Folic Acid Fortification

Baroness Merron Excerpts

Tuesday 25th July 2023 Lords Chamber

[Lord Markham (Con)]

Yes, the noble Baroness is correct, and the point made by the noble Lord, Lord Rooker—that each year’s delay involves another 200 or so babies—was very well made. The beauty of this process is that it makes me shine a light on this issue, so I will be working on quite hard on it.

[Baroness Merron (Lab)]

My Lords, the last time this issue was raised in the Chamber, the Minister put delays down to co-ordination with the devolved Administrations and consultation with the EU due to Northern Ireland—which he referred to in the previous Question—before allowing industry to get on board. Just yesterday, noble Lords debated two statutory instruments that apply to the devolved Administrations, including one specific to Northern Ireland. Can the Minister explain why timely co-ordination across the nations has been possible on tobacco products and pharmacies but not on folic acid in flour, in respect of which time is obviously of the essence, given the importance of the neural health of babies?

[Lord Markham (Con)]

I thank the noble Baroness for that question; as I am rapidly learning, this is a complicated area. For the benefit of noble Lords who were not present yesterday, the tobacco arrangements are part of the Windsor agreement, so we passed primary legislation to allow us to make those changes. On the items before us, which involve secondary legislation, my understanding—if I am wrong, I will make a correction in writing—is that the co-operation of each of the devolved authorities is needed. That is why we are not able to proceed in Northern Ireland without its involvement. The plan is that we will go forward with GB-only measures if we have to. For obvious reasons, we would prefer not to do that; we want Northern Ireland to benefit from these changes as well but, as I have learned, it is a complex area.

Human Medicines (Amendment Relating to Original Pack Dispensing) (England and Wales and Scotland) Regulations 2023

Baroness Merron Excerpts

Monday 24th July 2023 Grand Committee

[Lord Allan of Hallam (LD)]

My Lords, I start with the point made by the noble Lord, Lord Dodds. Reading the Explanatory Memorandum, it was curious that in paragraph 10.2 we are told that the consultation was carried out by all the United Kingdom authorities, including

“the Department of Health in Northern Ireland”

yet the regulations clearly state

“England and Wales and Scotland”.

This does not surprise me. We are dealing with two instruments on the same day, one of them Northern Ireland-only and one England, Wales and Scotland-only.

I was curious about the answer on the Northern Ireland instrument, which is that we would need primary legislation, so it is easier to regulate tobacco products in Northern Ireland than it is in England, Wales and Scotland. I hope the reverse does not apply here, and that Northern Ireland is not included because some kind of legislative barrier means that they would find it harder than we would to regulate something which, on the substance of it, seems eminently sensible. Many people outside here might be surprised that pharmacists did not already have some discretion over how they dispense, given that packs are quite often in odd numbers. Having dealt with the scope point, again, the substance of it seems entirely sensible.

This must be a pre-recess present, as it is rare that people bring before us regulations which are good for patients, pharmacists and GPs. It is not only that everybody wins from the change being promoted; the Government have managed to get a “two for the price of one” by incorporating another change, which I know has come up. The noble Baroness, Lady Cumberlege, and others have campaigned for some time to improve the information given to women who are prescribed sodium valproate. So here we are: we are making two sensible changes in one instrument, and the Government should be congratulated on that.

For once, we have an impact assessment. We have four pages of regulation and 40 pages of impact assessment. My heart always sinks when I see a huge impact assessment but this one was really good. Whoever prepared it should be congratulated. There are lots of really good facts and figures about how prescribing works in the United Kingdom to help support the case, so I thought it was very well worked out. The fact that savings were identified independently for patients, GPs and pharmacists was extremely helpful in trying to assess the impact of the regulations. It highlighted that there is a potential increase in drug costs but that that is far outweighed by the savings that all those other constituencies make.

I would be interested in the Minister’s reaction to one number in it that surprised me. The impact assessment said that the cost of an e-consultation that would be saved—I assume it is for some sort of repeat prescribing —was £1.40. That is a very precise amount, but less than the saving from a patient going to the pharmacist to pick up their drugs. That figure surprised me because it felt low. I would expect a greater saving from reducing the number of e-consultations for people being represcribed drugs. Again, I am curious about where that came from.

I thought the model of trying to price out where the savings are, in a sort of piecework way, was extremely helpful, down to the 45p that will be saved by assistants in pharmacies not spending 90 seconds on splitting packs. That is super precise, but it is the kind of data that we want, and which can be tested to really understand how you are making savings all through the chain.

