person between liaison officers, thus bypassing Europol. As my noble friend said, the Home Office said in its evidence that it was a matter of concern that up to 80 per cent of bilateral engagements are shared in this way. The sub-committee was unequivocal in its criticism. I will quote it; it is significant and to the point:
“For Member States to share information in a limited way through liaison officers is the antithesis of the purpose of Europol, which is the enhancement of the already existing combined effort of the Member States’ competent authorities so that the whole is greater than the sum of its parts. Limited sharing of information will not achieve a common approach to crossborder cooperation against serious crimes”.
This says it all.
The liaison system has much to recommend it, not least the rapid exchange of intelligence at the personal level. This is an example of unintended consequences—in this case, the bypassing of Europol. I am pleased that the Government’s response following the Home Office’s concerns states that, on this matter, the Government are prepared to lead by example. Yet in their response to the report they have failed properly to address the bypassing issue.
I am sorry that one of the weak links is a domestic issue within the United Kingdom and not directly concerned with Europol. Again I have to thank my noble friend for raising this. It is the poor liaison between SOCA and the police forces in the United Kingdom, to which the report has drawn attention. As your Lordships will be only too well aware, the creation of SOCA took up a huge amount of parliamentary time and resources. It was launched in 2006 as the UK’s first dedicated enforcement agency responsible for tackling drug trafficking, organised crime, money laundering and identity theft. My party has previously been critical of SOCA’s poor performance. Despite a budget of £894 million over two years and 4,000 staff, the agency achieved only five more convictions in 2007-08 compared with 2006-07—276 against 271. The agency missed three of its five asset-recovery targets.
We have a further problem with SOCA. The liaison between Europol and national authorities takes place through what is known as the national unit. In the United Kingdom, this national unit is SOCA. The report highlighted the fact that SOCA has no counterterrorism unit. That is why it is all the more important that SOCA should work closely with the Metropolitan Police and other forces which have such a remit. The report recognised that, while the relationship between SOCA and Europol was good, the relationship between SOCA and the UK police forces left a lot to be desired. In other words, in the chain “UK police forces-SOCA-Europol”, it is the domestic link that is weak. That must be a potentially serious handicap to the United Kingdom’s leadership in Europol.
The disappointing performance of SOCA that the report highlights has implications stretching far wider than this debate. The Government have made a robust defence of the present arrangements, emphasising in particular the close liaison between SOCA and the Met. What steps are the Government taking to ensure that this good relationship is being extended to all forces in the United Kingdom? In the Government’s reply they also state that UK forces are engaged regularly and directly with Europol on counterterrorism. What role, if any, does SOCA have in this liaison?
The report has highlighted two areas where the United Kingdom can be said to be leading the field: intelligence-led policing and organised crime threat assessment. I am pleased that the noble Baroness, Lady Henig, concentrated on this and gave us such good background. Both these concepts can be said to have been exported by the United Kingdom to other states. I do not want to be denied the privilege of sharing with the many noble Lords in this Chamber that “intelligence-led policing” means moving resources away from retrospective crime investigations to pre-emptive operations based on analysed intelligence. The two areas are recognised by the Government in their response. I would welcome an assurance from the Minister that these important initiatives, which reflect so well on this country, are being maintained and built on.
The expansion and increasing sophistication of organised crime never sleeps. Europol has the potential of being just the right vehicle to deal with this. The report has provided a valuable service in addressing not only the challenges facing this organisation and some of its shortcomings but also some of its potential. A huge amount of work has gone into the preparation of the report. The House will be grateful to my noble friend, his committee, its clerk and its advisers for this important document.
My Lords, I, too, welcome the noble Lord, Lord Roper, back to the Chamber. It is very good to see him, as everyone has said.
