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Brexit: Health and Welfare

Volume 790: debated on Thursday 29 March 2018

Motion to Take Note

Moved by

That this House takes note of the effect of the United Kingdom’s planned withdrawal from the European Union on the health and welfare of United Kingdom citizens and residents.

My Lords, this year the NHS is turning 70. Our universally beloved institution has transformed the health and well-being of the British people for longer than most of us have been alive—perhaps excluding Members of your Lordships’ House, where our average age is 70—and is the envy of many countries around the world. I am proud that a Liberal MP and economist, William Beveridge, wrote the report that made the proposal for a universal health system free at the point of delivery and paid for through taxes, which transformed healthcare in the United Kingdom. Beveridge understood that there needed to be widespread reforms to social welfare, first introduced by the Liberal Government in 1911, which had to address his five “giant evils” of squalor, ignorance, want, idleness and—perhaps most important to the NHS—disease. Fighting these giant evils is key to the health and welfare of UK citizens and residents.

Unlike in the United States and some other countries, the British believe that healthcare is a right, not a privilege, and we accept the opportunity to pay for it through general taxation. Recent polls show that a large number of people support the Liberal Democrat proposals for an increase in income tax to help fund the NHS, alongside reforms that are necessary for any healthcare system in the 21st century.

The NHS has a history of evolving in response to the changing needs of the nation, yet there is hardly any discussion about the effects of Brexit on our health and welfare systems. It therefore seems appropriate, on the first anniversary of triggering Article 50, for your Lordships’ House to look at these issues in some more detail. I look forward to contributions from other Members of the House who will cover specific items in detail; there is not time in the 15 minutes that I have to cover everything.

If you ask most people about Brexit and the NHS, regardless of how they voted in the referendum I suspect the first thing they would talk of is that large red bus from the leave campaign claiming that the EU costs the UK £350 million per week, which could all be invested in the NHS upon leaving the EU, while forgetting to tell us that that would remove funding from agriculture, fisheries and many other current EU projects based in the UK. Not only was this untrue—a fact checked repeatedly during the campaign by independent bodies—but there are figures to show that the cost of leaving the EU to our economy could now be equal to that £350 million per week.

Research by the Financial Times suggests the value of Britain’s output is now 0.9% lower than it would have been if the UK had not decided to leave the EU—and, guess what, that comes to just under £350 million a week. That irony is not lost on those of us who challenged the original leave campaign on its obviously fantastical claims at the time. Since then, much of the debate over the UK leaving the European Union has focused on trade, the single market and the customs union. Today, as we mark the first anniversary of the triggering of Article 50, we must start to identify some of the less visible but absolutely vital elements of Brexit that will affect the health and welfare of people in the UK.

At a time of unprecedented pressure on the NHS, it needs urgent and real investment to prevent it crumbling, so I welcome the Prime Minister’s announcements earlier this week and look forward to the detail. I hope that it can deliver the real financial help that is so desperately needed but woe betide her if it is neither real nor speedy. The Chancellor has set aside £3 billion for Brexit matters alone this year. With the chaos of where the negotiations are, who knows if that will be enough? What is clear is that people know that the NHS is in desperate need of resources. Yesterday, many hospitals across the country were still struggling with their A&E targets. Among many others, Addenbrooke’s in Cambridge was predicting 12-hour waits in A&E and had once again cancelled all non-emergency operations—and, indeed, some cancer treatments.

However, one of the lesser known pillars of protecting our NHS is also at risk with Brexit. With more and more parts of its services being put out to tender, the NHS has ultimately been protected by the EU directive on public health procurement. This directive governs the way in which public bodies purchase goods, services and works and seeks to guarantee equal access and fair competition for public contracts in EU markets. It includes specific protection for clinical services and more legal clarity on the application of procurement rules. The bottom line makes it clear that, unlike non-public services, a public body based in an EU member state can accept a contract that is not the cheapest if it fulfils the quality, continuity, accessibility and comprehensiveness of services and innovation. There is also no need to publish procurement advertisements cross-border, which, as Ministers have repeatedly said in Parliament, is a key tool to preventing mass privatisation of the NHS.

If we proceed with Brexit and leave the single market and the customs union, the NHS will lose its biggest but most invisible protector: this directive, which governs all public sector procurement in member states. It defines fair process and standards to ensure that all EU businesses, including the NHS, have fair competition for contracts. It prevents conflicts of interest through robust exclusion grounds and protects against creeping privatisation. PFI also remains a serious financial risk.

We must learn from the liquidation of Carillion and the ensuing loss of jobs that shone a light on the dangers of letting privatisation run rampant. The NHS now has more than 100 PFI hospitals, which originally cost £11.5 billion. After being privatised, they will cost the public close to £80 billion. The difference could have funded the NHS for two and a half years, but that is not all. The total PFI debt in the UK is more than £300 billion for projects worth only £55 billion. In order to protect NHS institutions from American corporations looking to buy after Brexit, we must write this EU directive into UK law. The NHS we all know is dependent on this. It is in danger. If we do not transfer the directive into UK law, there is nothing to stop the lowest bid for any service always winning wherever it might originate from and without regard for the standard of care. We know that there are many US companies already eyeing up the NHS.

As an aside, given the debate in Oral Questions about passports, the French Government have used this EU directive to ensure that French passports are made by French firms in France because they regard specialist printing as a security matter—funny, that. Despite Brexit, our Government chose not to use the same provision to print the next generation of UK passports here in the UK by a preferred UK company.

Returning to the NHS, while there was understandably concern about the TTIP agreement, it was this EU directive which provided a guarantee that US companies could not come in and cherry pick our NHS. On 18 November 2014, the noble Lord, Lord Livingston of Parkhead, answered my Question in your Lordship’s House by quoting an EU Commissioner:

“Commissioner de Gucht has been very clear:

‘Public services are always exempted ... The argument is abused in your country for political reasons’.

That is pretty clear. The US has also made it entirely clear. Its chief negotiator said that it was not seeking for public services to be incorporated. No one on either side is seeking to have the NHS treated in a different way ... trade agreements to date have always protected public services”.—[Official Report, 18/11/14; col. 374.]

That was under President Obama. I suspect matters have changed since President Trump came to power, so I am seeking unequivocal confirmation from the Minister and the Government that they will stand by their word in coalition government in 2014 and fully re-enact these procurement rules for public services in UK law to continue to protect the NHS from future trade agreements. More than that, I hope that the Government will remind the NHS of its rights under this directive; it seems that too many contracts are being let on value not quality of service.

Another key element of these procurement rules that needs to be protected is accessibility. This has meant that public money should no longer be used to introduce or maintain inaccessible structures, systems or services. It is essential for disabled people that these accessibility rules continue. I recognise that it is not without cost, but it is a core element of the EU directive and is essential for any Government who believe that all members of society need to be treated equally.

I know that many other issues affecting the health and welfare of people in the UK will be covered in the debate, and I am looking forward to hearing from noble Lords who will speak shortly. Their expertise is exceptional. I thank those from the Library and other specialist groups who have provided briefings for us. I only wish that I had time to do justice to all their recommendations, but I know that colleagues will speak far better than I could to prosecute their cause. These issues include the reduction in the number of EU workers, which is already having an impact on our hospitals and social care services from clinical to support staff, and the loss of the European Medicines Agency headquarters from London, and therefore our influence over it if we leave, which will be very serious; we may wish to join as a junior partner, but we will have lost our influence. It is also serious for London’s economy where more than 70,000 bed nights a year will be lost for tourism. Radiologists are very concerned that the extra paperwork and regulation resulting from not being a full member might disrupt supplies. Cancer treatment is so time-sensitive that delay can have a real effect. More than one quarter of clinical trials funded by Cancer Research UK involve at last one other EU country. That pan-European and international approach is crucial for paediatric and rare cancers. The UK has led or participated in the largest number of these trials for types of disease, but once we are no longer at the EU research table, what will our influence be?

Should Brexit move forward and should we leave Euratom, we would jeopardise the domestic nuclear sector, the regulation and transportation of life-saving cancer medication and research into using radioisotopes, as well as the UK’s decarbonisation initiative which will help with ozone and air quality. That is why your Lordships voted to pause leaving Euratom earlier this week. Interestingly, while pro-Brexiteers argue that membership of Euratom places us under the influence of the European Court of Justice, there has never been an ECJ case involving the UK and Euratom.

Dr John Buscombe, president of the British Nuclear Medicine Society, told a parliamentary committee that close to 1 million patients across the UK have medical imaging with radioisotopes each year, and 80% are imported into the UK from the European Union. Dr Buscombe was very concerned about the security of supply. He said:

“We have had problems with product coming in, particularly from places like Canada, where they haven’t turned up, got delayed or have the wrong paperwork”.

We must ensure that the future supply is maintained.

Moreover, what happens to UK citizens living or travelling in another EU country? Reciprocal services, starting with the well-known EHIC card, are built into our daily lives. During Brexit negotiations, and hopefully in transition, UK citizens will still be able to use the EHIC card to receive state-provided emergency medical care. However, yesterday’s excellent EU Committee report Brexit: Reciprocal Healthcare sets out the real difficulties. No deal has yet been made; no assurances have been given to ensure medical treatment for UK citizens outside the border.

As on every other Brexit issue, there is the real problem of Northern Ireland and the Republic. Joint health services, for example, allow patients to get medicine at any pharmacy north or south of the border, irrespective of the location of the GP responsible for the prescription. Ambulances on either side of the border are currently free to travel across the border to attend emergencies such as road traffic accidents and cardiac arrests. People across the island are allowed to receive radiotherapy at a new £50 million centre for cancer patients on both sides of the border at Altnagelvin Area Hospital in Derry, which opened just a year ago. Bernie McCrory, the chief officer of Co-operation and Working Together, said:

“In the past we would have had young mothers who would have declined to go to Dublin because of the time away from their children and they would have opted for radical surgery”—

instead of this specialist treatment. At Altnagelvin Area Hospital,

“we have created a pathway for patients that didn’t exist before”.

There is yet no pathway for how we manage the difficult cross-border issues in Ireland.

In conclusion, the health and welfare of UK residents will be affected by Brexit and there is much that needs to be done now to establish the rights of UK and EU citizens to strike effective deals and to recognise that the consequences of Brexit on our health and welfare might be serious. In that event, does the Minister agree that perhaps the people should have the final say? More than that, there are steps that the Government need to take now to reassure us: for example, in relation to the EU directive that I mentioned earlier. It is absolutely vital that that protection remains. I beg to move.

My Lords, I congratulate the noble Baroness, Lady Brinton, on securing this debate and so eloquently setting the theme. On a personal note, I am a doctor’s daughter, a doctor’s sister and a doctor’s niece. The noble Baroness mentioned that this year is the 70th anniversary of the founding of the NHS, and I am extremely proud that my father was one of the first NHS doctors, having come back from serving with the Royal Army Medical Corps in Hamburg, where he met my mother, who had come down from Copenhagen to work for the British Army at that time. Less savoury was the fact that he was referred to as a panel doctor by my uncle, who was a surgeon, but I am very proud of the service that my family has given to the NHS. As declared on the register, I also work with the board of the Dispensing Doctors’ Association, which represents GPs in rural practice.

