Grand Committee
Healthcare: Controlled Drugs
(8 months ago)
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Lord Butler of Brockwell
To ask His Majesty’s Government, further to the Written Answer by Lord Sharpe of Epsom on 24 July (HL9391), when they plan to introduce legislation to enable prescribing of controlled drugs by paramedic independent prescribers, as well as other changes to the use of controlled drugs in healthcare.
Lord Butler of Brockwell (CB)
My Lords, I want to thank the noble Lord, Lord Sharpe, for having raced from business in the Chamber in order to answer this short debate.
I start by saying that I need to declare no personal interest in the subject of the debate—my only interest is to try to do the world a bit of good. I should also declare that I have no difference of policy with the Government. The issue is this: the Government have said that, following the approval of the Advisory Council on the Misuse of Drugs, they will extend the list of drugs which paramedic independent prescribers and therapeutic radiographer equivalents may prescribe and administer to patients. These drugs include morphine, morphine sulphate and four other drugs.
This process has taken a considerable time. The advisory council submitted its approval in relation to paramedics in 2019—four years ago—and in relation to radiographers in 2020, three years ago. More than two years later, on 30 September 2022—nearly a year ago—the Minister of State in the Home Office wrote to the secretary of the advisory council and said that he had asked Home Office officials to commence the process for making these regulatory changes.
My purpose today is to ask the Minister to give us a date by which this will be done. I put two Written Questions to the Home Office, which the noble Lord, Lord Sharpe, has courteously answered. He has confirmed that the changes are capable of being made by statutory instrument, which the Government will bring forward
“as soon as possible, but this will remain subject to Parliamentary procedure”.
What is this parliamentary procedure? I am advised that it is a statutory instrument under the negative procedure, which means that the instrument comes into law without any parliamentary procedure unless someone dissents, which in this case is effectively unthinkable. So, the statutory instrument simply has to be drafted and laid.
The delay does not seem to be parliamentary procedure but the Home Office’s order of priorities. We know that Home Office lawyers have been very busy, but it is very difficult to understand why they have not been able to find time for this very simple instrument. I understand that the Advisory Council on the Misuse of Drugs approved the wording as long ago as 2019—four years ago. Home Office lawyers could simply take it out of their drawer. Equivalent amendments were required with respect to physiotherapists and podiatrists when these groups were given prescribing rights 10 years ago. They were made by the Home Office in a little over 18 months. Today, by comparison, paramedic independent prescribers have been waiting over five years for the necessary amendments to be made, and therapeutic radiographers have been held in limbo since April 2016—over seven years.
I said at the outset that I had no personal interest to declare, but that is not quite true. We all have a personal interest in this issue. I could describe to your Lordships a case study in which, in the absence of the changes we are discussing today, an advanced paramedic practitioner could not prescribe oral morphine to deal with an acute onset of pain without the patient having to have a further appointment with a GP, prescribing nurse or pharmacist. Following this statutory instrument, that paramedic would be able to prescribe oral morphine for the continuing treatment of pain. If I may make this personal, I do not welcome the prospect some time in the future of unnecessarily lying in acute pain which could be relieved by this simple statutory instrument. Nor do I want others to have to do so.
The statutory instrument offers a double whammy. It will both remove some unnecessary pressure on general practitioners, which the Government and all of us must surely welcome, and make available more immediate treatment for patients. If the Department of Health were responsible for this statutory instrument, I wonder whether it would have been made with more dispatch.
I am too long in the tooth to be fobbed off by statements saying that the Government will make the statutory instrument
“as soon as possible, but this will remain subject to Parliamentary procedure”.
I repeat that it is simple for the Home Office to make and lay this statutory instrument. It effectively requires no parliamentary procedure whatever. I hope the Minister will be able to clearly answer my question and say that the statutory instrument will be made forthwith, I hope by the end of the current Session.
Lord Patel (CB)
My Lords, it is a pleasure to follow the noble Lord, Lord Butler of Brockwell. I thank him for initiating this important debate. Like him, I hope it will result in the Government bringing in much-needed legislation to allow advanced paramedic practitioners to prescribe some of the controlled drugs in Schedules 2 to 5. I will speak briefly in support of the noble Lord. I may repeat some of what he said, but do not apologise for doing so because it is worth emphasising.
I thank the College of Paramedics and the House of Lords Library for their detailed, informative briefing on allowing paramedics to prescribe controlled medicines. I recognise the need to look at expanding prescribing by other health professionals, such as radiographers, as have been mentioned, and widening the list of drugs that can be prescribed by them. However, I shall confine my comments today to paramedics.
There is a misconception that highly trained, efficient paramedics work only in ambulances and are not allowed to prescribe and administer medicines, including some controlled drugs. Paramedics are now deployed in a whole range of healthcare settings, from emergency departments to GP practices, out-of-hours services and general and specialised wards. Some 25% of paramedics now work in wider healthcare settings. They are a versatile, experienced and valuable part of the healthcare system. There are more than 1,500 advanced paramedic practitioners, and the workforce plan recently published by the Government has the ambition to expand this workforce considerably in future.
Once qualified as an independent prescriber, a paramedic can prescribe any drugs, except controlled drugs such as morphine sulphate, as has been mentioned, Diazepam, Midazolam and codeine phosphate. Qualified paramedics can and do work independently in making the correct diagnosis. If the treatment involves giving controlled medicines, she or he has to seek assistance from another prescribing healthcare professional. This results in delay in care, disturbs the work of both professionals and increases the risk to patient safety.
I will give some real examples—the noble Lord, Lord Butler of Brockwell, already gave one such. A young man, having fallen off his bike, is brought to the emergency department by ambulance. He is in considerable pain and, after initial tests, the advanced paramedic practitioner makes a correct diagnosis of a closed tibia and fibula fracture. The advanced practitioner knows what he has to do next but is unable to prescribe morphine to alleviate the pain and has to seek assistance, disturbing the work of other clinicians, who have to leave the patient they may have been looking after to help the paramedic. This delays treatment and creates possible patient safety issues.
Another such example is a young woman, a known epileptic, who is brought by ambulance having had seizures at home. The practitioner is unable to prescribe prescribed drugs such as intravenous lorazepam to control the young woman’s epileptic seizures.
Another example is a young man with a shoulder injury who is brought in by ambulance. The paramedic makes a correct diagnosis of a dislocated shoulder and is competent to treat the patient. However, before she or he can perform the manipulation of the shoulder, they must seek the advice and assistance of another health professional to administer a mild anaesthetic such as midazolam. Being unable to prescribe and having to seek assistance means that the treatment is delayed and the young man remains in pain; this risks the dislocation causing more shoulder damage, with possible long-term effects.
Legislation, possibly introduced as a statutory instrument, as already mentioned, is urgently needed to allow highly trained, experienced advanced paramedics to prescribe some controlled medicines. Such legislation is a long time in coming. The concept of paramedics prescribing was consulted on in 2015. As the noble Lord, Lord Butler, mentioned, in 2018 legislation to approve the concept was accepted. In October 2019, the Advisory Council on the Misuse of Drugs approved the list of drugs that advanced paramedics could prescribe, which was also approved by the MHRA. Apparently, a letter was sent to the Home Office in 2019, so we have been waiting since then for the Home Office to approve and bring in the legislation.
I know that the noble Lord, Lord Sharpe of Epsom, is sympathetic to the proposals from the correspondence I have seen which others have had with him. I hope he will surprise us when he responds by telling us when the legislation will be brought forward—I hope before 7 November or soon after. Whenever it is, I cannot imagine that Parliament will do anything other than promptly approve it.
Once paramedics are able to prescribe some of the medicines in the controlled list of drugs, patients will benefit from prompt treatment, and it will free up the time of other clinicians and improve patient safety. If there is no action from the Home Office, I hope that the noble Lord, Lord Butler of Brockwell, will continue to badger the Government on a regular basis. He will have my support.
The Earl of Sandwich (CB)
My Lords, I too support my noble friend, and I am grateful to him for this chance to address a related subject of great concern: the highly damaging effects of the use of certain drugs prescribed in good faith. Older colleagues may recall that some years ago a member of my family had a bitter experience with benzodiazepine and sudden withdrawal from it at her doctor’s request. I introduced various debates and asked various questions at that time. I therefore declare my interest as a founder member of the Prescribed Drug Dependence—PDD—All-Party Parliamentary Group, which is soon to be renamed the “Beyond Pills” APPG. Most of the intellectual backup for the all-party group comes from the Council for Evidence-based Psychiatry, or CEP UK, which has found that the prescription of antidepressants and other drugs is still increasing rapidly year by year.
The Pharmaceutical Journal reported in July that the number of antidepressants prescribed in England rose by 5.1% in 2021-22, compared with the previous year, which was the sixth annual increase in a row. Over the same period, the number of antidepressant items prescribed increased by 34.8%, rising to 83.4 million items in 2021-22. According to Public Health England, as many as one in four adults in England over 18 are being prescribed benzos, Z-drugs, opioids or some form of antidepressant.
In 2019, following a lot of pressure from the APPG, Public Health England published a comprehensive evidence review of dependence-forming drugs. This showed that 26% of the adult population in England was prescribed a dependence-forming drug in the previous year. In its earlier review of data, PHE found that more people were being prescribed medicines inappropriately, and often for longer than good practice guidance recommended.
A recent BBC “Panorama” programme, I think in June, showed that there are still almost no NHS services to support patients who have been harmed by taking drugs as prescribed by their doctor. The programme detailed how patients experiencing severe and prolonged withdrawal symptoms have resorted to online peer groups for validation, support and safe drug tapering advice. My noble friend knows the inner processes of government from over many years, and he will have a lot more patience than me with the inability of officials to act on agreed principles. We have heard his frustration, and we can all easily sympathise with it. When it comes to helping those suffering from withdrawal, at least two promised policies involving a helpline and the support of the voluntary sector have been, if not shelved, then placed firmly on the shelf.
In response to the 2019 PHE review, NHS England published its framework for action, Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms. This was published in March and was intended to encourage integrated care boards to develop services. While that has been widely welcomed as a further positive step by government, a recent FOI revealed that only 6% of the ICBs are considering taking any action on the framework. The same PHE review also recommended that a national helpline to support people going through intense withdrawal from prescribed drugs should be set up in partnership with those with relevant experience—in other words, something very practical. At a time when issues of patient safety are very much in the public mind, it is disappointing that the DHSC has recently confirmed that it cannot find the £2 million necessary to set up this lifeline, which is urgently needed until local services start to become available.
There are a number of small voluntary organisations scattered across the country—in Camden, north Wales, Bristol, for instance—providing a vital service to patients. But their relations with the NHS are tenuous. As the BBC reported again this morning, many are so frail that without funding, some, such as the Bristol Tranquilliser Project, have ceased or are ceasing to operate. In another survey of 500 patients, 92% said that they were not told about withdrawal effects when they were first prescribed antidepressants. This seems unimaginable. Surely, this is a service much too valuable to public health to be allowed to collapse. I have seen the rather negative letter from the DHSC, dated 3 August. This was a key recommendation of the review. When will it be reconsidered?
On the specific Question and paramedics, I draw attention to the NICE guidelines concerning safe prescribing and withdrawal management for medicines associated with dependence. Will paramedics who are able to prescribe be required to comply with guideline NG215, entitled Medicines Associated with Dependence or Withdrawal Symptoms: Safe Prescribing and Withdrawal Management for Adults? The practicalities associated with following such guidelines in an emergency situation, such as my noble friend described, need to be assessed and specific provision made for informed consent and follow-up by a GP to put in place NICE’s recommended management plan for such drugs.
Secondly, patients who have had difficulty withdrawing from dependence-forming medications frequently choose not to take such drugs in future. Would the Minister agree that paramedics need to take account of that? They must be able to check records for any history of discontinuation or protracted withdrawal syndrome, or advanced decisions made about the future administration of those medicines.
Following the PHE review, the all-party group is aware of efforts by NHSE to create an internal information hub on drugs associated with dependence, agreed in principle to be held on the NHS Specialist Pharmacy Service website. Can the Minister also confirm that paramedics will be signposted to this information in the event of any questions?
As I said, I warmly congratulate my noble friend. He has made a point and created a scene of what might happen to any of us. I hope the Minister will give him a really solid reply.
Lord Allan of Hallam (LD)
My Lords, we are grateful to the noble Lord, Lord Butler of Brockwell, for pressing this issue for some time now, not just in this debate but in previous Questions, because it is frustrating when a policy decision has been taken that will bring benefits to people but its implementation is held up for months or even years for want of a technical change to regulation. It seems entirely misplaced that we have an important policy decision yet, as the noble Lord described very accurately, something quite trivial—drafting an instrument and getting it before us—is holding up that change.
It might be helpful to put this change into the wider health context to understand the weight of that frustration and why it is ringing alarm bells. This specific change to prescribing paramedics is in a context of changes to prescribing rules more generally. There is a recognition among policymakers of all parties and none, and among the health and care professional community, that there is a need for innovation in working practices, especially those practices around prescribing. That is essential if we are to meet the demand for health services, even if we keep putting more resources in. Resources on their own will not provide the answer; it is the kind of innovation where we use a broader group of healthcare and allied professionals to deliver services that will enable us to meet that growing demand. Prescribing is one of the key areas where innovation is happening and cost-benefit analyses are being constructed for potential changes to the prescribing model.
On the benefits side, these accrue to individual patients, who can have easier access to the drugs they need. The noble Lord, Lord Patel, elegantly set out the kind of situations in which an individual patient would certainly benefit from the change being considered—the paramedic being able to prescribe controlled drugs. However, we all will indirectly benefit if healthcare professionals can work in the most efficient way and professional A does not have to ask professional B to take time out to prescribe the drug that professional A could have prescribed themselves. The whole system benefits with that increased efficiency, as well as the individual who is immediately at risk.
There are of course some potential risks to individuals and society from any of these changes. Again, the noble Earl, Lord Sandwich, set out for us the kind of problems that can occur if drugs are prescribed inappropriately. We need to bear that in mind and that is why, with any of these changes, the analysis should look at those risks and the things that need to be put in place to manage and mitigate them. That is precisely what has happened here, with the report we had as far back as 2019 from the Advisory Council on the Misuse of Drugs, and other work that has taken place. People have looked at the benefits and risks of the change and concluded that the benefits significantly outweigh the risks, and therefore that we should proceed. That process has happened as it should, by looking at things within the full context. Now all we need is that enabling regulation.
I hope the Minister is going to explain to us today, first, why it has taken so long and why we are forced, in a sense, to bring him here to answer rather than it having just appeared on the Order Paper at an earlier date; and, secondly, whether he can point to a resolution in the near future. The noble Lord, Lord Butler of Brockwell, used the word “forthwith”, which was a novel take on this. I have heard that things will happen in due course or shortly. These are all terms of art, rather than precise dates, in government-speak. Forthwith is one that I like, as it conveys even more of a sense of urgency, but the noble Lord was right that better than any of these formulations would be a date. Having “12 October” is better than “shortly” or “soon” or any such formulation. I hope the Minister will be able to offer us a date.
I would also like to raise with the Minister a specific question, which I hope he can touch on in his remarks. Have the Government given any consideration to the impact on healthcare professionals of making nitrous oxide a class C controlled substance, which the Government are doing through a statutory instrument that I think will come before us next Tuesday? Again, it is interesting to note that the Government managed to produce that instrument in double-quick time, even though it goes against the advice of the Advisory Council on the Misuse of Drugs, while here we have one which is aligned with that council’s advice but has taken much longer. The noble Lord, Lord Butler of Brockwell, may have put his finger on it when he said that if this regulation was owned by DHSC it would have proceeded much faster, because if the change in regulating controlled substances is one the Home Office wants for its own policy agenda, it seems to be able to do that much more quickly than if it is being asked to assist the Department of Health. That is a shame, in what is supposed to be an era of joined- up government.
I have looked at the Explanatory Memorandum for the instrument that will be debated next week. It says that the impact for the public sector of this classification relates only to law enforcement and criminal justice, with no effect on anyone else. I hope that is true and that the Government have done all the work needed to ensure that healthcare professionals and those in allied professions who use nitrous oxide quite widely will not experience any change to their practices, or their ability to use nitrous oxide, post the reclassification. However, the fact that we are debating this today around other class C controlled substances, such as diazepam, suggests to me that there is some complexity. When I read some of the background notes, I understood that there are NICE guidelines and specific exemptions, so it is a very complex world where health service regulation and Home Office regulation come together.
As I say, I hope that the Home Office has done its homework and that when we classify nitrous oxide as a class C controlled substance, the Minister will be able to assure us that no health professional or allied professional needs to worry about that and that there will be no negative implications. If not, and if changes will be required pursuant to that reclassification, I hope he can indicate that those are in hand and nitrous oxide will not suddenly fall into this area, with some professionals being unable to prescribe it as and when they need to, as with the other substances we are talking about. I hope the Minister will have answers to this, as well as that crucial answer of a date when the changes that were already agreed so long ago might come into force.