The other numbers that came out, that were just fascinating, were on the spread of prescriptions of paracetamol. There were two prescriptions for 10,000 paracetamol in there that were checked and found to be correct, which did surprise me. Even more surprising than the two prescriptions for 10,000 were two prescriptions for 1,009 paracetamol each. 1,009 is a very large prime number, so there is no “so many per day”; you cannot divide it by anything to get anything else. I assume that is a mistake, and that they meant to write 1,000 or 100 and stuck a nine on the end, because that is the only way I can think of that any GP would ever prescribe a large prime number of paracetamol.

I welcome more impact assessments like this with fun numbers in them, as they are extraordinarily helpful on a Monday before we head off for our break. More substantively, I genuinely hope that we will see more innovation such as this around prescribing and dispensing, because this is one of the areas that we have talked about a lot with the Minister. If we are to see improvements in primary care, we have to look for the kinds of efficiencies that benefit patients and make everything quicker and easier for the patient, but also make it more cost-efficient, because there are savings to be made that can in turn be ploughed back into the new enhanced services that we want to get from our pharmacists.

Again, as a substantive point, the general sustainability of community pharmacies is a problem. They are not getting the kind of income they need to continue to be present in all our communities. We see that in the closure rates; there are hundreds closing every year. As we look at changes such as this—the Minister talked about things such as the hub and spoke model—we have to bear in mind all the time that if we are making savings and are able to put those savings back into community pharmacies, that will be essential if we are to continue to have the kind of network that we need for the Minister’s ambitious plans.

This is a very welcome development. It is great to get two for the price of one; reducing the risks to pregnant women from sodium valproate is very welcome, but in terms of the scale of the dispensing operation, it is the 10% change that will potentially have a significant impact. As I say, I hope the Minister can commit that savings made through this will go back into that community pharmacy network that we all depend on.

[Baroness Merron (Lab)]

My Lords, as the Minister said in his introduction, this is an important issue. I too express my enthusiasm for this SI. We do not have a lot of SIs for which we have a lot of enthusiasm, so I hope the Minister and his team will be very happy with that. The reason for that is that this is common-sense and practical, and provides savings that can be diverted to benefit elsewhere, but also increases patient safety and is a better service to patients. It also allows pharmacists and their teams to do the job they are there for. That, in itself, is somewhat liberating for members of the healthcare team, so it is very welcome.

I also felt that the Minister had given an extremely detailed and welcome introduction, so I will just focus on a few questions in that regard. The first is about pharmacists. Given the changes and the impetus on pharmacists’ professional judgments, will there be any extra training, checks, reviews or similar put in place? I talk about the review not just to ensure that it is doing the job; are there other innovations that we can welcome in SIs in the future? That would be a very positive outcome.

Tobacco and Related Products (Amendment) (Northern Ireland) Regulations 2023

Baroness Merron Excerpts

Monday 24th July 2023 Grand Committee

My final point is on the question raised by the noble Lord, Lord Dodds, about whether we are going to see a landscape in which there is divergence across the piece. We are dealing with a small segment of the market today but I can easily imagine that the European Union might get its act together and regulate vaping much more aggressively and quickly than we do. It is potentially a much bigger deal if we have one regime for vaping in Northern Ireland and a different regime for vaping in Great Britain. It seems to me that that would be much more unsustainable and create all kinds of issues around cross-border smuggling and people moving products around so, again, it will be interesting to hear from the Minister where the Government’s thinking is in terms of convergence, which seems entirely sensible around the whole range of nicotine delivery products, versus divergence, where we end up with different rules on vaping, combusted tobacco products and these heated tobacco products. If we end up with divergence across all these fields, we are potentially walking ourselves into trouble.

[Baroness Merron (Lab)]

I start by thanking the Minister for introducing these regulations, which we welcome, and expressing my appreciation for the way he set out their application, the summary of which is that, from October, it will be illegal in Northern Ireland to produce or sell heated tobacco products that have what is called a “characterising flavour”. As the Minister explained, this change is happening because of the requirements of the Windsor Framework and in response to a policy change implemented by the EU—more of that later.

With regard to heated tobacco products, unsurprisingly, some in the tobacco industry have claimed that they are less harmful than conventional smoking. Has the Minister had time to review the analysis by the University of Bath, which has shown that most of the studies referred to in order to back up said claim were either affiliated with or funded by the tobacco industry? Surely that raises a considerable flag. Conversely, the European Respiratory Society has pointed to independent research showing that heated tobacco products emit substantial levels of toxicity as well as other irritant substances. Although the use of these harmful products is said to be very low in Northern Ireland, they are increasingly being marketed, without evidence, as a healthier alternative to smoking.

