Health and Social Care Information Centre (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023
Baroness Merron Excerpts(1 year, 3 months ago)
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Lord Allan of Hallam (LD)
My Lords, I am grateful to the noble Lord, Lord Hunt, for ensuring that we have an opportunity to debate this statutory instrument. I am also grateful to the Minister for both his initial response to the amendment and the time that he and his officials have spent responding to queries from me and my noble friends Lady Brinton and Lord Clement-Jones.
I revealed in yesterday’s debate how I started my tech career in the Avon Family Health Services Authority. From there, I moved to the FHS Computer Unit and worked on national NHS IT, so this reorganisation has a special interest for me. The subsequent path of the system that I worked with, which was called the Exeter system because the developer hub was in Exeter, is illustrative of the constant reorganisation of NHS IT, of which the latest example is in front of us today; I note in passing that early versions of the Exeter system were written in a language called MUMPS, like the disease but in capital letters, proving that geeks do have a sense of humour. The FHSCU was incorporated into something called the NHS Information Authority, which was then split between the National Programme for IT—NPfIT—and the Health and Social Care Information Centre. NPfIT was later rebadged as Connecting for Health, while the Health and Social Care Information Centre found its way, via a couple more name changes, into NHS Digital; this was referred to by the noble Baroness, Lady Finlay of Llandaff.
It can feel like the architects of these reorganisations have drawn inspiration from peristalsis, the process that moves food through the body by contracting and expanding the gut. The belief seems to be that we can make progress with NHS IT by pulling everything to the centre then pushing it out again to the edges in a cycle of rinse and repeat. I fully expect us to be back here in a few years’ time being told that we have lost focus by pulling everything into NHS England and that we need to create some kind of new stand-alone agency. We might call that new body the Unified Trust Operational Process Information Agency, or UTOPIA for short—there is some free branding advice for the Government.
The serious point here is that, in spite of—or perhaps because of—these reorganisations, the NHS still has information systems that fall well short of what is possible and desirable. There are many excellent people who work in NHS IT, and there are examples of great systems being developed, but we cannot say that there is consistent excellence, which is what the service needs and deserves, as noble Lords have said. I sincerely hope that we might get it right in the public interest this time, but experience suggests that we should remain cautious and test thoroughly what we are being offered.
An early test for this new structure will be the mega contract that has just been opened up for bids to provide a federated data platform, to which my noble friend Lady Brinton referred and which looks like it will cost the taxpayer at least £500 million; that is the number on the face of the contract, and God knows what else will need be spent by trusts on ancillary services. We will be asking searching questions of the Minister at all stages of the development of this project, as some elements are already triggering the spidey-sense of those of us who have seen too many big NHS IT projects go south—by which I do not mean going to Exeter but further than that.
As well as the structural questions about whether this reorganisation will achieve its core purpose of improving IT support for health and social care, there are concerns about what it will mean for the treatment of personal data. The noble Lord, Lord Hunt, and my noble friend Lady Brinton have done a thorough job in describing those concerns so I will not repeat their arguments in detail. However, I want to reinforce their emphasis on the importance of independent oversight. I have worked in technology organisations and have huge admiration for the way in which software engineers, researchers and data scientists tackle problems using data, but their deep focus on addressing problems is not always accompanied by the same level of interest in documenting and getting approvals for all of their uses of data. This is not usually because they are doing anything wrong but because they are in a hurry to explore a task that we have given them. Given this tendency, it is essential that we put in place good governance systems that do not get in the way of necessary uses of data but ensure both that these are properly considered and that any risks are surfaced and mitigated.
As other noble Lords have argued, the IGARD system, which worked for NHS Digital, has broad support. We need something equivalent in this new structure. I ask for the Minister also to consider additional forms of transparency that will help people have confidence that data is being used appropriately. The overriding principle here is that you do not want people to feel surprised that particular kinds of data are being collected or used for particular purposes. A healthy discipline that will help avoid surprises is to ensure that the data schema and software code are made public, as this allows third parties to see for themselves what is going on inside the black box. This is not about publishing all the data held in the databases, which needs to be managed separately; it is about showing the kinds of data that sit in different systems and informing us what the systems are doing with them.