Baroness Merron (Lab)
My Lords, I too would like to thank the noble Lord, Lord Butler of Brockwell, for giving us the opportunity to air what we should not have to air, which is the need for the legislation for this important change. I would also like to pay tribute to his elegant tenacity on the subject, which is important in improving the provision of health care. The Government are failing to do that because they have not brought forward the necessary legislation. The noble Lord also set out clearly the background to what is a very long and winding road over many years which brings us to a position I am sure the Minister would rather not be in. It is a somewhat uncomfortable position, because it is so obvious that this should be done; all the agreements and approvals are in place, and yet we wait.
I am glad that the Minister has confirmed on a number of occasions that legislation will be brought forward as soon as possible and that this could be dealt with by statutory instrument. When it does come before us again, I hope that what the noble Earl, Lord Sandwich, said about the need to confirm that full consideration has been given to patient safety will be taken into account. The noble Earl helpfully flagged up a number of points, which I would regard as advanced warning to the Minister.
I agree with the point made by the noble Lord, Lord Butler of Brockwell, emphasised by the noble Lord, Lord Allan, that if this matter was sitting with the Department of Health and Social Care it would have been dealt with—I feel sure of that. The Minister shakes his head, and I am sure we will have an explanation later as to why that is not the case, but that is the feeling in the room, and for good reason. As the noble Lord, Lord Patel, explained, paramedics do not just work in ambulances, and what they need is the tools to do the job that is before them.
NHS England also states that advanced paramedics who have undergone additional master’s level training are increasingly taking on roles in varied critical settings. As the noble Lord said, these include GP practices, minor injuries units, urgent care centres and A&E, and they are prescribing in such settings. This aligns with the NHS long-term plan’s emphasis on multi-disciplinary care, which includes the aim to relieve pressure in accident and emergency units and to provide immediate care for people wherever they are. To have this change in legislation would be a considerable contribution to that.
Why do we need to go down this road? It is worth reiterating some of the points that have been made. I too was grateful to the Lords Library for the briefing it provided and was interested to read the 2021 study in the British Paramedic Journal. It reported that paramedics who participated in this study, and who had
“longer experience in primary care, out-of-hours or house calls or with an extended remit to provide end-of-life or palliative care”,
described not being able to prescribe controlled drugs as a “limitation”. I am sure that the Minister, who is a Home Office Minister, has heard many debates in the Chamber in which his ministerial colleague in the Department of Health and Social Care was pressed on why we cannot see change to existing staff practices in order to provide better healthcare. Indeed, the NHS workforce plan, which we have long called for and which has finally appeared—with its limitations—will be successful only if the question of how people can do their jobs is looked at. Here is an opportunity to equip people to do their job.
In answering a Written Question put to the Department of Health and Social Care in December last year, the noble Lord, Lord Markham, described who could prescribe beyond doctors and dentists. He gave a list of professions, referred to as non-medical prescribers in this case, and they included physiotherapists, therapeutic radiographers and so on. Interestingly, the Care Quality Commission lists the great benefits in this extension to non-medical prescribers, so there is a lesson to be learned here. The CQC talks about the enablement of “quicker access … to medicines” for patients, making the
“best use of the range of skills of healthcare professionals”,
and addressing “demand and workforce issues”. I say to the Minister: these are all things we have been pressing for in the Chamber, and which I think Ministers would also like to see. Here we have an opportunity to get on and meet that requirement.
I have a few questions for the Minister. As we have discussed, experienced paramedics have had prescribing powers since 2018. What assessment have the Government made of the success of this, and what can be learned from implementing the extension? Crucially, can the Minister tell us how much discussion has been had on this matter with the Department of Health and Social Care, as it seems to have fallen between the two departments? How many paramedics currently hold independent prescribing powers? Do the Government have any plans to encourage more paramedics to access prescribing training? What consultation have the Government undertaken, or will they undertake, on how to roll out these changes?
In a study on the introduction of prescribing for paramedics, those who had begun prescribing expressed concern about confusion in multidisciplinary settings about the different prescribing powers that colleagues possessed. What work can the Government and the NHS do to ensure clarity throughout the health service so that current powers and the new powers, when they are introduced, are clear to all clinical colleagues?
As the Minister knows, there is one main thing we would like to hear: the date when this matter will finally be dealt with. I hope he can offer us that today, with clarity, and that he will also explain to noble Lords present and the many people outside who are waiting for his response why there has been this delay. I look forward to his response.
The Parliamentary Under-Secretary of State, Home Office (Lord Sharpe of Epsom) (Con)
My Lords, first, I offer my thanks to the noble Lord, Lord Butler, for securing this debate. If I may say, I hope that no noble Lords, including the noble Lord, ever have personal need on this particular subject. I note his points on the simplicity of making this statutory instrument and the delay in legislating, and I shall come back to that in a moment.
I want to start by stressing at the outset, as the noble Lord and others noted, that the Government recognise the importance of this issue and the value that independent prescribing by front-line health professionals, such as paramedics, brings to the National Health Service. Doctors and vets are generally able to prescribe medicines containing controlled drugs, with accompanying rights to administer and direct others to administer them. In addition, other healthcare professionals can undergo specialist training to prescribe, supply and administer controlled drugs. Paramedic independent prescribers are therefore distinct from other paramedics and will be able to prescribe medicines specified in the legislation.
I am grateful to the noble Lord, Lord Patel, for going into some detail in this regard, because it gives me an opportunity to expand the definition of “advanced paramedics”, and perhaps add some colour. The number is expected to increase in line with the recommendations of the new long-term workforce plan, as referenced by the noble Baroness, Lady Merron. This change in legislation supports that development. As has been noted, that will benefit both the patient and the wider healthcare systems.
All paramedics are required by law to register with the Health and Care Professions Council. In answer to the noble Baroness’s question, according to its register, as of March, there are 1,708 paramedic independent prescribers and 219 therapeutic radiographer independent prescribers in the UK. Paramedic independent prescribers are utilised in a wide range of settings, which can include, but are not limited to, things like emergency departments—same-day emergency care, air ambulances, GP surgeries, out-of-hours services, walk-in centres, community palliative care teams, virtual wards and hospital-at-home services, hospices and so on, as well as on general and specialised wards.
Independent prescribing supports an expectation that patients should be cared for and treated by the most appropriate healthcare professional to meet their needs where it is safe and appropriate. The main purpose of paramedic independent prescribers is to allow those working at an advanced level of practice to be able to independently assess, diagnose and treat patients in a single episode of care, rather than refer them on to another healthcare professional. This is in line with the example that the noble Lord provides, in that, under this new legislation, a patient with an acute onset of pain could be prescribed oral morphine by a paramedic independent prescriber rather than being referred on to a GP or otherwise.
With all that in mind, the Government are wholly supportive of the proposals to enable prescribing of the five specified controlled drugs by paramedic independent prescribers, which is why we accepted the recommendations of the Advisory Council on the Misuse of Drugs, or ACMD, last year. We intend to legislate to make this change alongside other changes relating to the use of controlled drugs in healthcare by podiatrists, therapeutic radiographer independent prescribers, and those acting under patient group directions. As the noble Lord points out, the changes can be achieved by a negative Statutory Instrument, and we intend to bring forward this legislation by the end of the year. I have become a master of obfuscation while doing this job, but there is no need in this case.
The prescribing and supply of medicines is a policy lead for Ministers at the Department of Health and Social Care, as has been noted, and it is governed by medicines legislation. In the present case, the drugs involved are controlled under the Misuse of Drugs Act 1971, which is the responsibility of the Home Office. The 1971 Act makes specified activities in respect of controlled drugs generally unlawful. But because many controlled drugs have legitimate uses in healthcare, the 1971 Act enables Ministers to provide exemptions that are set out in the Misuse of Drugs Regulations 2001.
Under the 1971 Act, Ministers are required to consult the Advisory Council on the Misuse of Drugs, an independent scientific advisory body, before making changes to drugs legislation. Therefore, there are two departments, the Home Office and the Department of Health, working together on issues connected to controlled drugs in healthcare, taking advice from the ACMD and through consultation. The ACMD provided advice to Ministers regarding the prescribing of controlled drugs by paramedics, as has been noted, in October 2019. The Home Office and the DHSC worked together to consider this advice. After the report was published, the Government were required to focus on addressing the threat of Covid-19, as I am sure noble Lords will understand. Alongside other pressures on healthcare, the topic of independent prescribing was not prioritised. As noble Lords will be aware, the Government responded, accepting the ACMD recommendations in September 2022.
I assure your Lordships that Home Office and DHSC officials are working on the necessary amendments to the legislation, and we intend to introduce them by the end of the year. Where I referred to parliamentary procedure in the letter mentioned by the noble Lord, I am afraid that that is just standard language; there is no particular attempt to confuse or, to use my earlier word, obfuscate. We are carefully working through the legal drafting to ensure that each of the professions will have clarity on their new rights and responsibilities so that they can confidently carry out their duties. These include such details as whether the professional can direct others to administer the specified controlled drugs; whether the professional can compound the drugs; and whether they are obliged to record information about their prescribing and, when required, furnish information about it.
In addition, technical amendments need to be made to ensure that the measures are effective: for example, to ensure that patients supplied with controlled drugs in accordance with a prescription from the professional are in lawful possession, and to ensure that interdependencies between the 2001 regulations and those for which the DHSC are responsible under medicines legislation are properly aligned.
In his speech, the noble Lord described these changes as simple. Although the amendments to be made may seem simple, the complexity of the 2001 regulations should not be underestimated. My officials tried to explain them to me the other day and they will cheerfully attest to the fact that I looked very confused for a very long time. Officials from the Home Office and the DHSC have worked alongside lawyers to draft these regulations over several months to ensure that they are accurate and aligned with medicines legislation. I hope it is clear that the Government understand the imperative of this work and are prioritising the legislation accordingly.
To answer a few specific questions, the noble Lord, Lord Hallam, asked whether the forthcoming ban on nitrous oxide will have any impact on healthcare. I can assure him that it will remain available in healthcare as a Schedule 5 drug, and that can also be achieved by a negative statutory instrument. I suspect that we may return to that next week.
The noble Earl, Lord Sandwich, asked me about patient safety in prescribing. Prescribing policy is a matter for the DHSC, but I will make sure that he gets a detailed response on that subject. I can say that benzodiazepines—forgive my pronunciation—are controlled under drugs legislation, with three novel benzos being added in 2021. I hope that he does not intervene on me to ask for clarification because I am not sure that I will be in a position to provide much.
The noble Earl and the noble Baroness, Lady Merron, asked about the safety of prescribing. The ACMD advised that prescribers will have comprehensive training, and existing auditing and sanctions processes will manage inappropriate prescribing, should it occur.
In closing, I thank Members for all their contributions to today’s discussion, which has been both instructive and insightful. I particularly thank the noble Lord, Lord Butler, for securing the debate. He is absolutely right to highlight this important topic. I also thank Mr Johnny Hood, senior advanced clinical practitioner, who wrote to both the noble Lord, Lord Butler, and me. I rudely did not reply to his letter, but I hope he is paying attention to this debate. I thank him for his letter, which I read and noted.
I have heard what has been said and I hope I have provided some clarity and reassurance around the current position. As I have set out, we fully recognise the significance of this issue and work is at an advanced stage to address it as soon as possible by the end of this year.
Horseracing and Bloodstock Industries
Lord Herbert of South Downs
To ask His Majesty’s Government what plans they have to support the horseracing and bloodstock industries.
Lord Herbert of South Downs (Con)
My Lords, I am grateful for this opportunity. I declare a minor interest in owning a tiny fraction of an infuriatingly inconsistent horse of moderate ability. However, my real interest is as a lover of the sport of kings, and I know that my passion is shared by millions of others. Racing is the country’s second-largest sport—only football is bigger. It welcomes 5 million racegoers annually to 59 racecourses across England, Scotland and Wales and the industry generates £4.1 billion a year for the UK economy, supporting 80,000 jobs in the rural economy. This is not just a pastime. It is really important to the country. I sometimes wonder whether racing receives the political attention such a major sport and industry deserves.
Despite its size and prestige, there is much to be concerned about for the future of racing in the UK today. It is a global sport and must be competitive to attract owners, runners, racegoers and betters. Yet prize money levels in British racing are far lower than in rival countries. The average per race in Britain is £16,000; in Ireland it is £22,000, in France £24,000, in Japan £53,000 and in Hong Kong £155,000. This already large gap is widening fast. The clear and present danger is that there will be an exodus of equine talent from our country and horses running in other countries where prize money is higher. That is happening already. Stallions are already going abroad rather than staying here. Horses are not being kept in training here. There is a worrying mismatch between the reputation of British racing as the best in the world and its financing, which is among the worst. This gap is simply unsustainable.
The Government say that the levy is not the only source of funding for racing, representing just 6% of racing’s total income last year whereas owners and breeders contribute nearly two-thirds between them. That is true, but owners and breeders rely on the prize money, which is provided by the levy, so the level of the levy is a key concern for the future of racing. It is a vital source of income for the sport, delivering £80 million to £100 million of funding annually. However, that is way short of the £133 million annual target agreed by the Government in 2017. The current level has simply not been enough to keep pace with inflation or growing costs in the industry.
To take a step back, racing receives a return of less than 3% from the more than £13 billion bet every year by punters in the UK. That is a tiny percentage, the lowest of any major racing nation. Ireland’s return is 8.4%; even Australia’s 3.4%, not much above our current yield, would mean a £174 million levy yield going to the UK industry, far higher than it is currently. The centralised funding models in places such as Japan and Hong Kong lead to much higher returns still to racing, such as 16.6% in Japan. We do not have such models. Instead, we have profitable betting companies, which is why the levy is so important.
I welcome the Government’s review of the levy because three key reforms are urgently needed. First, the rate must be increased, as I think all sides now recognise. Secondly, it should be linked to inflation to ensure that it maintains its value and to provide certainty. Thirdly, we must close the loophole so that the levy applies to all bets by British customers, including on international races, which is not how it works at the moment. In fact, Britain is the only major jurisdiction not capturing domestic betters betting on international racing. That has not always been the case, as the levy captured British betting on international racing prior to 2004. This is a very important gap to plug, because a fifth of the money bet by British punters is staked on races abroad, so the industry is simply losing a lot of money that it would have accrued before.
However, there is a further risk to the financing of racing that is not external. I am afraid that it comes from government itself. To deal with problem gamblers, the Government and the Gambling Commission are proposing affordability checks on remote betters. The Government themselves say that this will impact on racing’s finances but that the checks will be minimal. However, the industry calculates a far worse impact than the Government suggest: an 11% reduction in levy income and a consequent loss of value to media rights deals, reducing funding by 15%. The overall effect could see racing lose millions of pounds a year. The industry can ill afford this at the moment.
I am afraid it is no good to say that the checks will be frictionless, because the technology to deliver frictionless checks does not exist at the moment. Checks every six months and no thresholds, which are already far too low, will effectively mean onerous checks for everyone. That is a clumsy, one-size-fits-all approach that will bludgeon punters.
We know how these institutions will apply these rules—with a sledgehammer. Just look at how the banks have applied the politically exposed persons regulations. It is not just the banks. In July, I received an email from Bet365, with which I have an account, which said:
“Dear Sir Herbert … we have identified that you are a politically exposed person”.
It went on to demand that I identify the source of funds through bank statements, proof of annual income and so on and so forth. Those are immensely onerous requirements, yet I can assure noble Lords that the sums I was betting were tiny: a few pounds a year. These checks were completely disproportionate, so we know how the betting companies will apply any rules. We have a good idea of how they would apply affordability checks. We are already seeing a reduction in betting turnover as bookmakers begin their own checks and high-profile betters say that they will quit.
This reform is doubtless well intentioned but it will not work in practice because it will simply drive punters to the unregulated black market. I am afraid that the Gambling Commission is in complete denial about that. However, I also think that these checks are wrong in principle. People should be allowed to spend their money in ways that they judge is right for them. Would we seriously propose affordability checks for alcohol or tobacco? We might take measures to deal with problem drinking and problem smoking; we might tax these products and so on, but would we actually say to people that if they cannot afford them we will not allow them to purchase them? It is an extraordinary suggestion.
For the state to decide whether someone may place a bet based on their job title or postcode is discriminatory. Actually, I would argue that it would be an outrageous abuse of state power. If there is an issue with problem gambling, affordability checks are an unwise and blunt instrument that will not deal with the issue. I suggest the Government drop these checks and focus instead on measures that are targeted on those most at risk: the problem gamblers.
There is a very important point here: there is no point in increasing the levy, if the Government finally decide to do that, which would be very welcome, only for any gain or even part of it to be cancelled by another government measure. That would be to give with one hand and take with the other, and racing would be the loser.
Finally, I will raise the issue of the proposed solar farm at Newmarket—2,500 acres of solar panels, the largest in the country. The visual impact from the Limekilns training grounds in Newmarket would be appalling. I should say that I live five miles from the centre of Newmarket but in completely the opposite direction. I would not be personally impacted by this solar farm. I have no vested or private interest in opposing it, but Newmarket does.