On that point, I would like to pursue the questions that have been asked by noble Lords in the course of this debate about whether there are plans to adopt similar legislation here so that there is parity between England and Northern Ireland; and whether there have been discussions with the other devolved Administrations in order to ensure that there is parity in legislation and, therefore, not the problems across borders that have been described. The noble Lord, Lord Dodds, explored this matter extremely well. I was particularly taken with the obvious practical example that somebody can purchase a product here and take it to Northern Ireland. What is the implication of that? That is going to happen all the time; it is just a fact. I am sure that all noble Lords will be interested to hear the Minister’s response on that.

Have the Government made any assessment of the prevalence of heated tobacco product use across the rest of the United Kingdom, principally in England, along with the wider health implications of such use? Perhaps the Minister could also outline what action his department is taking to combat the increased marketing of such products—marketing that is often underpinned by spurious tobacco industry-backed research, as I referred to earlier.

As was spoken to by the noble Baroness, Lady Ritchie, and the noble Lord, Lord Allan, can the Minister set out how the Government will assist Northern Ireland in the implementation of the ban, particularly given the possibility of illegal importation from England? It certainly seems strange—this point has come out in the debate—that, following the implementation of the draft regulations, there will be more stringent legislation in place to clamp down on heated tobacco products in Northern Ireland than in the rest of the United Kingdom. Can the Minister assist us in trying to understand how that will help? Are the Government considering implementing a ban on these products in their tobacco control plan, which was promised by the end of 2021? That leads me to the question of when—indeed, whether—we will ever see it published?

I want briefly to highlight concerns in relation to children and young people in particular. I note that the Secondary Legislation Scrutiny Committee referred to the fact that it was in the light of increased sales volumes among under-25s that the EU amended its legislation on heated tobacco products. In this regard, the Health and Social Care Committee in the other place recently took evidence from not only health experts but the industry. It made for interesting reading. The committee heard evidence that the topic of conversation for young people in the playground was often the different flavours that they were trying, such as

“Gummy Bear, Slushy and … Unicorn Milk and Unicorn Frappé”.

This was also referred to by the noble Lord, Lord Allan. These are different flavourings that are clearly not aimed at an adult audience. While we are talking about vanilla and other flavours in heated tobacco products, does the Minister agree that it will not be long before we see them being extended to products that are deliberately constructed to be attractive to children to get them to take up smoking? What is the strategy to deal with this?

It is absolutely crucial, in dealing with tobacco control and ensuring that we reduce harm to the health of people of all ages, that we look ahead. I hope that these regulations and the debate around them, including noble Lords’ contributions, will again alert the Minister to the need to anticipate future developments in tobacco products, not just in Northern Ireland but across the whole of the United Kingdom.

[Lord Markham (Con)]

I thank noble Lords for their contributions. As ever, they showed that there are interesting intricacies in every part of health; it is one of my key learnings over the past nine or 10 months that I have been in this role.

I want to clear up one thing. I admit that there was a bit of confusion on my part, as well. As the noble Lord, Lord Allan, said, we are not talking about vapes here—we are talking about heated tobacco. There is a heated tobacco stick, which basically heats to temperatures lower than that of a cigarette and releases an aerosol. I am sorry if noble Lords knew that already, but I thought that was worth clarifying. Because of that, this product is used by a very small number of people. It is estimated that less than 0.5% of smokers use this product; if you apply that to the population, it is 0.065%. I hope that this gives some sort of clarification behind our decision, when we talk about whether we did an impact assessment, because we are talking about very small numbers being involved here.

Emergency Healthcare (Public Services Committee Report)

Baroness Merron Excerpts

Thursday 20th July 2023 Grand Committee

[Baroness Merron (Lab)]

My Lords, I join other noble Lords in paying tribute to my noble friend Lady Armstrong for her leadership on this very important report. I also thank members and staff of the House of Lords Public Services Committee for taking the initiative to launch this inquiry to investigate the barriers to accessing emergency services, which we have discussed numerous times in the Chamber and will I suspect, sadly, continue to debate. I am glad finally to have the opportunity to debate this important report. As my noble friend Lady Morris justified and reminded us—although she should not have needed to justify it—the committee used the word “crisis”.

