NHS: Long-term Sustainability

Baroness Merron Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I congratulate the noble Lord, Lord Patel, on securing this debate and for introducing it with his characteristic authority, insight and care, with which we are so familiar in your Lordships’ House.

I am delighted that my noble friend Baroness Ramsey of Wall Heath chose this debate in which to make her excellent maiden speech. How proud her mother and father would have been today, and what a difference she made to the life of her late sister, and, indeed, to the National Health Service; and what a difference I know she will make to your Lordships’ House.

To give some context to the need for long-term sustainability, over the last 14 years, as we have heard, the health service has acquired the undesirable distinction of having the longest waiting lists, the lowest patient satisfaction and the worst strikes in its history. The noble Lords, Lord Patel and Lord Kakkar, not only described the harsh realities and inequalities of the current systems but asked what all parties would do about correcting it. I am flattered to be invited to give some flavour of how an incoming Labour Government—if there is to be such a thing—would approach the challenges ahead.

On that point, I am glad that my noble friends Lord Hunt and Lord Reid and the noble Lord, Lord Crisp, recognised the positive impact on the health of the nation of the last Labour Government, in which I had the honour of serving as a Public Health Minister. That allows me to say to noble Lords, including the noble Lords, Lord Bethell and Lord St John, and the noble Baronesses, Lady Boycott and Lady Finlay, that, when it comes to prevention and a focus on the broader improvement of health, I am totally signed up.

My noble friends Lord Hacking and Lord Parekh have brought a welcome analysis to today’s debate. I agree with my noble friends Lord Hunt and Lord Turnberg and the noble Baroness, Lady Hollins, that bullying, burnout and pressure on the workforce is no way to retain or get the best out of people—we need only talk to people in other sectors to remind us of that.

This change will require a change in culture on so many levels. The noble Lord, Lord Crisp, spoke of the fundamental need for shared vision, hope and energy. It struck me that they are exactly what is missing at present in health and social care. As we have heard today and so many times before, social care is inextricably linked to the health service. I remind any incoming Government, including a Labour one, that there are a number of first-rate and considered Lords reports, including on social care, primary and community care, and long-term sustainability. Therefore, any Government would be extremely well advised to delve into them. Wes Streeting, shadow Secretary of State, has been very clear about the measures that need to be taken on social care, emphasising the need for long-term planning, thinking and funding.

The right reverend Prelate, the noble Baroness, Lady Cavendish, and my noble friends Lord Turnberg, Lady Pitkeathley and Lady Warwick were absolutely right to speak about the invisibility of unpaid carers and the poor treatment of employed care staff. That is not sustainable—and neither are the record levels of sickness and long-term conditions that affect the workforce, which my noble friend Lord Davies and the noble Lord, Lord Londesborough, spoke about so clearly.

I do not consider myself a technological expert, but rather a technological convert, which I am sure the noble Lord, Lord Allan, will be very pleased to hear. So I have looked to countries such as Israel, which I believe to be at the cutting edge, which is where the UK needs to be. At the emergency department of the Sourasky Medical Center, people register digitally, identify themselves through facial recognition and measure their own blood pressure, temperature and heart rate in self-triage booths. Patients are given a barcode and a number is sent to their phone, which they can track on a screen. The most serious cases are seen within minutes, and virtually no one waits more than an hour. Last month, this Tel Aviv hospital became the first in the world to integrate an AI chatbot into its triage process.

What is the driving force behind that? This Israeli hospital is designing healthcare around the needs of the patient, which my noble friend Lord Carter and many other noble Lords called for. Sadly, that is very much in contrast with Britain, where our NHS reels from crisis to crisis, while the political debate circles around funding, staffing and pay. The way that we bank, shop, travel and work has been digitised in the past decade, yet the NHS remains largely outdated. There are multiple IT systems in the NHS and no requirement for them to be interoperable.

That means that systems cannot talk to each other, sometimes even within the same hospital, let alone between institutions or between primary and secondary care. There are at least 21 different types of electronic patient records in hospitals and 34 apps to book an appointment. No company would be able to survive with productivity like this, as the noble Baroness, Lady Tyler, said. Let me ask the Minister: how has the Government allowed the NHS to develop like this?