Newmarket is the centre of flat-racing in not just the UK but the world—it is known as its headquarters. Historically, the rail tunnel was put under the gallops. The gallops were not dug up in the war for food; special planning protection was given to Newmarket. That has protected it as the international centre of flat-racing, and we cannot be casual about losing these protections or that special status.
The 77 acres of batteries are just a device to obtain planning permission. I believe that solar panels should be on the roofs of public buildings, not on high-grade agricultural land. This proposal is opposed by all local councils, as well as the racing community. I appreciate that there is a public inquiry on it and that Ministers are taking a quasi-judicial decision, but I urge them to reject the proposal if they possibly can.
In conclusion, responding to a similar debate initiated last year by my noble friend Lord Risby, the then Minister said:
“The Government remain committed to supporting British horseracing and related businesses, which are vital to the lifeblood of the rural economy”.—[Official Report, 17/11/22; col. GC 232.]
The Government must mean what they say. If they are committed to supporting racing, they cannot bring in damaging and pointless affordability checks, knowing that the sport’s finances will be shredded. If they are committed to supporting racing, they cannot allow the erosion of our global competitiveness when a key solution—increasing and reforming the levy—lies in their hands. If they are committed to supporting racing, they cannot just ignore the concerns of the global centre of the sport and allow a development which would go against centuries of protection. I am grateful to the Government for acknowledging the importance of racing; their actions must now match their words.
Baroness Harding of Winscombe (Con)
My Lords, I thank my noble friend Lord Herbert for securing this debate and introducing it so comprehensively, such that I suspect I will not say anything that he has not already said—with one exception, as I declare my interests, which I am afraid are slightly longer than his. I am a steward, which really means a director, of the Jockey Club; I totted up that I have been a racehorse owner for more than 30 years, which makes me feel very old; and I am a 20-years’retired amateur steeplechase jockey. As we will discuss the levy, I should also declare that my grandfather was the first chair of the Levy Board, in 1961.
Racing is definitely in my heart, soul and blood. It has given me some of the best days of my life—I was encouraged to add the words “some of” into that sentence by my husband last night. When I have a bad day at work, I tend to close my eyes and remember how it felt to land over Becher’s Brook and how it felt to lead in the winner of the Cheltenham Gold Cup, and I suddenly feel better.
Although I have been phenomenally lucky in racing, I am not alone. As my noble friend said, racing is the second-largest sport in the UK, with over 5 million racegoers each year. It is internationally renowned, hosting some of the most prestigious races in the world, and underpinned by world-class talent, human and equine—not me, unfortunately. It has strong, respected and genuinely trusted governance, and it contributes more than £4 billion and 80,000 jobs to the economy. My noble friend listed all those facts. We also host some of the most memorable spectacles of the year in British racing. It is where Heads of State, captains of industry and everyday punters are all fans together.
My first question for my noble friend the Minister is this: does he agree that British racing is a substantial asset to this country and that he and the Government genuinely want to see British racing prosper? If so, as my noble friend Lord Herbert just asked, what have they done, or are they doing, to ensure that that is the case? That is the fundamental question that we are debating today.
As my noble friend set out—I will not repeat all the statistics—British racing’s international competitiveness is under serious threat. Our prize money is lower and good horses are increasingly leaving the UK. The number of higher-rated horses leaving doubled from 2021 to 2022. It is not sustainable for our equine talent to depart these shores. The percentage of top-rated, grade 1 races that the UK holds is dropping. In 2017, the UK held 24% of grade 1 races; four years later, in 2021, it was 17%. That is a 30% drop. The reality is that the rest of the world is copying and learning from us, but they are much more financially resilient, which is a real problem. Owners can win more money abroad, increasingly win better races abroad and sell their horses for more by sending them abroad. This is a really vicious, slippery slope of decline for something that I hope we would all agree is a great British asset.
There is much that UK racing can do itself. I am not making the case that this is only the Government’s problem. I would argue that UK racing needs to genuinely work together. I try to explain to my friends who are not keen racing fans but love other sports like this: imagine if, in tennis, the tennis ball, racket, court, net, player and team support were all separately represented in discussions about the funding of the sport—that is racing. For the horses, trainers, breeders, jockeys and fans, racing does not find it inherently easy to work together. The sport needs to get better at doing that itself, and I say that as a member of the sport.
The sport also needs to get better at appealing to younger, more diverse audiences. The sport needs to continue investing in equine welfare and in supporting responsible gambling and responsible drinking, and the sport must create events and entertainment that are fitting for the modern world and genuinely inclusive entertainment for all. I am not for a moment suggesting that racing cannot do some of that itself—it needs to—but there is also a really important role for government, and arguably there has always been.
For millennia, people have enjoyed racing horses and betting on which horse will win. For a very long time the British Government have been firmly on the pitch—or on the turf—playing a role as a regulator: in 1961, with the creation of the Levy Board as an arm’s-length body of what is now DCMS, and through the Gaming Act 1968, which brought the Government on to the pitch for gambling regulation. I know that it is hugely tempting, and I worry that we might hear it today, that the Government always would like racing and bookmakers to come to an agreement together, on their own, without the Government. I think every Secretary of State has always said that, but the reality is that we have needed the Levy Board and gambling regulation precisely because of the many conflicting interests in this sport, including the need to protect the vulnerable and to make sure that it is a fair and equitable, regulated sector. That is a role for government, and we need government to step up and act.
My noble friend the Minister has set out the two main areas, and I will simply reiterate them. The first is the levy. Despite prize money being the lowest of the major racing nations, the amount of money placed on horseracing betting makes it actually the second-largest market in the world—second only to Hong Kong. As my noble friend has said, only 2.8% of money bet on racing comes back into racing, compared to 16.6% in Japan, which is the high mark. Even just across the channel, in Ireland, it is 8.4%. We are at a structural disadvantage. What are the Government going to do to increase the rate bookmakers pay into British racing? That is their job description. That is what the levy does—it is an arm’s-length body of DCMS. What are the Government going to do to ensure that the levy is reformed to deliver a better, fairer return into racing?
There are a number of options on the table. My noble friend has described the obvious one, which is expanding the levy to British people betting on overseas racing. We created a depressingly British disadvantage, where, if I am Irish and I want to bet on a British race, Irish racing benefits—the Irish capture some of that betting revenue—whereas if I am British and I want to bet on Irish racing, nothing comes into the British coffers. It is not right. There is international precedent; we are the only racing jurisdiction that does not do this—and we used to. I really want to understand why we cannot do that. I know the Government will want to say that racing and the bookmakers should be able to sort this out, but they have not, for millennia. We need the Government on the pitch as the referee to drive this forward.
I will not dwell further on the levy, as I would like to take my remaining minute or so to talk about affordability checks. Problem gambling is a really serious problem. I have spent the last five years of my life, heart and soul, working in the NHS. We need to make sure that we are genuinely protecting the most vulnerable, but I really do not understand why checking whether everyone who wants to spend £125 a month on betting is the way to protect the problem gamblers.
I do not understand why the Gambling Commission refuses to acknowledge that there is and will be an ever larger black market. Also, by my calculations, £125 is the same as buying a family night out at McDonald’s once a week. Would we really challenge people to prove that they could afford to take their family to McDonald’s once a week? That is what we are proposing with the affordability rules, and it is not right.
Many big racehorse owners are being asked, like my noble friend, to prove that they can pay to bet. Several have publicly announced that they will leave the sport. We are shooting ourselves in the foot. This is a national asset that ought to drive economic growth in the country, bring people into the UK and give us joy.
The Earl of Effingham (Con)
My Lords, I thank my noble friend Lord Herbert of South Downs for raising this important debate. In around 200 AD, it was Roman soldiers in Britain who organised the first horseracing competitions. The sport continued to increase in popularity and, by the 10th century, famous racehorses were widely given as gifts for royalty. In the 1500s, breeding laws were set by Henry VIII, possibly when he was sitting in Cloister Court, just a few minutes away from where we are right now, and rules became standardised. James I visited Newmarket in 1605, acknowledged as the home of racing. In 1711, Queen Anne was out riding and discovered the beautiful terrain of Ascot. Her magical find is celebrated to this day with the Queen Anne Stakes, the opening race of Royal Ascot Week. The St Leger Stakes was first run in 1776, the Epsom Oaks in 1779. In more recent times, racing was one of Her late Majesty’s greatest passions, with her winning more than 1,800 races and overseeing the royal stud on the Sandringham estate.
British racing leads the sport on an international level, and events such as Royal Ascot attract competitors and spectators from all around the world. British horseracing is a treasured institution. It is part of our national identity and has been enjoyed by many for over a thousand years. But this is so much more important than just supporting a tradition. While racing is referred to as the sport of kings, that is entirely misleading because racing is enjoyed by adults and children alike from every different walk of life. If asked, many people would cite football as the most attended sport in the UK; they would be right, with around 15 million people enjoying Premier League matches alone in 2022. However, it might come as a surprise to some that racing is in second place, with over 5 million spectators every year enjoying a day out at the many courses we have across Scotland, Wales and England.
Racing is entertainment for the entire family. One can enjoy a picnic at the racecourse, watch the beautifully turned-out horses in the parade ring and immerse oneself in the thrill of the race with the huge excitement of your fellow spectators cheering on their favourite. You are out in the fresh air, walking around the course taking exercise. This is all-inclusive fun and human interaction away from mobile phone screens. Aside from the enjoyment for the nation, the benefits to the wider economy are significant. Racing contributes around £4 billion to gross domestic product. Our rural economies need all the help they can receive, and racing both directly and indirectly supports around 80,000 jobs. Training yards and studs needs many different skill sets in the individuals it employs, and these businesses are key to providing jobs for our future generations and giving them a great base from which to learn and grow.
We have an industry which has existed for centuries, provides an amazing day out for all, contributes £4 billion to the economy and supports around 80,000 people, but it is not without its challenges. For owners and trainers in the UK, it currently makes sense to race overseas. Horses are coming out of training in the UK and going straight to the Middle East. The industry is facing a talent drain, which we must try to stem. It is an alarming statistic that in 2022, the number of higher-rated horses being exported from the UK doubled versus the previous year.
The reason for this, as we have already heard, is prize money. Our trainers rely heavily on that money as a key source of income, which in turn supports rural economies. Our owners know that if their horses race overseas, it can materially help with running costs. Prize money in Japan is around five times more than that in the UK; in the United States, it is around four times more.
It is not only prize money. Trainers and breeders are also bearing the brunt of the cost of living crisis and supply-chain issues. Feed is more expensive; electricity and fuel for transportation are more expensive—the list goes on. I am reluctant to automatically go down the route of saying that more funding is the solution, without looking hard at alternative measures, but in this case I believe it is the right path. To support the racing industry, we need to increase the money available to it.
Levy income stood at around £98 million in 2022, but we know that the right number to support the industry is around £140 million. That number can be achieved without any material restructuring; we simply need to follow the existing precedents of our European neighbours, Ireland and France, which both have a global levy. If a UK-based racing enthusiast places a bet on the Kentucky Derby, surely British racing should benefit. Where was that love of racing nurtured and cultivated? Who made the investment to create that bond and enjoyment? It was clearly predominantly British racing, so why should British racing not benefit in that scenario?
A global levy would generate around £25 million of additional revenue. If we then increased the levy by just 1.5 percentage points, from 10% to 11.5%, that would generate another £15 million, which would result in an annual income of £140 million; that is where we need to be. For good order, increasing the levy not only increases prize money. Equally importantly, it provides invaluable funding for the welfare of our horses, with improvement in equine medical science and the sport at a grass-roots level. What plans do the Government have for the levy? What are the options on the table and what do the Government see as a realistic timeframe for improvement and change to support our horseracing industry?
Lord Addington (LD)
My Lords, when it comes to declarations of interest, mine is the most second-hand that I can think of. I live in the village of Lambourn, Lambourn valley being the valley of the racehorse. I married into equestrianism—I should be able to say that word properly on a day like today—and I have a wife and daughter who both ride and love horses. Indeed, I remember through my courting days being woken up in the mornings by my wife going out to ride three lots over the downs. That will mean nothing to anybody who does not know anything about racing; it means getting on a half-tonne animal, with its fight and flight responses geared up, to charge up a hill at about 30 miles per hour with, in this case, a woman perched on top of it.
If you look at the industry from the point of view of the people who take part, I do not disagree with much of what has been said today. That is what I would like us to look at now. Racing supports an entire industry of people who work with their hands and are engaged in something quite dangerous.
If you want to see a good selection of braces, limps and crutches, go down the streets of Lambourn. You will find people who get thrown by horses and kicked by them but who want to get back on. If you want to discuss the intricacies of how a collarbone is repaired, go to any of the pubs in Lambourn. There will be a small person who will tell you about how they sailed across the horse’s shoulder to land splatting on the ground—and, indeed, you can go down to the rehabilitation centres in Lambourn and Moulton.
The noble Baroness, Lady Harding, gave us the best insight into this: all sports like to talk about themselves to themselves in darkened rooms and tell everybody else that they do not understand. To an extent, they do not—but all sports do this. They do not understand, because that sport does not get out there and say “Enough!” to the rest of the world in language that it may understand.
What I would also say about racing is that it supports the other equine sports. In the Lambourn Valley, you have world-class event riding and show jumping. It is a centre of veterinary medicine and of farriering—that is, shoeing horses, for anyone who is reading this who does not understand and, believe you me, there are plenty of people who do. All these things come together and interact. The people at the bottom of it are generally people who love it, who get back in and have bought into a culture. When arguments come up about the levy, racing has led the field and has supported people who actually take part at the bottom. If nothing else, it deserves support for that. Of course, it could have done it better and sooner, but it was first. I cannot see anybody else who has done it that well.
If you are supporting racing, provided that you make sure that that support goes down and helps throughout, that is doing a social good. And just as it supports the other equine activities, it is also supporting things like pony clubs. A pony club is an amateur sports club, which means that you have involvement—people coming together, voluntary activity and fundraising. We are so lucky in this country: we have a tradition of supporting our own sports. All these things are taking place. The Government should look very hard at what we can do to facilitate this connection, in this sport as in many others. That is an important thing.
The levy has been spoken about and I cannot really add very much. Yes, if you are betting anywhere in the world, why should we not get a cut here? We provide a base and a structure, and in fact the rest of world racing probably wants us to, because we have the structure here and the tradition to help them to improve their games. When something becomes an international sport, there will be interaction and changes. Look at football—look outside your bubble—and at how that has changed and that structure has shifted. You cannot change the world; you can merely operate better in it.
Are the Government going to look at this ongoing process to make sure that this entire industry and amateur support system works properly? The noble Baroness, Lady Harding, has given the best example of where state intervention should come from under a Conservative Government in the long term. But there has there has to be some action here. People complain that it is difficult to place a bet, but the difference with racing is that it is the only sport that I can think of that is so incredibly tightly linked to gambling, and always has been. Ancient texts about bets on horse races go back to everywhere. There was a different type of activity—there was chariot racing—but you name it, it was all there. But there is going to be that interaction.
If we are worried about problem gambling because it is at the end of a phone, there will have to be some checks and changes. Whether it is done properly and well is a good question, and one that probably only government has the resources to check properly. But it has to happen; otherwise, the damage done outweighs the social benefit. Other countries have faced this—Kenya, for example, with betting on football. The gambling is the problem, not the football. How do you interact with that? If we can hear something from the Government today about their thinking, I would be very glad to take that back, as would many of my colleagues who look at this. What is that connection, what is that thought, and how does it come backwards and forwards here?
There is also the fact that you can overdo these complaints—when someone says, “It took my daughter several minutes to open dozens of accounts so she could check what was the best price, at the age of 18”. Grow up. If it takes a couple of days to get them online, that is fine—and it does not have to be at the age of 18. There are limits and realistic chances that you have to take here: certain people will be vulnerable, and you will have to intervene. If we are overdoing it at the moment, and it is clumsy, fair enough; let us look again. I do not blame the racing industry. We do not blame brewers because a few people become alcoholics, or most of us do not anyway.
How are we going to work this out? Are we taking into account the fact it supports an entire industry of people who are fairly low paid and in low-status jobs? It is an industry that has looked after them reasonably well; it could always do better, but it has. It set a precedent. It looks after the welfare of people who are injured doing these jobs. So it has good things about it, but its relationship with gambling has always been problematic and always will be. Keeping the benefits of it will require government action and for everybody to become grown-ups. Saying, “Oh dear, it’s difficult”, will not work for anybody.
Are the Government looking at this in the round, as a sports and leisure interactive sector? The fact is that football stadiums might host the odd concert, and I know for a fact that Newbury Racecourse hosts dozens. They act as part of that social link. How does that fit into this sector? It is more than just racing: it is a social structure and an industry that comes together. Can we please hear what the Government are doing about that? Gambling started with racing as a constructive activity—it was actually outdone by cricket at one point; that is odd, isn’t it? That was the way spot betting went in the 18th century. What are we doing to ensure that gambling’s symbiotic relationship with the racing industry functions correctly so that we get the best while at least mitigating the worst?