As we speak today, what concerns me most is that we need be in no doubt as to what the impact will be on the health and welfare of those working in the NHS and those benefiting from it in this country of the proposed withdrawal from the EU of the United Kingdom. What is missing here is a sense of urgency on the part of the Government. If this debate serves no other purpose, I hope that the Minister in summing up will take back a strong message to the department that we need to tackle the issues. Let us look at the sheer volume and scale of the problem. We are told on page 19 of the report, EEA-workers in the UK labour market: Interim Update, that 4.1% of professionals working in health and 5.1% of those working in residential and social care come from the EEA. That means that just short of 10% of the total workforce of health and residential and social care comes from the EEA.

The UK is therefore heavily dependent on our EU and EEA membership for our doctors, nurses and other health professionals. Yet the Minister recently confirmed in a Written Answer that there is as yet no accreditation scheme that will apply from 29 March next year. We are rightly told that this will be on the basis of mutual recognition. How many years did it take us to achieve mutual recognition the first time? I do not believe it took so long for lawyers like myself, or for doctors like my brother, who has now retired from general practice, but for architects it took 21 years to agree, on the basis of mutual recognition, that their qualifications would be recognised. I hope that the Minister will confirm today that this will be a top priority for the Government, because we are haemorrhaging. I know that from personal experience: a Danish friend of mine and her New Zealand husband are consultants in the health service, operating at the highest level, and they are returning to Denmark to work because they simply do not know what continuity of service they will have.

We learned today from the Brexit Minister that there will no longer be free movement of people and professionals between the UK and the EU; I understand that that would be from the end of the transition period—if we have an agreement and there is a transition period. Yet we know from the briefings provided to us today that 9.3% of UK doctors working in the NHS emanate from the EU.

We are currently on course to subscribe to and apply the falsified medicines directive. This will have huge cost implications, particularly for general practice, and yet, as I speak there is no clear guidance as to what the IT provisions will be. The drug will need to be scanned when it comes in and scanned again when it goes out, and there is obviously a question mark over who will pay. I hope that the Minister will take the opportunity to explain today to what extent we will apply the falsified medicines directive.

The noble Baroness, Lady Brinton, also spoke about clinical trials, which we debated in the EU (Withdrawal) Bill Committee. It is extremely important that we have a commitment that we continue to benefit from those clinical trials. It appears that we will no longer have access to EU Horizon 2020 funds, yet the briefings we had today show that we do not just pay into the current R&D programmes but are a major beneficiary of them. Again, it would be a huge potential loss if we were no longer allowed to participate in those programmes.

On our membership of the single market and customs union, let us remember that prior to 1992 we were not in the single market. I am proud that the single market was a Conservative initiative, but we did not benefit from it until it was set up and we joined in 1992. However, we currently benefit from both, and they are vital for both the exporting and importing of our pharmaceuticals. I hope that the Minister will reassure us that those will continue even though we are due to leave the European Union.

On the exchange of blood and vital transplant organs, these are extremely perishable and cannot possibly be held at the borders, yet from the exchanges we had at Question Time, it is still not clear what the arrangements will be. The noble Baroness, Lady Brinton, mentioned the current free flow of health professionals and indeed patients across the Irish border, but we do not know what the customs arrangements will be—not just in Ireland but between the UK and our current European partners.

It is a fact that we are certainly dependent. The Royal College of Physicians is recommending that the UK must continue to welcome new doctors to work in the NHS and provide express and urgent guarantees that EU doctors currently working in the NHS will be able to permanently remain in the UK even in the event of no deal. I know for a fact that the Minister and I share a rather charming dentist who happens to be French in origin and qualified in the EU, and I am sure we would wish to continue to benefit from his services. At the moment, though, it is still not clear, until the mutual recognition accreditation schemes are set up, what the arrangements will be.

The Government are asked specifically to grow and expand the medical training initiative by increasing the number of visas available and, in addition, to seek to establish a scheme similar to that for DfID or for low-income and middle-income non-priority countries, particularly those such as Australia that have similar training programmes to the UK and where we can recruit more doctors through such training places. The RCP reports calls by the medical Royal Colleges and the BMA to keep the current cap on restricted certificates of sponsorship for the short term and exclude applications for shortage occupation roles from the allocation process. The UK is currently considered a world leader in medical research, producing around 25 of the top 100 prescription treatments. As I have mentioned, we are still a net beneficiary of research grants and very successful, so I hope the Minister will continue to give an assurance today in that regard.

I conclude by asking the Minister to give a sense of urgency to the concerns being expressed in the House in this debate. The Prime Minister has stated that she wants a Brexit that works for everyone living in the UK, so will the Minister give the House an assurance that we will continue to welcome doctors from the EU and the EEA; that health professionals currently in practice here will be allowed to remain; that we will have a certification scheme in place as a matter of urgency; that we will continue to have access to the EU research and development funds; and that we will have smooth access to vital organs, perishable medical products and clinical trials in future? I am delighted to support the noble Baroness, Lady Brinton, in this debate.

My Lords, I thank the noble Baroness, Lady Brinton, for raising such a key aspect of the impact of the EU’s withdrawal from the EU. As others noted earlier in the House, at 11 pm exactly one year from today the UK will leave the EU, but I have no doubt that we will be debating the complexities of a post-Brexit UK well beyond even the agreed 21-month transition period that will follow.

There is also no doubt that the UK’s decision to leave the EU will have many far-reaching implications for health and social care in England, and for the health of UK citizens living or travelling in EU countries. It was only when I began to look at this more closely that I realised just how many crucial issues still await clarification. There are the future arrangements regarding the European health insurance card; without EHICs, a disproportionate insurance burden will fall on the elderly and those with existing conditions. There is the question of access to healthcare for UK pensioners resident in EU countries and of cross-border co-operation in public health. I think particularly of food safety and housing, but there are many other areas. There is the continuation of the open border in Northern Ireland so that healthcare professionals can move freely to deliver vital cross-border health services. There is the damage to our research base and the international standing of our universities if they can no longer recruit and collaborate with European researchers and scientists. There is the damage to our ambitions for the UK to be a world leader in the sciences and medical research if we are not able to make good the significant loss in EU funding for R&D. There is the question of our continuing participation in the European Centre for Disease Prevention and Control, the UK losing out on clinical trials for new drugs if we are not part of the upcoming revised EU directive on clinical trials, and losing our ability to attract EU research funding or to access EU research funding sources such as Horizon 2020 and the European structural and investment funds. We do not know the extent of Brexit’s negative impact on the UK economy. Additional pressure on public finances will have a direct negative impact on the NHS and social care.

The list goes on and on, and it is depressing how little we and the country know with any degree of certainty. It is essential that health-related issues are put high on the agenda as we negotiate our future relationship with the EU. I want to focus on just a few concerns. Like the noble Baroness, Lady McIntosh of Pickering, I ask how we will maintain the NHS workforce, given its reliance on EU nationals, and how we will address the pressing issue of social care. I declare an interest as chair of the National Housing Federation. Then I will briefly consider what our withdrawal may mean for the regulation of medicines and our access to new drugs in the UK.

The freedom of movement and mutual recognition of professional qualifications that come with EU membership mean that many health and social care professionals working here are from other EU countries. A recent King’s Fund report indicated that nearly 62,000 staff, or some 5.6%, of the 1.2 million total NHS workforce in England, and 95,000, or about 7%, of the 1.3 million workers in England’s adult social care sector have come from other EU countries. A recent report by Independent Age highlights that in the first part of 2016 alone, more than 80% of all migrant care workers who moved to England to take on a social care role were from Europe. The report posits a social care workforce gap of about 1.1 million workers by 2037 in the worst-case scenario of zero net migration following Brexit. In what I suggest is a more likely low-migration scenario, the workforce gap could be more than 750,000 people. But even if there were high levels of migration and the care sector became more attractive, Independent Age puts the social care gap at 350,000 people by 2037. The implications for older and disabled people are that far fewer will be able to access the care they need to live independent, meaningful lives.

Meanwhile, the most recent figures show that the NHS has gaps in nursing, midwifery and health visitors. Although the referendum result will not have been the only factor, it is nevertheless alarming that between October 2016 and December 2017, the number of nurses and midwives from Europe leaving the Nursing and Midwifery Council’s register increased by 67% compared to the previous year, while the number joining fell by 89%. The recent commitment and clarification that EU citizens currently working in the UK and UK citizens currently working in other EU countries will be allowed to stay has, we can only hope, provided some reassurance to those individuals, but it is clearly vital that we continue to persuade as many as possible to stay and continue their valuable contribution to the health and social care workforce, while we also take measures to increase the domestic NHS workforce and the attractiveness of the social care sector to British-born workers in the longer term.

We do not have much detail on what the UK’s policy on migration will look like post Brexit beyond the intention that after March 2019, migration of EU nationals will be subject to EU law. While we await the delayed White Paper, there are many unanswered questions about our future immigration policy, some of which we explored earlier today. I am concerned in particular that in future we might mirror the current non-EU system, which is focused on high-skilled labour rather than areas of shortages. Can the Minister assure us that providers of NHS care and social care services will retain the ability to recruit staff from the EU when there are not enough resident workers to fill vacancies? I note that the Migration Advisory Committee’s interim report on European Economic Area migrants to the UK was published earlier this week, ahead of its September final report. I wonder if the Minister would agree that a way forward would be to add specific occupations to the MAC’s shortage occupation list, which currently enables employers to recruit nurses and midwives from outside the EEA. Will he also agree that the Government will need to consider urgently how both the NHS and social care can continue to recruit lower-skilled workers from the EU and elsewhere who are less likely to arrive under systems focused on encouraging higher-skilled migration?

I should add that the context for considering the impact of Brexit on our health and social care workforce is the pressing need for funding reform of social care. Local authorities are struggling to make shrinking budgets meet the demand for care, which is growing as our population ages, with increasing complexity in their needs. Can the Minister confirm that the Government’s intention in the Green Paper on social care, due later this year, will be to find a long-term solution?

I also want to take a final minute to highlight, like others, the impact that our EU withdrawal may have on the regulation of medicines and clinical trials in the UK. EU legislation ensures a consistent approach to medicines regulation across its member states, and the UK is part of the European Medicines Agency, which operates this centralised authorisation system. The EMA, of course, recently announced that it will be moving from London to Amsterdam as a result of Brexit. Currently, companies can submit a single application to the EMA to be authorised to market their products in EU, EEA and EFTA countries. As a member of the EMA, the UK has first-tier market status, giving us priority in receiving new pharmaceuticals. With Brexit, the UK is expected to leave the EMA and seek then to “work closely” with it, while increasing the capabilities of our own national Medicines and Healthcare products Regulatory Agency. The EMA currently co-operates with other countries in this way, including Canada and Switzerland. But the concern here is that losing our tier 1 status would put us at the back of the queue for new medicines. In Canada and Switzerland, these typically reach the market six months later than in the EU.

