National Health Service (Primary Dental Services) (Amendment) Regulations 2022

Baroness Bennett of Manor Castle Excerpts

Tuesday 24th January 2023 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to follow the noble Lord, Lord Hunt of Kings Heath. I thank him for securing this debate and for so clearly setting out the pressing issues around dental treatment. He set out the massive, chronic underfunding—a quarter down since 2010—and the workforce problems. As he said, the regulations we are debating are an extremely modest, if welcome, step to address that to a very small degree.

I will take this opportunity to take a somewhat broader view of dental health and raise a couple of issues that are arising from the crisis of the lack of NHS dental provision. My first point draws on the WHO Global Oral Health Status Report, which was published in November 2022. It stressed that most oral diseases are fundamentally preventable through addressing the social and behavioural determinants, with risk factors such as tobacco, alcohol and sugars that are shared with many other non-communicable diseases. So the first question I put to the Minister is: are the Government really taking seriously the issue of addressing good oral health and public health conditions, which would have so many other positives in terms of issues such as obesity, diabetes, et cetera? Are the Government looking at this in this kind of way?

Secondly, the WHO global strategy on oral health says:

“Achieving the highest attainable standard of oral health is a fundamental right of every human being.”


I will refer here to an article published in the Lancet Public Health on 11 December last year by Winkelmann and other authors, which looked around the world at the different classes of oral health coverage available. There are four: no coverage at all, limited coverage, partial coverage, and comprehensive coverage. The UK, I am afraid, falls in the second of those four increasing levels of coverage: limited coverage. We know that the Government like to claim to be world-leading in many contexts, so do they have an aspiration at least to reach the comprehensive or advanced level of coverage identified in that study, which would mean making dental treatment available to all and ensuing a high quality of preventive public health provision?

My third point is on the issue of dental health tourism. This was prompted to the front of my head again this morning by sitting in a Tube carriage in which I was facing adverts saying, “Get your teeth fixed—go to Turkey”. A couple of days ago, there were a number of horror stories about this across the tabloid newspapers. I am not picking on Turkey in particular, because I do not have the stats on how many people are going where and what problems are arising—but I do not believe that the Government have stats on what is happening with dental health tourism or those problems, either.

As I understand it, there is no reliable source of data on all outbound UK medical tourism, whether it be dental or other forms, but the ONS has estimated that 248,000 UK residents went abroad for medical treatment in 2019. I assume that quite a number of those treatments were probably dental. Indeed, in a recent article the Guardian quoted the editor-in-chief of the International Medical Travel Journal—it is interesting that there is a journal on such a thing—saying that this was going up fast. Are the Government going to collect any stats on both dental tourism and other forms of medical tourism? Are they going to publish those? Are they going to look into whether this is an issue, in which case the stats would clearly be a starting point? Does the Minister agree with me that when these operations go wrong overseas, we will end up seeing the UK dental health system and general health system ultimately having to pick up the pieces?

I come now to my final point. Your Lordships’ House will shortly be engaging, I suspect at some considerable length, with the Levelling-up and Regeneration Bill. It is worth stressing how much dental health issues are a levelling-up issue. The south-west of England, Yorkshire and Humber and the north-west have the largest shortage of provision of NHS dental services, with 98% of practices in these areas refusing to accept new adult NHS patients, according to the latest figures I have been able to find.

I have raised a number of points, and I understand that the Minister may need to write to me on some of those. We sometimes have this sense that there is health, and then there is dental health. Indeed, the article I cited earlier stressed that the WHO is concerned that dental health is often seen as something that is done by private clinics in private places—but, of course, dental health is crucial to the health and well-being of a healthy population. We have, in so many different areas, a public health crisis in the UK. Dental health is one more of those areas, and it must not be left behind or neglected because of historic structural factors.

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to the noble Lord, Lord Hunt, for ensuring that we have an opportunity to debate this important statutory instrument today. We benefit from his detailed analysis of problems in the dental sector.

The facts are laid bare in the Government’s own impact assessment, which says:

“NHS dentistry was a challenging area prior to the COVID-19 pandemic, with patient access proving difficult in some areas of the country … The COVID-19 pandemic exacerbated problems with patient access and created a backlog of patients seeking access to NHS dentistry.”


There is a recognition in that analysis that people being unable to access NHS dentistry is a long-standing problem. As other noble Lords have said, the statutory instrument is correctly aimed at addressing some aspects of that shortfall, and we would not oppose it as a contribution to solving the problem. However, we would ask the Minister, “Is this all you’ve got?”, given the clear and enormous gap between demand and supply.

The figures are dire. Again, the Government’s own impact assessment shows that the success rate for patients seeking an NHS dental appointment has fallen from 97% in 2012 to 82% in 2022 for people with an existing relationship with a dentist—so one in five of those who already have an NHS dentist relationship are not being seen. But for those trying to get their first NHS dental appointment, this has become almost impossible in many areas, with only 31% of those who had not been seen before successfully getting an appointment, compared with 77% of the same group in 2012. When we drill down into these national figures, we also see significant variation around the country, with some areas having become known as “dental deserts” because of the lack of dentists offering NHS treatments.

Turning again to the impact assessment, we see that it tells us that

“the North West has generally good access (but with pockets of poor access in rural areas), compared to the South West and East of England where access is generally poor, particularly in rural and coastal areas.”

This is a terrible indictment of what is supposed to be a nationally available essential service—one that is likely to have a disproportionate effect on deprived people who often need intensive dental care. The noble Baroness, Lady Bennett, also raised this point, quite rightly, in the context of the levelling-up agenda—or is it the gauging-up agenda? In any case, the agenda to deliver better services to people in historically deprived areas is critical to this understanding of the disparate access to dental care.

These changes are supposed to incentivise better provision of these intensive treatments but I note that again there is no statutory review clause in the instrument requiring the Government to produce data that will show their actual impact. I hope the Minister will want to commit to producing such a post-implementation evaluation in due course, even if that is not a statutory requirement. I am sure he will talk up the benefit of making these changes but the proof will be when we come back in a year or two and we can see whether there has been a change in the number of people able to access NHS dentistry and the number of treatments that were given.