NHS England’s digital lead, Joe Harrison, estimates that every pound spent on technology generates between £3.50 and £4 in savings. Such an approach makes sound financial sense, as well as good health sense. While the case for reform is overwhelming, too often the innovators are thwarted by a fragmented system or vested interests. What is being done to overcome this?

We know that an estimated 13.5 million hours of doctors’ time is wasted every year due to inefficient IT. Fixing that would be the equivalent of 8,000 new doctors joining the NHS. That is the difference between the huge staff shortages that we see and filling almost every vacancy for a doctor. With our country’s population ageing, the health of the public worsening and chronic disease rising, the sustainability of the NHS is crying out for change.

I recently went to the National Theatre’s production of “Nye”, as I know many other noble Lords have done. When he created the NHS in the 1940s, Nye Bevan had absolutely no idea of the scientific revolution ahead. Regrettably, if we dropped Nye Bevan into the NHS today, he would see the modern-day pressures of an NHS that is overly hospital-based and gets to patients too late, at greater cost and with worse outcomes.

If Labour does get into government, we will arm the NHS with the modern technology it needs, doubling the number of scanners, and putting AI into every NHS hospital, so that patients are diagnosed earlier. We will get rid of the unnecessary bureaucracy whereby innovators have to tout their technology to each individual NHS trust; we would stop the need to sign separate agreements with each of them. We will streamline the route in for innovators and put the entire NHS in partnership with the technology and life sciences sector.

Following the pandemic, more than 32 million of us carry the NHS app in our pockets. That provides the potential to transform how the NHS interacts with patients, promotes good health and increases people’s control over their own healthcare. We would make the NHS app not just something to assist the NHS in healthcare but a key component in delivering care—both preventive and curative—and empowering patients.

Finally, what do the health and care leaders want? They know that investing in primary and community care results in a lower demand in hospital emergency care. For every pound invested in the NHS, £4 comes back to the economy. The greatest economic returns come from investing in primary and community care, where we see a £14 economic return for every pound invested. If Labour is to be in government, this is the step change that we will make.

Cass Review

Baroness Merron Excerpts

Wednesday 17th April 2024 Lords Chamber

[Baroness Merron (Lab)]

My Lords, Dr Cass and her team are to be thanked for their rigour and their care with this report, in which they have navigated many complex and sensitive issues. This review into the NHS’s gender identity services concludes that children and young people have been let down by inadequate research and evidence on medical interventions, and they have been failed by inadequate services amidst a debate which has, sadly, been marked by extreme toxicity.

At the same time, at the heart of the complexity around gender identity services are two aspects that are simultaneously true. There are trans adults who have followed a medical pathway and say that, for all the pain and difficulty involved, it was not just life-affirming; it was life-saving. There are also people who followed a medical pathway and say that it has ruined their lives irreversibly and ask how anyone could let that happen. For those children, young people, and now adults, but particularly those who are being referred into gender identity services today, there is a duty to get this right.

The Cass review refers to many scandals, which exposes both the inordinate amount of time that children and young people are waiting for care while their wellbeing deteriorates, and medical interventions that have been made on what could be called shaky evidence. Can the Minister say how it came to be that NHS providers refused to co-operate with this review? How was it allowed that adult gender services would not share data on the long-term experience of patients? What accountability does the Minister feel that there should now be?

The Minister will know that the discussion around the substance of the review has been highly toxic. People have felt silenced, and it has required investigative journalism to prompt this review to take place. Tribute should be paid to journalists, including Hannah Barnes, and to the whistleblowers, who together helped shine a light on the Tavistock clinic. It is concerning to note that Dr Cass said that the

“toxic, ideological and polarised public debate has made the work of the review significantly harder”,

and that will

“hamper the research that is essential to finding”

a way forward. This particularly vulnerable group of children and young people is at the wrong end of the statistics when it comes to mental ill health, suicide and self-harm. They have been badly let down, so we owe it to them to approach this discussion with the sensitivity it demands.

Parts of this report today will sound very familiar: services unable to cope with demand; significant staff shortages; a lack of workforce planning; and unacceptably long waits for the mental health support and assessments that children and young people need, such that in some cases children become adults before they even get a first appointment with the gender identity services. To this point, the Cass review recommends a follow-through of services up to the age of 25, to ensure continuity of care. Will the Minister indicate how long it will take to establish these services, and could the Minister set out what plans there are to cut waiting times for assessments for mental health and neuro- developmental conditions?

