Mental Health In-patient Services: Improving Safety

Baroness Merron Excerpts

Monday 3rd July 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I welcome the announcement in this Statement that the inquiry to investigate the deaths of mental health in-patients across Essex between 2000 and 2020, chaired by Dr Strathdee, will now be given vital statutory powers. This is an important and long overdue development. Not only have the grieving families suffered the pain and anguish of bereavement, and how they have felt in their fight for answers over so many years, but all of this has been compounded by an inquiry that lacked the necessary powers to seek the truth. It would be helpful for your Lordships’ House if the Minister could shed some light on why it has taken so long to allow the inquiry to do its job thoroughly.

More broadly, and connected with this issue, are repeated scandals in in-patient mental health settings involving abuse, dehumanising behaviour and needless loss of life, such that more than one in three people say they do not have faith that a loved one would be safe if they needed mental health care in a hospital. How will the Government seek to restore essential public confidence?

The situation set out in the Statement is against a backdrop of some 1.6 million people on waiting lists for mental health treatment. Their condition is deteriorating and can reach crisis point. At the same time, the incidence of poor mental health continues to rise. Those in poverty or financial difficulty are particularly at risk, to mention just one group. With the cost of living crisis continuing unabated and children from the poorest 20% of households four times more likely to develop serious mental health difficulties by the age of 11 when compared with the wealthiest 20%, this is an upward and unequal trend that the Government have to tackle. I hope the Minister can comment on how this will be properly dealt with.

I will pick up some particular aspects. Families of patients in Essex will welcome the news that this inquiry will be put on a statutory footing, but across the country those failed by inadequate mental health services are in desperate need of answers and need change. In March 2022 the CQC released its Out of Sight report to identify what progress the Government have made in addressing the culture, behaviour and design of services for patients in mental health in-patient settings. Will the Minister tell your Lordships’ House what progress has been made in implementing the recommendations in full?

If we are to bring about change, it is very important that the rapid review of data in mental health in-patient settings translates into action and the report does not simply sit on a shelf in the department. Can the Minister tell your Lordships’ House when the Government’s response to the review will be published and whether he will set out a timetable for when the recommendations are to be implemented?

Over the past year there has been a flurry of reports, as we know only too well in this House, of patients being failed in the care of mental health trusts around the country. Have Ministers actually met the leaders of those trusts to find out what has gone wrong? If not, do they plan to meet and when?

The Government have shelved the 10-year mental health strategy and, despite promises first made in 2018 to reform the outdated Mental Health Act, legislation has repeatedly been delayed. The Joint Committee on the Draft Mental Health Bill published recommendations for improving legislation in January, but thus far Ministers have still not responded to the report and the Bill is yet to be introduced to the House of Commons. Will the Minister please update the House on when it can be expected?

When it comes to mental health, taking a preventive approach would mean fewer patients needing to use in-patient services in future. Have the Government considered shifting the system towards prevention by providing mental health support in every school, for example, and a mental health hub for young people in every community? Ensuring that there are enough staff to provide adequate services is vital to improving patient outcomes, so can the Minister say some more about what plans the Government have to retain staff, to recruit new staff and to expand access to mental health treatment? I look forward to hearing from the Minister on these points.

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to have an opportunity to discuss mental health provision, and my comments will very much follow on from those of the noble Baroness, Lady Merron. We are also interested in the Government’s latest thinking about the draft mental health Bill. Now that the workforce plan is out—we will discuss it tomorrow—our new refrain may be, “When will the Government get on with the mental health Bill?”. It is long overdue, and a huge amount of work has gone in that is clearly fundamental to trying to deal with some of the structural issues.

Turning to some of the issues raised in the Statement, I first want to ask about people’s journeys when they are in need of mental health support. The Statement said that 111 will now provide mental health advice, which is very welcome, but can I ask the Minister for his thoughts on what is happening in primary care? My understanding is that at the moment mental health nursing provision is not a requirement of all general practices—some offer it and others do not. Can the Minister, who I know cares about joined-up, seamless services, give us some insights into the Government’s thinking on ensuring that people who present with mental health problems to general practice—which is the first port of call for many of them, before they even get to 111 or 999—see more consistency of support available at that level?

Thinking about the review—a major part of what is in the Statement—a significant proportion of providers of mental health in-patient services are private sector, which has been the case for some time. Can the Minister confirm that they will be included in the review and comment on whether the inspectorate’s powers will be applied equally to the private and public sectors? That is critical to understanding what is happening in all settings.