As well as amending the payment scheme, this regulation places new requirements on dental practices to update information about their services for publication on the NHS website. This may seem weird, but I experienced a twinge of fond nostalgia as I read up on this section. It took me back to my first technology job, where I was responsible for producing the directories of primary care practitioners for what was then the Avon Family Health Services Authority. These consisted of papers in ring binders that listed each dental practice and its services for distribution to libraries and other public information points.

That was in the mid-1990s before the massive growth of the public internet, but I managed to get hold of some software called the NCSA HTTPd, an early web server, and I produced an HTML version of our directory for people in the local authority. All of those products are now long discontinued, as indeed is the country of Avon itself, so this is of historical rather than current interest. However, that may have been version 0.001 of the public directory that we now have on the NHS website.

Fast-forwarding to the present day, it will be no surprise that we support improvements to provision of information to the public such as those in the statutory instrument. However, that has to be complemented by improvements to the availability of services or we will simply see increased frustration as people are given better information about what they cannot have. Does the Minister have a response to people who will go to the NHS website and find that there are no dentists taking on NHS patients in their area?

I hope that the Minister will not think it churlish if we say, “Thanks but not enough” in response to this instrument, and that he may have some additional remarks to make about what more the Government plan to do, especially in respect of creating the NHS dental workforce. I emphasise “NHS”; there are many areas where there is no shortage of dentists, but there is a shortage of dentists who are willing to work for the rates that the NHS is prepared to offer them. I hope that by making those improvements, we will be able to move on from where we are today, where seven out of 10 people in this country who try to get into the NHS dentistry system for the first time cannot find anyone to take them on.

NHS Winter Pressures

Baroness Bennett of Manor Castle Excerpts

Tuesday 10th January 2023 Lords Chamber

[Lord Markham (Con)]

I have seen very good examples of where that works. You have clinicians in the room with the data—the management and bed information. They make decisions according to the flow and number of people who they see are going to need a bed from the ambulances and the A&E situation, and the number who are ready to release. You have clinicians united with the information to make good decisions. Those are the best. The idea with the longer-term plan is to make sure those “best” have the tools in terms of the flight control system and have management processes in place so that they can adopt and follow best practice. It is key to what we are looking to make sure we have in place in time for next year, as the noble Baroness, Lady Merron, mentioned.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Minister replied to my Written Question on 5 January about commercial companies promoting strep A tests. The Answer said that these are “not currently recommended” by NICE

“for individuals aged five years old and over … with a sore throat”

and that UKHSA is conducting a

“bedside review of existing antigen-based lateral flow devices”

to

“identify the tests that are most likely to perform well”.

Given that, can the Minister explain why I have a number of emails from DAM Health headed “Concerned about strep A? Order your home test kit today. Only £12.99 per test kit. Quick and reliable results within minutes”? Can the Minister truly put his hand on his heart and say there is sufficient regulation and oversight of private testing companies, and indeed the broader private health sector? Is it not profiteering from the crisis in the NHS, potentially damaging the NHS and putting more pressure on NHS services?

[Lord Markham (Con)]

First, I declare an interest in this space. As many noble Lords will know, I set up a Covid testing company which never did any business towards the Government; I am very pleased to say that it served only the private sector. I am disposing of it as part of my obligations as a Minister. As the question relates to testing, I am quite keen to put that on the record.

Secondly, I would say “absolutely”. Dare I say it, but the reason my company was so successful is that we set the very highest standards according to the regulators. That is why we were able to win the crème de la crème—the Formula 1s and Wimbledons of the world. I cannot speak for other companies which may not be taking that high level of support, but there is absolutely a role for the regulator to make sure that only effective tests are marketed and those which are not effective should not.

Plastics: Health Research

Baroness Bennett of Manor Castle Excerpts

Monday 19th December 2022 Lords Chamber

[Lord Markham (Con)]

Again, my understanding from the science is that that is not a concern here. The presence of nanoparticles in the bloodstream has not caused concern to date. However, again, if there are good research proposals in this space, that is exactly what the research council was set up to look at.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Minister has said a number of times that there is limited evidence, yet we know, as the noble Baroness, Lady Meacher, said, that there are microplastics in our blood. There is evidence that nanoplastics cause change and inflammation in skin and lung cells, and plastics also contain additives, including bisphenol A, phthalates and polychlorinated biphenyls, which are endocrine disruptors and alter reproductive activity. Is a lack of knowledge, in the light of the Government’s supposed attachment to the precautionary principle, an excuse for not acting while all these risks are clearly evident?

[Lord Markham (Con)]

Again, the research bodies are very happy to look at any good proposals. The only place I would disagree with this is on whether you would want to ring-fence a certain amount to a space when you do not know whether there is a health risk there. Therefore, if there are good research proposals, we are definitely ready to take that forward. I will caution against some of the quotes where they are based on a sample size of 22 people, in terms of the common-sense study. That is why we place caution on this, but if there are good research proposals, I say: absolutely, please bring them forward.

Health Promotion Bill [HL]

Baroness Bennett of Manor Castle Excerpts

2nd reading
Friday 2nd December 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise to make the range of cross-party and indeed non-party support for this Bill even broader. I thank the noble Lord, Lord Addington, both for bringing it and for introducing it so comprehensively.

The noble Lord, Lord Crisp, made a powerful point when he talked about prevention of ill health; he then got to the point where we really need to be when he emphasised that physical activity is absolutely crucial to well-being and a healthy society.

Ahead of today’s debate, I looked back to a speech that I gave in July 2015 to the University of Manchester’s Festival of Public Health UK, which was in fact an international event. I said then that we have in the UK

“a society that’s making … its members ill. A society that’s failing to provide clean air … adequate housing … a healthy diet … safe jobs and decent benefits … opportunities for exercise … an education that prepares pupils for life.”