Perhaps I may say to the noble Lord, Lord Jopling, that I have a marvellous, crafted response from the Box on FRONTEX which says: “We recognise there were some issues a year ago but these have been addressed by the Home Office. Performance improved significantly. We are delivering 79 per cent”. We are getting better, but I have to say that I agree entirely with the noble Lord. The delay of which he spoke was outrageous and completely unacceptable, and it came within a whisker of being an insult. I was rather irked by it. I take his point completely. We have learnt the lesson; we are doing better in the Home Office.
I agree that my colleagues seem to be falling like flies. I feel rather like Admiral Collingwood on the quarterdeck of the “Royal Sovereign” at Trafalgar. The only difference is that I am not munching an apple as they all fall by the side of me. There is an element of that.
The Government welcome the European Union Committee’s report following its inquiry into Europol. Rather like other speakers, I commend the noble Lord, Lord Jopling, and his committee for conducting such a thorough and wide-ranging review. I join him in thanking all those involved in producing it. The importance of the review should not be underestimated; Europol is a vital element of the European Union’s fight against serious and organised crime. As was said by the noble Lord, Lord Jopling, and a number of other speakers, there are not many things more important to us than that.
An awful lot in the report was positive, and it is always encouraging to have confirmation where things are working well. However, the inquiry also identified a number of issues which the committee felt should be addressed in order to improve Europol’s capacity and capability to support our law enforcement officers and those of the other European Union member states in their fight against serious and organised crime and terrorism. In their written response to the committee in January this year, the Government acknowledged the findings of the inquiry and, for the most part, fully agreed with the recommendations. It will be useful to update your Lordships on the progress being made on implementing those recommendations, not least to get it in Hansard so that we know exactly where we stand.
Europol is facing an exciting and challenging time. It has a new director whose immediate priority is to ensure that the organisation is fully prepared for the introduction at the beginning of next year of the new Europol council decision. I am pleased to say that this preparatory work is on schedule for completion by the end of this year. I am glad that the noble Lord, Lord Jopling, shares our pleasure at the success of Rob Wainwright—his appointment was a very good move and I am delighted that he is there—who was the previous head of the international department at SOCA. Mr Wainwright gave evidence to the inquiry. It will be helpful and valuable that he will have in mind the committee’s recommendations as he approaches his new job. Even though he has been in post for just two months, we are already receiving reports of a more open and engaged approach by Europol to its stakeholders and partners.
Europol continues to provide significant support to our law enforcement authorities, and there are a number of cases where violent and dangerous international criminals have been brought to justice with Europol’s assistance. The noble Viscount, Lord Bridgeman, quoted some real successes. A typical example is an operation targeting an armed and violent Eastern European gang which committed around 20 armed robberies against high-quality jeweller’s shops in this country and more than 200 similar attacks across the European Union. In an action co-ordinated by Europol, officers from three UK police forces visited Estonia and, with the support of local authorities, seven suspects were arrested. With further support from Europol, UK police then identified offenders in 16 cases in this country and were able to bring prosecutions in 11 of those.
I mentioned Europol’s new legal base in my opening remarks. The Government believe that the new council decision will introduce a number of benefits when it replaces the Europol convention on 1 January 2010. While negotiation of this new legal instrument was lengthy and sometimes difficult, we are broadly pleased with the outcome. For example, we feel that we have achieved a good balance between extending Europol’s mandate so that it could support investigations into very serious crimes where there was no obvious organised crime link but also limiting Europol’s involvement to the extent that the investigation had to be cross-border in nature and involve at least two member states. It will be helpful that Europol will not now have to prove that a crime was “organised”, which can sometimes take one into rather technical areas of definition. It will be able to contribute its expertise to serious crime, such as multiple murders affecting several member states, but, equally, it will not see its mandate being diluted by being drawn into crimes that are more appropriate to national police investigation.
The Government are also pleased to see a strengthening of the rights of the data subject to gain access to personal information held about them in Europol’s systems and to have personal data deleted where prolonged storage cannot be justified. We note that Europol’s data protection standards exceed those that were envisaged by the data protection framework decision. However, we will continue to press for the highest standards of data security and data protection.