Will the Minister also talk a little about the input the review may get from related services? Again, we know that the police, local authorities and accident and emergency departments often pick up the pieces where mental health provision has not been made available. Can the Minister assure us that the review will also look at all those other parties to this journey of care that people require? Can he also comment on the data questions? I have seen evidence from freedom of information requests to the Office for National Statistics asking about deaths of people in mental health in-patient settings. My understanding is that the data is not recorded consistently. If we are to have a review and to understand what is happening in the mental health sector, it would be helpful to know what measures the Government will take to improve the consistency of data collection so that, when someone unfortunately suffers a tragic incident, we know where they were at the time and have the data available to build up the national pattern.

The final issue I want to ask for the Minister’s comments on is out-of-area placements. Will he acknowledge that it remains a serious issue that many people with serious mental health conditions are able to get treatment only in places that are far from home and therefore far from their families and support networks? I note from the Statement that the Government are providing three new hospitals. This is of course welcome, but I hope the Minister will also be able to confirm that there is a locality-based strategy, with the Government thinking hard about matching local facilities to local need so that we can end the situation in which people at a time of extreme distress are sent very far away from home, which can only add to the crisis they are facing.

Lung Cancer: Screening

Baroness Merron Excerpts

Monday 26th June 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I thank the National Screening Committee for its work and welcome this Statement, which outlines the only response that makes any sense: the establishment of a national targeted lung cancer screening programme. I also pay tribute to the many individuals and organisations that have worked over many years for this, in particular the Roy Castle Lung Cancer Foundation, which, in addition to campaigning, has been delivering its own scans since 2016.

I very much wish to associate these Benches with the thoughts of the late and much-missed MP for Old Bexley and Sidcup, James Brokenshire. I acknowledge the work he did in bringing this cancer screening programme about, which was continued by his wife Cathy. This is a very fitting Statement with which to honour his memory.

There is no doubt that diagnosing more people earlier is absolutely crucial. This programme will certainly improve that, but it does have to go hand in hand with treatment that is available rather quicker than is currently the case. The UK currently lags behind the European average for five-year survival rates for lung cancer. More broadly, since 2010, ever more cancer patients have waited longer than is safe to see a specialist. The target of 85% of patients to start treatment from initial GP referral within 62 days has not been met since 2015.

Can the Minister tell your Lordships’ House whether this extension of screening will be matched by the necessary improvements in access to treatment? If the treatment programme is to be improved—as surely it must be—how will this be done, and when? Will it be new money or a diversion from existing resources that funds the programme and any associated improvements in treatment?

Turning to the areas where lung disease is most prevalent, notably those with the greatest deprivation and health inequality, can the Minister give an assurance that resources for the screening programme will continue to be targeted at the areas that need it most? With existing health structures already worse in these areas, how will they be improved to support the delivery of the lung cancer screening programme?

Despite the Government’s support today, it has taken nearly nine months to act on the recommendation of the National Screening Committee, and there is now a timeline to reach 40% of the eligible population by March 2025, with full coverage by March 2030. Can the Minister say whether work is going on to hasten the timeline of this rollout?

The Health and Social Care Select Committee’s report last year into cancer services concluded that a lack of serious effort on cancer workforce shortages risks a reversal in cancer survival rates. While we have been promised the NHS workforce plan this week, after many years of waiting, I note that the Government’s press release had just one line on the workforce necessary to make the screening programme a reality, saying that additional radiographers are due to be appointed. Can the Minister assure the House that when we do get the workforce plan, it will address the major shortages that were outlined by the British Thoracic Society, whose report identifies workforce shortages as the main challenge in the provision of healthcare to those with lung conditions?

As the Minister rightly pointed out in the Statement, smoking is indeed the leading cause of cancer, causing 150 cancer cases every day and one person’s death every five minutes due to smoking-related ill health. It is therefore important that alongside diagnosis, we work to stop people smoking in the first place and support those who do smoke to quit. Yet the number of people quitting has slumped since 2010 and smoking cessation services have been cut. Can the Minister confirm when we will get the awaited Government response to the review of tobacco control policies, led by Dr Javed Khan?

It is not only smokers who have lung cancer and other lung conditions. The context in which all of this takes place is a range of other factors in addition to smoke and smoking, and that includes air quality. It would be helpful if the Minister indicated what is being done to tackle these broader challenges. Furthermore, it is not the diagnosis of lung cancer only that will improve through the screening programme, but also that of conditions such as cystic fibrosis. What expectation does the Minister have in this regard?

My Lords, I am sure we all want to see this national, targeted lung cancer screening programme save lives, and I hope the Minister can give the reassurances I seek today.

[Lord Allan of Hallam (LD)]

My Lords, I would like to follow the noble Baroness, Lady Merron, in welcoming the Government’s acceptance of the National Screening Committee’s recommendation to introduce a targeted lung cancer screening programme, and echo her tribute to the late James Brokenshire, whom I dealt with in a previous capacity when he was a Minister advocating for child safety online. I found him to be very effective; a firm Minister who was also very pleasant to deal with—the most effective model for all of us.