There is a common trope that Governments like to trot out to reassure the public and show that something is safe: putting in place a triple lock. This is part of the Government’s rhetoric around the Online Safety Bill, for example. I invite the Minister tonight to commit to a quadruple lock in this case, given the importance and sensitivity of health and social care data. Lock 1 is the commitment to meeting fully all the data protection standards that are already in place for NHS Digital and in the general data protection regulation. Lock 2 is to ensure there is a truly independent body assessing and authorising requests to use data. Lock 3 is the publication of data schema so that we can see the full extent of what is being held, and where. Lock 4 is the publication of code that will allow people to check that what was authorised is what has actually happened.
I hope that this reorganisation will both lead to positive technology outcomes and avoid negative data outcomes. The NHS needs success in these areas more than ever. I also hope that the Minister will agree that our scepticism on these Benches is healthy and makes it more, not less, likely that we will see those outcomes. Onward to UTOPIA.
Baroness Merron (Lab)
My Lords, I thank the Minister for introducing these regulations and for the assurances he has given your Lordships’ House. I also express my appreciation to my noble friend Lord Hunt for what, as other noble Lords have said, was an extremely detailed and helpful examination of the challenges that these regulations present. I hope that the Minister will take his amendment and this debate in the spirit which I know is intended.
I share the view of all noble Lords who have spoken this evening that digital transformation of the NHS is a good thing; on that we are agreed. We all support the use of information to make things better for patients. However, this is about getting it right, and I hope that the debate this evening has contributed greatly to that. It is about confidence. As the noble Lord, Lord Allan, just said, people should not be surprised. They should also not find themselves compromised, uncertain or in any way undermined by the use or misuse of data. That is the challenge before us.
PPE Expenditure
Baroness Merron Excerpts(1 year, 3 months ago)
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Lord Markham (Con)
As I mentioned before, the daily cost is roughly £700,000.
Baroness Merron (Lab)
My Lords, the National Audit Office found that during the pandemic one in 10 suppliers processed through the VIP lane were awarded contracts. This compared to less than one in 100 suppliers going through the ordinary lane. In view of this, could the Minister share with the House what particular qualities were required of suppliers to merit VIP status? Following up on his answer to my noble friend Lord Harris, in the event of a future emergency, was the Minister ruling out having a VIP lane?
Lord Markham (Con)
I think we all agree that, at the time, some mechanism was needed to sift the thousands upon thousands of offers of goodwill to help with PPE. A decision was made to take recommendations —the so-called VIP lane—and I think we all accept now that was not the right decision. Going forward, a different sifting mechanism would be set up in place of that. Now, of course, we have supply chains set up to do this, so we hope that occasion will not arise in future.
National Health Service (Primary Dental Services) (Amendment) Regulations 2022
Baroness Merron Excerpts(1 year, 3 months ago)
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Lord Allan of Hallam (LD)
My Lords, I am grateful to the noble Lord, Lord Hunt, for ensuring that we have an opportunity to debate this important statutory instrument today. We benefit from his detailed analysis of problems in the dental sector.
The facts are laid bare in the Government’s own impact assessment, which says:
“NHS dentistry was a challenging area prior to the COVID-19 pandemic, with patient access proving difficult in some areas of the country … The COVID-19 pandemic exacerbated problems with patient access and created a backlog of patients seeking access to NHS dentistry.”
There is a recognition in that analysis that people being unable to access NHS dentistry is a long-standing problem. As other noble Lords have said, the statutory instrument is correctly aimed at addressing some aspects of that shortfall, and we would not oppose it as a contribution to solving the problem. However, we would ask the Minister, “Is this all you’ve got?”, given the clear and enormous gap between demand and supply.
The figures are dire. Again, the Government’s own impact assessment shows that the success rate for patients seeking an NHS dental appointment has fallen from 97% in 2012 to 82% in 2022 for people with an existing relationship with a dentist—so one in five of those who already have an NHS dentist relationship are not being seen. But for those trying to get their first NHS dental appointment, this has become almost impossible in many areas, with only 31% of those who had not been seen before successfully getting an appointment, compared with 77% of the same group in 2012. When we drill down into these national figures, we also see significant variation around the country, with some areas having become known as “dental deserts” because of the lack of dentists offering NHS treatments.