I hope the Minister will give us a coherent answer. If he cannot, he should go back to his department and say, “Please, we need to know what is happening here”. That is what the question is.
Baroness Anderson of Stoke-on-Trent (Lab)
My Lords, I draw your Lordships’ attention to my declared interests. I wish they were as exciting as everyone else’s, but it is just hospitality with the Betting and Gaming Council. It serves me right for going to the cricket.
This has been a truly interesting debate. I thank the noble Lord, Lord Herbert of South Downs, for convening the debate and for his opening remarks, which have made clear the importance of the horseracing and bloodstock industries to our national economy, as well as to our international standing. It is only 10 months since we last debated the importance of this sector in your Lordships’ House. That fact alone is a testament to both the value of and fondness with which we consider the industry.
I stand here as the great-niece of a bookie, whose funeral was on the front page of the Racing Post, and the granddaughter of an amazing man who liked more than an occasional bet on the horses. One of my earliest memories was him taking me to the sweetshop to get sweets so that I would not grass him to my grandmother while he went in to place a bet. I am also a very proud resident of Staffordshire, where Uttoxeter Racecourse plays an important part in our county’s local economy; and, of course, Bet365 is the largest private sector employer in my great city. I am very sorry for the noble Lord’s experiences; when he started talking about Bet365 I got very worried about where that conversation was going. It should not surprise your Lordships that I have an affinity with horseracing, and I appreciate the importance of the bloodstock industry, which is so vital to the success of our sector.
This has been an incredibly informative debate and it has been a joy to listen to some of your Lordships’ contributions. It was a privilege to listen to the noble Baroness, Lady Harding, talk about her experiences. Much has moved on since your Lordships last debated the horseracing industry, not least the long-anticipated gambling White Paper, which we have touched on. I may be a fan of the sector, and even place the odd bet on my Bet365 app, but that does not mean that I am unaware of the darker side of the gambling industry. Addiction can ruin lives, and it is something we need to acknowledge. Problem gambling has not only a personal impact but economic and social impacts.
We know that some in the horseracing industry have been unsettled by constant speculation about what the review process might mean, and still are. We sympathise with those concerns, even though we believe the Government were right to undertake their review of existing regulation. It is regrettable that the progress has been so incredibly slow and that even now, nobody has absolute certainty about what the future holds.
Proper regulation, enforcement and support for gamblers can go a long way to ensuring that the overwhelming majority can enjoy the occasional flutter while the most vulnerable are protected. Many people visit a betting shop or use an online platform only once or twice a year, to back a horse in one of racing’s crown jewels: the Epsom Derby or the Grand National. While we must act quickly to better protect those who are at risk, that occasional punter should also not face excessive burdens.
As has been highlighted, we must also ensure that our domestic equine businesses operate on a level playing field and that any change is proportionate and enacted in consultation with the sector. This is especially the case when we consider the anticipated reduction to the online element of the horserace betting levy by up to 11%. As the industry seeks to recover from the impact of Covid, which we have not touched on, and which may feel like a dim and distant memory for some, it is still impacting too many businesses. We need to be careful that we do not move too quickly with any of these proposals, which may risk undermining local businesses as they strive to re-establish financial stability.
That brings me to the rural nature of the businesses concerned. We have spent many, many hours over the last year scrutinising the levelling-up Bill, and we will continue to do so next week. But what is levelling up if it does not also seek to improve the economic outlook of every community, including our rural communities, where over 20,000 people are directly employed in the sector, with many more in associated industries, as has been highlighted? We must strive to facilitate growth in every part of our economy, and this is no less true of horseracing, bloodstock and the associated industries. We ignore the sector at our peril, and I hope that the Minister has some reassurance for us regarding the support for our rural communities.
That brings me to the extra economic activities that are driving extra revenue into our racecourses, which we have not touched on. Lots of tracks, including my own Uttoxeter, are diversifying to increase their revenue and broaden their appeal, seeking to maximise the track as a venue. Can the Minister say whether His Majesty’s Government are working with the sector to expand that activity? Are there financial incentives available, and are they content that licensing rules are sufficiently flexible to allow additional activity while ensuring that the impact on local residents is minimised?
As we discuss the businesses which are at the heart of the sector, it would be remiss of me not to touch on matters of equine health and welfare, consideration of which must be at the core of every business in the field. Whether or not you agree with the tactics of the various campaign groups involved—I do not—protests at a number of high-profile race meets over the past year have brought these issues back into the public consciousness. We recognise the steps taken by breeders, trainers, jockeys and others across the racing and bloodstock industries to improve welfare standards, and to be more open about why certain practices exist or choices have been made. That is not to say that things are perfect, or that there are not individual cases which will cause public concern when they come to light, but enormous strides have been made.
That is why we are pleased that the Thoroughbred Breeders’ Association held its first ever conference in June this year, which explored many of the issues which have been touched on by others today, including sharing best practice regarding welfare standards. I believe that it is admirable that the TBA also used its conference to begin a conversation about social licence in the context of the breeding industry, especially with regards to changing attitudes towards animals in sport. If the sport is to survive, we need to start having those conversations—and there will be many more in the years ahead.
I have now finished my substantive comments but before I sit down, tomorrow is Jewish New Year, and new year is always about horseracing—although maybe not for Jewish New Year. However, I wish all your Lordships shanah tovah—happy new year—and I look forward to hearing the comments from the Minister.
Lord Harlech (Con)
My Lords, I declare my interests as having had the pleasure of attending this year’s Royal Ascot, and my uncle spent a great many years working in the training yards in Newmarket and Ireland. I thank my noble friend Lord Herbert of South Downs for tabling this important and timely debate during National Racehorse Week, and I thank all noble Lords for their heartfelt participation throughout.
His Majesty’s Government acknowledge the significant contribution that racing makes to our economy. The noble Lord, Lord Addington, mentioned the central role it plays in the livelihoods of rural communities. The employment that it supports across racecourses, training yards, breeding operations and related sectors reflects a powerhouse industry respected at home and abroad. The Government absolutely agree that British racing is a substantial asset to the country and remain committed to supporting the industry to prosper.
As has been noted, horseracing is the second biggest sport in the UK in terms of attendance, employment and annual revenue. According to the British Horseracing Authority, racing is worth more than £4 billion annually to the economy in direct, indirect and associated expenditure. The public’s love of racing is shown by the numbers attending flagship race meetings—65,000 to 70,000 at the Grand National and more than 200,000 over the four days of the Cheltenham Festival. British racing and breeding enjoys a reputation as a global leader and is promoted worldwide as part of the GREAT Britain and Northern Ireland campaign. This recognises the significant cultural and economic importance of horseracing to the UK and the role it plays as a soft power asset.
My noble friends Lord Herbert of South Downs, Lady Harding of Winscombe and Lord Effingham have all noted the importance of the levy. The horserace betting levy has evolved in step with the betting industry since it was introduced in the 1960s. In 2017, the Government extended the levy to online bookmakers and fixed the rate at 10% so that it no longer had to be negotiated each year. The 2017 reforms almost doubled the amount of levy collected from £49.8 million to £95 million and it has continued to perform well. Even in 2020-21, with racing suspended for two months and betting shops closed for much longer, it returned £82 million. The forecast for 2022-23 is £99 million.
Noble Lords mentioned prizes. Mechanisms for funding racing in other jurisdictions are not directly comparable with Great Britain. For example, France has a state monopoly and in Ireland there is a general tax and a grant to racing. The Horserace Betting Levy Board has made additional contributions to prize money, supported by a £21.5 million loan via the sport survival package. It should be noted that prize money in Great Britain is spread across a greater number of fixtures and the British Horseracing Authority is trialling changes to the fixture list from 2024 aimed at growing the sport.
I turn to the Government’s review of the levy. The British Horseracing Authority has presented its case that there is a significant gap in funding, meaning that it is unable to compete with jurisdictions such as Ireland and France. It has also submitted suggestions on how to close this gap. We are considering these proposals as we undertake our review, which is due in April 2024. I cannot pre-empt its outcome, but I reassure all noble Lords that the decision will be firmly based on evidence and that the suggestion made by many noble Lords that the scope of the levy should be amended to include racing outside Great Britain is being considered as part of the review.
Noble Lords asked what the Government are doing to increase the amount raised by the levy. These changes would require legislation, so it is sensible to explore a voluntary agreement when there are so many competing demands on parliamentary time. However, we are looking at all options, including—as has been pre-empted—encouraging racing and betting to work together in the best interests of the sport. Reaching a mutual agreement on the way forward for the levy would be beneficial to everyone. To support this aim, the BHA and the BGC were invited to submit evidence over the summer. I know that my right honourable friend the Minister for Sport, Gambling and Civil Society met both industries earlier this week.
The levy is not the only source of funding for racing, as noted by noble Lords. It represented just 6% of racing’s total income in 2022, with far greater proportions earned from owners, breeders, racegoers, media rights deals and sponsorship. However, we have committed to a review of the levy and asked racing and betting to explore jointly how they can maximise other sources of income. I am encouraged by the close engagement that has taken place thus far.
I turn now to the gambling review. Concerns have been raised by the BHA and the Countryside Alliance, as well as by noble Lords in this debate, about the impact of financial risk checks, as set out in the Government’s Gambling Act review White Paper. We specifically assessed the potential impact that gambling would have on the racing sector. Our assessment, set out in the White Paper, was that the impact on racing will be minimal in the context of its overall income but, as we committed, we are currently reviewing the levy to ensure that racing continues to be appropriately funded.
As noble Lords on the other side of the discussion mentioned, it is crucial that we undertake this review of gambling controls. We are challenging the industry to prevent the egregious examples we have seen, where customers are allowed to incur potentially life-changing losses without any checks on their circumstances. Operators have responded to that challenge in a variety of ways—some by taking a very risk-averse approach. We certainly do not want to go down the track of the PEPs situation that we have seen with banking; that is absolutely clear. The key to any outcome will be not just how it is described but how it is run and implemented.
The proposals on financial risk checks will apply only to online gambling accounts and will not affect betting shops or on-course bookmakers. They will support a standard approach and use a range of indicators to look at the behaviour of a bettor. Betting companies could and should already be checking when customers spend huge sums, which is one of those key indicators, but industry has sometimes failed to do enough to stop life-changing sums of money being lost by people potentially in the grip of addiction. That is why the Government and the Gambling Commission are stepping in.
However, we are alive to the need to be proportionate. The White Paper was clear: we want checks only for those most at risk of harm, and we want the checks themselves to be painless for the overwhelming majority of customers. We know that higher rates of problem gambling are associated with online casino games and that problem gamblers use multiple products. Therefore, it would not be responsible to exclude an individual’s use of a particular product from these protective measures.
Some concerns relate to details such as the frequency of assessment and how to consider previous winnings, but that is precisely why the Gambling Commission is consulting on how best to introduce these measures, rather than a diktat being administered straight away. It is a live consultation and an opportunity to shape the outcome. I also reassure noble Lords that checks will be introduced only when there is confidence that they will indeed be frictionless. The Government are keen to ensure that measures such as financial risk checks do not adversely affect racing, interrupt the customer journey or—this is key—push away high net-worth individuals, such as owners and trainers, who invest in the sport.
The noble Baroness, Lady Anderson, raised the important issue of welfare. The British Horseracing Authority is responsible for the safety of racehorses at British racecourses. The BHA works alongside the RSPCA and World Horse Welfare to make horseracing as safe as possible. The Government welcomed the formation of the racing industry’s Horse Welfare Board in March 2019. The board has assured the Government that it is committed to doing all it can to make the sport safer and improve welfare outcomes.
The noble Lord, Lord Addington, and the noble Baroness, Lady Anderson, talked about wider support for the sector. The numerous stakeholders in racing have recently agreed that the British Horseracing Authority is the decision-maker on the sport’s future strategy. The BHA has recently put forward proposals for a future racing product, which includes premierisation of the sport, protected time slots for races and reforms to the fixture list. I know that the potential for hospitality and conference facilities at racecourses is part of the sport’s plans to grow their tier income and to support owners and trainers. All these ways in which the key jewels in the crown can maximise their revenue will support the wider industries and communities involved in horseracing.
I listened carefully to what my noble friend Lord Herbert of South Downs said about the special status of Newmarket to the infrastructure of British racing. I will ensure that colleagues are aware of those concerns. The Government remain committed to supporting British horseracing, which is vital to the rural economy as well as a source of great pleasure to many people. I again thank my noble friend for securing this debate during National Racehorse Week, and look forward to further discussions on these important issues.
Abraham Accords
(8 months ago)
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Lord Polak
To ask His Majesty’s Government what steps they will take to ensure the success of the Abraham Accords.
Lord Polak (Con)
My Lords, I refer the House to my registered interests. Tomorrow marks the three-year anniversary of the signing of the Abraham accords. On 15 September 2020, the world witnessed a remarkable moment in Washington, as the United Arab Emirates, the Kingdom of Bahrain and the State of Israel came together to sign the Abraham accords. A few months later, the Kingdom of Morocco joined this transformative accord.
I would like to take a moment to express my deepest condolences and unwavering support for the people of Morocco in the wake of the devastating earthquake that struck earlier this week. I am deeply saddened to learn of the tragic loss of over 2,900 lives and hope for a swift and complete recovery for those injured or displaced. I pay tribute to the Minister for his leadership in getting aid to Morocco so quickly.
These accords were not merely ink on paper, they were a resounding statement—a pledge to normalise relations between nations that had once stood on opposite sides. It was a monumental achievement, initiated by the United States and one that many had previously considered an unattainable dream. Yet, I cannot help but observe that we in the United Kingdom were not, and are not, involved.
In a debate held in the other place in October 2021, Robert Jenrick posed a fundamental question about the accords. He said:
“what is the role for the United Kingdom, and for our Government in particular, in taking this forward?”—[Official Report, Commons, 25/10/21; col. 113.]
It is with a sense of disappointment and a desire for clarity that, nearly two years later, I ask His Majesty’s Government the same question. What is our role in the Abraham accords? What proactive steps are we taking to further the progress that has already been made? Are we actively engaging with neighbouring states, those nations that are close friends of the UK, to encourage their participation in the enterprise? What concrete measures are the Government undertaking to ensure the long-term success of the accords?
The Abraham accords represent a beacon of hope in a region that has endured decades of turmoil and division. They have already shown promise but their full potential is yet to be realised and it is incumbent upon us, as representatives of a nation committed to promoting peace, stability and prosperity, to take decisive action. We have a proud history of diplomatic leadership and it is my hope that we can harness that legacy to contribute significantly to the success of the Abraham accords.
Robert Greenway, president of the Abraham Accords Peace Institute, recently highlighted the crucial role of the accords in Middle East diplomacy—especially in countering the growing threat from Iran. The Abraham accords unite former adversaries around common interests. First, in security, particularly regarding Iran and the destabilising actions of the IRGC, the accords have created a strong coalition to counter Iran’s expansionist agenda and have enhanced co-ordination and intelligence sharing to respond to regional threats. I remind the Minister that I continue to urge the Government to proscribe the Islamic Revolutionary Guard Corps as a terrorist organisation.
Secondly, on economic growth, the accords have prompted co-operation and resource sharing among participating nations. This has diversified regional economies, reducing reliance on oil and increasing resilience against economic shocks. Lastly, Robert Greenway suggests that the accords enabled the United States to maintain a leading role in promoting peace and countering China’s influence in the Middle East. Securing the region is vital for global energy and trade, and the accords help to deter Russian aggression by uniting participating nations.
If the Abraham accords play a pivotal role in aligning regional interests, enhancing security, fostering economic growth and ensuring that the United States remains a key player in promoting peace and countering global tension, where is the United Kingdom? The UK is not playing a role in these accords and, as a result, we are acting against our own interests and our own national security.
I have previously likened the Abraham accords to a peace train that journeyed to Jerusalem, continued to Dubai and Manama and, further, to Rabat. The train shows no sign of stopping; instead, it is gaining momentum, with suggestions that its next destination may be Riyadh. The UK boasts strong ties with many countries in the region, and we should play a pivotal role in encouraging neighbouring states to join—most especially the Palestinian Authority. It must board this train and embrace the enormous opportunities that peace can bring.
Together with my friend, the noble Lord, Lord Mendelsohn, in September 2021 we cofounded the UK Abraham Accords Group, chaired by Dr Liam Fox MP, with the key aim of encouraging our Government to support, deepen and expand the Abraham accords to other Middle Eastern and African partners. Our hope is that His Majesty’s Government will not only secure more signatories to the accords but facilitate the expansion of relationships beyond normalisation into multifaceted economic security and cultural ties.
Let us just look at what has been achieved as a result of the Abraham accords. Total trade between Israel and the Abraham accords countries surged from $593 million in 2019 to $3.47 billion in 2022. Israel significantly increased its imports from those countries, going from $378 million to $2.57 billion in goods and services, and exports grew from $224 million to $903 million. Those are deep and significant achievements—things are happening.