Last month’s decision by NHS England to stop the routine prescription of puberty blockers to under-18s is welcome. However, the loophole that exists for private providers risks illegal trading. In the other place, the Secretary of State said that she expected private clinics to follow the report’s recommendations to follow the evidence. I underline our support for these expectations on compliance. Does the Minister consider that further regulation might be needed to enforce the recommendations? Could he say something more about the timescales involved in making progress, both for the CQC to incorporate the recommendations into its safe care and treatment standards and for NHS England’s urgent review on clinical policy for cross-sex hormones?

Children’s healthcare should always be led by the evidence and be in the best interests of their welfare. Dr Cass’s report has provided the basis on which to go forward. This report must also provide a watershed moment for the way in which society and politics discuss this issue. There are children, young people and adults, including trans children, young people and adults, who are desperately worried and frightened by the toxicity of the debate. There are healthcare professionals who are scared to do their job and make their views known. I hope that we can now put children’s health and well-being above all else.

[Baroness Burt of Solihull (LD)]

My Lords, I believe that the Cass review is an extremely thorough summary of where we are now and of the pathways available to young people that we need to explore. Most importantly, this report gives a way forward for young people and their clinicians who feel anxious and frightened because they find themselves at the centre of a political maelstrom.

Interestingly, the most balanced response I have seen to the report came from Stonewall, which was consulted by Cass, and I have used some of its points here. Cass says that these youngsters have been sorely neglected by the NHS, which sidelined them away from mainstream care to services that have fallen short. She points to how we can start the process of making it up to them, by giving them the holistic care that they need and deserve.

Despite the way in which the report was received by certain gender-critical individuals, it does not question trans identities or recommend rolling back healthcare access. It does not say that puberty blockers are unsafe or dangerous. It does say that there is insufficient and inconsistent evidence about some of the effects of puberty suppression. In addition, it notes that cross-sex hormones are well established and have transformed the lives of trans people, and supports their use from the age of 16. Importantly, it does not, at any stage, suggest a ban on social transition for any age of child or young person, but recommends that this be done with the support of parents and clinicians.

Cass says that gender incongruence is a result of a complex play between many biological, psychological and social factors, of which sexual orientation can be one. There are many factors, and no simple answer. For example, saying that such young people are simply confused gay people, unhappy teenagers, or that it is all the fault of social media, is all too simplistic. Regrettably, this has not stopped the Government spinning their own version of who is to blame.

For example, this week’s Statement by Secretary of State Victoria Atkins said that Tavistock clinicians “almost always” put children on an irreversible path of blocking puberty, then prescribed cross-sex hormones and on to surgery as an adult. This is not my understanding of the situation. In 2019-20, only 161 under-19s were referred by gender identity development services for puberty blockers. It was estimated that only around one in six GIDS patients ended up being prescribed puberty blockers. Is not the picture bad enough, without painting something even worse?

There are currently more than 5,000 children on the waiting list for treatment. The NHS has confirmed that everyone currently on puberty blockers via the NHS—fewer than 100 children—will be able to continue on them. These children, and any new recommendations for puberty blockers, will not be prescribed unless they agree to take part in a clinical trial to test the effectiveness of puberty blockers properly. How long does the Minister estimate that it will take for this clinical trial to be set up? Speaking of waiting lists, I understand that it currently takes three years for a child on the list even to be seen. How will the trial ever be set up, except for the few now on puberty blockers, while the rest languish for years on waiting years while their puberty seeps away? Does the Minister not agree that it is time to make up this shocking treatment which has, or rather has not, been given to children by the NHS and put them immediately on a par in priority with other NHS services?

These are our children. They, and the clinicians who want to treat them, have been intimidated by the toxic environment that we have all helped to create. I have heard the Cass report described as a rock that we can now all cling to. We will never all agree about some quite fundamental issues regarding trans and the nature of trans, but we must never make our children suffer for it; we must never make them pawns in a zero-sum game. We must rise above it and argue well, with more light than heat, to protect our children, who, after all, must be at the centre of all we seek to do.

Immunisation: RSV

Baroness Merron Excerpts

Tuesday 16th April 2024 Lords Chamber

[Lord Markham (Con)]

I too add my thanks; the noble Baroness is very good at holding our feet to the fire, and it is very important and appreciated. Regarding the age group, we are being guided by the scientific advice on what is most cost-effective.