Seven years on, I do not believe that there is a single measure that I set out then on which we have seen positive progress, which is extraordinarily terrible—although I note that it is not through want of the efforts of my noble friend Lady Jones of Moulsecoomb. Indeed, this House has, with broad support, just put through the Clean Air (Human Rights) Bill. I hope that that might be one area where we could see very rapid progress.

I shall concentrate in my speech on sports—appropriately, since the noble Lord, Lord Addington, is such a champion in your Lordships’ House in this area. I stress the need to change the conversation. I was on the politicians’ panel on BBC’s 5 Live this week. For reasons that my accent makes obvious, perhaps, there was a discussion of the England-Wales World Cup game to which I was not asked to contribute. However, had I been asked to contribute, what I was sitting there bursting to say was, “Where is the huge programme around this high-profile event to get people out, during and after the event, kicking a ball around, throwing a ball around, running around, as people are watching so many high-profile celebrities doing on television now?” That was one question, but another question, which other noble Lords have already raised, is: where will people, particularly children, kick that ball? Where will they be able to run around?

I submitted a Written Question to the Cabinet Office on 24 November:

“To ask His Majesty’s Government what assessment they have made of the public health impacts, including on loneliness, lack of opportunities for physical activity and provision of services locally … of the sale of public buildings and spaces each year in England.”


I got the Answer a couple of days later, quite surprisingly; it perhaps suggests not a great deal of involvement. I was told:

“Any decision … will consider social cost and public value, in line with HM Treasury Green Book guidance.”


I think the noble Lord, Lord Addington, is really making a point in this Bill about the need for a change of mind in the Government: they need to regard physical activity and sport as a crucial issue, which I do not think the Answer I received suggests that they currently do.

This is not a new situation. I draw noble Lords’ attention to an interesting campaign just launched by the Carnegie UK Trust and Fields in Trust charities, with the hashtag #FieldFinders. It is looking to find lost playing fields. Between 1927 and 1935, the Carnegie UK Trust gave nearly £200,000—£10 million in today’s money—for nearly 900 playing fields across the UK. It is interesting because, as is often typical with history, it did not keep a record of where they all are, so now it is asking the public to help find them and, very interestingly, to find out how many of them are still playing fields. Because that money was given so that those fields would continue to be in use in perpetuity. I think I can guess the result: it will find that many of them will not now be playing fields.

That is focusing on playing fields, but of course the space that is very near every child, every person, is a road. Again, we have seen not government leadership in this area but civil society leadership in the form of the Play Streets campaign, which started in Bristol in 2011 and has since grown around the country. This is a scheme by which streets are temporarily but regularly closed off to become sites of play, organised and managed by people in the neighbourhood. Of course, these are not just sites of play; they are sites of interaction. What this campaign is saying is that we need a long-term culture change: it needs to be safe for children to play out on the streets all the time.

I say many radical things in your Lordships’ House; I suspect that many might regard that as the most radical, but let us think about recapturing the streets for people. That is the space we all need to be able to use freely, without danger, and, circling back to my noble friend’s Bill, in a clean air environment. That would be a huge step towards a radical society and one which, as the Bill of the noble Lord, Lord Addington, makes clear, is absolutely a government responsibility.

East Kent Maternity Services: Independent Investigation

Baroness Bennett of Manor Castle Excerpts

Monday 24th October 2022 Lords Chamber

[Lord Markham (Con)]

I thank the noble Lord. As he rightly points out, the vast majority of workers are very diligent and good at what they do, and that should rightly be recognised. At the same time, I do not think any of us here wants to sweep under the carpet the problems that clearly exist. We need to be sure that, among the fantastic work, we are ever vigilant to root out the bad.

[Baroness Bennett of Manor Castle (GP)]

My Lords, a Department of Health statement on the appointment of the first ever patient safety commissioner—on which, as your Lordships’ House well knows, the noble Baroness, Lady Cumberlege, was a driving force—noted that the NHS Patient Safety Strategy was published in 2019

“to create a safety learning culture across the NHS”.

The statement also noted that it had introduced a statutory duty of candour, which requires trusts to inform patients if their safety has been compromised. I think everyone in your Lordships’ House is well aware that our NHS staff are exhausted, overstretched and overworked. When I read that statement, I could not help thinking about how there are different reports, strategies and approaches coming from all kinds of directions. Can the Minister assure me that staff are being given clear leadership from the very top and a clear framework in which to work, rather than a continual barrage of directions without the resources to deliver them?

Pharmaceutical Research and Development Spending

Baroness Bennett of Manor Castle Excerpts

Thursday 13th October 2022 Grand Committee

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Brinton. I thank the noble Lord, Lord Hunt of Kings Heath, for securing this debate, and the noble Baroness, Lady Wheeler, for so effectively introducing it.

I start this debate from a philosophically different position from other speakers. What we in the UK— and the world—need is not just or even primarily the most effective, efficient pharmaceutical research and development; more than that, we need the best possible health research and development, which often may not involve pharmaceuticals at all but instead improving public health by addressing the social and environmental determinants of health, so pharmaceuticals are needed less and can be reserved—saved—for the most essential, important and unavoidable uses, some of which the noble Baroness, Lady Brinton, just outlined. The noble Lord, Lord Goodlad, just focused on dementia, but of course huge and increasing amounts of research show that addressing issues such as diet, exercise and air pollution can have a tremendous impact on reducing the impact of dementia, and we must not forget that focus.

We are now living in the age of shocks. We have already had one pandemic shock in Covid-19, still continuing, both in the spread of the SARS-CoV-2 virus and the huge and little-understood impacts of long Covid, and we know that others threaten, including the avian flu virus that is cutting such a dreadful swathe through our wild bird populations—and the factory farming systems that incubated it.