Turning again to the impact assessment, we see that it tells us that
“the North West has generally good access (but with pockets of poor access in rural areas), compared to the South West and East of England where access is generally poor, particularly in rural and coastal areas.”
This is a terrible indictment of what is supposed to be a nationally available essential service—one that is likely to have a disproportionate effect on deprived people who often need intensive dental care. The noble Baroness, Lady Bennett, also raised this point, quite rightly, in the context of the levelling-up agenda—or is it the gauging-up agenda? In any case, the agenda to deliver better services to people in historically deprived areas is critical to this understanding of the disparate access to dental care.
These changes are supposed to incentivise better provision of these intensive treatments but I note that again there is no statutory review clause in the instrument requiring the Government to produce data that will show their actual impact. I hope the Minister will want to commit to producing such a post-implementation evaluation in due course, even if that is not a statutory requirement. I am sure he will talk up the benefit of making these changes but the proof will be when we come back in a year or two and we can see whether there has been a change in the number of people able to access NHS dentistry and the number of treatments that were given.
As well as amending the payment scheme, this regulation places new requirements on dental practices to update information about their services for publication on the NHS website. This may seem weird, but I experienced a twinge of fond nostalgia as I read up on this section. It took me back to my first technology job, where I was responsible for producing the directories of primary care practitioners for what was then the Avon Family Health Services Authority. These consisted of papers in ring binders that listed each dental practice and its services for distribution to libraries and other public information points.
That was in the mid-1990s before the massive growth of the public internet, but I managed to get hold of some software called the NCSA HTTPd, an early web server, and I produced an HTML version of our directory for people in the local authority. All of those products are now long discontinued, as indeed is the country of Avon itself, so this is of historical rather than current interest. However, that may have been version 0.001 of the public directory that we now have on the NHS website.
Fast-forwarding to the present day, it will be no surprise that we support improvements to provision of information to the public such as those in the statutory instrument. However, that has to be complemented by improvements to the availability of services or we will simply see increased frustration as people are given better information about what they cannot have. Does the Minister have a response to people who will go to the NHS website and find that there are no dentists taking on NHS patients in their area?
I hope that the Minister will not think it churlish if we say, “Thanks but not enough” in response to this instrument, and that he may have some additional remarks to make about what more the Government plan to do, especially in respect of creating the NHS dental workforce. I emphasise “NHS”; there are many areas where there is no shortage of dentists, but there is a shortage of dentists who are willing to work for the rates that the NHS is prepared to offer them. I hope that by making those improvements, we will be able to move on from where we are today, where seven out of 10 people in this country who try to get into the NHS dentistry system for the first time cannot find anyone to take them on.
Baroness Merron (Lab)
My Lords, I commend my noble friend Lord Hunt for such a thorough analysis and for bringing this debate before your Lordships’ House this evening. As ever, he brings his expertise, knowledge and incisive approach to this important subject: the provision, or lack of provision, of dentistry.
As we have heard, we have seen a quarter of the budget cut since 2010 and with dentistry, a complete failure to provide a proper service to the population of this country. We know that dentists suffer burnout and that there is difficulty in retaining and recruiting the dentists that we need, while insufficient numbers are in training. This is a toxic mix. We also know that even under the existing budget, even if it was utilised fully, funding is available to provide NHS dental services for only around half the population. We find ourselves in considerable difficulty.
Let us remind ourselves about this statutory instrument. It was drawn to the special attention of the House by the Joint Committee on Statutory Instruments in its report because the regulations are
“defectively drafted in two related respects.”
To look at the specifics of those, as the noble Lord, Lord Allan, also raised, I ask the Minister why it was not felt necessary in respect of primary dental service agreement changes to give a timeframe for dental practice profiles to be provided for the NHS website. Does this not, as the Joint Committee on Statutory Instruments criticised, insert a somewhat unacceptable level of uncertainty into the statute book? I look forward to the Minister’s comments on that point. Furthermore, in respect of the criticisms of this statutory instrument, can the Minister say why NHS England has received no steer within this as to what a “reasonable timeframe” is to take action against non-compliant contractors, which the JCSI concludes
“leaves this law unacceptably uncertain”?