The new programme is especially welcome as a step towards addressing the glaring health inequalities we face in the United Kingdom. I hope the Minister will reassure us that sufficient data will be collected in order to understand whether it is having the kind of impact the Government intend, as he outlined in the Statement.

I hope the Minister can also provide more information about how it can be delivered, given that we already have dire shortages in capacity to deliver diagnostic tests. This shortfall is reflected in today’s report from the King’s Fund, which shows a serious gap in CT and MRI scanner capacity between the UK and comparable countries. When can we expect to see investment from the Government in additional scanners, to bring us up to something more like the international mean? As well as the lack of machines, we do not have sufficient people to operate them or to assess the test results. I invite the Minister to refresh his formula for when we may see the long-awaited NHS workforce plan, including the element that relates to radiologists, perhaps updating it from “shortly” to “in the next week”, as it surely has to come before the 75th<sup>anniversary of the NHS on 5 July.

The concern we continually have with announcements of new services by the NHS in the current context is that they will come at the expense of existing services; the noble Baroness, Lady Merron, also referred to this. I believe this is a rational and reasonable concern to have, given the evidence of missed targets and unacceptable wait times that is all around us. I hope the Minister can give us further assurances that, as the Government will the end of catching more cancers earlier, they will also be willing to will the means to deliver on this promise.

Anyone with eyes in their head can see that vaping is being cynically promoted to young teenagers; it is all around us in high street shops and in the evidence from the litter around schools. The Statement refers to the role of vaping as a tool to help existing smokers give up their harmful habit, but there is increasing evidence that vaping is creating new nicotine addicts, with associated risks. The Australian Government have found that young people who vape are three times as likely to take up smoking, and they have plans to bring in a range of measures to suppress vaping among young non-smokers. Can the Minister explain what assessment the UK Government have made of the Australian evidence of vaping leading to higher smoking prevalence among young people, and are the UK Government considering similar measures to reduce vaping use here? It took us five years to follow Australia in introducing plain packaging for cigarettes. I hope we can follow faster here, on vaping.

The new screening programme is welcome, but it must be properly resourced with both machines and people. I hope the Minister can give us some insights into how that will happen, and at the same time explain what action the Government intend to take to reduce vaping among non-smokers, so that we do not end up creating a new wave of people who are at risk of lung cancer.</sup>

--- Later in debate ---

[Lord Markham (Con)]

I thank the noble Lord, Lord Kennedy, and I am sorry for the loss of his brother. I agree with his sentiment that while this is good news today and is welcomed by all, it shows that this is a journey and that we need to do more in lots more areas. I take on that point and say, from our point of view, that we agree that we must work together to make further progress.

[Baroness Merron (Lab)]

Could I give the Minister another opportunity to pick up on the key point I raised? We very much welcome the improved diagnosis rates—and my noble friend Lord Kennedy makes a very pertinent point that, of course, we are talking not just about one cancer. I thank him for sharing his views and feelings with your Lordships’ House. That takes me to my reminder to the Minister: I asked about matching improvements in diagnosis with improved access to treatment; otherwise, we are leaving people diagnosed but not matching it by giving them the treatment they need in a timely manner. Could the Minister assist with that point?

[Lord Markham (Con)]

I am sorry; I was answering in a generic format in terms of the new CDCs. The noble Baroness is quite right that diagnosis is one thing—and we all know that the early stages are key—but you then have to follow that up with treatment. Of course, the good news is that if you can detect cancer in people at the earlier stages, they need less treatment. The resources I mentioned, in terms of what is being spent on the programme, take into account the treatment required as well.

Of the people being identified at this stage, only 1.4% from the pilot were then positive and needed treatment, thankfully. Obviously, those resources are in place. There is a second interesting category of people—about 17% or so—who are fine but we want to make sure that what has been noticed is in an okay state.

I am going to grab my notes to make sure I am referring exactly to the right term at this stage. I apologise; about 1.7% have nodules, which is not a problem per se, but it is a problem if those are growing. The idea is that we will be getting those people back in for frequent scans on a three- to six-monthly basis and using AI technology to see whether or not the nodules are growing. If they are not growing, it is not a problem, but we then keep up the frequency of scans. Obviously, if they are growing, that would be a concern at the early stages, and that would then move them into the treatment category.

The other 80% or so of people fortunately will not have any concerns from the scan at all. At that stage, they will be put into this continual programme, where they will be reviewed every couple of years to make sure that we keep on top of it. I hope that this shows that this is a well thought-out, entwined service, with the idea being that for the 1.4% who are identified as needing cancer treatment, the treatment is there to back them up.

NHS: Performance and Innovation

Baroness Merron Excerpts

Thursday 15th June 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am most grateful to the noble Lord, Lord Scriven, for securing this debate and giving us the opportunity to think about the link between current performance and innovation. I am also grateful for his introduction of the subject before us.