What of Saudi Arabia? Although not yet a formal participant in the Abraham accords, a promising indication of the ongoing normalisation and relationship-building between Israel and other nations in the region has emerged. The development became evident when Israeli-founded smart energy tech firm Solar Edge entered only a few weeks ago into a joint venture with Saudi Arabia’s Ajlan holdings to deploy solar energy in the kingdom. This signifies more than just a step forward, improving environmental sustainability in the region. It represents the inaugural publicly acknowledged co-operation between the two countries, and I fervently hope that Saudi Arabia will normalise its relationship with Israel.
In the debate that took place in the other place two years ago, the Minister for the Middle East, who is now the Foreign Secretary, answered Robert Jenrick’s question by stating:
“I look forward to working closely with my opposite numbers in the UAE, Bahrain and Israel, and, indeed, any other country that wishes to join and support the normalisation of relations, and bring peace, strength and stability to the region”.—[Official Report, Commons, 25/10/2021; col. 118.]
However, I contend that since that statement, very little has been done by the Foreign Office to carry out that commitment. The political landscape has drastically changed over the past few years. Now is the time to grasp the opportunity to reassess policy on Israeli-Arab relations and, more broadly, our regional policies there. It is neither sufficient nor acceptable to use the same old words and policies that we have relied on for 50 or more years, which have continued to fail to bring about any practical help or change.
Earlier this year I was in Bahrain, at the Manama dialogue, when the Foreign Minister of Bahrain, Minister Zayani, requested from our Foreign Secretary that the UK join the Negev forum. Has the FCDO taken any steps to ensure that the UK is involved in the Negev forum? Furthermore, I ask my noble friend the Minister a purely logistical question. How many civil servants in the Foreign, Commonwealth and Development Office are working on developing the Abraham accords? It is my understanding that currently, most shockingly and shamefully, not one official has the role of focusing on the Abraham accords.
As we approach the three-year anniversary of the historic Abraham accords, and the Jewish new year, Rosh Hashanah, is upon us, there is a profound symbolism in considering the role of the United Kingdom in furthering the path to peace. Rosh Hashanah is a time of reflection and renewal: a moment to set intentions for the year ahead. It is a time when the Jewish community worldwide gathers to pray for a better world, where the pursuit of peace and justice is paramount. In that spirit of renewal and commitment to a brighter future, I urge my noble friend and the entire Government to take bold and decisive steps in support of the Abraham accords.
Just as individuals at Rosh Hashanah reflect on past actions and set intentions for the year ahead, so too should our Government contemplate their role in promoting regional stability and co-operation. In the spirit of Rosh Hashanah, let us find the courage and determination to play our part in this historic endeavour, ensuring a more peaceful and prosperous future for all the peoples of the region. The time for action is now: in the pages of history, let it be recorded that we, the United Kingdom, played our part in advancing a brighter, more peaceful future in the Middle East.
Lord Mendelsohn (Lab)
My Lords, I declare my interest as a board member of the UK Abraham Accords Group and as one of the co-chairs of the All-Party Group on the Abraham Accords. I pay tribute to the noble Lord, Lord Polak, for his excellent speech and for giving us the opportunity to debate this. His personal leadership and role in developing our country’s relations with that region is well known to all and we thank him for that. In particular, he—I would say “my noble friend”—has been a great colleague and, on many occasions, a great servant for this country. I also associate myself with the words that he said about the situation in Morocco. A terrible tragedy has been unfolding there, and I too extend sympathy to its people. Whatever we can do to help them would be most welcome. I am sure that the Minister will touch on that in his comments.
The Question we have here is to look at the Abraham accords and how we should view them. I think we have to consider them as one of the single most transformational moments in the Middle East. That is not to say that in and of itself, that moment was everything. We have to acknowledge that the region has changed substantially in the relations between countries due to different factors. For those who remember the work on the development reports that the United Nations was doing in the early 1990s, there has been a whole series of changes, not least in the security situation. We have to say that the Abraham accords are set within the context of a changing region—which is taking a very different view about what people can do and how they can define their futures. That includes the visionary leadership in the United Arab Emirates and Saudi Arabia, which are intent on changing the course of their nations’ participation in society.
These are factors that we have to consider, so the question is then: why it is important to the UK? It is fairly obvious, not least for anyone who has read our own review of our strategy on foreign and defence policy. We want to be involved at the real heart of shaping the international order of the future. We have vital security interests, which are being challenged all the time, and of course our competitive advantage is based around where the science and technology of the future will go. This region is really coming on in leaps and bounds in participation, and the collaboration between countries is immense.
The next question is: what should we do? The answer is, of course, to fully engage. The point about the Negev forum, which is in a sense the diplomatic and economic grunt-work of this process, is that it is absolutely vital for us to engage properly. The Americans sent 40 people from across government to the previous one. It is not about just one issue or the Foreign Office; it touches on every single part. We in the UK Abraham Accords Group are going to try to do our part, ably led by the ex-Minister Liam Fox, who is well known to people in this House. We also have Ruth Paris on the international advisory board and, most importantly, it is formally and strongly sponsored by the ambassadors of Israel, Bahrain and the United Arab Emirates. However, I really hope that the Minister will agree that the UK could consider engaging with it much more as a forum, an opportunity and as a strategic interest for our country. That is the most important and vital step we need to take.
Lord Purvis of Tweed (LD)
My Lords, it is always interesting to listen to the noble Lord. I served on the International Relations and Defence Committee with him and it was a pleasure to do so. I appreciate the usual channels facilitating the swap of my noble friend Lady Ludford and myself, as I am due to take part in and wind for my party on the next debate in the Chamber, which is on climate and migration—an issue affected by the region that we are discussing. Indeed, I will refer to Morocco and the region in that debate, so I apologise in advance if I miss the closing remarks.
The noble Lord is absolutely right that this is a changing region and there is a major shift. The Kingdom of Saudi Arabia and the Emirates are now seeing a growing sense of national identity. Indeed, the accords will provide an opportunity to ensure that that is not growing nationalism within the area.
We know, however, that there are areas of difference. These are all sovereign countries that have their own interests, and many of them compete both economically and militarily—we have seen that in Yemen already—but if this facilitates the reduction of tensions in that region, that is to be welcomed.
I therefore wish to make two points. First, what should we consider a peace dividend from the accords? That is hard to determine. We have not seen a reduction in the tension, violence and instability in Lebanon, Sudan or Palestine. Yemen continues to be a scar on the region and for humanity, with the challenges that the Yemenis face. What would we consider to be a regional peace dividend from the accords? At the moment, I would venture to say that it is hard to determine.
Secondly, we see not only a potentially declining UK position but a growing position on China. We have asked questions of the Minister regarding the Chinese-facilitated talks between the Kingdom of Saudi Arabia and Iran. What is the UK’s assessment of the position that China is taking? I want to quote the accords. These are all fine words:
“We seek tolerance and respect for every person in order to make this world a place where all can enjoy a life of dignity and hope, no matter their race, faith or ethnicity”.
They also say:
“We … recognize the importance of maintaining and strengthening peace in the Middle East and around the world”.
However, that was signed by the dictator of Sudan. Words should mean something when people sign up to accords. Unfortunately, the Sudanese experience means that we have difficulty defining things. What is the Government’s assessment with regard to the Sudanese?
In my last seconds, I wish to refer to the point made by the noble Lord, Lord Polak, and ask what the Government’s assessment is of the United States’s discussions with Saudi Arabia on a new security guarantee. It may also be for the house of Saud, not just Saudi Arabia. Is the UK supporting that initiative? Does the UK wish to be part of it?
The Lord Bishop of Leicester
My Lords, I add my thanks to the noble Lord, Lord Polak, for securing this short debate and my admiration and gratitude to all those who have supported and championed the Abraham accords all across the Middle East and beyond. They are truly an historic achievement, and I applaud the courage of all those who seek to bring peace to this long-troubled region. I add my thoughts and indeed prayers for the people of Morocco as well.
Noble Lords have already mentioned a number of reasons for why the accords are so significant for the region as well as for the UK. I wish to add to this debate my observation that, at the same time as supporting peace efforts in the Middle East itself, we must be proactive in addressing the tensions which conflict in the Middle East can cause here in the UK. We saw an example of this during the May 2021 Gaza conflict, when there was a steep increase in hate crimes committed against both Muslims and Jews in this country. We cannot presume, therefore, that peaceful coexistence between Jewish and Muslim communities will come about automatically in the UK simply because we are at a geographical remove from the Middle East. It is by no means impossible, but it does not come of its own accord.
A poll done in 2020 found that 44% of British Muslims believed that British Jews were more loyal to Israel than to the UK, a belief counted by the International Holocaust Remembrance Alliance to be anti-Semitic. That is nearly twice as many as among the general public at large. However, that perception of dual loyalty was significantly less common among those surveyed who had friends who were Jewish. It is true integration, then, and the opportunity to build friendships, that can make living well with difference possible.
I could give many examples from my local context in Leicester that work across different faiths, particularly our St Philip’s Centre. We are doing a lot locally to build these friendships. However, we also need action from the Government. We need a robust long-term strategy for integration for each of the four nations of the UK, with clearly defined responsibilities for local authorities and funding allocated at national, regional and local levels.
I was encouraged recently to hear that, after the Government had decided to revoke the Inter Faith Network’s funding, they agreed to offer it financial support for one further year. But what is the Government’s long-term strategy for supporting interfaith relations in the UK?
The Abraham accords are an important framework that makes relationships across divides possible and fruitful. The UK Government should passionately support them, but we must also ensure that such frameworks undergird and nurture our common life here too.
Lord Bilimoria (CB)
My Lords, it is now three years since the signing of the Abraham accords at the White House, arranged by the United States between the UAE, Bahrain, Israel and, as we have just heard, Morocco. Sudan has not signed them but is in the process of doing so. I join noble Lords in conveying condolences to Morocco, a country that many of us have visited and are very fond of, on the tragic situation there.
These Abraham accords are crucial in promoting interfaith and intercultural dialogue, peace, dignity and hope among the Abrahamic religions—and, quite frankly, among all humanity, not just in the Middle East but around the world. One cannot fault the accords’ intentions. It is clear, we hope, that other countries will join them. Oman was expected to sign; it then criminalised any relations or interactions with Israel, but has since opened its airspace to Israeli flights. I hope that these accords pave the way between Saudi Arabia and Israel. The US is very keen—as are we all—to normalise relations with Saudi Arabia. Is it the Government’s view that this is on the right track and will happen?
Concern is constantly expressed from the United States and the UK about the settlements on the West Bank. What is the Government’s view on this? There is a cycle of violence in Israel and the West Bank. I was privileged to be part of the delegation organised by ELNET in May to Israel, led by the noble Lord, Lord Turnberg. We visited not only Tel Aviv and Jerusalem but the West Bank; we met the Palestinian Authority in Ramallah and went to the Gaza border. If only we could have peace over there. We keep talking about the two-state solution, and the Minister has said that we should be committed to it, but how confident is he in the chance of it happening, given the circumstances that persist at the moment?
Finally, we have a big opportunity to take the Abraham accords further with COP 28 taking place in the UAE this November and December. This will be a phenomenal opportunity. The business champion is my friend Badr Jafar. The good news is that, for the first time, we will have a business and philanthropic forum right up front alongside the leaders’ meeting at the beginning of COP 28. One of the big objectives of the Abraham accords is to further trade, business and tourism in the region. Is the Minister confident that we will make the most of this great opportunity and will the UK be represented there?
Lord Stone of Blackheath (Non-Afl)
My Lords, ever since I spent a year in the Middle East in 1967 as a volunteer in the Six Day War, I have been involved with schemes trying to bring nations there together for peace. The Abraham accords are exactly what my old company, Marks & Spencer, was trying to do in the region for decades—on a smaller scale, of course. In 1977, we started deliberately buying goods in volume from Egypt, as we already were from Israel; we hoped this would persuade President Sadat to visit Israel and make peace, and he did.
In the 1980s, we persuaded our Israeli manufacturers to manufacture Marks & Spencer goods in Egypt, Jordan and Morocco. Delta Galil set up a factory in Cairo, employing 12,500 people making socks and underwear using the best Egyptian cotton, and another factory in Jordan, thus developing warm relations. Then, in the 1990s, Tony Blair asked if I would go to the West Bank and Gaza to do the same for the Palestinians. We did that successfully.
Why do I mention all this? It is because there is now a great opportunity, on a much larger scale, for the countries of the Gulf and north Africa to use their wealth and assets to include Israel in a massive transformation of the region, to move from oil and gas-producing industries to wind, solar and other clean forms of energy and greener technologies. By using the brilliant science, ingenuity and advanced technology in Israel, this can make them all very wealthy and create close partnerships, at the same time as saving the planet.
Specifically, to enhance the Abraham accords, Saudi Arabia can perhaps join in. It wants to recognise Israel but, at the same time, support Palestine. It can do this by combining recognition of Israel with a major, game-changing investment in Palestine—something spectacular that is not easy for Israel to agree to but doable. It needs to be something that Saudi Arabia can deliver, and be seen to have been delivered on the back of a recognition of Israel and benefits for Palestine.
Nabil Shaath had a plan for the redevelopment of Gaza Port with a “linked” port in Cyprus. This would mean Saudi recognition of both Israel and the Turkish Republic of Northern Cyprus. Although the costs of such a dramatic gesture of this kind would be immense, there would be private sector investment and other Governments might contribute—perhaps the USA—but Saudi Arabia would be the main shareholder.
As the UK has expertise in all this, possesses great diplomatic skills and has good relations with countries across the region, we could play a vital role. Perhaps the Minister could suggest to His Majesty’s Government that we could host a series of meetings here and discuss all this with these parties in this very House.
Lord Hannan of Kingsclere (Con)
My Lords, the prophet Abraham, after whom these accords are named, is remembered five times a day in the prayers of devout Muslims. He is a towering figure in Islam. He has the title Khalilullah—friend of God—and is seen as the ancestor of Moses, who watches over our proceedings stony-faced, Jesus and the Prophet Muhammad. However, he himself is not seen as Christian, Jewish or Muslim. He is rather a sort of primordial monotheist who lives instinctively within divine law and recognising divine justice.
In the Jewish and, by extension, Christian traditions, the salient fact is that he is a wanderer who settles down. The Bible says that Abraham
“spake unto the sons of Heth … I am a stranger and a sojourner with you … give me … a buryingplace with you, that I may bury my dead out of my sight”.
The return of Jews to Israel was with an overriding wish to be welcomed home—to have nothing more than peace with their neighbours. Finally, that prospect is on the horizon. It is a great cosmic irony that, just as Israel is improving its relations with its Arab neighbours, it is worsening its situation with many western and European countries, but that is a topic for a different debate.
I think these accords came about because other Arab states realised that it was no longer feasible to give an effective veto to the most hard-line elements in the Palestinian leadership. They saw that, even when offers were made, as under Ehud Barak or Ehud Olmert, that would have given 95% or an equivalent of 100% of the territory with land swaps and control of east Jerusalem, that was not enough and they decided to go further, over the heads of some of the Palestinian leaders but in the interests of the Palestinian people. That creates a new situation and a new opportunity, if Israel will now have the imagination and generosity to grasp it and if Palestinians will come on board with the process.
I am not saying for a moment that this is easy, but imagine a situation where there are no physical barriers around the Palestinian territories; where that country can be integrated into the world economy and can trade its way to prosperity—an embourgeoisement of Palestine, if you will; where you will have a propertied class that will not tolerate lawlessness or freelance rocket launchers but will want to remain on good terms with its customers, most of whom will find themselves in Israel. As Milton Friedman said, there is nothing like trade to make people who do not get on get on.
I appreciate that taking down the barriers to get there is not an easy thing, but is it not worth the effort? Is it not worth at least considering the Palestinians as an entity capable of making their own decisions—whether they want confederation with Israel or with Jordan or whatever—and recognising them as a unit? Surely Abraham has buried enough of his dead out of his sight.
Viscount Waverley (CB)
My Lords, noble Lords have referred to the incomprehensible earthquake disaster in Morocco, but let us not forget the equal horrors in Libya and Turkey.
Sustainable and lasting peace in the Middle East is an elusive goal that has been bedevilled over the decades. I reflect often on a long-ago meeting in Amman, discussing the role of Israel in the Arab world and the necessary building blocks of partnership that could come to fruition with a focus on security and intelligence. In essence, it was what Israel could bring to the Arab world and the Arab world could bring to Israel.
What gave the Abraham accords impetus was Iran, along with other security concerns. However, one should never forget that the elephant in the room—the Palestinian plight—remains. However, I am encouraged that US and Palestinian officials are in Riyadh for talks on a Saudi-Israel deal, but also remembering that it is now the 30th anniversary since the PLO signed the Oslo accords that officially recognised Israel—how time flies. Now is the time for the Oslo accords to be merged with the Abraham accords and come full circle, bringing equitable and purposeful closure of all the inequities, which would bring real, sustainable peace and partnership to the region.