There are so many areas where we need reassurance from the Minister. I hope he will be able to provide at least some concrete answers. Can he, above all, unequivocally tell us that he will do everything in his power to ensure that health-related issues are put high on the agenda as we negotiate our future relationship with the EU?

My Lords, I am very grateful to my noble friend Lady Brinton for calling this debate—and very timely it is, too. The repercussions of the UK’s decision to leave the European Union spread far and wide. That is why it is especially important that we are here today to debate the critical subject of UK health and social care in a post-Brexit world. The issue of health touches the lives of every citizen, and the gravity of our situation just cannot be denied. I shall mention some of the issues I raised in Committee on the EU withdrawal Bill, but we should not forget the huge role that EU workers play in both the health and the care sectors. I am going to look at some numbers too. Mine are not quite the same as those given by the noble Baroness, Lady McIntosh of Pickering, but they are all really big numbers.

My research has suggested that 5% of the UK’s health and care workers now come from the EU. Five per cent might seem a small number, but 5% of 4.5 million is considerable: 225,000 doctors, dentists, nurses, dieticians, therapists, care workers and cleaners—I could go on. According to a November 2017 survey conducted by the British Medical Association, nearly one in five EU doctors working here had actually taken steps towards the possibility of leaving the UK. The NHS, with its already existent staff shortages and funding cuts, really cannot afford to lose any more numbers or expertise within its hard-working personnel. Royal College of Nursing chief executive Janet Davies said that the NHS “cannot afford” to lose EU staff, with 40,000 nursing vacancies in England alone. She said:

“The Government is turning off the supply of EU nurses at the very moment the NHS is in a staffing crisis”.

I understand that the Minister has said previously that the number in training is considerable, but it is sadly not enough to fill the gap. It is a fact that merely the decision to leave the UK, and the agonising uncertainty that has accompanied that decision, moulds the future nature of our health workforce. The Minister has addressed this issue at the Dispatch Box many times, but I would be grateful if, for those who neither hear it nor believe it, he would send a message that they are still welcome to remain, and remind the House of other avenues of recruitment that are being considered.

I mentioned earlier that I put my name to several probing amendments to the EU withdrawal Bill, and I express my continuing support for the public health “do no harm” amendment, as tabled by the noble Lord, Lord Warner, to be included. It is based on Article 168 of the Lisbon treaty, which is longer than “do no harm”, but we are just calling on the Government to consider health issues and make sure that any decisions made at any government level do not impact on the health of our nation. At the recent meeting of Peers, Ministers and officials to discuss the withdrawal Bill, it even gained the support of the noble and learned Lord, Lord Mackay of Clashfern. He is a really good ally to have.

The desire to ensure the level of progression and sustainability of public health in our nation is not a divisive issue. There is no pro-remain or pro-leave precedent required to support the universal notion that the protection of our citizens’ health is, and must always remain, supreme. No Member of the House would deny the key three prongs of this proposal: first, ensuring the well-being of UK citizens; secondly, protecting citizens in times of public health hazards and crises; and, thirdly, continuing the drive towards equality of healthcare and access. This amendment would offer us a great opportunity. We have the chance to express to the people of the UK that we care about the well-being of each individual member of society and, more importantly, we will prove that commitment through legislation.

Moving to over-the-counter medicines, general sales lists or GSL medicines are thoroughly integrated into the EU model of research—design, production, packaging and distribution, just like cars. Any one product may pass through several borders before finding its way on to the pharmacist’s or the local supermarket’s shelves. The noble Lord, Lord Callanan, on the second day of the Committee the Bill, assured me, when I asked about the implausible timeline for changing regulations on these medicines and the practice I have just described, that the Government are indeed working hard to ensure that research groups and trade industries are offered,

“sufficient time to implement any changes necessary”.—[Official Report, 26/2/18; col. 451.]

The notion that the Government desire to continue a close relationship with pharmaceutical and trade industries on exit is understood. The issue, then, is simply that time is running out. The Minister claimed that industries will be given sufficient notice to recognise, address, deliberate and solve any licensing or manufacturing issues that may arise. Yet the time to offer sufficient notice was yesterday. Will the Minister today clarify these issues for the House? Is there a detailed timeline for ensuring that over-the-counter medicine licensing, manufacturing and trading issues that have arisen from Brexit can be clarified, and that no patient will suffer as a result of this quandary? Can he share the rationale for excluding GSL medicines from the Department of Health and Social Care’s ongoing review of the implications of EU exit on the continuity of medicines supply to the UK, and what plans the Government have to explore those implications?

To help the Minister, I wonder whether he would be happy to meet me and the relevant trade body, the Proprietary Association of Great Britain. The PAGB represents the manufacturers of branded over-the-counter medicines, self-care medical devices and food supplements —they would all be household names.

Under the European health insurance card scheme, British tourists and residents in the EU can access free healthcare, as can EU citizens when visiting the UK. I cannot imagine—I am still struggling with this issue—what it would be like to go on holiday without the EHIC in my wallet alongside my passport, tucked away in case of an emergency. However, as the EU Home Affairs Sub-Committee stated in its report published the day before yesterday, if the Government insist on bringing an end to free movement,

“it follows that one of the fundamental rationales for reciprocal healthcare arrangements … will disappear upon Brexit”.

The loss of the EHIC would create enormous barriers for UK nationals abroad and hurdles for EU nationals living in the UK. It is critical that UK and EU patients do not lose out on access to the best treatments and medical devices as we leave the EU.

We want to make sure that patients continue to benefit from early access to new health technologies and cutting-edge medicines, and that includes being able to take part in international clinical trials. For this reason, the Government must prioritise alignment with the new EU clinical trial regulation and commit to adopting it when implemented in March 2019.

The UK’s health and social care sector has benefited enormously from our EU membership. As British tourists and residents across the EU, we rest assured that our healthcare will be covered. At home in the UK, we take for granted the host of hay-fever tablets, cold and flu treatments, painkillers and indigestion remedies that line the shelves of our local pharmacies. We benefit from the latest in health technologies and cutting-edge medicines, as well as the dedicated care of over 60,000 NHS staff in England who are EU nationals. Exactly a year from now, on 29 March 2019, how many of these benefits will remain available to us? Will we be denied access to free healthcare in the EU? Will Calpol and Strepsils—other medicines are available—be available only on mainland Europe? As regards clinical trials, what confusion! At the meeting with Ministers and officials this week, I confess that I left feeling that the situation was about as clear as mud, so clarity from the Government on this and all these issues would be appreciated.

My Lords, I am immensely grateful to the noble Baroness, Lady Brinton, for giving us the opportunity to discuss this vital matter.

I have just completed 60 years of being a paraplegic after a horseracing accident, when I sustained a broken back. After the first 48 hours in an accident hospital, I was fortunate to be treated at the national spinal injuries unit at Stoke Mandeville Hospital under the famous Dr Ludwig Guttmann, a German Jewish neurologist who had escaped from Nazi Germany before the war. He had been asked to establish the first spinal unit, as many patients with spinal injuries were expected after Normandy.

I also had my life saved on my honeymoon in Barbados when swimming from the notoriously dangerous Crane beach. We were unaware of the strong currents. I got washed in and out of the surf and a German woman came to my rescue, dragged me out and gave me first aid.

I saw the devastation at the end of World War II, and now, with terrorism around us in Europe, I feel it unwise not to have a united Europe, with the threat of the UK being left out in the cold. Peace with no war in Europe should be the goal of all our citizens.

Until now very little has been said about the needs of disabled people who are living in the community and need help. I declare an interest as I employ help, with my helpers coming mainly from eastern Europe. In the last year, because of Brexit, this has become very difficult. Many people feel that England does not want them, and the economic conditions in their own countries have improved. In the past, Europeans have come to the UK to learn English and have been happy to have live-in jobs, as rented accommodation is so expensive. Many of them make excellent live-in carers, and often, when they have earned enough money to build a house, they go home.

Many disabled people are young and need active young carers. If the supply cannot keep coming on a needs basis, there will be a disaster. I speak as president of the Spinal Injuries Association. There is a real fear that, if the care packages of people who need several carers due to being paralysed from the neck down are not adequate, these people may be offered a place in a care home, rather than having the chance to live at home. To most young and middle-aged people, and some elderly people, this would be the end of the road, and suicide might be their only option. That is one reason why I feel that this debate is so crucial. There is a crisis in social care. The Government need to look at this in depth and produce a carers strategy.

There is concern that the European Medicines Agency has left London for Amsterdam. In her Mansion House speech, delivered on 6 March 2018, the Prime Minister stated for the first time her ambition that the UK should continue to participate in the EMA after Brexit as an associate member, and outlined the possible advantages of such an arrangement. Membership of the European Medicines Agency would mean investment in new innovative medicines and technology continuing in the UK, and it would mean these medicines getting to patients faster, as firms prioritise larger markets when they start the lengthy process of seeking authorisation.

It would also be good for the EU because the UK regulator assesses more new medicines than any other member state and the EU would continue to access the expertise of the UK’s world-leading universities. However, I ask the Minister whether being an associate member would mean not having all the privileges and status of being a full member. As the UK is one of the leaders in this field, with many brilliant and dedicated participants, will it not be frustrating to have second-class status?

I will quote the Royal College of Physicians:

“A number of key considerations that arise from the UK’s withdrawal from the EU relate to the NHS workforce. These considerations have an immediate and direct impact on patients and the public, and place additional pressures on an already stretched workforce. We not only need many more doctors, we need nurses, care and auxiliary workers as well. If Government Departments do not come together and realise what the UK needs there will be a breakdown of society”.

The RCP president said:

“It seems astonishing to block appropriately qualified doctors from working here when the NHS is under such pressure ... As our own census shows, as well as recent BMA data, there are huge gaps in rotas. As a result, doctors are unable to deliver the standard of care they were trained to, and patients are at risk”.

Data sharing between Europe and the UK is essential for public health, medical research and ensuring patient safety. The general data protection regulation, which comes into effect in May 2018, will provide important protections for individuals while also allowing data to be shared within the EU. It is currently unclear whether data will be able to be shared when the UK leaves the EU. Sharing data for European-wide clinical trials is just one example of where data sharing enhances the ability of patients to access new treatments. With so many rare diseases, the UK exit from the EU must not impact patients’ ability to participate in high-quality research.

I feel that many people who voted to leave the EU did not really know what it all meant—but it could mean, united we stand but divided we fall.

My Lords, I add my congratulations to the noble Baroness, Lady Brinton, on securing this timely but unfortunate debate. It is unfortunate because of the position we are in vis-à-vis Europe and the worst political decision of my lifetime—and I have been around for quite a long time.

You learn something every time you have a debate. I did not realise that my noble friend Lady McIntosh had a connection with Hamburg. My late father-in-law was on the control commission in Hamburg when my wife was born, so we also have a family connection.