Worryingly, the committee argued that there was no sign of an adequate plan or the necessary leadership to address the problems it had unearthed. I am sure that is a concern to the Minister. This is against a backdrop of dangerous waiting times which have meant some 5,500 more deaths in 2022 than we had in 2019. This debate is an opportunity to unpick the Government’s recovery plan, which I will come back to later. It is a step in the right direction, but it is not sufficiently ambitious to ensure that patients are not waiting longer than is safe and the ambition it does have is not sufficiently underpinned by substance.

Several noble Lords have referred to the workforce plan. It was indeed long overdue and still needs substance behind it to make the difference it promises. I highlight that it is not matched by a social care workforce plan, which will always cause a problem for the NHS workforce plan. The key findings of the committee’s report on social care referred to the finding that:

“Unmet need in primary and community care and low capacity in hospitals and social care has left the emergency health services gridlocked and overwhelmed”.


The committee also discovered that when patients are ready for discharge, as my noble friend Lady Armstrong highlighted, there are often waits for community or social care to become available, meaning that beds cannot be accessed by other patients. Demographic change means that this problem in social care is not going away and will get only worse.

We therefore have a problem of a lack of a joined-up approach. I particularly want to highlight that, because my noble friend Lady Morris rightly illustrated that the whole system, which needs to work together, does not work together to allow for positive change. She used a very good example of the Metropolitan Police not responding to mental health call-outs. She was extremely reasonable in how she described it and used one of the many connections that there are: the interface between the police and the NHS. There are so many more, such as the interfaces I have just referred to between social care and the NHS, and between rural and urban, as the right reverend Prelate referred to. I am sure we in this Room could come up with a whole list of interconnecting situations not being addressed in an interconnected fashion. Perhaps the Minister could tell the Committee what work is going on to address this. It seems to me that this is absolutely at the heart of it.

I am also struck that problems faced by the NHS are not exclusive to the NHS. The noble Lord, Lord Allan, referred to frequent callers. Frequent callers are an issue that many other parts of our services are trying to deal with—for example, social services and the DWP. My question to the Minister is: what work is going on across government to focus on dealing with this challenge, which does not recognise boundaries? Of course, people do not recognise boundaries when they make a call for help.

I am sure that the Minister will refer to a delivery plan for recovering urgent and emergency care services, so I have a few questions on that in anticipation of his reference to that point. The plan set out a number of ambitions and one was about patients being seen more quickly in the emergency departments. It gives a new target, which says that there will be further improvement in 2024-25, from the original target of 76% of patients being admitted, transferred or discharged within four hours by March 2024. Can the Minister give us something of a flavour of what further improvement we might expect?

Similarly, the same question applies to the ambition of ambulances getting to patients quicker. The Government have stated that their ambition is:

“Ambulance response times for category 2 incidents will decrease to 30 minutes on average over 2023-24, with further improvements in 2024-25”.


Again, what further improvements might we see?

Certain areas were focused on in the recovery plan. I have a few questions on that. First, in respect of improving discharge, what does the recovery plan’s reference to “strengthening discharge processes” mean in practice? Is this new metric in place currently? What is that new metric and what is its predicted impact?

On funding commitments, there is a commitment of £150 million to build 150 new facilities to support mental health urgent and emergency care services, which, with my simple mathematical approach, means £1 million per facility on average. Are these really new facilities—a question raised similarly in respect of so-called new hospitals? If they are being built anew, how much is the expected cost of running them and is there a commitment to that funding to do so?

NHS Providers made some interesting comments, including that funding needs to be available to deliver change. It also talked about rising demand and persistent workforce shortages, because they challenge targets. I absolutely agree with my noble friend Lady Armstrong that the key enabler for achieving targets is improved patient flow. That runs throughout the whole of this report.

On ambulance trusts, there is a reference to a number of ambulance services—this might fall into the category of good practice to be rolled out elsewhere—seeking to increase the proportion of calls that are closed as “hear and treat”, where there is an appropriately trained member of staff at the call centre to deal with things over the phone. What progress can we expect to see in order for this to increase, and does the Minister consider this a way of dealing with the many challenges?

Finally, my noble friend Lady Morris mentioned the NAO report, which was extremely timely. She referred to a number of concerns raised by the NAO. I will not repeat them, but they bore out the point about the need to improve patient flow. The NAO talked about considerable variation in service performance and access between regions and across different providers, thereby highlighting inequality. As the right reverend Prelate reminded us, a part of that is the challenges faced by rural areas. The NAO also made the point that these various challenges pre-date the pandemic. Will the Government look at the NAO report alongside the committee’s report?