Another important aspect of Europol’s new legal base is the effect it will have on the roles and the relationship between the Europol management board and the Europol director. We have long believed that the management board has tended to become too involved in the day-to-day activities of Europol, the result being that it could be seen that the position of the director was being undermined. At the same time, the management board has had less time at its disposal to develop its strategic thinking. We believe that the new council decision will be helpful in providing more clarity about the roles as well as a clearer demarcation of responsibilities. In general terms, we expect to see the new director become more responsible for the day-to-day operation of Europol with the management board holding him to account for delivery of his objectives.
We also felt that the rotation of the chairmanship of the management board every six months with the presidency of the European Union was unhelpful in two respects. First, six months did not give sufficient time to develop an effective working relationship with the director; and, secondly, with such a short tenure, the chairman of the board had little time—and possibly little incentive—to start to develop a long-term strategy for the organisation.
We share the disappointment of the members of the committee that we were not able to get agreement from a majority of member states during the negotiations to appoint a board chair by open competition between Europol members. Noble Lords can be assured that we tried very hard. We agree with the view expressed in the inquiry report that there is no logical connection between the nationality of the person best qualified to become the board chair and the country holding the presidency. However, we take some comfort from the compromise that the chair will be identified from among the trio of presidencies to serve for 18 months. This is an improvement on the current situation and we will push to reopen the discussion on the selection of the board chair by open competition when an opportunity to review and amend the legislation next arises. But, of course, any future success will be contingent on a change of attitude by the vast majority of member states. As the noble Lord, Lord Jopling, quite rightly said, it is very wrong that something so important should descend into political, nationality-type bickering. I fear that that sometimes happens in these international organisations; I have seen it happen at times within NATO. We will keep pushing, because it is important to go down that route.
The noble Lord, Lord Jopling, also spoke about the Serious and Organised Crime Agency, as did the noble Viscount, Lord Bridgeman, my noble friend Lady Henig and the noble Baroness, Lady Miller. I would like to touch on the role of SOCA, which has a pivotal role to play in developing and maintaining an effective connection between Europol and our law enforcement agencies. It is the home of the United Kingdom’s national Europol unit, which is connected to Europol by secure communications links for speedy and secure exchange of intelligence material. From within the national unit, SOCA provides a focal point for UK law enforcement agencies to access Europol. We believe that there is already an efficient network of contacts between the Europol national unit and police forces. Each force has an international liaison officer who is the local source of expertise in dealing with international police co-operation and these liaison officers maintain close contact with SOCA.
The noble Viscount, Lord Bridgeman, spoke specifically about this area and we accept that more could be done to improve awareness of police force links with SOCA and about links with Europol in general. More can be done, in particular Europol’s involvement in resolving requests for help submitted to SOCA. We need to do more domestically to promote Europol. SOCA has already started this process through keynote speeches and workshops in its annual international liaison officers’ conference, which is attended by representatives of the ACPO forces and key law enforcement partner agencies. Ongoing regional awareness and training events hosted by SOCA are also providing an opportunity to publicise Europol and its capability to a wider audience at the grass roots level of policing the United Kingdom, which is a point specifically raised by the noble Viscount, Lord Bridgeman.
Another network that is essential for exchanging information between member states, and between individual member states and Europol, is the network of liaison bureaux established at Europol’s headquarters in The Hague. The 10 UK liaison officers include experts from SOCA, HMRC, the Scottish Crime and Drug Enforcement Agency and the Metropolitan Police Service. SOCA has a very close working relationship with the Metropolitan Police Service and for the last four years a senior officer from the Met Terrorist Command has been seconded to the UK liaison bureau. This has ensured effective contact with UK police counterterrorism units and other agencies. It ensures that there is full and direct access to Europol’s counterterrorism activities.