I declare an interest as president of the British Dietetic Association, a trade union with most of its workers within the National Health Service and workers from all over Europe. I was also for some years, while David Cameron was around, the envoy to the trade union movement and, in that context, I came across the BMA, a noble trade union. I was once asked who I would choose if I needed to negotiate. I said that, as the general-secretary, I would have only two choices to negotiate for me: Hamish Meldrum, who was the general-secretary of the BMA and probably the most effective negotiator in the trade union movement; and the late Bob Crowe, who was also extremely good at getting benefits for his members—and “sod the politicians”, as he once said to me.

I wish to deal with three of the BMA’s concerns, one or two of which have been alluded to but not completely. The first concerns the register of doctors’ fitness to practise and the internal market information system, which is part of the wider directive. This system allows the GMC and medical regulatory authorities within the EU to communicate with each other when a doctor has his or her practice restricted in one or other of the 27 member states. In other words, it is a key safety feature. It will be important to consider how health regulators can ensure that professionals practising in the UK after we leave can get access to this register, should we withdraw. It is a fundamental safety issue. My question to the Minister is simple: do the Government agree that, to avoid the risks to patient safety, it is vital that the General Medical Council retains access to this system? Will they help towards the achievement of that important point? Euratom, which is vital in medicine because of the quick half-life of many nuclear isotopes, has also been mentioned.

Many have said that the British people did not realise what they were voting for. I think they simply voted to get rid of foreigners—an appalling reason for voting. Were it left to me—nothing is, these days, because I am so off message—I would tear the whole thing up, frankly. I would say, “Look, you’ve got it wrong. Have another try”. The Government did not even realise that we were going to leave Euratom; then, because they have a paranoid fear of the European Court of Justice, they decided, “Oh, we’d better leave Euratom as well”. This is sheer madness. The UK relies on supplies of nuclear radioisotopes and their quick delivery. Hospitals in Britain depend on these isotopes crossing the border, and doing so swiftly. They have a very short half-life and they cannot be stockpiled; we cannot just buy a year’s supply of them. Will the Government seek a formal agreement with Euratom to ensure consistent and timely access to radioisotopes for medical purposes? It is crucial.

My third point is on European reference networks, known as ERNs, which have been set up,

“to enable health professionals and researchers to share expertise, knowledge and resources on the diagnosis and treatment of complex and rare medical conditions … There are 24 networks, involving over 900 medical teams”,

around the European Union and “more than 300 hospitals” are involved in this network. I fully share the contention that it is essential that we continue to have ongoing access to and participation in the European reference networks. This will ensure that healthcare providers across Europe can tackle complex and rare medical conditions, which often require highly specialised treatment, and patients will continue to receive the best possible care. This is crucial. Medical knowledge benefits from interaction, not getting wrapped up and living in some little hole called—I was going to say, “some little hole called England”, but that is not very flattering to our country.

It is not done in this House to refer to Members of the Opposition as “my friend”, but I will make an exception in referring to the Member of the other House for Cambridge, Daniel Zeichner, as a good friend and someone who has consistently stood by the European ideal. Even when it is a curse to his future, he has been unwavering. One of the things that Daniel has recently brought into the public domain is the problem of getting workers into the UK. This goes away from the EU dimension slightly; we have a problem with EU workers but also with non-EU workers. As those of us who have studied these things know, or have learned from others, tier 2 visas are applicable to workers from outside the EU. In the city of Cambridge, where I live, Addenbrooke’s Hospital—one of the world’s leading hospitals—is not only short of key workers but has been refused permission to employ key workers who are waiting, need a job and are ideal for the job, because the tier 2 ceiling has been reached. They have been turned down not once, but in December, January and February. I put it to the Government that not only do they need to make it easier for UK hospitals to employ European workers but we need to look at tier 2 visa requirements. In the United States and Canada, very skilled workers can be employed with an underwriting by the employer. I am hoping to dispatch my son to the United States soon; under its system, there is no problem in getting a visa if the company will back the employment of the person. I put it to the Minister that we need to look at this issue. We need not only to make life simpler and easier for other EU workers, but to look at the tier 2 regulations.

My final point is this: we often talk in this country as though there is some great horror in having foreigners among us—that we need more UK this and UK that. Quite bluntly, I do not want a totally UK workforce. We benefit from the diversity of Europe—the different skills, attitudes and cultures that come into this country. I would regard it as an absolute disaster if we went back to the England I grew up in. Britain today is a much better place because of the huge number of different cultures and people who have come in to make this country. It is a great country because it is mixed and open, one that people want to come to live in because they get a fair crack of the whip. What I would say is—apart from “tear up this whole silly notion”, but assuming we cannot do that—for goodness’ sake, let us make it possible for this to be an open society, and start off in the medical sphere.

My Lords, I am grateful to the noble Baroness, Lady Brinton, for securing this debate and for her persuasive arguments. I am grateful to all others who have contributed to what has been a very comprehensive debate. I will say something on the impact of Brexit on health inequalities.

I am sure that many of your Lordships are aware of the work by Michael Marmot, who has highlighted that there is a social gradient in health—that is, the lower a person’s social position, the worse his or her health. People living in poorer neighbourhoods in England have lower expectancies and spend more of their shorter lives with a disability, compared with people in wealthier neighbourhoods. For example, the longest life expectancy in the country is in the richest borough, quite close to us, Kensington and Chelsea, where it is 83 for men and women there live to the age of 86. By contrast, the lowest life expectancy is in the north of England, where many people voted for Brexit. For example, in Blackpool we have life expectancy for men down at 74; in Manchester, it is only 79 for women.

Health inequalities stem from avoidable inequalities in society—inequalities in income, education, employment and neighbourhood circumstances. Inequalities present before birth set the scene for poorer health and other outcomes throughout the course of an individual’s life. Action on health inequalities requires action across all the social determinants of health. Marmot made a number of recommendations in his 2010 review to reduce health inequalities, which included giving every child the best start in life; enabling people to maximise their capabilities and have control over their lives; creating fair employment and good work for all; ensuring a healthy of standard of living for all; creating and developing healthy and sustainable places and communities; and strengthening, in particular, ill-health prevention.

The Government’s performance on these since 2010 has been very varied indeed. It is true that unemployment has gone down, but there are still very large question marks about the quality of the work that many people now undertake. We have of course seen of late that income has become virtually static. That is a cause for great concern. Efforts continue to try to make basic changes in education. Communities, through local grants and local authorities, have been starved of funding, with some councils now in dire financial straits, which is having a knock-on effect on social care in particular. Care and health services have generally faced increasing demands, with more patients, more people going into A&E, and people living longer.

In relative terms, while more cash has come in—it is true that the Government have put more money in—this has not matched what has been required, either in terms of the difference between GDP and inflation rate annually or the cost of the growing demand generally. Notwithstanding the defence that the noble Lord and his predecessor have put up that the Government are doing the maximum they could in regard to health, we have learned in the past week, with statements by the Prime Minister and the Secretary of State, that when many of us said for many years that not enough cash was going in and that more was needed, we did have a case. We now have the promise that more money is going to come. To a degree, I suspect that that makes the noble Lord’s response today somewhat easier than it might have been if that statement had not been made, because Brexit, the NHS and money was a central issue in the debate that led to people voting in particular directions. It is welcome news, but like others I hope that we are not going to have to wait too long to see the outline of the plans that the Government will draw up or have to wait too long before we start to see the extra money.

I believe, examining the poll results, that people in the areas of the country that voted for Brexit were influenced to a very substantial degree by the issue of immigration. They were also influenced greatly by the claim on the battle bus about money that would be available to be spent on the NHS. I think they also voted to a fair degree on the somewhat nebulous issue of taking control back from Brussels and being in charge their own country. The Government have to some degree started to answer the question on costs and the NHS but there is another worry and concern about where the NHS may end up, which will hit people in the Brexit areas if it works its way through, and that is that after we come out of Europe we will start to negotiate trade deals. In this speech I focus primarily on the topic which the noble Baroness opened on and wrote about in the House Magazine last week, which is the danger that we will not have the control over the NHS at the end of the day that we have at the moment when we are within the European Union.

All the rumours indicate that talks have been taking place on deals, particularly with the Americans, that the Government need to secure if Brexit is to be seen to be working in the fundamentals of our trade with the rest of the world. America is a very big part of that. There are concerns that the NHS will be on the agenda as part of the negotiations that may take place. If the NHS is on the agenda, it will be there for a purpose. From our angle it will not be improving matters; instead there will be a risk that the Americans want to make greater inroads into the NHS than they have been able to do so far, because of the protection we have had from the EU.

We had a short debate on this last week during which we raised questions about the American trade deal. The noble Viscount, Lord Younger of Leckie, responded for the Government. It was quite a wide-ranging debate within the eight minutes open to each of us and at the end of it we went away feeling we had had a good debate but that the noble Viscount had not been able to answer the points that had been raised by many participants from all sides of the House. We wanted to know why the NHS will be on the agenda and some of us had particular concerns that it may become part of the negotiating deal. If the Government are saying, “It is safe in our hands”, they can give us complete security by giving an undertaking that it will not be on the agenda and that therefore there will not be a risk of any changes, loss of control or damage to the interests of the people of this country. My question, which I put to the Minister last week, is a very simple one: in order to protect the NHS, could we not remove it totally from any agenda for negotiations with the Americans?

My Lords, I too salute my noble friend for securing this timely debate. Last year, seven of us spoke on this subject, when the emphasis was on the effect of Brexit on disabled people. We are now talking about the effect of Brexit on the health and welfare of everyone in the UK, but many of the same arguments are valid. Of course, “welfare” means many things: it means well-being, but it also means aid and benefits. Therefore, I will touch on a future without the European Social Fund, where negotiations concern reciprocal social security benefits, the blue badge scheme and the European health insurance card, which we currently all have. First, however, I will say something about EU health workers—as absolutely every speaker in this debate has so far.

Since the previous debate, I have spent much of my time in either a hotel or a hospital, where I have witnessed at first hand the extent to which both sectors rely heavily on workers from the EU, several of whom are now my friends. I have found EU workers outstanding in their work ethic, courtesy and willingness to go the extra mile. We are a rapidly ageing population, so our health and care needs will inevitably ramp up. I wish I was confident that all government departments had factored that into their future plans. Disabled people will also live longer with more complex conditions, so the UK needs as many good health and care workers as it can possibly take. Yet, not surprisingly, the numbers from Europe are dropping fast. Many of these invaluable people sense that the climate has changed and feel they are no longer welcome. I find this perception shocking and deeply shaming, and try to counter it whenever I can. Luckily for us, many other EU workers are not going down this route—perhaps because they are settled, with children at school.

Many younger disabled people who need full-time personal assistants—they prefer that term to “care workers”—are really worried about a potential shortage. What is not generally known is that emergency PA cover is often found from EU countries. One of Muscular Dystrophy UK’s trailblazers said:

“When I need someone at the last minute as an emergency, they often fly in from elsewhere in Europe”.

I was going to cite a whole lot of figures but I do not think there is any point as noble Lords have already done that. However, the independent Migration Advisory Committee, which was commissioned by the Government to advise on the new border policy, is not due to report until the autumn, so there will be uncertainty for many months to come. That makes planning for the future extremely difficult for everyone—we do not know what the status of these invaluable workers from the European Union will be. The King’s Fund has also speculated on how restrictive the future policy will be, and whether the set-up will focus on high-skilled labour or will target specific shortages.