We will see, of course, whether winter pressures are going to be dealt with adequately. This will be an indication of whether the Government’s current plan is going to be helpful. However, my final question to the Minister is, what is his assessment of how the winter will look? I do not want us to get to the stage the committee alerted us to: that when we get to winter, we will have the same problems, only worse. The committee has done an excellent job in giving advance warning, and I hope the Minister and his department will take heed.

Food: Two-For-One Offers

Baroness Merron Excerpts

Wednesday 19th July 2023 Lords Chamber

[Lord Markham (Con)]

As I mentioned in answer to a Question on ultra-processed food yesterday, as a definition that is not particularly helpful because wholemeal bread, baked beans and cereals are all examples of ultra-processed food. The real point is the content of the food, and that is what our regulations should look to.

[Baroness Merron (Lab)]

My Lords, when the anti-obesity strategy was published, this ban was said to be supporting food affordability, citing evidence that multi-buy offers such as “buy one, get one free” increase the amount that people spend on foods by around 20% but often on foods high in fat, sugar and salt. With the Government now making the opposite argument to support this postponement, do they no longer stand by the evidence? Would a ban on these deals make it easier or harder for those who are struggling to get by?

[Lord Markham (Con)]

As we have mentioned before, our general direction of travel is to educate, reformulate and give people the best chances through having choices, and a good start in life through the fresh fruit and vegetables that we have in schools. Those are the things that will really make the difference.

Ultra-processed Food

Baroness Merron Excerpts

Tuesday 18th July 2023 Lords Chamber

[Lord Markham (Con)]

I thank my noble friend; that was excellently put. Again, it is the content of the food that matters and not what it is called.

[Baroness Merron (Lab)]

My Lords, to follow on from the Minister’s comments about the definition of ultra-processed foods, can he confirm what work is taking place to nail down a definition and, upon this definition, will the Government carry out the research that scientists believe to be necessary?

[Lord Markham (Con)]

As I have said, the fact that something is processed is not a helpful definition. I would recommend that we focus all our activity on the contents of the foods—whether they are high in saturated fat, sugar or salt—and not on whether they are processed.

National Health Service (Performers Lists) (England) (Amendment) Regulations 2023

Baroness Merron Excerpts

Thursday 13th July 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, we welcome the debate as an opportunity to look at some of the challenges around the number of GPs, dentists, optometrists and other primary care workers that we have available to us. I welcome the fact that the noble Lord, Lord Hunt, has given us that opportunity.

At the core of the statutory instrument, it seems sensible that we should accept registration from other parts of the United Kingdom where people are on the performers list in another part of the devolved system. To many of us, it is perhaps a surprise that it is not already the case that people on a list in one part of the UK are not automatically passported through to other parts. I am interested to hear from the Minister whether he has any information on how much of an issue this has been and whether there is quantitative or qualitative data around whether we have had significant numbers of practitioners in these fields finding that they had a problem as they moved from London to Edinburgh, Cardiff or Belfast and found that there was a barrier to them restarting their work as a professional because of this performers list issue. Any information he has on that would be helpful.

It would also be very interesting to know whether discussions are ongoing about reciprocal arrangements—whether the constituent parts of the United Kingdom will now plan to do something similar when a doctor on the performers list in England enters their system and whether there will be a similar arrangement for automatic entry to the performers list, subject to later checks, rather than having to apply from scratch.

My second point is to reflect on the user experience of trying to navigate the system, either as a practitioner who wants to work and is thinking about how to get on the performers list or as a member of the public. As the noble Lord, Lord Hunt, pointed out, part of the value—or intended value—of the performers list is that a member of the public can see if somebody who they are going to for treatment has been authorised effectively to offer treatment in their area. We want this to be very simple for everybody concerned, but it is quite confusing at the moment.

As part of my research for this debate, I went to a popular search engine and typed in “NHS performers list”. What I got back was a web page from digital.nhs.uk. The website had .uk at the end, so I assumed it was for the UK; the page was called “National Performers List”, and I assumed “national” meant it was for the United Kingdom. I clicked on that and then, on the next page, it told me that it is only for England. Nowhere in this does it explain to me that there are other performers lists for other parts of the United Kingdom. Nowhere am I given a link to say, “If you are interested in Scotland, go here”. The whole experience is a real confusion between the United Kingdom and England—I speak as a supporter of the devolved settlement, but if we are going to do it, let us do it properly. It seems to me that there is no excuse for not making it clear, given that the .uk bit of the service is not for the UK, that this relates to England and, if you do not want that, here is how to get to the other parts of the United Kingdom.