The noble Lord, Lord Crisp, and other noble Lords were absolutely right to remind us that innovation is about not just technology, important though that is—I will come back to that—but people, their practice, their professionalism and the way they work together. I hope the Minister will bear that in mind, because we are going to come to the issue of the workforce plan, which we still await.

A number of noble Lords have made the point that they have resisted talking about the difficulties faced by the NHS, but I am not going to resist. While the Minister has had a break, we must return to that subject because the fact is that the NHS has just not been able to meet many of its pledges—for example, on maximum waiting times—in recent years. The noble Lord, Lord Allan, made reference to the gap between the expectation that people have of the NHS and the delivery that they experience. We have raised that many times in this Chamber, and it is not just about expectation; it is also about people’s absolute need. It is more than disappointing that so many legitimate targets—which were set for a very good reason, which was to provide the best kind of healthcare—have just fallen by the wayside.

At the beginning of the year, the number of people on a waiting list for hospital treatment rose to a record 7.2 million. That number consistently rose between 2012 and 2019, and has risen more quickly since early 2021. I hope the Minister will resist constantly blaming the pandemic. It is of course true that the pandemic exacerbated waiting lists and has created many new challenges, but these problems existed before the pandemic and it would not be right to hide behind it, particularly when, for example, the 18-week treatment target has not been met since 2016.

The percentage of patients who have waited more than four hours in hospital A&E also rose consistently between 2015 and 2020, with a new record high reached in December 2022. We have discussed ambulance response times in this Chamber many times. These too have risen, with the average response time to a category 2 call in December 2022 standing at over one hour and 30 minutes, when the target was 18 minutes.

On cancer waiting times, targets are repeatedly missed and performances in April were among the worst on record. To give just one example, in April the 62-day target of 85% was not met, as only 61% of people started their treatment for cancer within 62 days of an urgent referral. This means that some 5,200 people who started treatment for cancer in April waited longer than 62 days after an urgent referral, when we all know that speed is of the essence.

In all this, my noble friend Lord Parekh and other noble Lords were right to say that there is much concentration on hospital care. Hospitals are of course a key part of the infrastructure, but we need to have more focus on primary care and to see joining-up—not just across government but, as noble Lords have said, across the whole NHS, along with social care. Noble Lords also spoke rightly today about the importance of prevention. The noble Lord, Lord Addington, and others raised this; we have to put far greater emphasis on prevention.

It is true that there has been a number of innovations and they are very welcome, but they are small fish when we compare them with the big picture. When we look at the revolution taking place in medical science, technology, working practices and data, we are missing out on the potential to transform our healthcare. There is absolutely no reason why this country should not be leading the rest of the world in this field, but it so often feels as if the NHS is stuck in something of an analogue age and that it has been allowed to happen under the watch of this Government. The future of the health service has to see, as noble Lords have said, more care taking place in the community. That would reduce the burden on hospitals; it would also allow patients to receive healthcare in their own home or close to home. But a slow adoption of technology has worked against this, as has the lack of joining-up within the system.

In his welcome intervention, my noble friend Lord Turnberg gave examples of both existing and previous practices that could be called upon. He also referred to the importance of having higher standards and a higher regard, and reward, for social care workers. If we are to support the development of social care and the healthcare system, those workers are absolutely essential.

The noble Lord, Lord Crisp, drew on examples of the network of community health workers in other countries, including Brazil. When I was an International Development Minister, prior to being a Health Minister, I also saw such networks growing and flourishing across African countries. They were built on trust, on locality and on harnessing people’s abilities and their links with communities. As the noble Lord asked, is it not interesting that that has inspired innovation in places such as Westminster and Calderdale? Who would have thought that?

I must say to the Minister that throughout the debate, I have been left reflecting that innovation, while it does exist, is patchy, and that is part of the problem. The IPPR estimates that, for example, the introduction of automation could be worth some £12.5 billion to the National Health Service by freeing up, among other things, staff time and by creating better productivity. Why are we not drawing on that?

I will refer to some missed opportunities, and then perhaps the Minister can explain why we find ourselves in this position. There are now tools which can map radiation therapy on to cancer cells and avoid organs more precisely than can an oncologist working alone. They do that in seconds, rather than the hour it takes a doctor. This is standard technology, used across the United States. However, just one in three radiotherapy planning centres in England uses this technology.

Between 1 million and 2 million mammograms are done across the UK every year. Although 96% will not find cancer, women are currently left in the dark for weeks, and even months, waiting for their results. The noble Lord, Lord Allan, suggested something quite obvious: why is there not a better technological means to notify people of their results? Why is there a hold up on mammograms? Because two clinicians are required to check them, and there is a workforce crisis. However, AI could rule out cancer-free screens in seconds, giving patients their results faster and freeing up clinicians to focus on the tests that display abnormalities. It has been rolled out across Hungary since 2021, but not across the National Health Service.