So, were I to be wording this question, I would rather ask how the UK most effectively contributes to global health, and in pharmaceutical research—with our current academic and industry frames—we certainly play an important part. But some of our role should surely be to promote and support research and development of pharmaceuticals in the global south to strengthen systems there. I will restrain myself from venturing off into the disgraceful state of ODA funding, although I directly ask the Minister what assessment the Government have conducted on the dangers of the UK failing to deliver the support that others do to the Global Fund, given the assessment that the UK’s current plans could put over 700,000 lives at risk and lead to over 17 million new infections across the three diseases it covers?

What I will focus on specifically is influenced by an issue that many may have seen highlighted last week in the New Statesman in an interview with Dame Sally Davies, the first female Chief Medical Officer of England. It focused on antimicrobial resistance, on which Dame Sally said:

“I do wonder how long I have to go on pushing this. Have I failed? Well I haven’t succeeded, have I, or we wouldn’t be sat here.”


I have to warn the Committee that I am planning on pushing hard on this in the coming months, with the assistance of two brilliant senior interns, Julze Alejandre and Emily Stevenson, whose work is supported by the British Society for Antimicrobial Chemotherapy.

So how is this relevant to pharmaceutical research in the UK? As a rich nation with a well-developed health system, we need to provide a framework for drug development and purchase that acknowledges the need not just to look at the immediate impact of a treatment on a patient but its full impact on public and environmental health. How biodegradable is a drug, what is its ecotoxicity, and what will be the complete impacts of its development, manufacture and use? The Environment Agency has just started providing funding to a new research group looking at the impact of biocides and cross-resistance—but that is starting at the other end, after the damage has been done.

If we think of the UK as a place that truly seeks to understand the impact of medicines, both existing and developing, we can look to the pharmaceutical formulary used in the Stockholm region in Sweden, which considers not just the efficacy and safety, pharmaceutical suitability and cost effectiveness of drugs, as does the NHS, but their environmental impacts. Should not the UK, to provide “world-leading” research and treatment, be operating on the same basis?

I turn now to some specific questions, of which I have given prior notice, about the environment for research, development and use of drugs, particularly relating to the Government’s approach to the European Commission’s water framework directive, which sets out a watch list of priority substances. Once they are included on the watch list, EU states are required to monitor these substances, and the inclusion of these compounds helps to raise research interest in these agents, including their AMR selective potential at environmentally relevant concentrations. Until recently, the data used to inform selection of compounds on the watch list determined ecological risk based only on ecotoxicology tests, and it was only in 2020 that AMR selection risk was also considered as an end point.

Featured on the watch list, updated in August this year with five more drugs, are a variety of compounds with a host of essential applications, including antibiotics, antidepressants, synthetic hormones, diabetes maintenance medication and both human antifungals and agricultural fungicides. Can the Minister update me on how this EU update will be treated in the UK, and how talk of sweeping aside regulatory frameworks transferred from the EU to the UK after Brexit that has arrived with the new Prime Minister will be treated in this area of assessing water issues?

In the post-Brexit era and considering the potential risks of these pharmaceuticals on the environment and in terms of AMR, as a proportion of the UK’s pharmaceutical research and development budget, what is the commitment of His Majesty’s Government to ensuring that the monitoring and reporting of these pharmaceuticals will be done in the UK in a more robust, comprehensive and transparent manner? We were after all promised stronger environmental protections after Brexit. In addition, what are the Government doing to ensure that the results of these environmental monitoring assessments are available for researchers and healthcare providers so that they can make informed and wise decisions in choosing and developing pharmaceuticals that have less ecological impact and risk in terms of AMR?

A number of noble Lords will remember that one of the first votes that I called in your Lordships’ House was as a result of sheer exasperation at the Government’s failure to take seriously in the Medicines and Medical Devices Act, as it now is, the environmental, particularly AMR, risks of human medicines, to mirror the terminology in the Bill used for veterinary medicines. The Minister today has the opportunity to reassure me that, with even more concerning scientific research in the area since then, the Government are now taking it seriously.

Health and Social Care Update

Baroness Bennett of Manor Castle Excerpts

Monday 10th October 2022 Lords Chamber

[Lord Markham (Con)]

We live in a time of a very competitive jobs market and such a competitive market brings challenges with it, as the noble Lord says. We need to make sure that people feel that these jobs not only are recognised as important but make sense economically for them as well. We are investing £15 million in expanding our recruitment and resourcing to attract more people into the industry. We also need to look overseas and I think many are aware of our plans to do that. It is not lost on the team over here that we need to make sure that this is an attractive job and career for people to move into.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I join others in welcoming the Minister to his new place. I acknowledge that he has stepped in very late in the piece to pick up this Statement, but we are right to ask questions on it. Unlike the noble Baronesses on the Front Benches, I want to address the issue of the number and supply of doctors, particularly GPs. There are some strong statements here about “setting the expectation” of getting an appointment within two weeks, “opening up time” for 1 million more appointments and helping practices “improve performance”. Think about what GP practices have done in improving performance: there were 4.9 million more appointments in December 2021 than there had been two years previously—a 20% rise. A BMA survey found that nine out of 10 doctors reported that their workload was excessive and dangerous. This Statement says that there will be more and more GP appointments, but where will the doctors needed to provide this service in a healthy and safe manner come from?

[Lord Markham (Con)]

As I mentioned, we have 3,500 more doctors, but the 50 million more appointments target, which we are well on the way to delivering, is from not just GPs but across the piece. It is also from nurses and community pharmacies. I think we would all agree that doctors are our most precious resource. Given the comments on not wishing to overburden them and the stresses of that, we need to make sure that their limited time is focused on the patients that most essentially need that time. We are expanding supply and spreading it among nurses—as I mentioned, from my experience with my mother, they are very capable and willing to pick up a lot—and among pharmacies as well.