[Baroness Merron (Lab)]

My Lords, earlier this year we discussed the busy pipeline of new vaccines, including those for RSV, which, coupled with the concerning decline in the uptake of immunisation, does point to the need for a fresh look at delivery mechanisms. What steps are being taken to move beyond traditional arrangements, and when can we hope to see an improvement plan in place, in readiness for the RSV immunisation programme?

[Lord Markham (Con)]

Of course, the communication needed for each one is different, and that is a vital consideration. As I said, we found that, often, it is easier to put RSV in the infant rather than the pregnant mother. It is a question of considering which is the most effective way to get the best outcome and the highest take-up rate. That is one of the key criteria we are looking at. Regarding general communication, the noble Baroness will be aware that, on MMR, we have challenges in both London and the West Midlands. That has shown that you need other communication routes to get to some ethnic minority groups, using technology such as the app. There is no one silver bullet —you need a series of measures in place.

Children’s Cancer Services

Baroness Merron Excerpts

Wednesday 20th March 2024 Lords Chamber

[Lord Markham (Con)]

I want to be fair to the NHS here. It has done an extensive study, with a lot of professionals rating extensive criteria, and they really did believe that in certain areas, the Evelina scored higher than St. George’s and the Marsden. It is a balanced decision; all I can do is absolutely promise noble Lords that we will take all those factors into account.

[Baroness Merron (Lab)]

My Lords, I appreciate that the Minister is looking at all of this, but given the difficulties of achieving the number of clinical trials in the UK, what effect is anticipated on research because of the proposed relocation of paediatric cancer services? Is there an intention to factor into the final decision the need to expand research capacity for childhood and adult cancers?

[Lord Markham (Con)]

Among the criteria the NHS has taken into account are clinical services, the patient care experience and research, and it scored the Evelina higher on research. I want to understand that, because many noble Lords will be surprised by that finding. I assure the noble Baroness that research and the ability to do clinical trials, which is a vital component of our life sciences industry, is an important factor in this decision.

Sexual and Reproductive Healthcare

Baroness Merron Excerpts

Tuesday 19th March 2024 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I start by congratulating the noble Baroness, Lady Barker, on securing this important debate, and on her thorough assessment of what is a very worrying state of affairs. As I am sure the Minister has heard, that assessment has been received with some unanimity of concern across the Chamber.

The Health Foundation estimates that sexual health services will have seen spend lowered by some 39% between 2015-16 and 2024-25, which is far in excess of the already problematic 27% cuts to the public health grant. However, the situation gets even worse as the reductions in the public health grant tend to be largest in the more deprived areas. In Blackpool, for example, ranked as the most deprived upper-tier local authority in England, the per-person cut to the grant has been one of the largest. Perhaps the Minister could address how this disparity in the provision of funding for sexual health services will be put right for people in the most disadvantaged areas. It would also be helpful to hear how we have got to this situation.

My noble friend Lord Hunt raised some key questions about the Office for Health Improvement and Disparities, which I certainly want to echo. I look forward to the Minister’s reply on that, as well as to an explanation about how these cuts, which are more extreme in disadvantaged areas, square with the Government’s levelling-up agenda.

I anticipate that the Minister will give your Lordships’ House a number of statistics to refute the negative impact of the reduced funding that I have referred to on sexual health services. However, a recent Written Question tabled in the other place by Rachael Maskell MP asked what recent assessment had been made of the quality and adequacy of the availability of sexual health services. Minister Leadsom replied:

“No formal assessment has been made of the quality and availability of sexual health services to meet demand nationally or locally”.


As this is the case, how can the Government assure themselves that they are satisfied with the impact of the funding that they provide? How can they address, therefore, the very real questions that have been put in the debate this evening?

I turn to the current state of demand. The Local Government Association, using data from the Office for Health Improvement and Disparities, reports on a number of areas. For example, almost all council areas have seen an increase in the diagnosis rate of gonorrhoea, with 10 local authorities seeing rates triple, while nearly three-quarters of areas have seen an increase in cases of syphilis and more than one-third of local authority areas have seen increases in detections of chlamydia. It is interesting to note that councils, as well as other groups, have called on the Government to publish a new 10-year sexual and reproductive health strategy to address infections in the long term. Perhaps the Minister could advise the House what consideration the Government have given to that proposal.