I note in passing that, if you have a problem with this system, the email address is for the Exeter helpdesk. As I think I have referred to before, I spent many happy years working on the Exeter system—the system for registering GPs—and I am pleased to see it still lives on in the helpdesk for people trying to find out about the performers list.

Equally, if you then come back and search for “performers list” for Wales, Scotland and Northern Ireland, you get a real mishmash of results. There is no consistency. Each of the constituent parts of the United Kingdom has some kind of thing that explains the performers list to you; none of them will link to the others or give you consistent information. In fact, the only place you can find it, if you are really lucky, is by stumbling across the website of the National Association of Sessional GPs, which I assume is intended for GPs looking for locum work. It has a really good explainer with links to all of them, but it seems to me that the Government should be at least as good as the National Association of Sessional GPs at signposting people to the right bit of the performers list.

The other significant area of the statutory instrument which is worth looking at is the question of the inclusion of overseas dentists, which I know the Minister is very familiar with and spends time on. Again, the Explanatory Memorandum tells us that this will improve the situation but is not very forthcoming on how. It tells us that one form of EU exemption will be removed and another system put in place. It would be helpful if the Minister could flesh out a bit about why he is confident—I assume—that it will be a genuine improvement. It would be interesting to hear a bit more detail about how he thinks it will be an improvement and how the new assessment process will help.

I have a final couple of questions. One foundational question, which comes back to the point about the impact assessment, is whether anybody has looked at how much value this performers list system actually adds over and above the existing professional registration systems. I do not think we should just take things as read. We have done it like this previously, where we have people registering with a professional body which requires passing all kinds of tests to get on to the register as a practising dentist or doctor within the United Kingdom—then we have this performers list system. I am genuinely interested in whether we have ever thought to ask whether it is useful to have the performers list layer on top of the general registration layer; if so, how useful it is; and whether the cost of having these two layers of registration is justified. It seems to me that we should always ask those questions; otherwise, we will have bureaucracy on top of bureaucracy.

Finally, I cannot miss this opportunity: I noticed today that in the Prime Minister’s announcement about the funding settlement, which is a welcome increase for various public sector professionals, he said that the Government are going to fund it in part by raising visa fee rates. That is critical. Here we are debating a measure which will make registration on the performers list as an overseas professional a little easier—and we all know that we need a continued stream of overseas professionals in this area. However good we are at training people, we are not going to get there for a while. I am interested in and hopeful about the Minister’s views on whether we are not giving with one hand and taking back with the other. We are making registration a bit easier, but we are going to make it a lot more expensive for people to get here in the first place. As I say, I cannot miss the opportunity to flag that there may be some inconsistency in government policy across that piece.

[Baroness Merron (Lab)]

My Lords, I think this debate is all about whether these regulations will do the job they are intended to do. As my noble friend Lord Hunt said at the outset, it is difficult to see whether that is the case in the absence of, for example, an impact assessment. I start by thanking my noble friend for again bringing this issue before the House. NHS dentistry is so important to people’s health and well-being in this country, and it has deteriorated, sadly, over a number of years. This is not an issue with the regulations themselves but whether they assist primary care in the way that it is said they are going to and that we all seek to do.

In terms of the background, there is no doubt—we all know this from our own experience and that of the people we know—that finding an NHS dental practice in the UK which will accept new adult patients for treatment under the health service is something of a rarity. Only one in 10 practices is offering that at present. That situation remains unsustainable.

Community Health Services: Waiting Lists

Baroness Merron Excerpts

Wednesday 12th July 2023 Lords Chamber

Asked by

[Baroness Merron]

To ask His Majesty’s Government what recent assessment they have made of current levels of waiting lists and times for community health services for (1) children and young people, and (2) adults.

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

We regularly monitor community health services’ waiting lists and recognise the variability between the number of people waiting and the time on waiting lists across services in local areas. We are committed to reducing waiting lists; that is why the NHS Long Term Workforce Plan sets commitments to grow the community workforce, with increases in training places for district nurses and allied health professionals and a renewed focus on retaining our existing staff.

[Baroness Merron (Lab)]

My Lords, long waits have a more severe effect on children because delays in assessment and treatment have a knock-on effect on their communication skills, social and educational development and mental well-being. With over 37% of children and young people on waiting lists for community health services for more than 18 weeks, compared to under 16% of adults, when will the Government address this ever-widening gap and what steps are they taking to prevent a disproportionate impact on vulnerable families both now and in the long term?