While talking about the importance of EU workers in both the health and hospitality sectors, I should like to put in a word for those doing low-skilled but vital jobs, such as cleaners—thousands of whom are not British. I fear that Brexiteers who were critical about freedom of movement rather implied—as I think the noble Lord, Lord Balfe, said—that only high-skilled migrants would be welcome. This is very short-sighted when we know that many crucial but low-skilled jobs are difficult to fill with British-born workers—I think the noble Baroness, Lady Warwick, mentioned this too. Are the Government taking any initiative to make sure that we hang on to our EU workers in the health, care and hospitality sectors? Many younger disabled people have had their care packages slashed already because of cuts. In the future this could be because of the chronic shortage of labour, not just the expense.

Last year I spoke about the long-standing provision in EU law to co-ordinate social security schemes for people moving within the EU and the EEA. Can the Minister tell us where the negotiations are with regard to this reciprocity? Similarly, with the blue badge disabled parking scheme, will there be reciprocal arrangements with EU member states after the UK leaves the EU? As we have heard, around 27 million people in the UK currently hold a European health insurance card, yet we do not know what is going to happen to that. Will any rights we hang on to be portable?

A different matter entirely is the question of the European structural funds, of which the European Social Fund is an important part. Very basically, the structural funds aim to level the playing field between regions in the EU by helping fund projects in less developed regions, largely through local authorities. Two areas in the UK which have received a lot of funding are west Wales and the West Country. The European Social Fund promotes the EU’s employment objectives by providing financial assistance for vocational training, retraining and job creation schemes. It partners thousands of small projects run by neighbourhood charities and not-for-profit organisations to help disadvantaged people find work; for example, projects which try to improve the employability of people with disabilities. Although the Government have said that they will guarantee funding for existing projects even after we have left the EU, will new projects under this heading get funding? We know that the Government are going to replace the structural funds with the UK shared prosperity fund but we have no details. The Government say that it will be,

“cheap to administer, low in bureaucracy and targeted where it is needed most”,

but we have absolutely no idea how it will work.

Others have mentioned, at length, the European Medicines Agency, which is moving—perhaps it has moved already—to the Netherlands. We know that the Prime Minister is keen that we should have some sort of membership of the agency, for which we should pay, but we do not know what the other member states think of this plan. We certainly do not want to have to set up a parallel body. The risk is that the UK not playing any part at all in EMA processes might result in the UK being behind the EU in the queue for approval of new treatments for all kinds of rare diseases. For boys with Duchenne muscular dystrophy, who have only a certain number of days on which they can walk, this will be tragic. In any case, as a result of Brexit, the influence the UK will have on the EMA will be significantly diminished compared with the role which the Medicines and Healthcare products Regulatory Agency currently plays within the EMA. Negotiations should try to secure the quickest access to treatments for UK patients.

Others have mentioned clinical trials. Currently clinical trials must comply with the clinical trials directive, soon to be replaced by the clinical trials regulation. This much more satisfactory new regulation will apply from 2018, facilitating large pan-European trials. Should the UK no longer be governed by the clinical trials regulation, UK involvement in these trials may become more difficult and costly. We need to adopt the new regulation to ensure harmonisation and the continuation of UK participation in Europe-wide trials.

My Lords, it is a great pleasure to follow the speeches so far in this debate, which has been serious and solemn but also moving. I am very grateful, like others who have expressed their gratitude, to the noble Baroness, Lady Brinton, for launching this important debate.

If I may say so, without sounding in any way unctuous or sentimental, I was struck by the fact that not only are there eight noble Baronesses speaking in this debate but, just behind the Clerks’ table, we have three of the experts in this House on the National Health Service, because of both their own personal experiences and their deep knowledge of all the subjects that come within the NHS ambit. I was very moved by the description from the noble Baroness, Lady Masham, of her earlier years and how she coped with them. Those things will register, too, because the NHS is a most precious institution in this country, which the Government tamper with or undermine at their peril. People would not forget it if they did it any damage in the future.

Having said that, I am also grateful to the noble Lord, Lord Balfe, a colleague for many years, and the noble Lord, Lord Brooke, for being among the three mere males in this debate. It is an interesting reflection that women really know far more about the National Health Service than men do. That is a silly comment on my part, and I apologise for the tweets and comments that I may get on the internet from male practitioners in the NHS, saying “That’s not fair”. However, there is some connection there with the knowledge women have, given that so many women work at all levels of employment, including as technicians or the so-called unskilled. But as someone said earlier in the debate, those workers are very skilled in their work even if they are cleaners, because cleaning medical premises is a skilled job. The majority of all those people tend, I believe, to be women, including those who come from overseas.

The National Health Service is a precious institution. I was going to say that everybody in the debate is anti-Brexit except the Minister, who has to pretend to be in favour of Brexit because that is his portfolio task. I thank him for being here.

The Minister has confirmed that he is in favour of Brexit. It is nice to have the odd view given in a debate where everybody else is in favour of staying in the European Union, but I thank him for his personal efforts in this field as a Minister. I attended the meeting he held at the beginning of this week on the new death certification procedures that are coming in. We were grateful, since he is very busy. He is highly regarded in this House for the detailed and caring answers he gives to many complicated NHS questions. In that spirit, I hope that he will forgive my frivolity in referring to his official duties. We will see what happens in the future with those.

It is important for us to reflect on what is at stake here, with the damage done by this foolish decision to proceed with Brexit. There are still Ministers who are in denial psychologically about the damage already done to this country. The economy is already in the beginnings of what might even be a slight recession because of the decisions made by enterprises of one kind or another, mainly putting a halt to their long-term investment plans or transferring overseas.

I share the contempt enunciated by previous speakers—including the noble Baroness, Lady Brinton, herself—for the infamous red bus used in the pro-Brexit campaign, with Boris Johnson triumphant and chortling at the untruths written on its side; we now know that to be so. As a keen European as well as a patriotic Britisher, I am glad to say that there is now a different red bus travelling around this country with a different slogan for Europe. It is getting a tremendous reception everywhere it goes and has been a great success so far.

The NHS does millions of transactions every week. Most of them are carried out very well despite the pressures on employment, the reduction in the number of staff and so on and the huge pressure that NHS staff, doctors and specialists are experiencing because of the Government’s austerity cuts. There are millions of successful transactions every week. They are not noticed by the right-wing papers in this country, which pounce on the slightest unfortunate incident. Incidents are bound to happen, given the many different transactions that take place in our wonderful NHS. It is probably the best in the world, although there are many other good examples in smaller countries and in Scandinavia. In this country we are lumbered with six extreme right-wing newspapers—whose overseas owners do not pay UK personal taxes—with repetitive and boring editorials urging us all to be very patriotic. They always pounce, whenever they can, if something goes wrong in the health service. It is quite right for the press to follow up legitimately, but not when saying that there is something wrong with the National Health Service is propagandistic; millions of satisfied patients and customers—if I can use that word—know what it is like.

My personal experience has been twofold. I have had to go to A&E at St Thomas’ several times and I have used the European health insurance card, which other speakers in this debate have mentioned. The way St Thomas’ A&E is organised is utterly brilliant—it is fantastic. I have been there late at night when it is under huge pressure, and I pay tribute to it. There are numerous other examples of A&Es that are under very severe pressure nowadays that manage to cope. The European health insurance card is precious to so many British people and has reciprocal effects for those coming here and using our facilities. The idea that it would be in any way dented at the margin because of this foolish Brexit plan would be intolerable for many members of the public.

I apologise to the noble Baroness, Lady McIntosh of Pickering, for missing the last two minutes of her speech because I had to take an urgent phone call. I shared the pleasure of the noble Lord, Lord Balfe, at the fact that she has medical connections and connections with Hamburg. She is a great European spokesman and I thank her for what she did in the European Parliament. I know she has always been interested in the health service and therefore believes that these things matter.

Are we not lucky in this House to have the excellent Library briefing service? The document on health and welfare in the UK is outstanding, and I shall refer briefly to two items in it. I could mention its author but perhaps I should not in this parliamentary forum, because she is an official of the House; however, I thank her for the quality of the report. In the third paragraph on page four there is a reference to the December 2017 agreement that the Government reached with the EU negotiators:

“that EU citizens living in the UK before the UK withdrawal date of 29 March 2019 would have the right to remain and to apply for settled status after a period of five years. In a subsequent document, the Government proposed that EU citizens who arrived in the UK after the withdrawal date … but before the end of the subsequent transition or implementation phase should be allowed to enter the UK on the same terms as before the withdrawal date”.

I hope that will not change and that the Minister can confirm that that is the position, to reassure the many people who have been so worried about it that they have already left this country, having given good service and paid taxes as NHS workers, or in the care services in general.

Page six of the Library Note refers to the total budget. There is always the canard, the misleading reference to one of the richest countries in the EU, like Germany, France and now Italy, I believe, paying more into the EU budget—which is a very virtuous budget because it has no deficit and its receipts equal its payments—because it is wealthier than new countries coming in that need money to go to them. We now see, therefore, that an enormous amount of that money has to be deployed in the future in the health service in this country. The Government need to reassure us on this; I hope they will also have second thoughts and stop this nightmare happening at all.

My Lords, I, too, congratulate my noble friend Lady Brinton on securing this vital debate and introducing it so powerfully. I was also very moved by the compelling personal testimony that we heard from a number of contributors to this debate.

As we have discussed in this Chamber on many occasions, the NHS and social care sector—and we simply must see it as one integrated picture, not two separate sectors—has been struggling to cope under tremendous pressures for too long now. We have already been hearing—and we heard it powerfully in today’s debate—how Brexit and the ongoing negotiations are compounding existing serious problems. At last week’s debate in another place on this very subject, it was frankly alarming to hear details of the flight of EU staff from across the NHS. My right honourable friend Tom Brake explained that this flight was because EU staff had been hit by what he called “a triple whammy”. He explained that not nearly enough had been done since the referendum to make NHS staff feel valued and appreciated in the UK. With the falling pound, their salaries are now worth less back home and, as the UK economy slows behind the G7, they are increasingly likely to miss out on more lucrative jobs there too. These reasons to leave, he said, are sadly also reasons why critical talent with skills that we are crying out for in the UK are now thinking of not coming.

In that same debate, Dr Lisa Cameron MP reported that nearly half of EEA doctors have said,

“that they were considering leaving the UK following the referendum vote”.—[Official Report, Commons, 22/3/18; col. 228WH.]

As a Londoner myself, I was alarmed to read of a recent poll of doctors, in which 86% of London doctors who responded believed that leaving the EU will have a negative impact on recruitment to the NHS in London. These perceptions really matter.