Osteoporosis: Early Detection
Baroness Merron Excerpts(1 year, 3 months ago)
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Lord Markham (Con)
As I mentioned earlier, this is the responsibility of all the ICBs. Part of my job is making sure that we as Ministers now regularly communicate with all the ICBs. There are a number of boards that I regularly speak to, check in with and visit on a frequent basis, and one of our checkpoints is making sure that they are on top of services such as these. I am delighted to say that every ICB has now set up a community base fall service, to make sure that if someone should fall in a case such as these, rather than an ambulance and two paramedics, we can have someone specially set up to right these people, put them on their feet and avoid an A&E visit.
Baroness Merron (Lab)
My Lords, the UK primary care base trial on screening for osteoporosis in older people examined a systematic approach to identifying older women for fracture prevention, leading to a 28% reduction in hip fracture risk, significantly reducing costs and seeing increased adherence to treatment. What plans are there to extend and learn from this important study?
Lord Markham (Con)
I thank the noble Baroness for bringing this to my attention. Clearly a 28% reduction is impressive and something that we should take seriously. If she can give me the reference, I will definitely take it up and write back.
United Kingdom: Future Pandemics
Baroness Merron Excerpts(1 year, 3 months ago)
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Baroness Merron
To ask His Majesty’s Government what assessment they have made of the United Kingdom’s readiness for any future pandemics.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
My Lords, we cannot perfectly predict the characteristics of a new pandemic pathogen, and therefore pandemic preparedness is an area kept under review. The UK has flexible and well-tested pandemic response capabilities. We are continuously enhancing our preparedness using the latest scientific information, lessons learned from exercises and our response to emergencies, including Covid-19. The UK Health Security Agency maintains constant vigilance on emerging infectious disease threats. This includes co-operating globally to detect and counter future pandemics.
Baroness Merron (Lab)
My Lords, Dame Kate Bingham, former chair of the UK Vaccine Taskforce, told the health and science committees in the other place that many of the initiatives set up by the taskforce have been dismantled, that key recommendations have not been acted on, and that the clinical research environment has deteriorated. Does the Minister acknowledge the pressing need to go further than the Government’s targeted spend on research and development, and can he say why the Government have been so reluctant to act on the taskforce’s conclusions from the last pandemic?
Lord Markham (Con)
Our approach to this has been led by the science. As the House is aware, we set up the UK Health Security Agency precisely to make sure that we have a team of experts in place ready to answer what is needed, in any eventuality. We also set up the 100 Days Mission to make sure that we have the ability to deploy effective diagnostics, therapeutics and vaccines within 100 days, which is pretty good.
National Health Service Pension Schemes (Member Contributions etc.) (Amendment) (No. 3) Regulations 2022
Baroness Merron Excerpts(1 year, 4 months ago)
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Lord Allan of Hallam (LD)
My Lords, regrettably I do not have an interest to declare in respect of the NHS Pension Scheme. I say regrettably because I was an NHS employee during much of my 20s but foolishly opted out of the pension scheme. Older me would have words to say to younger me about the lack of foresight in that decision, because the NHS pension was and is an excellent support in retirement, as the noble Baroness, Lady Altmann, has pointed out. If only I had had someone like her to advise me back then, I would be in a better position today.
Apart from that reminder of personal grief, I am grateful to the noble Lord, Lord Davies of Brixton, for enabling us to have this debate today, as it allows us to return to a key topic that we rightly discuss regularly in this House—the issue of staff shortages in the health and social care sector. He and the noble Baroness, Lady Altmann, have described some of the really quite profound structural challenges related to NHS pensions and taxation, and I hope that the Minister will agree to look at them in some detail.
On the narrower subject of the regulations themselves, the response to the consultation on this instrument is enlightening in describing the nature of the staffing pressures that the NHS faces, which brought around the original changes made in the Covid legislation that have then been prolonged in a series of statutory instruments, and especially in describing those that relate to staff sickness absence rates. I note that the consultation response was written last autumn but accurately predicted the fact that those staff sickness absence rates would continue through the winter. If anything, they have been worse than anyone anticipated, through the combination of Covid and flu. That makes the case for us not disincentivising experienced staff who are past retirement age from returning to help us out at a time of national crisis. It is of special note that, in this consultation, 98% of respondents said that, yes, this should go ahead and we should continue to offer some relief to those who are coming back into work, with only 2% against. That is quite a majority for any consultation.