An analysis by the Guardian just last month found that spending by English councils on sexual health services had reduced by one-third since 2013 despite a rise in the necessity for consultations for sexually transmitted infections. Advice, prevention and promotion services have had the largest cuts to funding, with net spending down some 44% since councils were made responsible for public health in 2013. Meanwhile, STI testing and treatment fell by one-third and contraceptive spending by nearly one-third. Yet we know it is costly for people to end up in hospital who could otherwise have been treated through sexual health and reproductive services. So could the Minister comment on how cuts such as these make sense in terms of value for money, when research shows that each additional year of good health achieved in the population by public health interventions costs £3,800, around three times lower than the costs resulting from the NHS interventions that become necessary in the absence of those preventative measures?

The noble Baroness, Lady Barker, was right to draw attention to the workforce that is necessary to provide these services. There have been many warnings that a large number of skilled medical staff have left the NHS and, even in the unlikely event of a major injection of resources, it would just not be possible to replace that loss of workforce overnight.

I think we in this Chamber all agree that long-term workforce planning is essential to ensure the sustainability of crucial sexual health services. There is currently a retirement cliff edge for all members of multidisciplinary teams. That has been exacerbated by difficulties in recruiting new staff into the specialty, as well as the experience of the pandemic, which saw more healthcare professionals leaving the sector. As we have heard today, there is an urgent need to recruit new trainees by addressing the low number of training posts in GUM and HIV and lower awareness of the specialty. A survey of RCN members reported that sexual and reproductive health is not regarded as attractive to new staff, while concerns were also raised about the diminishing options for education and training. That is borne out by the limited exposure to the specialty that we see in undergraduate training and in the core general training following medical school—something highlighted by the noble Baroness, Lady Barker.

In all this, the failure to plan and invest in a sexual and reproductive workforce only exacerbates pressures elsewhere in the healthcare system. People are being pushed into hospital now due to untreated STIs, with admissions to hospital for syphilis and chlamydia doubling between 2013-14 and 2022-23 while gonorrhoea admissions have tripled.

As the noble Lord, Lord Allan, said, the workforce plan refers to what I would describe as a hope—a hope that there will be benefits from improved joint working between ICBs and local authorities on workforce planning, development and training for public health areas, including sexual and reproductive health services. In answer to a Written Question that I tabled last month, the Minister confirmed that NHS England conducted an annual performance assessment of the ICBs for the 2022-23 financial year. Can the Minister indicate what assessment has been made of those promised improvements through joint working in respect of sexual and reproductive health services; in other words, is the joint working delivering in the way that the workforce plan hoped for?

Importantly, how will the Government address the very real issues that have been highlighted in this debate? They are real, they have been with us for years and they need resolution.

Cancer: Staffing

Baroness Merron Excerpts

Thursday 14th March 2024 Lords Chamber

Asked by

[Baroness Merron]

To ask His Majesty’s Government, in the light of warnings by the Parliamentary and Health Service Ombudsman, what assessment they have made of the risk to cancer patients in England presented by the staffing levels, workloads and working conditions of healthcare professionals.

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

I express my regret about the cases referenced by the ombudsman. The department is taking steps to reduce cancer diagnosis and treatment waiting times across England and to improve survival rates across all cancer types. Through announcing the first ever NHS long-term workforce plan, we are taking meaningful steps to build the NHS workforce for the future. The Government are backing the plan, with over £2.4 billion of funding for additional education and training places.

[Baroness Merron (Lab)]

My Lords, the Minister will know that numerous complaints relating to patients with cancer that were investigated by the Parliamentary and Health Service Ombudsman included misdiagnosis, treatment delays, the mismanagement of conditions, poor communication and unsuitable end-of-life care. As the NHS is grappling with over 110,000 staff shortages, how is patient safety being compromised by the Government’s long delay in bringing forward the workforce plan? What immediate action will the Government take to deal with the continuing risk to cancer patients posed by a workforce that the ombudsman describes as “understaffed, under pressure and exhausted”?

[Lord Markham (Con)]

As the noble Baroness says, we see increasing the workforce as a core component here. I was speaking to the president of the Royal College of Radiologists about this the other day, and we obviously need to make sure that the workforce can be as effective as possible at what it does. We are doing a lot of new diagnosis, and 80% of all the medical AI technologies are in the radiography space, which is making a huge difference to diagnosis and productivity. It is clearly fundamental that we get the treatment to these people as quickly as possible.