A significant benefit of having a liaison bureau for every member state is the opportunity for bilateral and multilateral information exchange. Your Lordships can imagine how convenient it is to simply walk a few yards and to have access to counterparts from all other member states who can provide information and support to aid our criminal investigations. The Government accept that the vast majority of the interactions simply bypass Europol. The information gathered from these bilateral exchanges is rarely entered into Europol’s systems and the opportunity for collecting potentially useful intelligence is lost. The issue is one that affects all member states to one degree or another, but we have taken a lead and SOCA now routinely copies details of its bilateral exchanges, sensitivity permitting. The noble Lord, Lord Jopling, mentioned the sensitivity issue but it is extremely difficult sometimes. We cannot see how we can arrive at a position where we can totally share all data. There will always be some issues that are so sensitive that you have to get approval from a bilateral partner who you got it from. If they do not give that, it is extremely difficult to do that. While ideally it would be lovely to share everything, it is quite difficult in some of these intelligence areas.
Europol has established a front office which can receive such information even where it does not fall within one of the existing analytical work files. This, allied to our initiative, is increasing our engagement with Europol. The UK at the level of heads of national unit meeting and at the Europol management board has actively promoted these steps and received considerable support from the other member states.
A key function of the Europol national unit is to provide information to Europol’s information system. This is essentially an indexing system enabling law enforcement to find data obtained by member states. Europol information system has the potential to link individuals who have been arrested or are under investigation and once these links are identified then traditional international police co-operation can take over. The noble Lord, Lord Joplin, quite rightly focused on information sharing and your Lordships will appreciate that the information system will only realise its potential if member states send their material in large volumes to Europol. As we have heard, the UK is one of the many member states that is not yet able to upload large volumes of data to the Europol information system. What information that is currently transmitted by SOCA is of high quality but it has to be input manually and this is resource intensive. In order to use the automatic data loader facility SOCA has to replace its legacy database system.
Progress has also been made on connecting police forces to the Europol information system. The Metropolitan Police are now connected via the secure police national network. Europol experts visited the UK in April to provide the necessary training and they will return in July to provide further training.
SOCA has revised its policy of rolling out access to the Europol information system to individual forces in favour of a regional approach. Plans are well advanced for the creation of regional intelligence units and these will be linked to the Europol information system as a priority. This will extend the reach of the system to police forces far more quickly and in a more focused way. Following the rollout of this regional approach, SOCA will review further connectivity once the impact of linking the Europol information system to the regional units has been assessed.
In its deliberations, the committee also took a close look at Europol and made a number of recommendations for improving that organisation’s capability. An initiative of the United Kingdom presidency in 2005 was the introduction to Europol of the concept of intelligence-led policing principles. I thank my noble friend Lady Henig for her strong support of what has been done there. It was mentioned by a number of other speakers as well. SOCA manages a national intelligence framework to support inter-agency activity against the main serious and organised crime threats to this country.
There are three key elements to this approach—an intelligence gathering process; a threat assessment; and a control strategy. Europol has embraced this concept in the form of the European criminal intelligence model and the most obvious manifestation of this approach is the production by Europol of the third annual organised crime threat assessment—or OCTA—which was approved by the Council in July 2008.
The European criminal intelligence model includes an intelligence-gathering requirement used by Europol to collect information from member states and EU agencies and organisations. It is the collection of this core information that we feel needs to be further developed. The model is still in its infancy, but we are optimistic that we can go forward in this and we are working hard to develop it. Last year, at the request of the Council, Europol drafted a threat assessment on the impact on the EU member states of Russian organised crime—the so-called ROCTA—and this represents another step in the application of the European criminal intelligence model.
Following the development of the organised crime threat assessment, Europol drafts specific threat assessments which support political decision-making. It is very encouraging that Europol’s draft work programme 2010 contains at least two objectives that promote the use of intelligence-led policing.
It is a source of optimism to the Government that the new Europol director was responsible for the introduction of the intelligence-led policing concept to Europol when he chaired the management board during our presidency in 2005. I am confident that the future of intelligence-led policing is in the best hands and Europol will continue to be promoted across the European Union.