AI can also help to interpret chest X-rays, saving 15% of a radiologist’s workload. When combined with interpretation by a consultant radiologist, it could reduce missed lung cancer cases by 60%, but it has yet to be fully adopted by the NHS. Can the Minister tell us why?

We all know that staff shortages across the NHS workforce are not only a barrier to meeting important waiting times but also limit the NHS’s ability to adopt and develop innovation, in both a technical and technological sense, and a people sense. We have recently been told that the NHS workforce plan will arrive shortly—after many years of it not arriving shortly. Perhaps the Minister could again answer the question of when we will see it, whether it will be fully funded, whether it will ensure a look to the future and how it will deal with the immediate.

The NHS should not be lagging behind. It is a universal, single-payer service and it ought to be the best-placed healthcare system in the world to take advantage of changing technology and medicines. After all, what other health service can offer innovators a market of some 50 million patients and give the life sciences industry access to a diverse and large population sufficient to develop new medicines, in the way that our NHS can?

In drawing my comments to a close, I want to offer some solutions from these Benches to add to the points raised by noble Lords in this debate. On procurement, the NHS should identify the goods and services that should be purchased at scale and buy them at a discount. This would also cut out unnecessary bureaucracy and stop new technology being re-evaluated for years, while the world moves on and beyond. In clinical trials, I suggest that every trust could operate through a standard system so that the number of contracts needed is minimised and the administrative burden is eased across the system.

While I accept the point made by the noble Lord, Lord Allan, that apps are not everything, they are important and proper use of the NHS app could be made and extended. It currently has some 30 million users—that is a tremendous reach—but every patient should be able to see their medical records through it. They should be able to use it easily to book appointments, order repeat prescriptions and link to appropriate self-referral routes. When patients reach an age at which they should be screened or need a check-up, the app should alert them, just as we are constantly alerted by apps in other areas. If people are eligible for a clinical trial, the app should tell us.

For the NHS to be fit for the future, it has to make fundamental change and there has to be a different way of doing things. I hope the Minister will reflect on the debate today and take heart from the fact that we all want to see change, but that he has the responsibility to deliver it at present.

Cancer Referral Targets

Baroness Merron Excerpts

Monday 5th June 2023 Lords Chamber

Asked by

[Baroness Merron]

To ask His Majesty’s Government what steps they are taking to ensure that NHS trusts in England meet their target for cancer patients to be treated within two months of an urgent GP referral.

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

My Lords, NHS England continues to actively support those trusts requiring the greatest help to cut cancer waiting lists. This work is backed by funding of more than £8 billion from 2022-23 to 2024-25 to help drive up and protect elective activity, including for cancer. To increase capacity, we are investing in up to 160 community diagnostic centres—CDCs. Within CDCs, we are prioritising cancer pathways to help reduce the time from patient presentation to diagnosis and treatment.

[Baroness Merron (Lab)]

My Lords, nearly 90% of cancer patients in 2010 received their first treatment within two months of urgent referral, which exceeded the operational standard, something the Government have not achieved since 2014, while last year fewer than 65% of cancer patients were treated within this standard. With earlier intervention being key to saving lives, what is the Government’s estimate of how many lives are lost each year due to failure to meet this agreed standard? What is the impact on survival rates of continued delays to a workforce plan promised long before the pandemic and still being reported as not having been signed off by the Treasury?

[Lord Markham (Con)]

The noble Baroness is correct about early diagnosis. That is why we have invested in 160 CDCs, which will be primarily focused on cancer, and why there are 11,000 more staff than in 2010, a 50% increase, as well as 3,000 more consultants, a 63% increase. We are seeing more supply than ever but at the same time, given Covid and the pent-up demand caused by that, we are also seeing more than demand than ever. The major expansion of supply is focused on making sure that we quickly detect those people.

NHS GP Surgeries: Purchase by US Companies

Baroness Merron Excerpts

Monday 5th June 2023 Lords Chamber

[Lord Markham (Con)]

My understanding on this is that actually it is not a massively profitable area at the moment. The biggest provider in this area, Babylon Health, as we all know, did not manage to make it work. So, while I think we all understand my noble friend’s concerns, I do not believe that this is the case with the GP funding model.

[Baroness Merron (Lab)]

My Lords, research has shown that GP surgeries owned by some private limited companies have been offering a lower level of care, with unqualified staff seeing patients. So, in view of the Minister’s comments on quality, how much of a concern is this for the Government? On top of this, with some 4,700 GPs being cut over the last decade, cuts to training places and the many years that it takes to train a GP, what response will the Minister make to the latest GP patient survey, which reports that patients are now ever less likely to be able to see a GP?