Where do we go from here? Without any question, we are living in a changing world, where new players on the block are expressing that enough is enough of the ways of old. We must commend the historic Comprehensive Security Integration and Prosperity Agreement signed yesterday between the US and Bahrain, which enhances co-operation in areas from defence and security to emerging technology, trade and investment—useful building blocks indeed in the region. Nothing now can be taken for granted. You see it in the Chinese-brokered Saudi-Iran rapprochement, in Africa with the BRICS enlargement that more increasingly will drive self-interest, and in a China pushback with the proposed India-Middle East transport corridor.
On the Abraham accords themselves, undoubtedly a regional trade agreement must be on the table. But where is the UK in all of this? Why, with all our past associations and deep sense of understanding, has the US shuttered us out of the Negev process? Disrespect, I would call it, for what we could bring forward, and for what in reality we need in a post-Brexit world. The accords have been successful for the signatories, and this is an opportunity for the UK to make an impact in the Middle East. The UK should be viewed, as we are, as a rock-solid friend who is forward-thinking and an innovator.
The Abraham accords should be seen as a platform to demonstrate leadership, and with our financial, legal, and enterprising expertise, the UK should be moving full steam ahead in supporting trade and FTAs with the Abraham accords membership. The deeper the relationship with these countries, the better for the UK and the West generally in terms of security, peace, and prosperity, with the additional plus of it becoming more likely that more countries will join. I join with others in encouraging the Government to task a dedicated official at the FCDO to advancing the Abraham accords.
The Deputy Chairman of Committees (Lord Russell of Liverpool) (CB)
My Lords, given that we have time, and with the leave of your Lordships, I will make an executive decision and suggest that the noble Baroness, Lady Ludford, and the noble Lord, Lord Collins, should have four minutes rather than three minutes.
Baroness Ludford (LD)
My Lords, I am so shocked—I am recalling life in the European Parliament, where we were lucky if we got two minutes.
I am pleased that we are having this debate and congratulate the noble Lord, Lord Polak, on securing it, almost on the third anniversary of the signature of the original accords. In fact, the anniversary is tomorrow, which is also the festival of Rosh Hashanah, so I wish Jewish colleagues and the community in general a happy new year and shanah tovah.
I strongly welcome the Abraham accords as a factor of peace and development in the Middle East region. In the 1970s, I visited Israel on a scholarship from the Anglo-Israel Association. This led me on a journey to being today a vice-president of the Liberal Democrat Friends of Israel, so I am deeply committed to the security and flourishing of Israel at peace in its region.
I wrote a pamphlet as a result of that trip which urged regional economic integration. Yes, I was inspired by the then EEC and I was thinking of Israel’s neighbours, not Gulf or North African countries beyond Egypt, but the destination is more important than the route. People-to-people contacts as much as official ones will help to normalise relations. Beside trade and tourism, support in bad times can help. We are, of course, particularly thinking, as the noble Lord pointed out, of Moroccan, Libyan and, previously, Turkish victims of terrible disasters. I understand that several Israeli teams are assisting with the rescue effort on the ground in Morocco.
The largely positive picture from the Abraham accords is marred by a deplorable rise in extremism in some quarters. This includes the absolutely shocking recent remarks by Palestinian President Mahmoud Abbas that Hitler murdered European Jews in the Holocaust not because of anti-Semitism but because of Jews’ “social role” in society. Those remarks have been greeted with widespread horror, including by leading Palestinian public figures in an open letter in which they
‘unequivocally condemn the morally and politically reprehensible comments’.
Sadly, we also have shocking extremists sharing in government on the Israeli side. While I will always be a friend of Israel, this has not made me a friend of all Israeli Governments, but the current Government are the worst I have ever witnessed. The make-up and domestic policies of this Netanyahu Government in encouraging illegal settlements and failing to stop settler violence against Palestinians are surely deterrents to reinforcing the Abraham accords—although they in any case bring their own headaches, such as how to treat Saudi Arabia’s leader Mohammed Bin Salman—and to any peace with Palestinians. Of course terrorist attacks by Palestinians on Israeli civilians as much as Israeli settler violence are deplorable, and I condemn both. The prospects for peace and a two-state solution with the Palestinians have rarely looked worse, and the Abraham accords are not an alternative to that.
On a trip last November with Caabu, I found it sobering to hear the alienation of young Palestinians from not only Israel but their own Palestinian Authority, which was last elected 15 years ago. It is interesting and possibly hopeful that a recent poll found that while only just over one-quarter of Palestinians in the West Bank had a positive view of the regional impact of the Abraham accords, this rose to almost half in Gaza and nearly two-thirds in east Jerusalem, and a majority of the respondents in all three places agreed with the statement
“Arab governments are neglecting the Palestinians and starting to make friends with Israel, because they think the Palestinians should be more willing to compromise”.
That is food for thought.
I conclude with the obvious questions for the Minister, who can perhaps report on the Foreign Secretary’s recent visit to Israel. They are: where do the Government think the Abraham accords are going? What is the UK Government’s role in them, as the noble Lord, Lord Polak, asked? Do they offer any hope for Israeli-Palestinian peace? What shoots of peace can he discern for us to deliver a happy new year?
Lord Collins of Highbury (Lab)
My Lords, I too start by mentioning the natural disasters: the earthquake in Morocco and the horrendous floods in Libya. It looks as though there were even more deaths in Libya than in Morocco. We have to give every possible assistance in both cases; I know the Minister is actively involved in that. I too mark the new year—Shanah tovah—and hope that our prayers will be heard.
The normalisation of relations between Israel and the Arab states is an important step forward that I wholeheartedly welcomed when the accords were first agreed, and they have improved the economic prosperity of the countries involved, as we have heard from the noble Lord, and facilitated co-operation and positive dialogue. Emphasis needs to be placed on using the accords as a springboard for meaningful and lasting peace to be negotiated between the Israelis and the Palestinians. I know the Minister and the Government share the view that this can only really be achieved through a two-state solution. The commitment by the US and others to expand the Abraham accords and organisational agreements are very much to be welcomed, but, like the noble Lord, Lord Polak, I urge the Government to use their strategic influence in the Middle East and north Africa to offer political leadership for peace and reinforce the Abraham accords.
Will the Minister outline how he believes the improvement in relations between Israel and its neighbours can be used to bring about a renewed focus on a peace process for Israel and Palestine? As my noble friend Lord Mendelsohn mentioned, neither the Government’s integrated review nor the refresh mentioned the Abraham accords, so how will the Minister ensure that the UK’s approach to the Middle East and north Africa is co-ordinated and that the UK’s international policy is fully aligned? I certainly believe that they are a positive move and I hope will form a positive start for peace.
Like the Minister, I visited the West Bank not too long ago with a cross-party delegation. I visited exactly the same areas as he did and witnessed some of the violence that was perpetrated against some of the Palestinian villages. I hope he will agree to meet that delegation as soon as possible. Whatever is going on in those areas, we need to ensure that the people who speak for peace are properly heard and that we reinforce the accords as a way of achieving that.
The Minister of State, Foreign, Commonwealth and Development Office (Lord Ahmad of Wimbledon) (Con)
My Lords, I join others in thanking my noble friend Lord Polak for tabling this debate. I put on record my sincere thanks to him for what he has done, not just since the accords were signed but, in advance of that, in strengthening security and stability. I share very much the belief of those, including my noble friend and the noble Lords, Lord Bilimoria and Lord Mendelsohn, who say that stability and security lead to economic prosperity. That can only be good for the region and the world as a whole.
I join those who have expressed their thoughts and prayers for the people of Libya. I have spoken to the Libyan President and, this morning, to Martin Griffiths at the UN. We are co-ordinating our efforts. I know we will discuss that in the Chamber next week.
I join others in saying that we stand in absolute solidarity with Morocco. For most of Saturday night and Sunday morning I was working through the logistics of our response to the earthquake. I am delighted that, through the co-ordination we have and our investment in those relationships—it is not just the Government; many noble Lords here today have played their part in that—we were one of the few countries that were first in to make assessments. I pay tribute immediately to our search and rescue teams, which are doing such a sterling job. I assure noble Lords that we have other offers in place in place for both of those tragedies, and I will update the House accordingly.
Today we are discussing the Abraham accords. I was taken by my noble friend Lord Hannan’s contribution, when he reminded us of what looks over us and, indeed, that God minds over us. I totally align myself with his comments because that is something that we as people of faith—whatever faith we follow, but particularly those who follow the Abrahamic faith—should always reflect on.
My noble friend’s Question is equally poignant today, on the third anniversary of the historic Abraham accords. Regarding the UK role, I can put this simply to my noble friend. He rightly challenged the Government, but a lot has been done. I took on this brief in November last year and, by the sheer count of visits to those countries that are within the Abraham accords, Israel and the Palestinian territories, but equally to those countries that have not joined them and which are necessary to ensure stability and security, I can say that the Abraham accords are very much central to our dialogue.
As several noble Lords have pointed out, my right honourable friend the Foreign Secretary has just completed his visit to Israel and the Occupied Palestinian Territories. I have not had a chance to speak to him because he is currently in Turkey, but I hope to catch up with him tomorrow morning on the outcomes of his visit.
I assure my noble friend and indeed all noble Lords that the accords that were signed unblocked new relationships: they were truly historic. We always talk about the real conflict between Israelis and Arabs, but we are seeing that narrative change, and these accords have been central. I assure the noble Lord, Lord Mendelsohn, and my noble friend Lord Polak that the work being done by Liam Fox and his team is very much part and parcel of our thinking. The accords formed the discussions in bilateral conversations I have had with Bahrain, Morocco and the UAE. Equally, I assure noble Lords that we have had strategic dialogues with all these countries, either in that country or here, led by either the Foreign Secretary or me. In all these respects, the Abraham accords have been pivotal to where we stand and the role we play.
Several noble Lords raised the issue of the Negev courts. This has indeed been part and parcel of our engagement and conversations with the United States and all those participating, including the likes of Morocco, which is to host the next key meeting. We have also scoped where the UK can really add value, including on common areas relating to climate. I confirm to the noble Lord, Lord Bilimoria, that we can use the opportunity of COP 28 in the UAE to again demonstrate our commitment in this respect.
As I said, this week, my right honourable friend the Foreign Secretary visited Israel and the Occupied Palestinian Territories. Importantly, the noble Baroness, Lady Ludford, and the right reverend Prelate reflected on this. As the noble Lord, Lord Collins, said, it was an opportunity to mark the 75th anniversary of the strong UK-Israeli bilateral relationship and our close collaboration across a range of priorities. My right honourable friend engaged with both the Prime Minister of Israel and my dear friend the Israeli Foreign Minister, Eli Cohen. The relationship includes extensive security and defence co-operation, which continues to safeguard the UK and Israel’s national security, as well as our ambitious science, technology and sustainability partnerships, epitomised by our UK-Israel tech hub. I have a really positive story from when I visited Israel. One city that I think the noble Lord, Lord Collins, did not get to was Haifa, where there is a real demonstration of technology and community cohesion working so well.
The right reverend Prelate reminded us about the challenge we all face not just internationally but domestically. What happens in that part of the world—in the Middle East—plays out in the United Kingdom. I put on record my absolute abhorrence of those who seek to use anti-Semitism or Islamophobia and divide communities. That is not our way, and it should not be the way anywhere in the world. We will continue to stress that. That rhetoric has rightly been condemned by this Government—by me and my colleagues.
During his visit to Israel, my right honourable friend the Foreign Secretary met key leaders but also community leaders. He also made clear the UK’s position on the Middle East peace process and called on both Israelis and Palestinians to take meaningful actions and steps forward, first and foremost, to reduce tensions and secure peace. If we do not reduce tensions, we will see a continuation of the current tragic trajectory of loss of life on both sides. Stability leads to security, and security feeds economic prosperity.
As I said, the Abraham accords were historic and remain so. In March this year, my right honourable friend the Foreign Secretary signed the UK-Israeli bilateral road map with his counterpart, Foreign Minister Cohen. The historic significance of the Abraham accords is rightly in that document—their potential to nurture profound advancements for security, coexistence, prosperity and peace for the region and all its peoples. The road map also sets out our shared ambition to strengthen our partnership with Israel, boost our economic, security and technology ties, advance our co-operation on the environment and climate change and leverage our combined strengths to address global health challenges.
The UK also continues to work with other Abraham accord countries on some of these priorities. We work with partners across the region, including those who are yet to join or sign agreements with Israel. We believe that we need to build on the positive and historic progress made at the Negev summit in March 2022. The noble Lord, Lord Collins, talked about his visit. I am always keen to meet, so we will of course schedule in a meeting with the delegation that went.
However, we are negotiating positive relationships with all countries. In Israel alone, we have started negotiations on an upgraded trade agreement and our tech hub has now facilitated hundreds of innovative partnerships. Today, Israel supplies one in seven of all medicines to the NHS.
While my noble friend Lord Polak is a great advocate for dedicated resources in the Foreign, Commonwealth and Development Office, I assure him of two things immediately. He has a very dedicated Foreign Secretary and I hope, with all humility, he would also recognise a dedicated Minister who is absolutely committed to the Abraham accords. Equally, from today’s debate we can see the dedication across your Lordships’ House to ensuring that the Abraham accords are not just sustained but strengthened, and that they deliver. My noble friend Lord Godson sought to interject, and I regret that he arrived late; but I know that he, too, is committed to the important actions we see with the Abraham accords.
Whenever I hear the remarks of the noble Lord, Lord Stone, he gives a positive picture and his experience is well documented. He remarked that the Abraham accords are a great opportunity for the region. I agree. He said that we want to explore these opportunities for regional co-operation and development. I agree. We can all commit to this co-ordinating with the emerging regional architecture in the areas of security, stability and economic progress. We continue to work with Israel through the British Israel investment group, exploring opportunities to combine UK and Israeli expertise to tackle technological and sustainability issues across the Middle East.
On the other Abraham accord countries, I have already alluded to the extensive programmes, visits and engagements we have had. In December 2020, the UK Government warmly welcomed the normalisation of relations between Israel and Morocco. We also value the normalisation of relations with the UAE, Bahrain and Sudan that the accords enabled. The accords have led to a substantial increase in trade, as my noble friend Lord Polak highlighted, between all the countries. Just this month, Israeli Foreign Minister Eli Cohen visited Bahrain further to strengthen economic and cultural tries.
I can report to the noble Lord, Lord Purvis, who has had to leave, the noble Lord, Lord Bilimoria, and the noble Baroness, Lady Ludford, that we are very much committed to this. Earlier today, I had a very good meeting with the Deputy Foreign Minister of the Kingdom of Saudi Arabia, and part of our wide-ranging discussion was on the important support that the United Kingdom lends to normalisation between Saudi Arabia and Israel. We are working very closely in several respects.
However, we must not forget the importance of current Israeli peace agreements, such as those with the Kingdom of Jordan and Egypt, which are crucial partners and neighbours of Israel. We have seen great benefit to all these countries. Great courage and conviction were shown by the leaders of Israel, Egypt and Jordan in signing peace agreements, and we must ensure that they too deliver. That is part of the security and stability for resolving the Palestinian issue.
My noble friend Lord Polak and the noble Lord, Lord Mendelsohn, talked about encouraging other countries. Of course, we are committed to that. I assure the noble Baroness, Lady Ludford, that we are equally committed to finding a lasting solution to the current conflict between the Israelis and the Palestinians. This month is the 30thanniversary of the Oslo accords, a moment of hope that showed us what is possible in the peace process, and we are committed to that.
I thank all noble Lords for their insightful and expert contributions. We believe that the Abraham accords have generated new momentum and have brought greater stability and security to so many. The UK is committed to ensuring that normalisation delivers benefits for the Palestinian people. It was a historic milestone that brings us closer to the goal of shared prosperity and peace throughout the region.
I shall end with a personal anecdote which my noble friend Lord Polak knows all too well. My noble friend Lord Hannan talked about the prophet Abraham. I remember as a born-and-bred Brit Muslim by faith attending a Church of England school, returning home looking rather confused and asking my mother “What is Judaism?” Like all good mothers, she gave me something to eat, and after food for the stomach, she gave me food for thought. She said: “Tarik, when we build a house, we lay a foundation, then we put in the walls, and then we lay the roof on top of that house. As Muslims, we believe the foundation of our faith is Judaism. Without the foundations of Judaism, the walls of Christianity would not have been erected and without the walls of Christianity, the roof of Islam would not have completed what we call the house of Abraham. The other doors and windows represent other faiths and beliefs and how, ultimately, to find peace, security, stability and progress, we must come together in the house of God”. In that spirit, on the occasion of the Jewish new year, Rosh Hashanah, I, too, wish everyone of the Jewish faith here in the UK and across the world shanah tovah u'metukah.
Health: Osteoporosis and Fractures
Lord Black of Brentwood
To ask His Majesty’s Government what plans they have to improve access to, and quality of, services in England for people with osteoporosis and those at risk of fractures, including Fracture Liaison Services.