Urgent and Emergency Care

Baroness Bennett of Manor Castle Excerpts

Tuesday 6th September 2022 Lords Chamber

[Lord Kamall (Con)]

I thank my noble friend for his question. We have a debate this week tabled by the noble Lord, Lord Patel, on reform of the health system. One thing the noble Lord believes, as do a number of other practitioners and noble Lords who have worked in the health service, is that it is time to reform the old model of seeing your GP, getting five or 10 minutes if you are lucky, and then being referred to secondary care elsewhere. In this day and age, we need such reform. We need to take advantage of data and new technology but also to look at work processes. Some of the stuff that was being done in secondary care until recently can now be done at primary care level. Even in primary care, it does not always have to be the doctor who sees the patient; it can be a practice nurse, a physiotherapist or a local civil society group.

Clearly, there is a need to look at the model of the NHS and how services are provided; all parties recognise that there are areas for reform. It would be great if we could get consensus but, sadly, this issue is too much of a political football. When I speak with my friends from other parties, we say candidly that something has to change and that there has to be reform, but it is clearly too tempting to bash any Government. I know that, when we were in opposition, we would have bashed the Government of the day on health. It is, sadly, too tempting a political football.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I follow on from a point raised by the noble Baroness, Lady Merron. The Statement refers to the new contract with St John Ambulance—I join others in welcoming that—and to recruiting call handlers, paramedics and social carers. There is no reference to the acute crisis we have regarding doctors, nurses, midwives and associated health professionals.

To pick up on the question of whether we need a royal commission and systems change, the underlying situation is that the UK has 2.8 doctors per 1,000 people and 7.9 nurses, which is the second lowest in the OECD. Our number of hospital beds per head of population is on average lower than everywhere in the OECD but Denmark and Sweden. We simply have an acute lack of resources, which is independent of systems and is putting enormous pressure on services. We are now seeing huge pressure being put on medical professionals. Being a specialist in A&E is an acutely difficult and challenging task. The issues of ambulance response times and the queues of ambulances outside A&E are clearly putting huge pressure on people.

The Minister referred to the fact that, as we speak, we have a new Secretary of State. Surely it is time to acknowledge the contribution that those doctors, nurses and other medical professionals are making, through some kind of new, big gesture from the new Secretary of State to say, “We have to keep you. We really value you.” We are recruiting new people but others are walking out of the door as quickly or more so. This has to change. Surely a recognition of the care and service that has been given and continues to be given would help.

[Lord Kamall (Con)]

The noble Baroness makes a very important point which noble Lords across the House will agree. We should pay tribute to the hard work of medical staff in our system of care; there is no doubt about that. I take the point that this is about not just the ambulance service but other parts of the health service. In fact, had my right honourable friend the former Secretary of State stayed in post, he would have issued subsequent Statements on what we are doing about the GP workforce and some of the other issues that noble Lords have raised.

It is clear that one of the issues is retention. The NHS has its people plan, published in July 2020. We understand that people are leaving and, yes, there are newspaper headlines, but what are the issues behind those headlines? There is a very difficult issue around pensions and, particularly for some of the wealthier GPs, whether it is worth their while, having built up a massive pension over the years. There has been a bit of discussion and to and fro with the Treasury over that. However, it is quite clear at trust and workplace level that we have to make sure there are well-being courses and that we are looking after staff. We also have to look at the individual decisions as to why people may want to leave.

No doubt many staff are exhausted after the last couple of years. An amazing amount of pressure has been put on them and, as the noble Baroness says, it is right that we find ways to send a strong message that we value them and want to keep them as well as recruit new staff. We also have to look at this against the wider picture. We have more doctors and nurses than ever before. The question is: why, despite that, do we have this pressure? It is because the demand is outstripping supply.

We are now aware of far more health conditions than we were, say, five, 10 or 20 years ago. When preparing for a debate on neurological conditions the other day, I asked my officials to list them all. They said, “We can’t do that, Minister—there are 600.” Let us think about that. We were not even aware before of all those conditions. How many staff does that require? Or let us think about mental health: 30 or 40 years ago, it was not taken seriously; it was all about a stiff upper lip and pulling yourself together. Now we take it all seriously, and have mental health parity in the health Bill, which will need more staff. We will have more staff—more doctors and nurses—but the demand will outstrip supply. That is why a proper debate is needed across parties.

--- Later in debate ---

[Lord Kamall (Con)]

I thank the noble Lord for sharing that personal story—the good and bad side of it. I was on a visit to a hospital a few months ago where they showed us a nice, new scanner, which they were very proud of. The question was: how much is that used? Does it sit empty at weekends? With more networks and being more connected, we can find out where there is capacity in the system. If there is equipment, why are there not staff available? It could be for staff absence reasons. If it is not there, where can people go? With more community diagnostic centres, you will find lots more diagnosis facilities and scanners, so if the acute place does not have it, there should be availability in the community.

On the wider question about being “radical”, the noble Lord will know that, while we may have candid conversations as friends from different parties, sadly, health is too tempting to use as a political football. There are some issues that people feel very strongly about. Some of the points about charging that the noble Lord mentioned would be seen as too radical by some, or as undermining the very ethos of the NHS. I think we have to be prepared to be radical and think the unthinkable, but, sadly, this is the formal, political debate that we have got, and we have to work within the remit of that debate. Why should it be, for example, that millionaires could not pay a little bit more to help—not through taxation, but maybe direct?

Some local trusts have tackled this issue. For example, my local trust has set up a private arm, but the money paid for private diagnosis or surgery is reinvested into the hospital to help NHS patients. I know that more than one trust has done that. That might be an interesting way of raising more money and making sure that people value the service and care they get.

On the specific issues, one of the reasons we are having this discussion is because the former Secretary of State was looking at all the issues that need to be tackled now, both in the short term and the long term.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the noble Baroness, Lady Brinton, referred to overseas recruitment of doctors and nurses. The Statement refers to the “international recruitment task force” for social care. I am not sure if the Minister is aware of the report prepared by the Rights Lab at the University of Nottingham, The Vulnerability of Paid Migrant Live-in Care Workers in London to Modern Slavery. If not, I ask him to assure me that the department will be looking at this. The report highlights real issues about the treatment of migrant care workers, particularly in live-in situations. It is a cross-departmental issue, looking also at immigration issues like being tied to one employer where migration status is a real problem. It also looks at the need for a registration system for recruitment agencies. Can the Minister assure me that the department will look at that?