[Lord Markham (Con)]

The noble Baroness is correct about the urgency for young people; I have personal experience of this as well. We are taking steps by piloting nine early language and support services for all children focused on exactly what the noble Baroness mentioned. There is £70 million behind that pilot, with the intention being that we learn lessons from that and roll it out quickly.

NHS: Doctors’ Strikes

Baroness Merron Excerpts

Wednesday 5th July 2023 Lords Chamber

[Lord Markham (Con)]

I think the morale of doctors is best approached by a number of measures. As I said yesterday, there is not one silver bullet. There are a number of things: clearly, pay is important; pensions are very important, and we have addressed those, and so are working conditions. I was at Whipps Cross Hospital, one of the new hospitals, last week. The morale boost to staff there, knowing they are getting a new hospital, is massive. All those features are vital to improving morale.

[Baroness Merron (Lab)]

My Lords, in celebrating the 75th anniversary of the NHS, I too pay tribute to all NHS staff. It is therefore highly regrettable that the Government are currently presiding over the largest amount of industrial unrest in the history of the National Health Service, with doctors’ leaders warning that the strike action could last until 2025. With that in mind, what is the Government’s assessment of the impact of their failures to resolve NHS disputes?

[Lord Markham (Con)]

As we have seen, it is having an impact, regrettably. We saw that from 14 to 17 June: almost 100,000 appointments were lost during that strike. We are now looking to cover that up. That is why we are firm in our conviction that we want to resolve this situation. These sorts of things are not good for anyone. We have a formula that worked; we have managed to do this with nurses and the Agenda for Change unions, which make up the vast majority of the health service. Our hope is that we can sit down and have sensible conversations and do the same with doctors and consultants.

NHS Long-term Workforce Plan

Baroness Merron Excerpts

Tuesday 4th July 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am absolutely sure that the Minister is as relieved as anyone to see this Statement on the NHS workforce plan before your Lordships’ House today, after many years of waiting and promises of it being published shortly, imminently, or at some time in a very extended spring.

The plan promises much, but it is the delivery that will count and the difference it will make to the health and well-being of the nation. But at the heart of it, its effectiveness will stand or fall on how successfully it joins up with other key aspects of the NHS and social care. It is not just about delivery: the commitment to updating the plan every two years is essential in the hope that it will be a lasting way out of the continuing workforce shortages that have blighted the NHS for many years. Ministers have a lot at stake and are investing a lot of hope in this workforce plan, not least because the lurch from crisis to crisis has to come to an end, with proper consideration of the long-term challenges ahead.

This long overdue plan started and continues its life against a backdrop of chronic NHS understaffing. It is long overdue. If it had been launched eight years ago, it would have been enough to fill the NHS vacancy levels—yet we have had to wait. Instead, the NHS is short of 150,000 staff, and this announcement will take years to have an impact, while patients continue to wait longer than ever before for operations, in A&E, or for an ambulance. While the plan is a positive step, it is only the first step. Much more detail is needed on how the plan will be implemented and what measures will be used to judge its success. What attention is being given to training staff and key leaders in what quality management looks like?

Retention is key, and the plan has little to say about that. The overall staff leaving rate increased from 9.6% in 2020 to 12.5% in 2022. The plan acknowledges the importance of retaining workers, offering more flexibility and improving the culture in the NHS, but it is light on detail about how it might do that. We know that more NHS strikes are planned—and that work culture, bullying and harassment continue to be a real issue, and nearly one in 10 staff experience discrimination. When will there be details on retention, pay and working conditions, such that they can add some detail on how retention might be improved in the NHS?

It is a missed opportunity that there is no social care workforce plan, especially as the NHS workforce plan identifies the impact that delayed discharge due to difficulties securing a social care package is having on patients and staff alike. Without such a plan, it will not be possible to enhance the quality of care and support provided by the NHS—they are inextricably linked. There are currently 165,000 vacancies in social care, an increase of 52% and the highest rate on record. Average vacancy rates across the sector are at nearly 11%, which is twice the national average. What assessment has the Minister made of the impact that having an NHS-only plan will have on the social care workforce? Social care workers already seek jobs in the NHS, where pay and conditions are better. Does the Minister share my concern that an NHS-only plan is likely to exacerbate this situation and the number of vacancies in the social care workforce? Does the Minister consider that this will undermine the ambitions of the NHS plan?