[Lord Markham (Con)]

Clearly, we have our targets in terms of making sure that people can see a GP. I am glad to say that 70% of appointments are now face to face, and we are on target to hit our 50 million increase in appointments. So it is good to see that we are getting that done. Do we need to do more? Clearly, there is ever-increasing demand from the demographics of the situation, so we need to increase supply through additional training places, as I said.

National Health Service (Dental Charges) (Amendment) Regulations 2023

Baroness Merron Excerpts

Monday 5th June 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am very grateful to the noble Lord, Lord Hunt of Kings Heath, for giving us the opportunity to have this debate. I think he is having an even busier day than the Minister, given his contribution to the Illegal Migration Bill debate that we just had.

There are two real questions that people are asking about access to NHS dental services. The first is whether they can get an NHS dentist. That is something that we have debated in the context of other regulations along similar lines discussing the way in which the remuneration scheme works. The second question is about how much will it cost if they do get one—if they are the lucky few who can navigate through the system and find an NHS dentist, and that is what we are primarily discussing today.

It is also important to touch on dental deserts, particularly in rural and coastal areas. I hope that the Minister may also have some to say on availability. He has assured us in this House previously that the Government have ideas to try to improve the ability of NHS dentists generally, and I know he had some creative ideas about attracting dentists into under-served areas.

Having got through the barrier of finding an NHS dentist, we now need to think about the question of charges—a question that is entirely academic if you are unable to get one in the first place. The Government are proposing in these regulations an uplift—in common language, an increase, but they prefer to use “uplift”, which I think is supposed to sound a little softer— of 8.5%. I find that curious language. When I go to supermarkets they do not tell me that they are applying an uplift value to their prices; they apply an increase to their prices, but here we are told it is an uplift value.

In paragraphs 7.8 and 7.9 of the Explanatory Memorandum we get a lengthy and quite convoluted explanation of where that money goes, which makes it clear that patient charges make no direct contribution to the remuneration that the dentist receives. People out there may think that the payment they are making to the NHS goes to the dentist, but it does not. Again the Explanatory Memorandum makes it clear that there is intentionally no link between the contract price paid to the dentist and the contribution that the individual pays. Paragraph 7.8 states that the money is essential to improve access challenges, and that current and future work to improve NHS dentistry would be undermined by the risk of reduced funding if the patient charge revenue was lower. Yet, as we heard from the noble Lord, Lord Hunt, it is reported that there was a £400 million underspend in the NHS dentistry budget for last year, so I have a couple of questions for the Minister, a maths question and a logic question. The maths question is: will he confirm that £400 million is approximately five times as much as the £78 million in extra revenue that we are told that this 8.5% increase will achieve? In other words, if we were not to have the increase but were simply to roll the underspend into dentistry, we could cover five years of that additional revenue-raising from the underspend that already exists. The logic question is simply: how can we say logically in this paragraph that these charges are essential to improve NHS dentistry when we are not spending the money that is already available? Perhaps the Minister is going to make us all happy by confirming that that £400 million underspend is all going to be spent on NHS dentistry, in addition to the extra £78 million, but I suspect that is not going to be the case. Listening to the noble Lord, Lord Hunt, I wondered whether one of the solutions might be that the new charges should not be allowed to be levied unless and until all the existing budget has been spent. If there is going to be a £400 million underspend, perhaps the patient should benefit from that if the money is not going to be rolled back into NHS dentistry.

The overriding concern is one that the noble Lord, Lord Hunt, also referred to: that the long-term commitment from this Government to provide dentistry within the National Health Service just is not there. The right words are being spoken, but the actions are telling us a different story.

The Government’s own impact assessment notes, at paragraph 37, tell us:

“There remains uncertainty about whether higher patient dental charges would lead to lower levels of patient access”.


They say that, although the research is not clear,

“it is very likely that higher charges will reduce the number of patients seeking NHS dentistry services, relative to there being no patient charge uplift.”.

So, again, the Government’s own notes tell us that it is likely there will be reduced demand for NHS dentistry as a result of the charges that we are discussing today.

Paragraph 32 very tellingly talks about the relationship between NHS and private dentistry, which, of course, is an alternative in most parts of the country. It says:

“There is also a risk that increases in NHS charges could mean that the cost of NHS dental treatment becomes closer to prices of private dental care. Some patients may choose to receive private care if the cost differential is lower”.


It seems logical that, if a patient is confronted with real difficulty in getting an NHS dentist compared with getting a private dentist and if they understand that there is no real price differential, those two forces combined will act to steer people away from NHS dentistry towards private dentistry.

As I know the Minister and I have heard him speak on these issues before, I suspect he will say that this is not the Government’s intention—but we need more than words. We need evidence that we are not seeing a succession of measures leading inexorably in one direction: a direction in which dentistry ceases to be available on the NHS at a fair NHS price for people in large swathes of this country.