In 2017, for the first time in a decade more nurses left the profession than joined. Indeed, the Commons Health Select Committee reported that the proportion of EU nurses choosing to leave the NHS has risen by a third in just one year. Critically, Nursing and Midwifery Council data shows that in the year following the referendum there was a fall of 89% in new EU registrations. Meanwhile, the social care sector is being drastically hit too, with the Nuffield Trust predicting a possible shortfall of 70,000 carers by 2025. We all know how shortages in social care exacerbate problems in the NHS and vice versa. I am sorry to quote so many statistics, and I know that other noble Lords have quoted many figures too, but it is really important that we understand the big picture. To say that it is not encouraging would frankly be a bit of an understatement.

I am particularly concerned about staffing in mental health services, and that is going to be the main focus of my remarks today. Though the staffing data for NHS mental health services is not as good as it could be, the available information is also not encouraging. According to the King’s Fund, there has already been a 13% reduction in mental health nurses since 2009, with in-patient care nurses being reduced by nearly a quarter. According to the Royal College of Psychiatrists, child and adolescent psychiatrists have fallen by 6.3% since 2013, something that we debated yesterday at Question Time. Currently, almost a 10th of all posts in specialist mental health services in England are vacant, and the mental health network of the NHS Confederation warns that it simply will not be feasible to meet health and social care staffing needs through domestic recruitment, training or non-EEA recruitment.

The conclusion that I draw from this is that psychiatry, as a shortage specialty, is under stress. We are undeniably struggling to fill roles, and we are highly reliant on international trainees, with more than two out of five coming from abroad. That is the highest of any medical specialty. Any exodus of EU-trained psychiatrists would throw an already overstretched system into crisis. The Government’s plans to recruit an additional 570 consultant psychiatrists by 2021 might be welcome, as are their plans to recruit child and adolescent psychiatrists and other mental health staff set out in the recent Green Paper. But as the Royal College of Psychiatrists reminds us, it takes 13 years to become a fully qualified psychiatrist, and the scale and ambition of these plans will work only if medics choose to become psychiatrists.

What is the effect of all this happening? As staff and budgets are strained across the NHS, morale is taking a hit, and consequently, outcomes for patients can suffer too. A recent Guardian survey of NHS staff showed that only 2% of participating staff felt that there were always—it is important to stress that word—enough people to provide safe care. As someone who has had occasion to use the NHS quite a bit recently, I find these figures truly shocking and frightening.

What are the Government doing about these alarming trends? In response to the debate in the other place I already mentioned, the Minister of Health, Stephen Barclay, seemed intent on ignoring the mounting evidence of EU staff’s flight from the UK and instead repeated a single figure that seems to justify the Government’s position, saying repeatedly that 3,200 new EU staff were working for the NHS. However, as the helpful briefing pack for this debate produced by the Library pointed out, this number is almost certainly inaccurate. The increase reflects an improvement in the way we record this information; in the same timeframe, more than 10,000 staff are no longer counted as “unknown nationalities”.

Pay is clearly an important factor in recruiting and retaining staff in the NHS. Although of course I welcomed the news of an end to the NHS pay cap, it seems that a pay rise of 6.5%—which sounds good, and I am sure it is welcome—may not amount to that much in real terms. If the OBR’s inflation forecasts are accurate, a 6.5% pay rise will increase pay by just a third of 1% in three years, still leaving wages significantly below what they were in 2010.

Similarly, the recent announcement to increase the number of midwifery training places offered, while again welcome, may not be enough to make our system sustainable. As with psychiatrists, the increase in these fee-paying places may increase the number of newly trained midwives in the UK from 2022, but there is little guarantee that these extra places will be taken up by students or that those who study will necessarily be employed by the NHS once they graduate. The only way to ensure that we have a real shot at making the UK a safer place to give birth will be through further incentivising training, recruitment and development of midwives at home and abroad, not simply offering more places.

I do not wish to sound simply like a counsel of despair—although there is a lot to be gloomy about—but I will suggest some positive steps that the Government should be taking. As the noble Baroness, Lady McIntosh of Pickering, so forcefully said, we need to see a much greater sense of urgency from the Government. First and foremost, we must move beyond mere lip service and demonstrate how much we value the contribution of our health and social care staff. Parliament has an important role to play here in the way we talk about these issues and in the language we use. There are other concrete steps that we can take to make the UK a more attractive place for people to work.

The UK must continue to welcome new doctors and provide urgent guarantees to those working here as to their rights under future residence. We should also give clarity to those who might come during the 21-month transition period as to their rights. We must better recognise EU and overseas professional qualifications to reassure doctors that their skills are respected, and broaden the national shortage occupation list to include staff with much-needed skills from the EU—a point I made yesterday with regard to psychiatrists. The visa application process for international staff should be simplified, streamlined and improved, and the Medical Training Initiative—a government-approved exchange programme—should be extended and enlarged to send a message to the world that the UK is not closed to foreign doctors. I hope the Minister will respond to those points. I have one specific question for him. Would the Government consider extending the cap on the length of the Medical Training Initiative to give more international psychiatrists and other medical professionals a chance to work for a period in the NHS while alleviating our workforce challenges?

I am pleased that the Prime Minister, albeit very late in the day, has come to recognise that the NHS needs significantly more funding and has started to talk about a long-term funding settlement. This revelation was no doubt helped by the broad coalition of MPs pushing for the adoption of the Liberal Democrats’ proposals to sustainably fund our NHS and social care through an earmarked tax. There is growing public support for such a tax because the public recognise the pressure that the NHS is under and it is so important to them in their lives. I strongly encourage the Government to include the cash-starved social care sector in the funding plan and to implement these proposals soon, in order to signal to the British people and the international community that we are serious about maintaining the best health system in the world.

My Lords, this has been a very well-informed debate, led by my noble friend Lady Brinton with her excellent and wide-ranging speech, on which I congratulate her heartily. There have been some excellent and moving speeches from across the House. I hope others will forgive me if I say how much I support the passionate and robust comments of the noble Lord, Lord Balfe.

As ever in your Lordships’ House, we have covered the ground very thoroughly. My noble friend Lady Brinton started us off by expressing her concerns about procurement and the need to protect our NHS from United States predation. We heard worries about the levels of staffing in both health and social care, and particularly the effects on some of our most vulnerable citizens of the loss of care workers from the EU. We heard about the loss of the EMA and its consequences for medicines regulation and for the access of UK patients to cutting-edge medicines. We heard concerns about clinical trials and the availability of clinical isotopes if we leave Euratom. We heard concerns about the recognition of qualifications; about research; about medical treatment across the Irish border; about data sharing; about health inequality; about reciprocal parking for disabled drivers; and about mental health. Lastly, from my noble friend Lady Tyler we heard a welcome, which I endorse, for the Prime Minister’s recognition at last that we need a long-term funding settlement for the NHS.

For myself, I would like to mention two issues that have been mentioned but not dwelt upon. The first is my concern that, if we leave the EU, we will no longer be part of the European Centre for Disease Prevention and Control, the ECDC, and have a seat at its table, currently occupied by Professor Dame Sally Davies, the Chief Medical Officer. The ECDC is an EU agency aimed at strengthening Europe’s defences against infectious diseases. It works in partnership with national health protection bodies across Europe to strengthen and develop continent-wide disease surveillance and early-warning systems. The ECDC pools Europe’s health knowledge to develop authoritative scientific opinion about the risks posed by current and emerging infectious diseases. It provides the NHS with evidence for effective decision-making, helps to strengthen our public health system and supports our response to public health threats. It does so through surveillance, epidemic intelligence, scientific advice, microbiology, preparedness, public health training, international relations and health communication. Its programmes cover a number of important issues that have been debated in your Lordships’ House over the past couple of years, including: antimicrobial resistance and healthcare-associated infections; emerging and vector-borne diseases; HIV; influenza; TB; and vaccine-preventable diseases. All in all, the ECDC monitors 52 communicable diseases.

If we no longer have access to these services after Brexit, we will suffer when, for example, there is a flu epidemic or pandemic and vaccines or other specific treatment need to be rationed across the EU. This is almost inevitable, as it is not possible with current technology for vaccine production to be scaled up fast enough since we need to know the specific flu mutation that we are dealing with before we can start manufacture. The ECDC will be driving who gets what, as it will be the conduit to the World Health Organization for the EU; the UK will be a single nation at the back of the queue, as we will be with new medicines licensing and access. What action have the UK Government taken to ensure that UK patients do not suffer because of our exit from the ECDC?

My second issue is that of food safety. I am sure that all noble Lords agree that the safety of our food is an important element in enabling our citizens to be healthy. In order to ensure safe food, our food producers need to practise the highest possible standards of hygiene, which most of them do, and our consumers need the best possible information. It is because of this that scandals such as 2 Sisters, Muscle Foods, DB Foods and Fairfax Meadow are relatively rare. It is also because of this that British food producers are currently able to sell their goods in large quantities across Europe and the rest of the world. Indeed, one claim the Government make about the potential benefits of Brexit is that British food producers will be able to sell more, thus benefiting our economy. We shall see.

There does not seem to be much emphasis on food and health in current government thinking. The agriculture Command Paper Health and Harmony, which came from the Environment Secretary, makes little reference to food apart from the issue of pesticide residues. The fisheries paper focuses on maximum sustainable yields—again, nothing about health. The focus seems to be more on cheap food than on food standards. But the British people want decent, affordable, sustainable healthy food, not a race to the bottom. I am concerned that this is not the direction in which we are going. I certainly do not think we should be opening our doors to a lot of foods from the United States, where its need to export large amounts of corn syrup means that sugars are found in the most surprising foods. For example, breast milk substitute in the United States can contain any kind of sugar in any amounts. We do not want that here.

Let us look at how our food industry standards are currently maintained. Currently, they must be up to the standards of the European Food Safety Authority, controlled by the European Commission. In the UK, the regulator is the Food Standards Agency, but it relies heavily on local authority environmental health officers and trading standards officers. I expect that the Government will say that the UK food supply is safe and that we are currently aligned with EU standards and that that will continue, so what is the problem? The problem is this. Between 2012 and 2017, the FSA’s budget was cut by 23% and the number of samples taken for testing by EHOs fell by 22%, so resources, including local authority funding of EHOs, are already stretched.

On top of that, Ministers have insisted that the FSA makes even greater savings, as a result of which last year it obligingly published a document entitled Regulating Our Future: Why Food Regulation Needs to Change and How We Are Going to Do It. I have just read a critique of this document by a collaboration of academics from the University of Sussex and City, University of London. I have scarcely ever read such a scathing academic study. The authors have the grace to support the proposal for mandatory registration of food business operators. They also support demands by environmental health officers that they should have the power to refuse registration to,

“FBOs that cannot demonstrate they can produce food that is safe and honestly labelled”.

However, the rest of the report is strongly critical, in particular of the proposal that inspection of FBOs should in future be outsourced—and not just outsourced. The proposal is that the food producer itself should contract a third party to inspect it on a basis it thinks is right at an agreed frequency and decide whether the inspection is notified—talk about marking your own homework. The fear is that the food producer will go for the cheapest option, which is unlikely to be the most rigorous, and our food safety will be affected. The other worry is about access to information—and the list goes on.