If the consultees had any criticism, it was that the easements did not go far enough. I note that the Government have agreed to remove the 16-hour rule permanently from 1 April this year, and I hope that the Minister will confirm that this is the case. It was the pension scheme board itself that said that there was no rationale for requiring people who agreed to work past retirement to stick to a 16-hour limit.
The response also goes into some detail about the position of special class status members who can retire at 55, and what happens if they return to work before the age of 60. It included a graph that showed how much a nurse in this category could work before abatement applied. I understand that the word “abatement” in this case means that there is a limit to the number of additional hours that a nurse could work before losing, pound for pound, some of their pension entitlement. In other words, if they work past that amount of time, effectively they are working for free. The Minister may correct me if I have misunderstood, but the chart implied that there would be a straightforward loss.
The chart tells us that the most experienced nurses, those with 35 years of pension entitlement, would be able to work around 0.5 of a full-time equivalent before the pension ceiling kicked in. The Government in their consultation, because they were not lifting the abatement permanently, put a glass-half-full spin on it, saying, “Look, these people can come back and work half time”. But of course there is a glass-half-empty angle on it as well, which is that we are potentially losing half the time that those experienced staff could give to us if they did not feel that, by working those extra hours, they would lose out on their pension entitlement. I note that the abatement for this group has been extended to 2025, acknowledging that concern, but that there is still no permanent solution. Again, I hope that the Minister today has some ideas for how we may go further and ensure that the NHS can persuade retired staff of all classes to put in as many hours as they feel fit to do. We do not want to be in the position whereby someone is willing to work more but, purely for financial reasons, feels unable to do so.
I am sure that we will return to the theme of the impact of NHS Pension Scheme rules on staffing levels over the coming months. As the noble Baroness, Lady Altmann, pointed out, it is clear that there are unforeseen and unwelcome consequences of some of these rules, which I suspect is because they were crafted in a different climate for NHS staffing, at a time when people would retire and plenty more people were coming in. Today we are in quite a different situation where, frankly, we are desperate for those people who can still work, who are at retirement age, to postpone in many cases well-earned retirements to come back and assist us. In that climate, it is essential that the Government commit to revising rules where that would make a material difference to staffing levels and therefore to the health of the nation.
Baroness Merron (Lab)
My Lords, I thank my noble friend Lord Davies for tabling this regret Motion and for comprehensively setting out the issues before us this evening. As the noble Baroness, Lady Altmann, said, this is a real problem because we see workplace penalties incentivising staff not to work, which cannot be a state of affairs that is allowed to continue.
I will start by making a general point of context. I have great concerns at how many regret Motions concerning regulations produced by the Department for Health and Social Care have been tabled in recent months, with more to come. Is this a concern that the Minister also shares? If so, I wonder whether he has a view on what action needs to be taken within the department in order to stem this flow. I suggest to your Lordships’ House that perhaps the reasons for justified dissatisfaction with a number of regulations that are being brought forward have roots in both procedure and policy that are falling short. I will return to that point later. I hope that the Minister will act swiftly and systematically to deal with this continuing problem.
As we heard in contributions from across the House, inadequate numbers of staff underscore the crisis in the National Health Service, which is creating a situation of irrevocable damage being done to the lives of people who experience record delays across the whole of the system. We have a crisis of failure in getting and keeping a workforce in place to provide the services that we need. This has not just happened by accident. It is evidenced as predating the pandemic and it is the result of nearly 13 years of very particular choices that have been made by this Government.
In 2021 alone, 2,000 dentists and over 7,000 nurses quit the NHS. There are more than 46,000 empty nursing posts across hospitals, mental health, community care and other services, which means that around one in 10 nursing roles is unfilled across the service overall. That is the context in which we are discussing this regret Motion. As noble Lords on all sides of the House have asked repeatedly—as the noble Lord, Lord Allan, rightly reminded us, and as I and other noble Lords asked on yesterday’s Statement—where is the comprehensive and detailed workforce plan to retain, recruit and train the doctors, nurses and other health professionals whom the NHS so desperately needs? Will this plan take account of NHS pension arrangements?