Lord Black of Brentwood (Con)
My Lords, I note my interest as co-chair of the APPG on osteoporosis. I am incredibly grateful to all colleagues who have stayed late today to take part in this important debate. Osteoporosis is an urgent public health crisis; half of women over 50 and a fifth of men will suffer fractures due to the condition. Osteoporosis weakens bones, so they break after simple everyday occurrences: a cough, a fall, even a hug from grandchildren can be enough to cause a debilitating fracture with often life-changing consequences. I saw this at close hand with my own mother, the last years of whose life were blighted by this cruel disease. It was diagnosed and treated too late, robbing her of her independence and, above all, quality of life because of multiple fractures.
Such fractures are no minor inconvenience; they are the fourth-worst cause of premature death and disability in the UK. As many people die of fracture-related causes as of lung cancer or diabetes. Fractures are also the second-highest driver of bed occupancy in the NHS. Today, they cost the health and social care system £4.6 billion. By 2030, this will edge towards £6 billion as we all live longer. Furthermore, fractures account for 2.62 million sick days annually in the UK, and spinal fractures in particular are a significant cause of older workers exiting the workforce in their 50s and 60s—figures of which the Treasury should take careful note.
But it need not be that way, as osteoporosis is treatable with safe, effective therapies that are highly affordable for the NHS. We do not need a miracle cure; the medicines already exist to halt the progress of the condition. The newest therapy can even rebuild bones. The stark problem is simply that we are overlooking 90,000 people every year who desperately need these drugs, because we are falling behind the rest of the world on modern diagnostics. The key to all of this is fracture liaison services—or FLS—which are the world standard for diagnosing osteoporosis early, straight after the first break, so that life-changing spine and hip fractures can be prevented.
In our 2021 inquiry, the APPG found that FLS have an unrivalled record in identifying people who need treatment. That is up to 95% of at-risk patients in a local population being put on a treatment plan and monitored so that they stay on their medication. Yet, incredibly, only half of NHS trusts in England have them. In areas without FLS, people are fixed up in A&E and forgotten about. They have their first break mended, but no one assesses them for osteoporosis and the disease is left to continue its deadly path. These are the people who present later with devastating hip and spinal fractures.
That is why 88 Members of this House have endorsed the better bones campaign that has run for the last two months in the Sunday Express. Week by week, in partnership with the Royal Osteoporosis Society, the paper has been setting out the enormous opportunities FLS can deliver. I take this opportunity to thank the Sunday Express and praise it for its fantastic coverage. The campaign calls for all areas to have quality FLS, for the provision of a very modest amount of funding to set them up and for a new national specialty adviser in the NHS to drive the step change we need. The level of support for the campaign has been staggering, demonstrating the public, professional and political demand for FLS. As noble Lords know, it is rare that such a wide coalition comes together in full and passionate agreement.
Already, 240 parliamentarians across the UK have backed the campaign, along with seven royal medical colleges. Their president spoke powerfully as part of the campaign on the role FLS can play in reducing waiting lists, freeing up operating theatres and releasing terrible pressure on A&E. The representative bodies for care home providers and ambulance workers have joined the call, along with 42 other charities and organisations, and business leaders and trade unions have joined forces because they know that FLS can help keep people in work.
The stark truth is that 31,000 hip fractures can be prevented over the next five years if we make FLS universal and high quality. We would stop treating the symptoms and prevent the damage in the first place. Today, we are spending money the wrong way around, managing the costs of failure rather than preventing harm in the first place. To coin a phrase, that is voodoo economics. Hip fractures are the most costly fragility fractures to treat: the average length of stay in hospital is three weeks, and a million acute hospital bed days are taken up by patients every year. Yet half the people with a hip fracture have suffered a previous fracture, which could have flagged them as being at risk and led to prevention. But, of course, they needed an FLS to do the flagging.
That can all change. If we front-end just 1.5% of our current spend on fixing hip fractures into setting up an FLS in every area, we can prevent a tenth of hip fractures happening. That is 31,000 people’s lives changed for the better, around 8,000 of whom would otherwise have died shortly after injury. Ending the postcode lottery for FLS would cost just £27 million per year in additional funding but have a total benefit of £440 million over five years. FLS, which break even in just 18 to 24 months—another point that the Treasury should note—deliver return on investment of roughly £3.26 for every pound invested. Is £27 million not just a rounding error in the grand scheme of NHS budgets compared with the £4.6 billion cost of unprevented fractures today?
For the population, the benefits of FLS would be vast, with 74,000 fractures prevented by 2028. It would also release 750,000 hospital bed days, which must be worth doing. If the Prime Minister wants to meet his pledge to reduce hospital waiting lists, this would be an easy win. In fact, I doubt he can do so without it. It would be a win for patients and their families, who have to care for so many of those suffering, for the hard-pressed NHS and for the taxpayer.
I know that the Government support the FLS model: NHS England has signalled to integrated care boards that they are a good thing. But there is nothing holding ICBs and trusts accountable for their delivery. That is why we are flatlining. The hard power of NHS England KPIs in 63 other areas is crowding out fracture prevention. Why would a commissioner spend £1 on something that the Government say may be a good idea when that pound is pulled away from 63 other areas in which they are publicly held accountable by NHS England and Ministers? These stubborn factors have led to fracture prevention flatlining since the APPG—I am pleased to see so many members of it here—published its report in 2021. There has not been a single percentage point of improvement: 90,000 people are missing out, which is 90,000 lives at risk.
The current approach has failed, and we need a step change in leadership from Ministers. A very modest, simple policy change, backed by limited investment, can deliver huge savings for the NHS and a significant boost for economic productivity among people in their 50s and 60s. We all want to see this, and it is of real importance to the Government. It can be a real demonstration that they are committed to the prevention elements of the long-term plan. That is vital. As our population continues to live longer, which is fantastic, broken bones caused by osteoporosis are a demographic time bomb. Without urgent action, a longer life will not be a better life.
This is a big strategic challenge for the whole of our society. Bold, visionary leadership from the Government could change the terms of the game, improving the lives of tens of thousands, relieving pressure on our beloved NHS and saving money for the taxpayer. We have such a huge opportunity here to save and change lives. I implore the Government to take that opportunity.
Baroness Donaghy (Lab)
My Lords, it is a real pleasure to follow the noble Lord, Lord Black of Brentwood. I thank him for all his work in this important area.
I have been a member of the Royal Osteoporosis Society for about 13 years, not because I had any family association with osteoporosis—at least, that is what I thought until March this year, when a close family member was diagnosed—but because I thought that it was a good organisation, which deserved support.
When I was a non-executive director at King’s College Hospital in the 1990s, I was asked to be the older persons’ champion. I spent considerable time looking at hospital processes and staff awareness to identify the needs of older people. The impact of falls, and the cost not only to the health services but to individual quality of life, was and is immense. That impact has to be multiplied several times if the faller has osteoporosis or is subsequently diagnosed with it.
Too often overlooked is the loss of confidence, an unwillingness to go out and an increase in fearfulness. We cannot assume that sufferers will want treatment or welcome attention, which is why it is so easy to neglect this disease and why two-thirds of people needing medication miss out.
I want to ask some questions about the Government’s women’s health strategy. In a Written Answer to the APPG’s report on the undertreatment of osteoporosis, which was referred to, the Minister Helen Whately indicated:
“The report’s recommendations are predominately being addressed through the women’s health strategy and National Institute for Health and Care Excellence’s guidance”.
However, osteoporosis is mentioned only 12 times in the 128-page women’s health strategy report, with no actionable plan for addressing bone health for women throughout their lives. NICE guidance is of course important, but it cannot address the need for leadership that the noble Lord, Lord Black, called for.
On 6 June, Minister Maria Caulfield said:
“NHS England is expanding fracture services for high-risk women with osteoporosis, and it is working to prevent falls”.—[Official Report, Commons, 6/6/23; col. 668.]
Can the Minister give any examples of an area where fracture services are being expanded for high-risk women? How many of the new women’s health hubs will have arrangements for density scanning and referral to fracture liaison services?
I conclude by thanking the Sunday Express for its Better Bones campaign and the noble Lord, Lord Black of Brentwood, for initiating this debate.
Lord Alderdice (LD)
My Lords, I also thank the noble Lord, Lord Black of Brentwood, for obtaining this debate and for his work on the APPG on Osteoporosis and Bone Health.
Osteoporosis has a huge impact, especially on women and not least as they get older. As we have heard from the noble Lord, Lord Black, fractures caused by osteoporosis affect 50% of women aged over 50 and a fifth of men. It is one of the most consequential health conditions if measured in disability and premature death. It is, in many ways, a hidden condition, since even those suffering from it may not be aware that it is the cause of some of their problems. When anyone sustains a broken bone and the trauma that caused it does not seem severe enough to have warranted a fracture, underlying osteoporosis should be considered as a vulnerability factor and addressed before more fractures and disability arise.
A friend of mine in her 60s took a relatively minor tumble during a 10-pin bowling game, yet sustained a fracture. As a doctor, she was alert to the possibility of osteoporosis and appropriate investigations showed that she was indeed suffering from the condition. This is not an unusual story and I have no doubt that many other noble Lords in this debate will rightly flag up the high incidence, especially among older women.
However, a theme that I suspect may receive a little less attention is how spinal fractures from osteoporosis affect people of working age, contrary to the misconception that it is just about hip fractures in older people. The first time I came across the situation of a spinal fracture was when I was working in Belfast in the 1970s, in what was then Northern Ireland’s only psychosexual clinic. One day, one of my patients, who in those days we described as transsexual—we would now call them transgender—arrived in a wheelchair. A previous clinician had prescribed steroids as part of their gender transition process, and the consequence was a crumbling of some of their spinal bones from the resulting steroid-induced osteoporosis. My patient was now coming to see me in a wheelchair with spinal fractures.
More recent decades have seen a massive increase—we are not really sure why—in the number of people suffering from a whole range of autoimmune diseases. These often require treatment with steroids. Both patients and their healthcare professionals need to be constantly aware not just of the symptoms of the disorders, but of the potential sequelae of their medical treatment. One of those is steroid-induced osteoporosis, resulting in fractures that lead to disability and problems in employment.
The Treasury is currently looking for ways to keep older workers in the workforce, and recently committed £400 million for the same. Apart from looking to the health budget to address osteoporosis, will the Minister explore whether some of this £400 million could be devoted to investment in diagnostics and treatment for osteoporosis, so having a significant impact on keeping people at work by raising the alert level on osteoporosis?
Baroness Finlay of Llandaff (CB)
My Lords, I declare that I am president of the Chartered Society of Physiotherapy and that I chair the Commission on Alcohol Harm.
We must all appreciate the noble Lord, Lord Black of Brentwood, for having secured this very important debate. Osteoporosis is predicted to cost the UK health service £2.2 billion by 2025, so I want to focus on the very early part of the prevention pathway. With age, fragility fractures become more common, particularly in the long bones of the arms and legs and in the vertebrae. These bones are made up of a scaffolding of less dense and trabecular, and therefore less heavy, bone, where about 26% of bone is remodelled every year. Old bone is gobbled up by osteoclasts, and osteoblasts, under the influence of signalling cells, lay down a scaffolding of unmineralised osteoid, which then becomes fragilely mineralised as the new bone solidifies. As we have just heard, many hormones—proteins, vitamin D, calcium—all influence this process. When imbalanced, prolonged osteoclast activity gobbles up more bone and the bone becomes increasingly fragile.
In osteoporosis, this bone loss in the long bones and the vertebrae is particularly evident. Bone mass declines over time, accelerated by smoking and moderate to high alcohol intake, as well as by illness and its treatment, such as some cancer treatments and treatments with steroids, as we have heard. Gut disease, diabetes and chronic kidney disease all impair absorption of calcium and magnesium, as do some of the indigestion drugs so commonly taken across the population and anti-epileptic drugs, which impede the absorption of nutrients required for bone growth.
No one would advocate not treating this serious condition, but all is worsened by physical inactivity. Preserving skeletal muscle with exercise increases bone strength and slows the development of osteoporosis, as well as improving balance, thereby reducing the risk of falls. A diet rich in fruit and vegetables, with an increased protein intake, helps maintain muscle mass and bone strength.
Yet, we are a nation of inactivity, with 36% of the adult population physically inactive. Our healthcare costs related to inactivity are the third highest across 15 nations in western Europe, running at £20.53 per person in the UK, compared to £5.11 in Finland or £12.25 in France, which is near the middle of group. When bone has become fragile, early treatments, as we have heard, can lessen the chance of fragility fractures and prove cost effective, but prevention through exercise and healthy eating is essential. It is never too late to start.
Baroness Chisholm of Owlpen (Non-Afl)
My Lords, I thank the noble Lord, Lord Black, for initiating this debate. I have long been involved with the Royal Osteoporosis Society and, in the short time available to me, I am going to have to gallop through what I want to say.
As has been part of the campaign in the Sunday Express, I am going to set out the reasons why a national leadership on osteoporosis and fracture prevention within the NHS is essential. Either a national clinical director or, at the very least, a national speciality adviser will enable us to have a strong, visible leadership. There is already a long list of 41 leadership roles within NHS England for virtually every condition—from long Covid to flu, from tobacco addition to eye care—and it seems to me the fact that fracture prevention is not mentioned on that list sends a clear message to local commissioners that it is not a priority.
Surely that is wrong. When you consider—as the noble Lords, Lord Black and Lord Alderdice, mentioned—that half of women over 50 will have a fracture due to osteoporosis and that these fractures are the fourth worst cause of disability and premature death in the UK today, it is a no-brainer that osteoporosis and fracture prevention should be represented with national leadership. I am aware that it is felt that the present NHS national director for musculoskeletal conditions includes osteoporosis in the portfolio, but the existing leadership bandwidth is extremely stretched, and osteoporosis is such a distinct specialism, so even if it continues in the MSK basket, in my book there is still a very strong case for a national speciality adviser.
From what I have learnt, good intentions at national level are failing to filter down across ICSs, leading to commissioners’ awareness being extremely low when it comes to the financial benefits brought by increasing FLSs. We need a specialistic leader in NHS England, properly resourced to get the job done. For over a year, the ROS has indicated that it will part fund such a role, surely an offer that NHS England should embrace. Rumours are that there is a freeze on recruitment, but that appears to have been lifted, as there is a recent advert for two new clinical director roles—so a place for us. On what possible NHS England criterion can a condition which affects so many people and costs so many years of healthy life and creates such a strain on public services possibly be allowed to continue?
Baroness Hayter of Kentish Town (Lab)
I, too, thank the noble Lord, Lord Black, for introducing this debate. As has been clear, the Government have simply passed the buck on this. The Written Answer from the noble Lord, Lord Markham, told me that:
“NHS England does not have a specific budget … The Department continues to work with NHS England on the consideration and implementation of musculoskeletal policy, including Fracture Liaison Services”.
That means no national action, and it is not good enough.
It is not enough just to highlight NICE guidelines and the Getting It Right First Time programme which has led to huge gaps in coverage. As we have heard, only half of English trusts have fracture liaison services and chronic underinvestment means that, even where services exist, performance is below par. High-quality services can identify 95% of at-risk patients, compared to a quarter using other non-specialist services. The Government need to take concrete, immediate action. All involved, including professionals, know we need these specialist services, with bodies representing over 650,000 doctors and nurses supporting the Better Bones campaign.
But, as we heard, locally, commissioners have poor awareness of osteoporosis and the benefits of fracture prevention. As we heard, they often wrongly think that investment in these services takes time to pay off; in fact, they break even within two years. However, the catch is that the savings occur in a different part of the health service from where the money is spent. So, without a government mandate, money simply will not be ring-fenced and allocated.
In Wales, the Health Minister, our former colleague my noble friend Lady Morgan of Ely, mandated all seven Welsh health boards to ensure 100% coverage of fracture liaison services by this time next year, and she set up a government-led taskforce to help meet that deadline. That shows how strong leadership can improve and save the lives of tens of thousands of people, particularly older women—I had better declare an interest.
The Royal Osteoporosis Society does an amazing job, as do thousands of clinicians and carers, but this urgent issue needs government resolve and leadership. Yes, it needs resources, but it also needs investment to save not just money but pain, discomfort and the diminished quality of life that fractures cause. As the noble Lord, Lord Black, said, these are no minor inconveniences. We live longer, which is great, but we need to live longer healthier, and this issue can make a difference. A clear mandate from Westminster is needed for English ICSs to prioritise fracture liaison services.
Baroness Bloomfield of Hinton Waldrist (Con)
My Lords, it is a pleasure to follow the noble Baroness, Lady Hayter, and I applaud my noble friend Lord Black for securing this important debate and for his work in the APPG. Like many noble Lords, I suspect—indeed like my own mother, who suffered from this pernicious disease for decades, causing her much pain, misery and distress—I speak as someone who has this inherited condition as well.