[Lord Kamall (Con)]

I thank the noble Baroness for the question. I am not aware of that report. If the noble Baroness would be happy to send a copy to my parliamentary email, I will happily forward it to officials in my department and see if we can get an answer to that.

Health Improvement and Food Production

Baroness Bennett of Manor Castle Excerpts

Thursday 7th July 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, I thank the noble Baroness, Lady Walmsley, for securing this debate and her excellent introduction. I particularly thank her for focusing on the work of Bite Back, which is a powerful demonstration of how the whole process of governance needs to listen much more to young people, who are getting more engaged in politics and political campaigning. We need to think about how we can get that to have more influence on decision-making.

It is a great pleasure to follow the noble Baroness, Lady Jenkin of Kennington. Your Lordships’ House will probably think she and I are entirely co-ordinating this because my speech focuses on exactly the same theme as hers—ultra-processed food—but, in practice, we have not exchanged a word in any form.

The practical reality is that there is a reason for this and a reason why we can see two opposite sides of the House arriving at the same point: this Government are failing to catch up with the science and the reality of what is increasingly happening around the world. The focus on foods that are high in fat, sugar and salt is simply not adequate to capture the reality of ultra-processed foods, as identified by what is known as the NOVA classification system.

Of course, the Government often like to talk about how they are world-leading. Well, they have some catching up to do with the Welsh and Brazilian Governments and other Governments around the world. Indeed, in researching this speech, I noted that the next set of dietary guidelines for Americans, for 2025 to 2030—they are now being drawn up—are expected to contain a new emphasis on the damage done to health by ultra-processed foods. So the Government have a small window here at least to catch up with the Americans; they could be doing so.

The extra theme that I want to introduce into my speech, in addition to what the noble Baroness, Lady Jenkin, said, is the impact of economic and regional inequality. This should be feeding into the Government’s levelling-up agenda. The disparities in our deeply unequal society, where levels of inequality are speeding past the Edwardian and heading back towards the Victorian—another time when we were very concerned about the impact of food on the health of the nation—are really having an impact. If we look at some of the people who are the most deprived, according to research by the Social Market Foundation and Kellogg’s from 2018, 1.2 million people live in food deserts. Research by Dr Megan Blake, from the geography department at the University of Sheffield, points out that living in a food desert

“can mean having to carry … food shopping a long distance, a struggle that many older people living in food deserts experience.”

I would go further than that. If we think about people with disabilities, who are one in five of the working-age population, or people caring for young children, carrying food long distances will tend to bias them towards ultra-processed food, which is lighter because it contains less liquid than fresh food. In that study, 41% of respondents did not have a car, but there is also the problem of financial barriers—something that we know is becoming more of an issue with the cost of living crisis. The latest ONS data from March 2022 showed that nearly a quarter of adults reported that it is difficult or very difficult to pay their household bills.

It is also worth thinking about the fact that people debating this issue often talk about choice. However, the type of food that we have access to and eat affects us in many ways, both obviously and subtly. When people have access to fresh produce, they can readily select the ingredients for the meals they want to prepare, whereas people relying on ultra-processed food, ready meals and takeaways are under the manufacturers’ control. Those who talk about choice need to look at who is in control in this relationship.

There have been detailed studies on this issue. A recent Japanese study showed that children who frequently eat instant food have significantly higher rates of inadequate nutrient intake and excess nutrient intake, while children who eat more take-out food had significantly higher levels of inadequate nutrient intake. Another study from Luxembourg showed that:

“On controlling for age, sex, socio-economic status and lifestyle factors, daily consumption of ready-made meals was found to be associated with higher energy intake and with poor compliance with national nutritional”


standards. A study by the American Journal of Clinical Nutrition in the past month showed that children aged three to five who ate more ultra-processed foods had lower locomotive skills, while children aged 12 to 15, again eating more ultra-processed foods, had higher levels of obesity.

Beyond the macronutrient considerations, it is worth thinking about what impact the consumption of ultra-processed food has on the human microbiome—something that we are increasingly coming to understand is crucial for physical and mental health. As Dr Rodney Dietert points out in his book The Human Super-Organism, many additives that are now common in our foods have been shown to dramatically alter the human gut microbiome, often leading to inflammation and disease. One example that he cites is the emulsifiers polysorbate 80 and carboxymethylcellulose, which show effects such as thinning the mucus layer and increasing inflammation, eventually leading to inflammation-driven disease in mice. A US National Institutes of Health report in 2015 shows that common food emulsifiers disrupt the gut microbiome and provide pathways to non-communicable disease, including inflammation-driven obesity.

These are issues that the Government have been told about, and of course they have to cite the excellent Dimbleby review of the national food strategy. This picks up the point from the noble Baroness, Lady Walmsley, that we are talking about not just human health but the health of nature. An agricultural system focused on producing commodities to put into this ultra-processed food has terrible impacts. As the Dasgupta review—another government report—said,

“the agricultural system has completely wiped out the natural system”.

So the food that we are producing causes enormous damage to both the environment and human health. Mr Dimbleby referred to “the junk food cycle”, saying:

“We will not be able to educate our way out of that feedback loop. It needs strong government intervention on commercial interests.”


Because the Motion focuses on food production, I want to pick up and focus on the point that farmers produce what the system has forced them to produce. We know that farmers are getting only about 8p in the pound of the cost of food. This is a situation where the Government urgently need to act to provide different options and different kinds of food system that provide a good living for farmers while ensuring healthy food for people.