Prioritising Early Childhood: Academy of Medical Sciences Report

Baroness Merron Excerpts

Monday 11th March 2024 Lords Chamber

[Lord Markham (Con)]

One of the recommendations of the report is a cross-cutting approach of the kind the noble Lord mentioned to avoid silos. The family hubs we are investing in alongside the Department for Education are trying to do exactly that sort of thing to make sure the healthy start for life exists.

[Baroness Merron (Lab)]

My Lords, these Benches will greatly miss my noble friend Lord McAvoy. I had the pleasure and education of serving with him as a Whip in the other place. May his memory be for a blessing.

The Academy of Medical Sciences report highlights the importance of continuity of maternity care, which can reduce the likelihood of pre-term birth by 24%. Given that premature babies are more likely to have complications that affect vision, hearing, movement, learning and behaviour, which will all impact later life, what steps are the Government taking to increase the number of women receiving dedicated midwifery support throughout their pregnancies?

[Lord Markham (Con)]

I agree with the noble Baroness and my noble friend Lady Cumberlege about the importance of continuity of care in the maternity space. We are investing resources as part of the long-term workforce plan to increase the number of people trained in maternity and in this area generally. To give another example, we are investing in family nurses by increasing the number of training places by 74%, because it is understood that we need the workforce to provide all these services in an ever more complex world.

Mental Health Patients: Discharge

Baroness Merron Excerpts

Tuesday 5th March 2024 Lords Chamber

Asked by

[Baroness Merron]

To ask His Majesty’s Government what assessment they have made of the current level of (1) safety, and (2) patient and carer involvement, where mental health patients are discharged from inpatient settings and emergency departments.

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

In January, the Government published new statutory guidelines setting out how health and care systems can work effectively together to support a safe discharge process for mental health patients from hospital and ensure patient and carer involvement in discharge planning. This is particularly important given that the National Confidential Inquiry into Suicide and Safety in Mental Health has found that there is an increased risk of suicide within three days of discharge.

[Baroness Merron (Lab)]

My Lords, the Parliamentary and Health Service Ombudsman’s recent report found many failings in care around the discharge of mental health patients, with the most common being a lack of involvement of patients, their families and carers. With the pre-legislative scrutiny of the mental health Bill highlighting the need to address this preventable situation, and the Government still not bringing forward this crucial legislation, what immediate steps will the Government take to involve those who are essential to the care and safety of mental health patients?

[Lord Markham (Con)]

The noble Baroness is correct; the question is of the utmost importance. It is about putting more care into the community—that is why we have put £1 billion of extra spend into community support for mental health. Some 160 local mental health infrastructure schemes are being set up, with 19 in place already, and they are starting to work. The crisis cafés have resulted in an 8% decrease in admissions, while the telephone helpline has resulted in a 12% decrease.

NHS: Neurology Care

Baroness Merron Excerpts

Monday 26th February 2024 Lords Chamber

[Lord Markham (Con)]

Yes, absolutely. Of course, this is what the CDCs are about as well in trying to get that diagnosis capacity. At the Neurological Alliance forum I was just at, the main thing was needing help with early diagnosis, because getting treatment is key to it all and, also, seeing whether we can sometimes refer people directly to the CDCs so that the GP is not always the bottleneck.

[Baroness Merron (Lab)]

My Lords, as Lord Cormack was a fellow of Lincoln, as I am, I pay tribute today to his considerable contribution to the City of Lincoln, as well as to this House and to the other place. May his memory be for a blessing.

The Neurological Alliance has expressed concern about the lack of clarity over whether new therapies for those affected by neurological conditions and their changing needs have been factored into the workforce plan. Can the Minister set out how the workforce plan will respond to these changing circumstances both for those with neurological conditions and those with other conditions?

[Lord Markham (Con)]

I echo the noble Baroness’s comments regarding Lord Cormack.

In terms of the long-term workforce plan, I was talking this morning to the national clinical lead in this area and to Professor Steve Powis. The next stage in terms of the detail is looking at the individual specialties and neuroscience experts are part of that. In the last five years, we have seen an increase of about 20% or so in this space but understanding that need going forward is the next stage in the long-term workforce plan.