I do not think that this proposal from the FSA will give confidence to the European Commission or the European Food Standards Agency, in which case UK FBOs will have great difficulty selling their produce to either the EU or other countries, given that all over the world countries are moving to EU standards so that they have only one set to deal with. Add to all that the fact that the majority of vets contracted to supervise abattoirs and meat-cutting plants were recruited by the FSA’s outsourcing contractor from non-UK EU countries and you have a recipe for disaster in UK food safety.

This is one of the issues that the Government need to take extremely seriously when they are negotiating our exit from the EU. We need some confidence that the safety of our food, which has such a big effect on our health, will be taken into account by the Government.

My Lords, I congratulate the noble Baroness, Lady Brinton, on initiating this debate and, of course, on its timing—the 70th anniversary of the NHS, and one year from Brexit. I thank all those who have taken part. They have taken a break from their Easter egg hunting to be here this morning.

I think the Minister is aware—if he was not, he certainly is now, as the noble Lord, Lord Dykes, said, from the serious and solemn nature of the debate—that, one year away from leaving the EU, we are discussing health and care issues that affect every person in the UK. They affect those from the EU who live and work here; those from the UK who work in the EU; those of us who go on holiday; those who retire to the EU; those who use medicines of any sort, including over-the-counter purchases; those, and their families, who have rare diseases—in fact, all of us. It is a long list of issues. So when the noble Lord, Lord Callanan, talked about, as he puts it, a “snapshot” of the EU law transferring in a year’s time, I can only wonder whether even the widest-lens panoramic view camera will be able to capture all the issues that will need attention if only in the health and social care arena.

As my noble friend Lady Warwick put it, uncertainty is still the problem. I spoke about uncertainty on Second Reading of the European Union (Withdrawal) Bill—thankfully, we finished the Committee stage yesterday—and every speaker in this debate has talked about uncertainty and lack of clarity. We have talked about workforce issues, reciprocity of health and social care, the licensing of medicines and clinical devices; clinical trials, research and infectious disease control, which the noble Baroness, Lady Walmsley, mentioned; food regulation, which I agree is vital in this matter; Euratom and European network references; and indeed, as my noble friend Lord Brooke said, concerns about the trade deals that are to follow Brexit and how we will move forward on those.

I shall focus on two main issues which I think bring into focus the whole challenge facing the UK in the years to come, beginning with workforce issues. A substantial proportion of UK health and safety regulations and workers’ rights originate from the EU and provide important protections for healthcare workers and their patients. As we know, the employment environment for NHS staff, including nurses and healthcare assistants, links directly to patient outcomes and patient safety. We need to ensure that nurses, midwives and doctors working in the UK from elsewhere in the EU are made to feel welcome and that their families and futures are secure, and that our NHS staff can benefit from access to medical staff from all over the EU, as we do now. These are vital workforce issues. We know that there has been a drop in the number of midwives and nurses applying to work in our NHS already. The BMA says that EU nationals—highly-skilled doctors and researchers—will choose to leave the UK because of continued uncertainty in the Brexit negotiations. In other words, 45% of EEA doctors are considering leaving the UK. This will not help with rebuilding the NHS, which we need to do now.

The working time regulations provide a framework to reduce fatigue within our nursing workforce, and put critical safeguards in place. These include compensatory rest and controls on working time, to address the health and safety effects of shift working patterns. We strongly supported their adoption in the 1990s and their subsequent updating. Fatigue, long working hours, lack of rest breaks and poorly managed shift rotas are a risk factor that again impact on the health of nursing staff and on patient safety. It is essential that the working time directive stays in place, as currently drafted.

The Royal College of Nursing and other royal colleges wrote to the Prime Minister asking for clarity on this matter in 2017. In response, the Prime Minister did not reassure them that the working time directive was a negotiating objective and priority for the UK Government, so can the Minister give that guarantee now? With one year to go until Brexit, we are calling on the Government to be louder and clearer in reassuring the tens of thousands of EU nurses, carers and doctors working across the UK, not only on their right to stay here, but how desperately the NHS and social care system needs them to stay, and how much we welcome them.

Turning to clinical trials, I thank Cancer Research UK, Genetics Alliance UK, and others for the briefs they have sent to noble Lords about this matter. As the Minister is aware, the EU clinical trials regulation—CTR—replaces the existing clinical trials directive, and will reform the governance of clinical trials across the EU. It was adopted in 2014, with the UK’s full support. However, due to a technical delay with the set-up of the portal and the database, it will come in after 2019, rather than later this year. As a result, it will not be covered by the EU (Withdrawal) Bill and automatically be converted into UK law. The noble Lord, Lord Callanan, keeps referring to “snapshots” but it will be off the edge of that snapshot.

It is important that the UK adopts and aligns with the CTR, as it will harmonise the regulation of clinical trials taking place across Europe, making it easier for cross-border research collaboration. We need action from the UK Government that an agreement will be reached to align the clinical trials regulation and remain aligned until after the end of the transition period. Let us take rare diseases as an example, which can be written across the whole of medicine development and clinical trials. Patients affected by genetic or rare conditions often have few or no effective treatments available to them. There are over 6,000 known rare diseases, yet only about 140 medicines licensed in the EU for those rare conditions.

The EU’s medicines regulator, the European Medicines Agency—EMA—has created the largest single supranational regulatory environment, covering a population of 500 million people. Why would we want to be outside that regime; why would we want to put at risk those with rare diseases, particularly children? The Minister needs to reassure the House that this will not happen. Losing the leverage that comes from being in the single market, and therefore this regime, means that the incentives of the centralised process could be the difference between UK patients being able to access a new treatment for a rare disease or not, or it could cause major delays. It looks like we might already be losing that leverage.

Can the Minister confirm that the UK has now been informed that it can no longer be the lead assessor in clinical trials and that the UK has been removed from every EU medicine committee? Can he also explain to the House the implication of this action? When the Prime Minister talks about associate membership, can the Minister explain whether that exists at present, whether it is in the negotiations and whether it means that those things that are already happening will be reversed?

European reference networks are equally important as they have the potential to revolutionise the care and treatment of patients with rare diseases. Without the UK’s involvement, those patients in the UK and, indeed, the rest of Europe will lose out. Will the Brexit negotiations include provisions for the NHS to continue to take part in ERNs so that we can ensure that families with rare diseases are not disadvantaged?

These are huge and vital matters to be solved for the whole population of the UK. If the Minister senses a whiff of panic, he would be correct. One noble Lord after another, including the two from his own Benches, has explained the consequences of not sorting this out, not resolving it and not giving clarity and assurances in these vital areas, so I hope that he will be able to do so now.

My Lords, first, I congratulate the noble Baroness, Lady Brinton, on initiating this debate and express my gratitude to her. I commend her contribution and those of all noble Lords, who have touched on many health issues. They have occasionally strayed into the kind of Second Reading speeches we may have heard a few of in the last 11 days in Committee on the EU (Withdrawal) Bill, but I think more or less everyone has retained their discipline and focused on health issues. That is absolutely right as these essential topics will be affected by our withdrawal from the European Union and we need to debate them. It is important to be as clear as possible both about what has been achieved through negotiations so far, what we intend to achieve and what the consequences of that are.

Before I get into the meat of my response, I express my particular thanks to my noble friend Lady Chisholm. She will not thank me for this, I am sure, as she is not always keen to put herself in the spotlight. However, it is her last day on the Front Bench as a Whip. As noble Lords know, she has been a great servant of the House and a great friend and support to me, and I want to place my thanks on the record.

All noble Lords clearly agree with that. I reassert and reaffirm that no one disputes the importance of health in the Brexit process. It is only right that we are all concerned with protecting and promoting our wonderful NHS in its 70th year. I take noble Lords back about nine months, when the Secretary of State set out three guiding principles to govern our future relationship with the EU on health. First, patients should not be disadvantaged in any way. Secondly, it should be no more difficult for industry and others to get medicines, devices and other treatments to those patients than it is now—of course, ideally, it should be better. Thirdly, and very importantly, the UK will continue to play a global role in public health, as it always has and will. Throughout that process, patient safety is our number one priority. I also know that it is the main priority of the Commission, from talking to the EU Health Commissioner and other Commissioners, and of the Governments of the other EU 27. We want to make sure that patients and citizens are safe throughout this process. The reason for that, of course, is that, as we all know, health is different. It is not the same as any other traded good or service. You cannot just pay a little bit more for it or take a little bit less for it, if you are undergoing a course of treatment which is essential to deal with a disease, so health is different. I think that is recognised by everybody from the Prime Minister downwards.

It is also worth saying that our regulatory system and our research staff in the NHS and elsewhere are the envy of the EU. We make an enormous contribution through agencies such as the MHRA and through the European reference networks and the GMC to patient safety. It is our very strong desire to continue making that expertise available for the benefit of EU citizens. That is why, as the Prime Minister has pointed out, we want continued collaboration with the EU 27, the Commission and the whole EU, and that is supported by those organisations. It is also widely supported by industry and charities, which are taking this message across the world, as well as Europe, for the benefit of a strong and deep future partnership.

Inevitably, the legal basis of our relationship will change but there is every reason to believe that we will strike a deal that delivers on the principles I have talked about, not least because of the progress we have made to date. As I will set out, I believe there is good cause for optimism. I know that optimism on this issue is sometimes in short supply—I think back to the last debate, which was marginally less gloomy than this one—but I cannot help but think that, as has been revealed in some speeches today, it is a prejudice about the benefits of Brexit in general that informs some of the opinions on the risks here, and I hope to alleviate some of that concern in my comments today.

It is also worth pointing out, as the noble Lord, Lord Brooke, did, that from a domestic point of view we had a very important statement from the Prime Minister about her intentions for the long-term funding and success of the NHS. I know that the Liberal Democrats like to think that they had a critical role in getting her to that point but I assure them that she is more than capable of reaching that conclusion on her own. What I cannot promise is that, whatever funding for the NHS is decided—and like the noble Lord, Lord Brooke, I hope it comes soon—we will be putting the figure on the side of a red bus. However, it will build on recent real-term increases, as well as Agenda for Change funding, to reward our wonderful NHS staff.

Inevitably, people and the workforce have been a big part of our debate today, and I want to use this opportunity, as I hope I always do, to thank and express my admiration for the approximately 150,000 EU nationals who work in our NHS and care services. As my noble friend Lady McIntosh pointed out, I have particular cause to be thankful, and other noble Lords, including the noble Baroness, Lady Masham, very movingly described their gratitude.

It is important to point out that there are more EU staff in the NHS since the referendum. That is true of every single specialty and every type of staff, apart from nurses—we know that the impact on nursing numbers has been driven in large part by the introduction of the language test—so we are continuing to welcome them. Indeed, just this week I chaired a Brexit round table with those who are interested in workforce issues. The message is going out very clearly through the Royal College of Nursing, NHS Providers and so on that we value the work that EU nationals do and their presence in our society.

I believe that noble Lords have welcomed the agreements that we have made on citizens’ rights, not only for after withdrawal but for during the implementation period. I can confirm to the noble Lord, Lord Dykes, that the more generous offer of citizenship rights during the implementation period has been agreed. Clearly, we also need to make sure that we have an immigration system that supports our shortage subjects. We have had the MAC interim report and we will have a future report. I can promise noble Lords that the department is contributing to that work to make sure that we do not run short of the staff we undoubtedly need to serve people in the health and care sector.