The noble Baroness, Lady Walmsley, referred to the crucial and final government decision to introduce a land-use strategy. I propose, as I proposed during the passage of the Agriculture Act a couple of years ago, that it needs to focus on how we use land for food production for the best possible nutrient production per hectare, which without a doubt would mean huge amounts more vegetable and fruit production and much less grain and oil—which, incidentally, is what is recommended in the recent Sustainable Food Trust report, Feeding Britain. I urge the Minister to speak to his colleague, the noble Lord, Lord Benyon, who I know was at the launch of that report, which looks at the intersection of food production and health. I know that may not seem to fall within the remit of the Minister’s department, but it is something that he really should take a look at.

Of course, not all food has to be produced by farmers and growers—people operating commercially. We are seeing the NHS increasingly focus on green prescribing and looking at how people can be given access to healthy food but, even better, how people can grow healthy food for themselves. I will focus here on the work of the excellent Incredible Edible, founded in Todmorden but now a movement around the world. Let us see our green spaces producing food that is accessible and free to all. That is one way in which we can grow a much healthier diet.

When the Government talk about innovation in the food system, they like to focus on things such as gene editing—people in labs with test tubes. Some of the finest, most important and leading innovation is the kind of social, economic innovation that looks at how to produce food in different ways. When thinking about how we help farmers, growers and communities to produce that healthy food—we have been working on the infrastructure Bill—what could be a better addition to the UK’s infrastructure than an excellent system of research, support and advice, working with farmers and growers to produce a healthier food system? It would also need to focus on distribution systems—the ways in which food reaches people.

My final thought is on how often this debate drifts back into, “We can’t have a nanny state; people make choices for themselves.” Marie Antoinette was castigated for saying, “Let them eat cake.” What we have is far worse. The supermarkets, the multinational food companies, seed and chemical manufacturing, and fast food companies control what we eat, saying, “Let them eat extruded, moulded, milled, additive-rich food with added sugars, starches, fats and artificial colours, flavours and stabilisers. Let them eat this ultra-processed pap.” Indeed, people are not being given any choice but to eat this ultra-processed pap.

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)]

My Lords, I also congratulate the noble Baroness, Lady Walmsley, on securing this debate. I am also grateful to all noble Lords for their considered and thoughtful contributions. It is a self-evident truth that we all need food to survive. However, as with many things in life, it is not enough simply to restate this. As noble Lords have rightly said, there are many factors to be considered. How is the food produced? Is it done sustainably? How affordable is it, and what is its impact on our health?

We know that access to good-quality, healthy food is essential to achieving our ambition to halve childhood obesity by 2030, to reduce the gap in healthy life expectancy and to reduce the number of people living with diet and weight-related illnesses. The Government are committed to supporting the production and availability of good food to help improve the nation’s health.

As noble Lords have referred to, our recently published food strategy puts food security at the heart of our vision for the food sector. Our aim is to maintain broadly the current level of food that we produce domestically and to boost production in sectors where there are the largest opportunities. It sets out our ambitions to create a sustainable and accessible food system, with quality products that support healthier and homegrown diets for all. Our farming reforms are designed to support farmers to produce food sustainably and productively and in a more environmentally friendly way, from which we will all benefit. I am sure we all want to see a sustainable and healthy food system, from farm to fork and catch to plate, seizing the opportunities before us and levelling up every part of the country so that everyone, wherever they live and whatever their background, has access to nutritious and healthier food.

We all know that the food we consume plays a role in our overall health. Covid-19 highlights the risks of poor diet and obesity, driving home the importance of better diets and maintaining a healthy weight. As noble Lords have referred to, the Eatwell Guide outlines the Government’s advice on a healthy, balanced diet. It shows the proportions in which different types of food are needed to have a well-balanced and healthy diet, to help meet nutrient requirements and reduce the risk of chronic disease. We know that too many of us are eating too many calories, too much salt and saturated fat and too many large portions, and are snacking too frequently.

While some parts of the food and drink industry are leading the way, by reformulating products or reducing portion sizes, and I think we should pay credit to those parts of the industry that have done so and sometimes met targets in advance of target dates, the challenge to go further remains.

We know that obesity does not develop overnight. When you look at the behavioural contributions, it builds over time through frequent excessive calorie consumption and insufficient physical activity. It is not the stereotype of Billy Bunter stuffing his face with 75 cream cakes. Even eating small amounts of excess calories over time can add up for both adults and children. It catches up with many people over time.

As noble Lords have rightly said, obesity is associated with reduced healthy life expectancy. It is a leading cause of serious non-communicable diseases, such as type 2 diabetes and heart disease, and it is often associated with poorer mental health. We also know now that it increases the risk of serious illness and death from Covid-19.

Helping people to achieve and maintain a healthy weight and a heathier diet is one of the most important things we can do to improve our nation’s health. We all have a role to play in meeting this challenge: government, industry, the health service and many other partners across the country. As a government, we can play our role in enabling healthier food choices by making a greater range of healthier food more accessible; by empowering people with more information to make informed decisions about the foods that they eat; and by incentivising healthier behaviours.

As noble Lords have acknowledged, the food industry supplies most of the food and drink that we consume. Therefore, it plays a critical role in supporting the aims that we want to see, such as selling healthier food and drink. Through our reduction and reformulation programmes, we are working with the food industry to encourage it to make everyday food and drink lower in sugar, salt and calories. The programme applies across all sectors of the food industry: retailers, manufacturers, restaurants, cafés, pubs, takeaways and delivered food. We have seen some progress since the publication of chapter one of the childhood obesity plan in 2016, with the average sugar content of breakfast cereals and yoghurts decreasing by 13%, and drinks subject to the soft drinks levy decreasing by 44% between 2015 and 2019. These statistics are very welcome, but we know there is more to be done.

However, we also need to be careful about the unintended consequences. As an example, when the sugar content of Irn-Bru was reduced, customers complained about the taste. How did the company respond? By claiming to rediscover an old recipe from 1901, which contained even more sugar. It was a huge hit with Irn-Bru drinkers. How do we address these unintended consequences?