[Baroness Merron (Lab)]

My Lords, I am grateful to my noble friend Lord Hunt for tabling this regret Motion and speaking so clearly to it, describing for your Lordships’ House what this actually means for people by its effect on NHS dentistry.

I am glad to follow the noble Lord, Lord Allan, and I absolutely associate myself with his remarks about the word “uplift”. It is a very positive way of describing an increase in costs to those who need NHS dentistry. We should remind ourselves that this is why we are having this debate, not only about the costs but about the sorry reality of the state of NHS dentistry at present—and bearing in mind that all this takes place in the context of a cost of living crisis.

It is incumbent on us this evening to remind ourselves that poor oral health—which is where we end up when people do not look after their teeth because they cannot afford and/or cannot access NHS dentistry—does not just affect the teeth. It impacts on our general health and well-being; it affects what we can eat, how we communicate, and how and whether we can work, study and socialise with ease, and it affects our self-confidence. Yet it is right to say that tooth decay is largely preventable.

There is also a significant public health problem linked with considerable regional variation and inequality. A three year-old living in Yorkshire and the Humber is more than twice as likely to have dental decay as a three year-old who lives in the east of England; and one in three five year-olds in the north-west has experience of dental decay, compared to nearly one in five in the south-east of England. It would be helpful if the Minister could tell us: what is the Government’s aspiration in respect of NHS dentistry? That aspiration and the practical means to achieve it seem to have got rather lost on the way.

As we heard from my noble friend Lord Hunt, the last 13 years have seen dentists quitting in very considerable numbers. In 2021 alone, 2,000 quit the NHS, which represents almost 10% of all dentists employed in England. An estimated 4 million people cannot access NHS care, with some parts of the country now described as dental deserts, where remaining NHS dentists are not taking on new patients.

To secure a future, we need staff, which I will refer to later, and the equipment, technology and access to ensure that patients get the treatment they need. This raises a number of wider questions. We are spending less on dentistry per head of the population in the areas with the highest levels of deprivation. Statistics from the British Dental Association suggest, for example, that 1 million new or expectant mothers have lost access to dental care since the start of the pandemic. Could the Minister say what the Government are doing to prevent those on low incomes or in more vulnerable groups being disproportionately impacted?

Tooth extraction in hospital due to tooth decay remains the most common reason for hospital admissions in the six to 10 year-old age group, with an estimated cost of hospital admissions for children aged between nought and 19 for this intervention being some £33 million per year. What steps are being taken on early preventive action to reduce what has become a shameful situation?

We know that 91% of dental practices are not able to accept new adult patients in England and 80% are not able to accept new child patients. Millions are having to face the unpalatable options of waiting for months in agony, resorting to their own DIY dentistry, or stumping up for private dental fees they simply cannot afford. My question to the Minister is not just about what the Government are doing to tackle this crisis, but how did they allow it to get to this situation? From inadequate support for the prevention of oral ill health in childhood to dental deserts, net government spend on general dental practices in England has been cut by over one-third over the past decade. Again, perhaps the Minister could explain how the situation has been allowed to deteriorate to this extent.

We know that not enough is being done to recruit and retain dentists and dental care professionals. A recent British Dental Association member survey showed that more than nine in 10 owners of dental practices with a high NHS commitment found it difficult to recruit a dentist, with 43% of vacancies unfilled for more than six months.

On the workforce, there is a point I want to underline following the points raised by my noble friend Lord Hunt. In June last year the House of Commons Health and Social Care Committee reported the findings of its inquiry into the health and social care workforce. It found that the headcount—to underline this—of primary care dentists in England providing NHS treatment or otherwise conducting NHS activity in 2020-21 was at its lowest level since 2013-14. While the register has the highest number of dentists, the number doing NHS work is decreasing. In 2021 alone there was a decrease of 951 dentists with NHS activity in England. That is the near equivalent of the whole intake target of dental students for the whole year. Perhaps the Minister could explain how this all stacks up.

On the matter of substance—we have heard much about this from the noble Lord, Lord Allan, as well as my noble friend Lord Hunt—at almost 500 practices across England the British Dental Association tells us that the amount paid by NHS patients was greater than the amount paid to that practice to provide NHS services. The analysis suggests that patients at those surgeries were topping up government funding by an estimated £2 million last year. It would be helpful to hear from the Minister how and in what way this makes sense.

NHS National Health Inequalities Improvement Programme

Baroness Merron Excerpts

Thursday 25th May 2023 Lords Chamber

[Lord Markham (Con)]

Absolutely. We work very closely together. The Healthy Start programme gives seven fruits a day to kids up to the age of seven to make sure that they get fruit and vegetables, and that is very much a joint initiative. Clearly, we need to be joined at the hip on some things, but as regards school meals, the DfE takes the lead.