With specific reference to NHS pensions, we have long been calling for the Government to sort them out and to remove the deterrents in the system to NHS staff staying in post or returning to work. This includes, for example, the cap on doctors’ pensions as, under the current rules, many experienced doctors are deterred from working later into their career because they are unable to opt out of paying into their NHS pension even if they have reached the cap. The result is that GPs are taking early retirement, which they would not have done otherwise, as the noble Baroness, Lady Masham, referred to.
We also know that record numbers of GPs are indicating that they will retire or leave the profession, with burnout and low morale at an all-time high. Can the Minister say how the numbers will stack up, when 4,700 GPs have been cut over the past decade and the long-promised 6,000 GPs are not on course to be delivered? How will the current pension arrangements assist in keeping GPs from wanting to retire and leave the profession? What action will be taken?
I turn to the specific comments of the Secondary Legislation Scrutiny Committee that form the basis of this regret Motion. I understand why my noble friend Lord Davies has seen fit to table this Motion. The committee’s report on this statutory instrument laments the short-term approach taken by the Government. The SLSC has drawn these regulations to the special attention of the House because
“some of the extensions proposed are quite short term and may not give re-employed retired staff or their employers the certainty first to encourage and then to retain staff to deal with the current NHS backlogs.”
Excess Deaths in Private Homes
Baroness Merron Excerpts(1 year, 4 months ago)
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Baroness Merron
To ask His Majesty’s Government what is their assessment of the reasons behind ONS figures showing excess deaths in private homes in England and Wales in the week ending 23 December 2022 were 37.5 per cent higher than the five-year average for the same period.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
My Lords, while the detailed assessment is not yet available, it is likely that a combination of factors has contributed to an increase in the number of deaths at home, including high flu prevalence, the ongoing challenge of Covid-19, and health conditions such as heart disease and diabetes. On 12 January, the Office for Health Improvement and Disparities will update its excess deaths report, providing further insight into causes that have contributed to excess deaths.
Baroness Merron (Lab)
My Lords, while a patient may choose to die at home, the spike in home deaths rings considerable alarm bells. Analysis suggests that record ambulance and emergency delays could be the explanation for a significant number of many more sudden deaths that are occurring at home. Can the Minister point to any government analysis, whether published or ongoing, to explain this unexpected increase in home deaths and a potential link with these delays? If there is no such analysis, how will the Government know how to overcome this shocking state of affairs?
Lord Markham (Con)
I thank the noble Baroness. This is an important question, and I had the opportunity to speak to Sir Chris Whitty on this very subject this morning. The statistics show that, over the course of the year, home deaths have increased by about 22%—a lot of that through personal choice, because it was happening over the summer and earlier in the year. Sir Chris told me that a lot of factors are in play at the moment. Flu is a clear example. There were about 1,000 more deaths in the week mentioned than would normally be expected. The cold snap came early, creating more cardiovascular deaths. However, clearly, the challenges are also a component part, which is why we made yesterday’s announcements about the further measures.
NHS Winter Pressures
Baroness Merron Excerpts(1 year, 4 months ago)
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Baroness Merron (Lab)
My Lords, from this Statement one might conclude that the NHS is facing challenges but that, overall, things are moving in the right direction. This could not be further from the truth and does not reflect how dire the situation has become. It is clear that the Government have failed to grasp what everyone else has managed to: that there is a deeply urgent crisis in health and social care, where irrevocable damage is being done to people’s lives.
While on the one hand the Government are bringing in legislation that will mean that NHS staff can be sacked for exercising their right to strike, on the other they are refusing to conduct meaningful pay negotiations that could end the strikes in the health service. Indeed, they only thought to convene an NHS recovery forum this week, when we are already half way through the winter.
It is increasingly becoming clear that the sporadic pots of money proposed as sticking plasters for various pinch points are not being deployed quickly enough. For instance, the £500 million emergency adult social care discharge fund was announced in September, but some half of it still has not yet reached the front line. The NHS has now said that it is too late to make a difference to the winter crisis. Has the Minister identified what is stopping the funding coming through? What plans are in place to deal with this so that funding can promptly get to where it is needed? It is no good making announcements and then not following through.