[Baroness Bennett of Manor Castle (GP)]

I thank the Minister for giving way. He referred to “everyday food and drink” and the formulation thereof. Will he acknowledge that, if we are talking about everyday foods, we should not be talking about formulation? You do not talk in that way about fruit and vegetables, and unprocessed food.

[Lord Kamall (Con)]

The noble Baroness makes an important point, but we have to recognise the reality: not where we want to get to, but where we are at the moment. People do eat food that will need to be reformulated if we want to make it healthier. Of course, we know that fruit and vegetables are healthy, but not everyone, as we help them transition, will eat fruit and vegetables, or make stuff from the raw products. They will buy products in supermarkets, and therefore if they are buying them, we have to make sure that they are healthier and reformulated. We do not yet live in that ideal world where everyone buys fruit and vegetables, and cooks everything for themselves.

Given that, we also need new regulations on out-of-home calorie labelling. As we know, many people go to restaurants, buy takeaways or have their food delivered. It is important that we have calorie labelling for food sold in large businesses, including restaurants, cafés and takeaways, which came into force on 6 April 2022. As noble Lords are aware, there will be further legislation, on restricting the promotion and advertising of products high in fat, salt and sugar, which will come into effect in the next few years. I know that many noble Lords disagreed with the Government’s views on delaying some of those measures. We will continue to have the end-of-aisle promotion on the target date, but others, such as “buy one, get one free”, are delayed because of the trade-off with the cost of living crisis, but will come. It is delayed, but we have set target dates.

Once again, we have to be open—

Nursing: Staffing

Baroness Bennett of Manor Castle Excerpts

Thursday 16th June 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a great pleasure to follow the right reverend Prelate the Bishop of London who, together with the noble Baroness, Lady Tyler of Enfield—whom I thank for securing this debate on the report—have covered clearly the huge issues that it raises. I want us to take a broader, global view and then look at some of the structural issues behind the immediate reality in that report.

On the global view, the World Health Organization tells us that there is a shortage of 5.9 million nurses around the world; that is nearly a quarter of the current global workforce of almost 28 million. The biggest shortfalls are in low and middle-income countries, notably in Africa, Latin America, south-east Asia and the eastern Mediterranean. I agree with the noble Lord, Lord Lilley, that we in the UK should not be taking people from other countries, particularly ones with a nursing shortage. We should be training in the UK more nurses than we need. As a wealthy country, that should be our responsibility.

The International Council of Nurses says that behind this shortfall are many structural problems, including low pay, poor conditions and—remembering we are talking about the global scale—inadequate training availability. I note that McKinsey & Company did a study which found that, in five of six nations surveyed—the US, the UK, Singapore, Japan and France—one-third of nurses said that they were likely to quit in the next year. This is not a problem simply contained within the UK.

Of course, Covid is a huge factor here; the WHO estimates that about 180,000 healthcare workers died from Covid, many of them no doubt occupationally exposed between January 2020 and May 2021. Many others would have been harmed by long Covid, burnout and mental ill-health from the difficult conditions they were facing. Looking back to 2021, a long-term study by JAMA, a US research network, found that female nurses were twice as likely as women in the general population to commit suicide. That is a very disturbing statistic.

The noble Baroness, Lady Tyler, set out very clearly that we have a problem in the UK; the Government have stepped up recruitment, but it is not even keeping us at the levels of staffing we have now. There are aspects of this job that are enormously, immensely difficult. There will always be people needing care at all hours and on weekends. It is not possible ever to make this a nine-to-five job for many people.

Nurses and midwives have to deal with tremendously difficult situations. I think of a student midwife testifying about being on a work placement in a delivery room which had just had a stillbirth. She was left, as a student, comforting the mother while other professionals in the room looked after the medical needs that needed to be cared for. Think about the fact that that student midwife is now paying to be in that situation. To study as a student midwife, that is what you do: you pay.

My thesis, which I want to explore a little today, is that the underlying structural issue is that nursing and midwifery as professions are profoundly undervalued. That is why we find ourselves in this long-term global situation. I am drawing on another Royal College of Nursing report from last year, titled Gender and Nursing as a Profession: Valuing Nurses and Paying Them Their Worth. I note that in the UK—I think this is broadly reflected around the world—this is one of the most gender-segregated professions; only about 10% of nurses are male. As this report notes:

“Nursing suffers from a historical construction as a vocation”.


Individuals, usually women, were seen to enter it because they had a calling, and the salary was almost incidental; it enabled them to keep pursuing that calling as it was just enough. We know that many nurses feel this and that, through the pandemic and at all times, they display huge amounts of good will, working far beyond their paid hours and in very difficult conditions, often without financial reward.

We have to go further even than thinking about the gendered construction of nursing. The question here is the gendered construction of care. As the RCN report I am citing says, care is seen as

“a naturally feminine skill or characteristic”

that sits opposed to professional skills and qualifications. But being able to care for anyone in even the most difficult situation is an emotional labour. This should not be taken for granted. It should be properly recognised and remunerated.

In the UK we are in a position to provide potentially global leadership. The Government should like this, as I will say that we were historically world-leading in the nursing profession, with Mary Seacole, Florence Nightingale and many other names I could cite. We helped establish the global pattern for nursing as a profession. Of course, the NHS as a large single employer has the potential to turn this situation around and truly acknowledge the contribution nurses and midwives make.

Yet over recent years we have seen austerity suppress wages. Our heavily suppressing the ability of trade unions to act in the UK has also had a huge impact on wages. It is interesting that, as the RCN report notes, there is very

“little variation in earnings across the nursing workforce”—

among registered nurses—

“despite the wide range of roles and responsibility”.

There is a huge undervaluing of all levels, but particularly the highest levels.

I am out of time. I wanted to comment on how, although only about 10% of the profession are men, they occupy 20% of the highest-paid roles, but I will leave the exploration of that for another day. I finish with a little thought experiment for your Lordships’ House. Bankers are paid an awful lot more than nurses. Why?