Nevertheless, it is true that we need to do more to grow our own. I do not agree with my noble friend Lord Balfe that that is jingoistic or narrow-minded; I think it is our obligation to the 1.5 million people who are still unemployed in this country, despite the fantastic growth in employment here. That is why we are increasing nursing midwifery places and doctor training places. I know that there is a particular concern about unskilled or low-skilled labour. This is a thorny issue, not least because it was concerns about that kind of uncontrolled labour coming through immigration that was a driver of people’s desire to vote leave—to get back control of the immigration system. Therefore, there is a balance to be had and things such as the apprenticeship route, Skills for Care and nursing associates offer us a way through.

Several noble Lords asked questions relating to issues in this area. We want to continue with mutual recognition, although, again, there are concerns about language requirements. Social care is undoubtedly an issue and we are trying to deal with that through Health Education England’s workforce strategy, covering health and care, as well as through the social care Green Paper. That of course focuses mainly on older people but there is a separate strand of work looking at, for example, adults with learning disabilities and others. This was mentioned by the noble Baronesses, Lady Masham and Lady Thomas.

In terms of our offer to Europe, my noble friend Lord Balfe talked about the GMC and sharing data on professional conduct. My understanding is that the GMC provides more professional conduct alerts to the European system than the other EU 27 countries put together—a figure provided to me by the BMA. Clearly that is a reflection not of the quality of our staff but of the rigour of our regulation. We want to continue to contribute to that. Our strong desire is to remain part of that registry so that we can share in the safety agenda across Europe.

The noble Baroness, Lady Tyler, asked about staffing in mental health. We do not need to rehearse the discussion we had yesterday about our desire to increase numbers. No Government in the EU have been more ambitious in their intentions on that. She asked specifically about the medical training initiative for psychiatrists and the length of time involved. I shall look into that issue as I understand it is a long training process.

The noble Baroness, Lady Thornton, asked about employment rights and health and safety issues emanating from the EU. These issues emanate from the EU because they concern competencies that it has taken for itself. They will be within our competence in future and, frankly, it will be our choice. That is the point of leaving the European Union. Woe betide any Government who tried to make life more difficult for staff, particularly when we are trying to recruit them. The point is that it will be in our gift and not in the gift of any other Government.

On reciprocal health work care—which, again, several noble Lords have mentioned—we have got a good achievement on both EHIC cards for people accessing planned care and for British pensioners living abroad accessing healthcare through the withdrawal agreement. I will not go into detail but I encourage noble Lords to look at that. It gives us confidence that we will be able to deliver a good outcome on continuing similar versions of the schemes. It is worth pointing out that EU countries have bilateral agreements with non-EU countries now and we had them before we entered the EU. It is a common arrangement that countries have with each other and much valued by people who are travelling abroad or looking to retire.

Another key issue that has been raised is the safety and availability of medicines. We have a fantastic regulator in the MHRA, with 30 years of knowledge as a lead regulator through the MA process and over 3,000 medicines. We will continue to play a role in the EMA during the implementation period to make sure that there is no interruption to supplies. We will support the transition of the EMA to Amsterdam. Some specific details still need to be worked out about membership of the committee, rapporteur rights and so on during that period. The noble Baroness is right, they will be less than we have at the moment, but their exact nature needs to be determined.

The big question concerns the future relationship. The Prime Minister has been admirably clear about her desire for associate membership but there is not a template we can follow for that. The MHRA makes a huge contribution to patient safety and we do not believe that the EU will want to jettison that ability. As I have said, we have a great deal to contribute not only in this area but in chemicals and airline safety. That will help not only for medicines but for blood, organs and, to some degree, medical devices.

Specifically on medical devices, there has been a good outcome on the continued flow of those during the implementation period. Two big questions remain: one is about the trading relationship we have; the other is about our regulatory environment. We have not touched much on trade but we have commissioned work on the supply chain in this area, which I have committed to share publicly once that investigation has taken place. There is, of course, a commitment from the Government for as frictionless and tariff-free trade as possible, and we have had meetings with HMRC to make sure that that can happen whatever the circumstances.

On the regulatory front, we have achieved mutual recognition of the work of notified bodies during the implementation period. Our notified bodies approve more high-risk devices than any other, so that is yet another element of our huge contribution to patient safety across the EU.

Clinical trials have been the subject of much discussion both in this Chamber and in meetings outside it. We all know that the UK is a leading centre for clinical trials. More than that, we helped to develop the Clinical Trial Regulation, which is a significant improvement on the directive that went before it. If, during the implementation period, the portal that is the final key which unlocks the door of the CTR becoming applicable is agreed, we will take part in it and continue to implement it after the implementation period.

There is of course the question of what will happen after 2021 because it is not solely in our gift to be part of this portal; it has to be a mutual decision. Again, it is our desire to continue to be part of that but it needs to be negotiated. Discussion is going on in government ahead of Report on the EU (Withdrawal) Bill so that we can give the kind of reassurances about the nature of our clinical trials environment that I know noble Lords and others are looking for. We want to make sure that we continue to increase the number of people who take part in clinical trials and have more trials in combination with EU and other countries.

Another issue that has been well covered in both the EU withdrawal Bill and discussions today is public health and the “do no harm” principle. I remind noble Lords of the principles I set out at the beginning from the Secretary of State about playing a leading role in public health, which this country has always done, whether in responding to the Ebola crisis or in domestic action on reducing smoking, drinking, sugar and salt in food and so on. We have a world-leading system that is admired around the world and that, as I said, makes a contribution to patient safety and health across the EU.

The noble Baroness, Lady Walmsley, asked about our desire to play a continued part in EU mechanisms such as ECDC, which provides surveillance, information sharing and action on antimicrobial resistance, where the UK has been in the lead. I can tell her that our desire is to continue to be part of those processes. We want to maintain our high standards. The phrase “a race to the bottom” has been used. We want the opposite: a race to the top. We will be able to say more about our intentions in this area in the coming weeks. We are, and will always remain, part of international agreements under the WHO’s auspices, as well as our own international health regulations. I make a commitment to the noble Baroness, Lady Masham, that it is our desire to continue to share data on the dangers and risks that we face—of course, diseases honour and respect no boundaries—to make sure that we can have the right information, through whatever means possible, to keep our people safe.

I want to touch on a couple of other issues. I am afraid that my noble friend Lord Balfe is quite wrong about Euratom; it does nothing to impact on the supply of medical radioisotopes. I implore noble Lords to be careful about the language they use so as not to create fear where it should not exist. We want to make sure that we have the right customs arrangements for those isotopes to come through quickly—as they do now if they come from outside the EU—and we will make sure, whether through the Euratom Observatory or the NCAs, that we agree with other countries so that we have the right level of information and, therefore, the correct supplies.

We have a world-leading research community and a leading role in Horizon 2020, which has been underpinned and underwritten by the commitment of the Prime Minister and the Chancellor to our involvement. We want to go on designing future arrangements with the EU, just as third parties and third countries do now. That would include being part of European reference networks; I believe that we lead more of those than any other country.

The noble Baroness, Lady Brinton, and the noble Lord, Lord Brooke, asked about procurement. I can tell them that we have implemented our obligations under the EU directive. The Government are absolutely committed that the NHS is, and always will be, a public service, free at the point of need. It is not for sale to the private sector, whether overseas or here. That will be in our gift and we will not put that on the table for trade partners, whatever they say they want.

Our ability to leave the EU successfully is dependent on having the right agreement with Ireland, where health services are co-commissioned. Primary care can span both borders, and there is trade in medicines and other things. I have met the Irish Health Minister to discuss these issues. We have a good working relationship and we are working hard to make sure that those cross-border issues do not disadvantage patients in the way we have talked about.

Finally, we are pushing ahead with the implementation of the falsified medicines directive that my noble friend Lady McIntosh asked about. I met SecureMed, the body implementing it, yesterday. The noble Baroness, Lady Thomas, asked about the welfare rights of disabled people and the European Social Fund. Those are policy areas for the Department for Work and Pensions, so I hope that she will forgive me if I do not answer specifically now; I will write to her.

The noble Baroness, Lady Walmsley, asked about food standards. I can promise her that they are on my radar; they were raised at a public health round table on Brexit that I held a couple of weeks ago. We want to maintain the highest standards through the FSA that we have at the moment.

I hope that I have been able to answer and, to some extent, alleviate anxieties expressed by noble Lords through the debate. I know that we will continue to have many discussions on these issues in the Chamber and privately. I hope that noble Lords also know that my door is always open to discuss these things. I want to make sure that we get the right outcome—as do all noble Lords, and I respect that.

The Government are undertaking a huge amount of preparatory work to mitigate the potential risks associated with leaving the European Union and to make sure that we can take the most advantage of the opportunities as well. I happen to be the lead Brexit Minister in the department, so I feel a very personal responsibility for getting this right. We want to continue to be global leaders in all the facets of health, as we are today. That is something that the Prime Minister has recognised—an important recognition. She said that our principle for how the UK approaches leaving the EU is to be,

“consistent with the kind of country we want to be as we leave … A country that celebrates our history and diversity, confident of our place in the world; that meets its obligations to our near neighbours and far off friends, and is proud to stand up for its values”.

Nowhere is this more important than in our commitment to continue meeting the health and welfare needs of the UK’s citizens and residents as we leave the European Union.

My Lords, I start by thanking the Minister for his response. I will link that with the comment of the noble Lord, Lord Dykes, about the noble Baronesses’ contribution to the debate. While it was very flattering for us to be so mentioned, the Minister in particular but other noble Lords who spoke also have that in-depth knowledge. I want us to recognise that.

I will not attempt to summarise things in the very brief time I have now, but I thank all noble Lords who spoke. As I predicted, the contributions were of considerable depth and expertise, combined with experience and anecdote that demonstrated the real concern many of us have about health and welfare in the light of Brexit. The key things that stuck out for me were the problems with high-skill and low-skill recruitment in the health sector. The tier 2 limits are ridiculous. I thank the noble Lord, Lord Balfe, for his comments on Addenbrooke’s. My clinic has been delayed by a year because it has been unable to bring in the consultants it wanted from abroad. We heard about trailblazers, and the fact that young people with muscular dystrophy are flying in help from Europe because there is not the specialised care and support; that is really worrying. While I admit that the Government are trying to negotiate the rights of people to come to work here, they are not in place yet. The compelling personal testimony of my noble friend Lady Thomas and the noble Baroness, Lady Masham, was very moving. I thank them for that.

I will end on a phrase that the noble Baroness, Lady Thornton, used. She asked why we would want to be outside the EMA. I will add to that the working time directive, the ECDC, the EU directive on public procurement, Horizon 2020, medical devices and Northern Ireland border issues, all of which came up in depth during the debate. So perhaps the best note to end on would be to say that we can have the best of all worlds—and that is by remaining inside the EU.

Motion agreed.