Nor is it easy enough to work out whether funding is new or recycled money. I hope the Minister will be able to clarify this now and in the future. The nature of this Government’s approach to funding health and care—half a billion pounds here one week, another few million there—gives the impression of knee-jerk reactions rather than strategic policy-making. In fact, the approach is so last minute that, after making the announcements in yesterday’s Statement, an extra £50 million was suddenly found and a further press release was issued.
Yet we know that prevention is better than cure in every sense. A GP appointment costs the taxpayer much less than a desperate patient turning up at A&E. Is the Minister content with this eternal hole plugging? What plans are there to move towards a more holistic and sensible long-term approach, including plans to fix primary care so that patients can see the GP they want in the manner they choose? What plans are there to recruit the care workers needed to care for patients once they have been discharged from hospitals, and to pay them fairly so that we do not lose them to other employers? As ever, where is the comprehensive and detailed workforce plan to train the doctors, nurses and health professionals that the NHS so desperately needs?
Underlying this has been an abject failure to make the social care system sustainable. Half a million people are waiting for social care assessments. They clearly are at major risk of having to be admitted to hospital as a result. How will the Minister work to prevent this, especially when care workers are leaving in droves to work in retail and other sectors? Is there a government target for when the number of people waiting for assessments, often in pain and discomfort, might finally start to come down?
The Statement cites Covid, flu, strep A, scarlet fever, and even CQC inspections as reasons why the NHS is under such strain. Is this not surely passing the buck, when other countries face similar challenges and yet are not gripped by such chronic crises every single winter?
In the context of an ageing population where demand on the system will only increase, is the Minister willing to assure your Lordships’ House that a sustainable social care solution will finally be produced before the next winter hits? The NHS Confederation has responded to yesterday’s Statement by referencing the obvious contained in the Government’s words on the need for
“the right wraparound care for those being discharged from hospital”.
The NHS Confederation also says that
“after a decade of austerity neither the social care sector nor the government are in any position to ensure it.”
Does the Minister agree with that analysis: that it is the choices of this Government over the past 12 years that have had a direct and devastating impact on the current delays? It is this fundamental that the Statement has failed to address.
National Health Service (NHS Payment Scheme—Consultation) (No. 2) Regulations 2022
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Lord Allan of Hallam (LD)
My Lords, I am pleased to be able to take the reins from my noble friend Lady Brinton, starting with this short but important statutory instrument. I echo the happy new year wishes and thank the Minister for his welcome. I understand that a key function that we perform in this House is to ensure that legislation is implemented in the way that Parliament intended as we put flesh on the bones of primary legislation through statutory instruments such as the one we are considering today.
Today’s statutory instrument is a small element of an important part of our modern health service infrastructure: the mechanism for pricing services within the NHS’s internal market. It was a prompt for me to read more pages of tariffs and rules than I ever intended or wished to do, which is mind-boggling and fascinating in equal measure. The subject of our debate today is not the substance of the payment scheme but rather the trigger for when the scheme might be reviewed if there are objections.
As the Minister pointed out, the Government’s intention is to maintain a 66% objection rate for triggering a further consultation period, which is unexceptional as it maintains the previous level. However, like the noble Lord, Lord Patel, I am curious as to why 66% was picked, particularly as I understand that it will not trigger a referral to the Competition and Markets Authority, which would have been a major step, but simply a further consultation period. There may be an argument for why a 51% or 60% threshold would not be appropriate, given that the threshold triggers something less significant than the previous regime.
I am also curious about the experience that we have had over the last decade or so while the other tariff scheme has been in place. Does the Minister have data on the levels of objections received in previous consultations? I suspect that they were much lower than the level we are talking about here but, as we review the scheme, it would be interesting for us to understand whether we were previously getting 10% objection levels, or 50%. I assume that there must be some experience of that within the National Health Service.
Like the noble Lord, Lord Patel, I would like more words about why 66% remains the effective level, and some information about objection levels we have experienced previously. That would be helpful to put our minds at rest, but I think we are all broadly supportive of the instrument as it stands.
Baroness Merron (Lab)
I thank the Minister for introducing this statutory instrument. It is a great pleasure to follow the noble Lord, Lord Allan, for the first time in his new role. I am sure there will be many more times, and we all wish him well. Of course, from these Benches, I echo the happy new year greetings. The new year gift to the Minister is that on no side are we opposing these regulations today. I am sure that will make him absolutely delighted as he starts 2023.