Anaesthesia Associates and Physician Associates Order 2024

Baroness Merron Excerpts

Monday 26th February 2024 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, this statutory instrument has triggered a debate that I think is happening on multiple levels. There are two meta questions around the structure of the medical professions, writ large, and the legislative process for establishing professional regulations and updating these over time. This is something on which the amendment from the noble Baroness, Lady Bennett, focuses, and around which the noble Lord, Lord Hunt, has helpfully provided some extra history.

There is one question, which I would call an adjacent question, around the treatment of junior doctors and their frustration at the moment, which they are expressing largely through industrial action. That has been mentioned, quite rightly, by a number of noble Lords, but I do not think that is core to the debate around associates; it is an adjacent question spilling over into this debate.

We have to recognise that the Government have got themselves into a mess over the junior doctor situation and that unhappiness is now having these knock-on consequences. The noble Lord, Lord Bethell, interestingly pointed out that the BMA was unable to come up with examples of the positive use of associates. I thank the Minister for bringing some associates here so that we could hear from them. I thank the consultants in emergency medicine at Leeds hospital who wrote to me and, I suspect, to other members, describing how associates work on the ground and full of praise for the work they do, which has rightly been echoed in the debate today.

There are three questions around the associate roles themselves, which are touched on more in the two regret amendments. The first is whether these roles represent a valuable innovation for the NHS and, importantly, for the patients of the NHS, and so have a long-term place in the system. I hear broad support for the answer to this question being yes, qualified by some questions around the name and the scope, which I will come to shortly. Broadly, I have not heard anybody say that they disagree with the development of these associate roles within the NHS.

The second question is whether they should be regulated by the GMC, as proposed in the statutory instrument. Here I hear a more grudging “Yes”, but still a broad acceptance that the GMC is the only game in town and that it will do a good job. I was interested to hear from the noble Lord, Lord Harris, about the role of the GDC; the comparisons between the GDC and GMC are helpful for us to consider. Certainly, there is a broad sense that the GMC will do a good job if it is the regulator; I am inclined to agree with that.

A particular benefit of the regulation is that it will provide a clear and well-established route for any issues to be investigated. Again, people have raised particular instances in the debate about where things have gone wrong. They will go wrong from time to time with any group of professionals—including politicians, dare I say? It does not matter which group of professionals it is, things will go wrong. What is important for a member of the public is that there is someone they can go to who has a clear and well-established procedure for getting to the bottom of what happened and finding a resolution. I have every confidence that the GMC will provide that for physician and anaesthetist associates and that this will add to any complaints mechanism that exists within individual trusts, which is all there is today so long as these professions are outside of a regulated entity.

Again, importantly, it has been mentioned in the debate that the GMC will provide for a regular review of these professionals to ensure that they continue to remain fit to practise. I think we all can welcome that. I hope the Minister will be able to commit to there being full transparency from the GMC about the activity that takes place on the new associates register so that we can understand how many are coming on and going off it and understand any issues that have arisen, such as the reasons they might have been taken off the register.

The Minister referred to annual reports to Parliament. In 2024, we expect a little more real-time information so I hope he will be able to commit to there being full transparency about associates coming on to that new GMC register and that we should be able to see that much more frequently than simply a report to Parliament.

The third question that has arisen and the one I want to spend the most time on—not too much given the lateness of the hour but enough to try to elaborate the point—is whether the roles are properly defined to avoid confusion and whether they are being used appropriately. Some of this is in the name, which we have discussed already, and I hope the Minister can point to some evidence about there being a lack of confusion.

It seems to me instinctively that there is confusion, partly because “physician” is not common parlance in British English—it is something we more typically associate with American TV shows. The noble Baroness, Lady Watkins, made the point about how we now talk about junior doctors. If you said to somebody, “Do you think a physician associate or a junior doctor is more highly qualified?”, I suspect a lot of people would opt for the physician associate because “physician” has a grandness.

We should be honest enough to test this with ordinary people, not people in the medical profession. That is the test we should apply and if it is true that people think that the physician associate is more highly qualified, we need either to help people understand that that is not the case or change the name. It is really important that we go out there and talk to ordinary people about how they experience those names to understand what is going on. I hope the Minister can commit to that.