As the King’s Fund rightly observed, the projections are likely to be based on ambitious assumptions. Yet there needs to be realism about the investment in buildings, technology and equipment that is needed to realise productivity gains. Can the Minister say whether and when we can expect plans relating to the various and absolutely crucial aspects of investment? Page 121 of the plan sets out a labour productivity rate of 1.5% to 2% per year. That was never achieved by the NHS or any other comparable health system, so what assumptions are being made in relation to achieving that?

The focus of the plan is crucial. It appears on reading to have been seen through a rather hospital-focused lens, so will the Minister ensure that the lens includes healthcare in the community? At the centre of this plan has to be the patient in all their different facets. In the consultations that took place in the lead-up to the development of this plan, could the Minister advise your Lordships’ House on how patient organisations were involved and which ones were consulted?

It appears that the plan seeks to look to the longer term. As happened in 2000, when the Labour Government of the time produced a 10-year plan of investment and reform which included seeking frequent staff increases, we will look to this workforce plan to make a difference to patients and care and the health and well-being of the nation in the same way as we saw come out of the plan in the year 2000. I look forward to the Minister’s response.

[Lord Allan of Hallam (LD)]

My Lords, I shall try not to be too grudging, as we have been calling for this plan for so long. I start by recognising the enormous amount of work that has gone into this from people working in the NHS and the department over a very long period, but the reality is that the plan is too late for those who are waiting for treatment today and are unable to get it, because the investment was not made in the workforce years ago for it to be available now on the front line. However, the plan certainly is substantive and there is much to welcome in it, looking forward. There are several areas where I hope the Minister can explain the Government’s thinking further.

First and perhaps most importantly, we need a similar, sister plan for the social care workforce. As we have discussed many times across these Benches, health and care work in symbiosis and both have seen too little supply to meet demand in recent years. Can the Minister confirm that the Government have no plans to further reduce capacity in social care by acceding to some of the requests from his political colleagues to limit visas being made available for essential social care staff? Can he say when the Government intend to release a sister plan to the NHS plan dealing with the social care workforce?

The plan also depends on ambitious productivity gains, and these will require certain things to be put in place. First, we need technology that will make life easier rather than more difficult for staff. Will the Minister explain what work is being done to understand how front-line staff in the NHS actually experience the technology they are being provided with, to ensure that we are not setting them back? Technology, when implemented well, leads to productivity increases, but technology poorly implemented can simply add to the frustrations of staff and make their jobs more difficult.

Another key factor in productivity is good management. This is a much less fashionable area to comment on than additional doctors and nurses, but the evidence seems to suggest that the National Health Service is actually quite lean in terms of its management. Will the Minister comment on what is in the plan to boost management capacity so that we can make savings on that other kind of consultant, the management consultant? Far too much is still being spent on externalising management expertise rather than building capacity within the service.

The final area I want to comment on is retention. The plan has hard numbers and new targets for getting new people into training but is much less precise on how we can improve staff retention over the long term. This is of course, quite importantly, a matter of pay and working conditions across all grades of staff. I invite the Minister to comment on some of the press stories we have seen saying that there seems to be some reluctance on the part of the Prime Minister to implement pay review body recommendations in full, something that he himself has said we should rely on to resolve issues particularly around junior doctors. Certainly, understanding that pay is important and that review body recommendations are going to be respected is critical for retention.

We can see that the Government have looked very closely at the specific factors that discourage senior doctors, in particular, from staying on as they approach retirement age. I suggest to the Minister that similarly detailed work needs to be done to understand the precise factors that are leading more junior staff at earlier stages in their career to leave the profession. Similar attention must be paid to resolving those specific issues if we are to address the retention problem.

One way we can motivate staff to stay on is through continuous professional development and retraining into more highly skilled roles, yet training opportunities can be constrained by the capacity of those delivering it. Can the Minister assure us that training opportunities will be provided for existing staff as well as new staff, so that we do not end up holding back Peter in order to train Paul? It will be net negative if we lose staff from the existing workforce through missed training opportunities as we bring in new staff. More generally, is there an understanding of how we are going to build up that capacity for training existing and new staff?

When I was younger, I had a teacher who would often write on my essays, “Okay as far as it goes”. This would annoy me, but with the benefit of wisdom and age I have to concede that it was often fair and accurate. Today, we might say that this plan, into which I know a huge amount of work has gone, is okay as far as it goes. We can be confident that it will really make a difference only if it is delivered in full, and in particular if there is a sister plan for the social care workforce and a real effort made on staff retention. I hope the Minister will comment on some of those aspects.