The example of my mother was actually a benefit, in that I was diagnosed very early. Spending 10 years on HRT did little, and alendronic acid has done much, although I am out of time on that, so, for now, I am successfully keeping my density levels stable with load-bearing exercise and vitamin D. However, not everyone is so lucky: osteoporosis is asymptomatic—I never suffered from any breaks—so, until fragility fractures occur, it is often not diagnosed. So I am fully supportive of any mechanism by which fellow sufferers can be identified as early as possible.
Today, we heard of the need for, and the clear benefits of, fracture liaison services. I welcome Minister Maria Caulfield’s recent commitment, in the Sunday Express, to explore setting up more fracture liaison services and to say more before the end of this year.
According to the ROS, the amount of money needed to fill the gaps in population coverage and the quality of FLS in England is very modest: just £27 million per annum. This is out of a total annual spend in the NHS of £180 billion. We can give everyone over 50 access to an FLS, and it will improve the quality of all these bodies so that they can deliver well against the quality standards monitored by the Royal College of Physicians.
We all recognise the difficult economic environment, but there is a clear need for a national catalyst to get things moving. The Royal Osteoporosis Society suggested a capped two-year transformation budget of £54 million to pump-prime FLSs to become universal across England. This will light the spark so that we can have change. Then, after those first two years, the services can be absorbed into ICSs as “business as usual” within conventional funding channels, overseen by ICBs, when the benefits materialise. This offers a pragmatic way for the Government and NHS England to catalyse the change in an affordable way. It reflects perfectly the principles in the long-term plan, replacing cash badly spent on fixing avoidable injuries with sensible investment in prevention.
The ROS also suggested several other approaches, and there are many ways to create change in this area, with a quicker pay-off than officials might expect. The Better Bones campaign has shown that the national support for FLS is only growing. Rather than going round in circles, can we now take action to make it happen? Will the Minister please meet with the ROS to discuss these proposals?
Lord Bilimoria (CB)
My Lords, my 87 year-old mother Yasmin lives in Dehradun in north India, in the foothills of the Himalayas. She has had severe osteoporosis and osteoarthritis—a point that has not been made is that many sufferers of osteoporosis also suffer from osteoarthritis. In India, of the hundreds of millions of Indians over the age of 50, it is estimated that at least 20% are women with osteoporosis, so it is a major public health problem with Indian women.
As the noble Baroness, Lady Bloomfield, has said, osteoporosis-related fractures are associated with substantial pain and suffering. My mother, fortunately, was diagnosed very early. The gold-standard diagnosis is the dual-energy x-ray absorptiometry DXA. However, very few of these machines are found in India.
This is a global phenomenon: 54 million people in the United States have osteoporosis; women are four times more likely to develop it than men; in Italy, its expense is €10 billion, and in Spain the burden of fragility fractures was estimated at €3 billion; in the Netherlands, the burden of fractures will increase by 30% to over €1 billion.
I thank the noble Lord, Lord Black, for initiating this debate. As he noted, the condition is asymptomatic until fragility fractures take place. It is estimated that there are around 180,000 fractures presenting each year as a result of osteoporosis. This is a huge number. There are GPs who spot it, and, of course, fracture liaison services. I was shocked to discover that only 63 out of 123 NHS trusts—just over 50%—were able to confirm that they have an FLS, whereas 100% in Scotland and Northern Ireland do. Could the Minister confirm why 100% of NHS trusts do not have these FLS services?
There seems to be a lack of the DXA scanners, which I mentioned earlier. From May 2023, 66,469 patients were waiting for these scans, which is 11.2% more than in May 2022. Why can we not have more of these scanners available throughout? Why can there not be a public health campaign about bone health—far more than is taking place now—to make people aware of it? The noble Baroness, Lady Finlay, made the very important point that there should be much more awareness and encouragement of physical activity and access to physiotherapy. I have seen this first-hand with my mother, who suffers so much pain that she has access to physiotherapy. Do we give enough access to physiotherapy? The conclusion is that detection and prevention have to be the way ahead.
Lord Shinkwin (Con)
My Lords, I join other noble Lords in congratulating my noble friend Lord Black of Brentwood on securing this debate on an issue very close to my heart, as someone who lives with the bone condition osteogenesis imperfecta, to give brittle bones its medical term, which forced me to spend much of my childhood in a hospital bed. The cost-effective proposal that my noble friend highlighted constitutes a win-win for people faced with my condition, OI, and osteoporosis.
Sticking with my condition for a moment, I understand from bone expert Professor Kassim Javaid, that there were 16,245 hospital admissions for OI patients between 2014 and 2018, with a total cost to the NHS of £24,052,451. Yet, incredibly, OI is not listed as a condition on the NHS website. You can be in hospital and get a diagnosis, go home and look at the NHS list of conditions and see that the condition you have just been diagnosed with supposedly does not exist. How unhelpful for patients and their families looking to manage the condition and reduce fracture risk. I would be really grateful if my noble friend could have that simple but cost-effective anomaly corrected.
I turn specifically to osteoporosis, which people with my condition often go on to develop. I am not going to rehearse the arguments that have been so excellently and eloquently made by my noble friend and others. The key point for me, as for my noble friend, is value for money, so I ask the Minister to give one example of bigger bangs for bucks than investing £27 million in the urgent rollout of fracture liaison services, when the ROI is £3.26 in savings made for every £1 spent. To its credit, Mid and South Essex Integrated Care System has shown what can be done at the working level; now we need it in Government. As the Royal Osteoporosis Society has made clear in its excellent campaign with the Sunday Express, 41—that is, all other—health authorities have yet to act, so we urgently need that top-down mandate.
I finish with this question to the Minister: it may not be a medical term, but does he agree with me and my noble friend Lady Chisholm that this is a classic case of a no-brainer?
Lord Allan of Hallam (LD)
My Lords, I am grateful to the noble Lord, Lord Black of Brentwood, for securing the debate and to the Royal Osteoporosis Society for meeting me recently.
In the short time available, I shall focus on an aspect that many speakers have already raised: fracture liaison services. I was struck by looking at the Royal College of Physicians database of fracture liaison services, which has a map showing vividly just how variable the provision is across England. We have a protocol that we know both improves patient outcomes and is ultimately less expensive for the NHS, as the noble Lord, Lord Black, and the noble Baroness, Lady Hayter, have pointed out to us, and we have it working well in some areas—the noble Lord, Lord Shinkwin, has just given us an example of places where it is—but we do not seeing it rolling out everywhere in a timely way.
I wonder how the Minister feels about those areas of England where it is not rolling out. Is he disappointed, frustrated, irritated or all of the above? We should be frustrated, irritated and disappointed that people in England are not getting the service that will mean that they have fewer negative health outcomes and that we will all save on the NHS budget as they get cheaper care, rather than more expensive care further down the track.
I turn to the potential fixes, and we have discussed some of those today. How long will it be before the department intervenes more directly? I hope the Minister can talk about the kind of interventions that it is thinking of. My understanding is that the provision of a fracture liaison service is relatively straightforward in health terms. It requires trained nurses, administrators, access to systems and some tools, such as the scanners that the noble Lord, Lord Bilimoria, referred to, but these are not at the cutting edge or at least the most expensive end of what is needed in the health service, so it is certainly achievable.
Building on the point made by the noble Baroness, Lady Chisholm, about a national specialist leader, that seems to be essential. I would perhaps be even more aggressive: there needs to be someone whose responsibility is to get us from 51% to 100%. All they should think about when they wake up in the morning is, “How do I get to 100% coverage of fracture liaison services?” They should praise the best and make the worst feel very uncomfortable for not doing their job. They should help to build business cases for ICBs that, for whatever reason, have not built their own business case, to demonstrate to them how they would be stupid not to do so—and, if the ICBs still do not do it, make sure that everyone knows they are not doing it, because the evidence is there. They should look at creative ways to unblock any barriers and quite simply not accept no for an answer.
I hope the Minister can say that the department is thinking creatively about how it can put that kind of structure in place, where incentives exist to get from 51% to 100% in the shortest time possible.
Baroness Wheeler (Lab)
My Lords, I thank the noble Lord for this important debate, for his excellent introduction and for his work with the APPG. We have heard a number of speakers who are very active in the group, so ably co-chaired by the noble Lord and my colleague in the Commons, Judith Cummins MP. She has led the charge in the Commons campaign for improved access and quality of services, as has the noble Lord here in this House.
The APPG’s two reports, on the FLS postcode lottery and setting out the role that primary care needs to play in identification, treatment and care, have been landmark reports in raising awareness among parliamentarians and NHS leaders about osteoporosis and the importance of bone health. We look forward to its further report later this year on bone density scanning, following the public evidence-taking session.
I also thank the Royal Osteoporosis Society for its very succinct key facts briefing for today. It makes for pretty stark reading, as we heard from noble Lords. It includes the fracture treatment gap, which leads to thousands of people each year missing out on anti-osteoporosis medications; the patching up of people in existing fracture clinics without underlying osteoporosis being diagnosed; and the enormous burden of preventable fractures on the NHS, which mean that half of hospitalised hip fracture patients who have had a previous fracture could have been flagged up as being at risk.
On the absolutely key issue of why only 51% of NHS trusts provide FLS, I note the response from the noble Lord, Lord Markham, to the Oral Question on osteoporosis early detection on 19 January, in which he emphasised strongly that all ICBs have the responsibility to roll out these services “or their equivalent”, and that the others—the 49% that have not done so—had “different versions of it”. I look forward to the Minister’s explanation today of exactly what those different equivalent versions comprise and how their outputs are measured and assessed for fracture treatment and prevention. Why is the treatment gap so wide and shocking?
For the record, the ROS warns of the barriers to ICSs in seizing the missed opportunities. It notes a lack of a central directive through the standard NHS contracts in emphasising fracture prevention; a general lack of awareness of the impact of fractures and the cost benefits of secondary fracture prevention; the patchy clinical leadership in drafting business cases; and the short-termism in business planning, including the break-even issue that has been mentioned. I would be interested to hear what steps the Government are taking to address those issues.
On 19 January, noting the impact of osteoporosis affecting half of women over 50, my noble friend Lady Merron drew attention to the UK primary care base trial on screening for osteoporosis for older people. It examined a systematic approach to identifying older women in fracture prevention, leading to a 28% reduction in hip fracture risk, thereby significantly reducing costs and seeing increased adherence to treatment. It is an exciting trial, and I would welcome further information on it from the Minister.
Finally, I will briefly follow up on a previous issue I raised about research on osteoporosis. Can the Minister say what support the Government have provided to the ROS’s research academy and its potentially game-changing road map, which charts the key steps for researching a cure for this extremely debilitating disease?
Lord Evans of Rainow (Con)
My Lords, I thank my noble friend Lord Black of Brentwood for bringing forward this Question for Short Debate. As chair of the All-Party Parliamentary Group on Osteoporosis and Bone Health, he has long been a champion for those with osteoporosis. I thank him for sharing his experience of looking after his own mother over many years.
My noble friend is absolutely right that osteoporosis represents a growing challenge, particularly for older people. In the UK, it is estimated that over 3 million people have osteoporosis and over 500,000 fragility fractures occur every year. People of all ages want to enjoy good health for as long as possible, but remaining independent often depends on health and social care services being effective enough to support them wherever they live. Many people of working age also suffer preventable fractures, with an estimated 2.6 million sick days taken every year in the UK due to osteoporotic fractures. Studies show that over 22% of the population aged 50 to 64 will suffer from a fracture at some stage.
To that end, this year’s spring Budget announced a package of measures to support individuals at risk of, or experiencing, musculoskeletal conditions, including by making best use of digital health technologies to support people to manage symptoms better and to increase mobility, and by designing and scaling-up musculoskeletal community hubs, thereby expanding access to community-based services and delivering physical activity interventions. These will be effective as exercising regularly reduces the rate of bone loss, lowering the risk of fractures and falls. Given that good work improves health and well-being, the spring Budget also announced measures to support people with musculoskeletal conditions to remain in or return to work, including by integrating employment advisers into musculoskeletal pathways, building on the success of the NHS talking therapies programme, and piloting the WorkWell partnerships programme to support disabled people and people with health conditions who want to work.
The Government are also undertaking two consultations to understand how best to increase employer use of occupational health services. Osteoporosis disproportionately affects women, who often face a one-size-fits-all health system that does not consider their specific health needs. The women’s health strategy for England set out plans to achieve the 10-year ambition for women to have improved outcomes with musculoskeletal conditions, including through increasing early identification and treatment of those at risk, which many noble Lords pointed to in the debate.
The noble Baroness, Lady Donaghy, asked what the Government are doing. We are proposing to announce, in the forthcoming Autumn Statement, a package of prioritised measures to expand the provision of fracture liaison services and improve their current quality. NHS England is also setting up a fracture liaison service expert steering group to explore the expansion and improvement in quality of services for people with osteoporosis and those potentially at risk of fractures. We also have the major conditions strategy. I assure noble Lords that we are committed to making sure that people get the best care, no matter what condition they have.
Last month, we set out our initial plans for the major conditions strategy, with the case for change and strategic framework. This report identifies actions to improve outcomes for individuals across six major conditions groups, including musculoskeletal conditions. It includes exploring how best to support musculoskeletal service improvement and leadership—for example, through improving collection of data. Joining up patient experiences across datasets will enable more effective commissioning of support for those with musculoskeletal conditions. It is also includes, together with NHS England, exploring further support in the provision of fracture liaison services, which many noble Lords mentioned here today. This could include identifying people at risk of further osteoporotic fragility fractures, and implementing strategies to reduce risk of future fracture, including falls, and mortality.
Fracture liaison services are key to prompt diagnosis of osteoporosis and are acknowledged as the world standard for secondary fracture prevention. According to the Royal Osteoporosis Society, for every £1 spent on fracture liaison services in the UK, the taxpayer can expect to save £3.28. By levelling up provision to cover everyone over the age of 50, we could prevent just under 5,700 fragility fractures every year, a point very well made by my noble friend Lord Black.
As noble Lords will be aware, fracture liaison services are commissioned by integrated care boards, and while we expect musculoskeletal fragility fracture and fall services to be fully incorporated into planning and decision-making, coverage is not universal, with only 50% of the country able to access services. The noble Lord, Lord Allan of Hallam, always gives very demanding targets, 100%, and he is absolutely right to demand that. It will take time, but it is the intention to be able to do that across the way. I have noted the 100% and I look forward to discussing that in future debates.
NHS England is already working with commissioners to support the mobilisation and implementation of fracture liaison services in each area and to establish a greater number of clinics. It has provided local health systems. My noble friend Lord Black talked about leadership, and I will certainly make sure that colleagues in the department are fully aware of what he is talking about: it will certainly be considered by Ministers.
NHS England’s “getting it right first time” programme has a specific workstream on musculoskeletal health and is exploring how best to support integrated care systems in the diagnosis and treatment of osteoporosis. As part of this work, NHS England is reviewing pathways for secondary prevention of fragility fractures. Systematic vertebral fragility fractures and non-ambulatory fractures feature, and we will publish guidance to support local health systems to implement these pathways. The programme has also produced a draft adult orthopaedic trauma national speciality report, which includes recommendations on adopting fraction liaison services.
I turn to some specific questions. My noble friends Baroness Chisholm and Lord Shinkwin asked about having a dedicated fracture tsar. As the noble Lords will be aware, the role of the NCD as speciality adviser is to provide specialist clinical advice, and leadership to drive transformation of services for patients and support the commissioning of services. I think it is an important point to have somebody focused day in, day out, whose waking worry is to take it from 57% to 100%. I certainly will feed that one back.
The noble Lord, Lord Bilimoria, talked about DEXA scanners. Unfortunately, I have not got precise detail on that so I will write to the noble Lord on the specific details of that particular question.
I pay tribute to the noble Baroness, Lady Finlay, and her colleagues for the work that she does on this. She reminded us that prevention is better than cure, and that physical exercise and diet throughout one’s life helps with this. I didn’t realise “gobbling up” was a technical, clinical term, but we know exactly what you mean; that is the importance of diet and exercise to keep that bone mass and muscle mass there. As the Minister always says, in one week in hospital for patients, you lose 10% of your body mass, which is a sobering thought.
I do not underestimate how painful and debilitating this silent disease is, but I am confident that real advances have been made and will continue to be made. I assure noble Lords that the Government is determined to support improving access to, and quality of, services for those with osteoporosis.
In answer to my noble friend Baroness Bloomfield, I am very happy to meet with the ROS at a time convenient, and I extend my thanks once again to noble Lords for securing this debate and for the thoughtful comments and questions.
I note, on this particular date and others, the fact that noble Lords have actually cared for, and looked after, family relatives, which gives you first-hand experience of the challenges for family and friends of people living with this difficult disease. As a noble Lord mentioned—I do not know who—the good news is we are all living longer, but the bad news is that, at some stage, we may all suffer from this terrible disease.
Baroness Wheeler (Lab)
Can I ask if the noble Lord is going to follow up with a letter on the questions he did not cover please? Thank you.
Lord Evans of Rainow (Con)
Do forgive me, apologies. I have not got that information in my notes, I am afraid, so I will write to you and the noble Lords on that specific question.