[Baroness Merron (Lab)]

My Lords, the levelling up White Paper promised to design and test a new approach to ensure compliance with school food standards. Although pilot schemes were meant to start last September, a recent Written Answer from the Schools Minister stated that

“standards are being kept under review”,

with no sign of the pilot scheme. Have the Government given up on their promise and does the Minister consider the existing standards for school meals and the means of compliance sufficient to tackle nutritional inequalities across the country?

[Lord Markham (Con)]

As mentioned previously, the review did not happen because of Covid, and it is very much within the plans that it is time to look at school standards again. Clearly, that is key to making sure that there is a healthy diet in schools, and of course that goes across the board.

Autism: Diagnosis Targets

Baroness Merron Excerpts

Tuesday 16th May 2023 Lords Chamber

[Lord Markham (Con)]

First, I totally agree with my noble friend’s sentiment about the power that AI, when done in the right way, can have in this space. Clearly, the stress is on the words “the right way”. I think it is fair to say that we are all on the nursery slopes as regards what it can do. I have seen how effective it can be in taking doctors’ notes, recording a meeting and drafting action points, which a doctor can then review. I am sure that we would all agree that that is very promising. There are future generations of AI being talked about that may be able to perform diagnosis. In the 10 to 15 years of looking ahead in the long-term workforce plan, these are some of the things that we will have to try to take into account. However, we are in the very early stages.

[Baroness Merron (Lab)]

My Lords, when it comes to autism services, we know that there are major disparities across the country which predate the pandemic but which were made much worse by it. The number of people waiting for an assessment has grown by 169% from pre-pandemic levels. How will the Minister ensure that the national framework and the standards for autism assessment within it are deliverable at a local level and in every part of the country?

[Lord Markham (Con)]

First, each ICB now has to have a lead for autism and learning difficulties. The noble Baroness is correct that there are some disparities— I am sure that she is aware of the two ICBs which have restricted their services quite significantly, although, thankfully, they are now rowing back on that. We need to make sure that we are on top of all of them. As the noble Baroness is aware, I and other Ministers are taking a personal interest in this. Clearly, there is a lot of work to be done.

NHS: Allocation of Financial Resources

Baroness Merron Excerpts

Thursday 11th May 2023 Lords Chamber

[Lord Markham (Con)]

Yes, and we are doing it. We have committed to an up to £7.5 billion increase in funding over the next two years. We announced last month a social care plan which is addressing this and reforming the sector, and we are starting to see the changes.

[Baroness Merron (Lab)]

My Lords, the Royal College of Emergency Medicine described as unambitious the Government’s plan to see 76% of A&E waits meeting the four-hour standard by 2024. As this target has not been achieved in the past two years, how does the Minister see it working to drive down waiting times? How will the Minister ensure that hospitals are not prioritising patients with minor conditions at the expense of those in greater need of admission simply to allow them to meet the target?

[Lord Markham (Con)]

Numbers out just this morning show that we are now at 75% of people being seen within four hours, so we are close to the 76% target. That is the best since September 2021. I am the first to admit that we want to go further, as the noble Baroness states. It is about making sure we have got the care in the right places. We are triaging to make sure that the most important cases are seen first and, as I mentioned in a previous answer, we have things such as fall services, which can avoid trips to A&E in the first place, and more primary care in place to avoid visits in the first place. That is what the primary care recovery plan is all about.

Life Expectancy: Pensions, Health and Insurance

Baroness Merron Excerpts

Wednesday 26th April 2023 Lords Chamber

[Lord Markham (Con)]

My noble friend is correct: it is a key issue. There have been successes such as the sugar tax levy, which has reduced sugar consumption by about 40%. But clearly, you need only to look at the statistics to see that all western nations, including the UK, are facing this problem. It is a challenge that we have to attack. We can learn a lot in this space from Japan, where employers and the whole society are very much involved in the healthy lifestyles of their workers and people.

[Baroness Merron (Lab)]

My Lords, life expectancy for those with a learning disability is particularly shocking: only four in 10 live to see their 65th birthday, nearly half of their reported deaths are avoidable, and those living in the north-west and the Midlands are at greater risk. What action are the Government taking to address the specific barriers faced by people with learning disabilities in getting access to the timely, quality healthcare which could perhaps extend their life expectancy?

[Lord Markham (Con)]

As noble Lords are aware, we have been putting significant investment into mental health; from memory, there has been a £2 billion-plus increase over the last year. In recognition that learning disability is an issue we particularly need to tackle, as the noble Baroness is aware, we are putting investment into schools so they can identify it early on. Some 35% of schools now have the right educational leads in this space, and the figure will rise to 50% next year. It is a big improvement, but do we need to do more? Absolutely.