More significant is the scope of the role as defined in national guidance and how that is exercised within health organisations in both the NHS and the private sector. The noble Lord, Lord Hunt, and others rightly raised the scope of practice. I think my most significant concern is not about individual physician associates presenting themselves wrongly but the decisions that will be made by their employers about how to deploy them. We need to look at general practices and large NHS trusts separately. With GPs, in many places we are already operating in a commercial market and in some cases physician associate roles have been growing quite significantly under the additional roles reimbursement scheme which has been operating over the last few years. I thank whoever in the department who is responsible for coming up with a scheme whose acronym is ARRS, which brought a smile to my face when reading the briefing notes late at night.

This issue was brought home starkly to me when I, along with thousands of other people, received a note from my practice telling me it is being sold by a large US corporation called Centene to a British private company, owned by private capital, called T20 Osprey Midco Ltd—very catchy. GP practices are bought and sold en masse between these corporations. I looked into the business of the Centene corporation and found that in 2022 “Panorama” did an investigation specifically into its use of physician associates and came up with some quite disturbing data around the preponderance of physician associates in practices being operated by this US corporation.

I am not a raging anti-capitalist but I do not think it is crazy to think that private businesses will try antod find whichever ways they can to reduce their costs and increase their margins. I would like the Minister to explain how the Government will make sure that these roles are not misused in general practice, especially where they are owned by corporates rather than being operated by some part of the NHS structure. In particular, I would like him to explain how we ensure that practices follow the Royal College of GPs’ position that the physician associates must work under the supervision of GPs and not be used as substitutes. That was something the Minister said in theory. I would like him to clarify in practice how he is going to make sure that happens in this multiplicity of individual contractors who are not NHS employees but operate independently of it.

There is a real concern that if there is a shortage in GP recruitment, that will clearly add to the pressure for practices to think, “I’ll hire the physician associates because I can’t get the GPs”. Again, if we follow the RCGP guidance—I hope the Minister will agree with this—if a practice cannot hire a GP, it has no one to supervise the associate so it should hire fewer physician associates, not more. The hiring of physician associates is contingent on practices hiring sufficient trained general practitioners.

When it comes to NHS trusts, the concerns relate to the decisions that the management may take. This is not intended to be NHS manager-bashing, particularly not with my noble friend Lord Scriven sat behind me; it is more a bit of Government-bashing. If the Government leave trusts with constrained budgets, managers will naturally look again at ways to keep the services running, including using less expensive staff where they can. The risk will be compounded again if the more expensive fully trained staff are not available because there is some shortfall in the Government’s training programme.

I know that the Minister will have to say, “The Government will meet their targets for training doctors and GPs”, but in the real world we have to imagine a scenario where, sadly, they fall short. Again, I want to hear assurances from him that where trusts start heading down the route of thinking that they can hire associates because they cannot get the doctors, the levers will be in place for the NHS centrally to stop that happening and to ensure that associates, who are valued and valuable members of teams, will not be left by their managers to do all of the job, rather than being part of a team with a trained medic leading it.

I hope the Minister can reassure us on the scope in both GP practices and NHS trusts. Again, the SI and this regulation are welcome but there are some questions to answer around how these measures present to people. However, the most significant questions that we may come back to in two, three or four years’ time will be around how individual trusts and general practices have decided to use these roles, rather than any questions around the professionalism or effectiveness of the individuals doing that work, whom we value.

[Baroness Merron (Lab)]

My Lords, the point that the noble Lord, Lord Allan, has just made about respect for the professionals we are speaking about is a very good one for me to follow on from, because I believe we are at our most vulnerable when we are in the care of the NHS. We have a right to expect to be seen and treated by a competent and regulated professional, in whom we have confidence. This debate has highlighted the sensitivities and practical challenges in trying to get that right. I am sure the Minister will take note of the many valid points that have been raised.

I start by associating myself and these Benches with thanking physician associates and anaesthesia associates for their professional and continued service. I feel particularly strongly about saying that in view of the points raised by my noble friend Lord Hunt and other noble Lords on the considerable toxicity that has been generated about this issue. That has brought bullying and intimidation to these very valued members of the NHS team. I am sure that all of us in your Lordships’ House believe that this is just not acceptable.

In the debate tonight, I feel that I have heard broad agreement that regulation is important—indeed, crucial —to maintaining high standards of patient safety and care, and providing clarity around the boundaries of the functions that can and cannot be performed. Yet, as we have heard, there has been significant delay in getting there when it comes to PAs and AAs, even though regulation needed to come alongside workforce planning. Can the Minister tell your Lordships why this regulation has taken so long?