We recognise that Europol can function effectively as an information exchange agent only if its partners are willing to share information. As the noble Baroness, Lady Miller, said, confidence is an important issue. We have heard concerns voiced by some member states about Europol’s ability to keep secure data. Some member states feel that Europol is a bit distant and disengaged from them. However, we are confident that Europol has very stringent data security and data protection rules and compliance is overseen by internal and external oversight functions. But we shared the concern voiced by the committee when the then Europol director said in evidence that he delegated overall responsibility for security to one of his deputy directors. Noble Lords can be assured that the current Europol director takes his security responsibilities extremely seriously and has indicated that he does take personal responsibility for security. We absolutely support that line.
Another security issue that emerged from the inquiry was the time taken by some member states to respond to security clearance information requests from Europol when their nationals take up employment contracts with the organisation. Until they are security cleared, such staff have only limited access. Apart from that being an inefficient use of the resources that could be at its disposal, we would acknowledge that the suggestion of staff being at Europol without security clearance will not engender confidence in the minds of the users of Europol’s service. I am pleased to say that that issue is currently being considered by a working group and along with a number of other member states we are taking a firm line on improving the situation.
I hope that I have painted a picture that shows a positive response to the recommendations made by the Home Affairs Sub-Committee. There is a way to go, but not all the solutions lie in our hands. We can and are getting our house in order but of course the United Kingdom is just one of 27 member states which use Europol’s services. Through our seat on the management board we can encourage our partners to increase their engagement with Europol, and of course we are doing that.
Europol itself has a very critical role to play in promoting awareness of its services. I am extremely heartened to note the objective in the current Europol work programme that aims to enhance the trust and confidence in all those involved and to improve the exchange of information with Europol national units and liaison bureaux.
There are a couple of other points that I have not answered yet. The noble Lord, Lord Jopling, talked about the problems in delays in appointing Europol directors. Part of the problem is the selection process, which did not provide sufficient evidence of the strengths of the candidate to rebut claims from candidates who are not proposed for appointment. The selection process has already been revised and is in place for the current selection of deputy director, which will be a lot better.
The noble Lord, Lord Jopling, also asked about ACPO. If ACPO was asked now, it would say that things have improved a great deal but that there is also still much to be done, especially in linking forces with Europe. Your Lordships have heard what we are doing to try to achieve that. My noble friend Lady Henig and the noble Baroness, Lady Miller, talked about accountability. We agree that Europol should be held accountable. There is a role here for the European Parliament and national parliaments. We will continue to push for greater accountability in that area.
The noble Viscount, Lord Bridgeman, said that SOCA had not achieved what it had hoped to achieve and that, indeed, perhaps it was not achieving very much. The formation of SOCA was highly complex, pulling together five national organisations. It is now beginning to function properly and is moving forward. There is no doubt that the big, serious criminal groups are very concerned about SOCA. However, the noble Viscount is absolutely right that the liaison between the police and SOCA in this country is not as good as it should be. A small part of this is turf warfare, people saying, “We did that; you did that”, or whatever it might be. It has to be made better. I am absolutely sure that we are going down the right track and that it will get better. That SOCA has such a good link with Europol can perhaps help the disjointedness that it has in working with our own police force, which is absolutely the way forward.
I hope that I have covered the majority of points. I have gone slightly over my time. I apologise if I have missed anything. This has been a useful and valuable debate. I thank everyone who was involved in it. It is important to get these matters into Hansard and to get people talking about them. The Government thank the noble Lord and his committee.
My Lords, I and, I am sure, the committee, will be grateful to the Minister for his very comprehensive summing up and his clear answers to many of our questions. These are hugely important matters, as the bogey of international, and domestic, crime seems to get worse rather than better. I am particularly grateful to those of my colleagues who have spoken in the debate, especially to the noble Baroness, Lady Henig, who is a member of the committee.
House adjourned at 6.08 pm.