The consultation that we are talking about here is important because, as noble Lords have said, the NHS payments scheme governs how billions of pounds of taxpayers’ money is spent. Of course, quality of care and value for money have always to be at the core of our health service and its decision-making, and we need financial management within the health service to be able to deliver both quality of care and value for money in parallel—they are not an either/or. We saw during the pandemic what happens when the NHS strays from these principles, and we do not want to allow such events to happen again.
The former tariff system which these regulations form part of replacing sought to deliver a more competitive environment to drive up quality and to improve outcomes for patients yet, regrettably, it was often something of a rather rigid system that did not allow for the flexibility that individual commissioners actually needed. Therefore, giving local decision-makers the tools that they need to improve services in their areas is absolutely vital to ensuring that the NHS meets the needs of patients where they are, not where the system thinks they should be. The noble Lord, Lord Patel, raised an important point about meeting the needs of patients where there is variability across the country, and it would be helpful if the Minister could offer us some comment on that. With that in mind, a rigorous and effective consultation on changes is absolutely vital, because we know that, when done properly, payment schemes can deliver a meaningful impact on patient outcomes.
The payment by results incentives that were used by the last Labour Government made a significant impact on the elective waiting lists. We know that this may not be the appropriate way forward in every case and that options have to be carefully considered, but we are now in a situation where elective waiting lists are at record levels. So, given the reports that Ministers are considering bringing back payment by results incentives in some form or another, perhaps the Minister could give some comment on what plans are in place to do that.
I will ask a further question to get a sense on this. As we are talking about billions of pounds of public money—of course I believe that this SI and other discussions that we have treat this point with the gravity that it warrants—it would be helpful to hear from the Minister whether he considers that there is enough input through the Secretary of State into this process. I am of course not suggesting that Ministers should be setting payment levels for various treatments, but it would be helpful to have a sense about whether there is enough political input into how we might ensure that the extraordinary purchasing power of the NHS might incentivise innovation, prevention or, for example, buying British.
Furthermore, in previous consultations on the national tariff, such as in 2014, the objection percentage was met, but how have the NHS and the department worked since then and engaged with stakeholders to prevent that from happening again, as far as possible? I was also pleased to read that the department will be monitoring and reviewing the implementation of this legislation. Can the Minister give us some more detail on what form this will take and whether the analysis could be made public? That follows on from the point made by the noble Lord, Lord Allan.
It is important that we get right these changes that we are considering today, and effective consultation is absolutely key. It is in the interests of everyone, because it will ensure better outcomes for patients. I therefore look forward to hearing from the Minister how this will be delivered.
Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022
Baroness Merron Excerpts(1 year, 4 months ago)
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Lord Allan of Hallam (LD)
My Lords, I do not have any direct professional interest in the subject at hand, but as somebody who lives in London and needs dental care, and as a parent, I am grateful to those dentists and midwives from all over the world who have provided me with excellent service through the years. We should be grateful to them all.
From these Benches we also broadly welcome the order the Minister is putting forward. It is clear that we should make it possible for all suitably qualified healthcare professionals to practise in the UK and it is, frankly, a waste of an individual’s talent and a detriment to public interest if there are unnecessary delays or barriers to registration. The noble Lord, Lord Hunt of Kings Heath, described dentists coming here from countries such as Ukraine and Afghanistan who can make a significant contribution, and we need to enable them to do so rather than disabling them from doing so.
Of course, there are necessary checks to protect patient safety, but what we are saying with this statutory instrument is that we believe that the professional bodies, such as the General Dental Council and the Nursing and Midwifery Council, are the bodies most competent to determine what those checks should be and to set out the right testing and assessment processes to allow applicants with overseas training and experience to apply their skills here. In this debate I have learned a lot from the detailed experiences of the noble Lords, Lord Hunt of Kings Heath, Lord Harris of Haringey and Lord Patel, about what this means in practice. It seems to me to be the right decision that we should empower those bodies even further and give them the flexibility that they need to be able to adapt over time as circumstances allow, balancing out the need for safety but also the need to get people on to the register as quickly and reasonably as possible. We agree with the Government on the broad thrust of these provisions and that the additional flexibility is important.
I raise one question with the Minister. Do the Government have any criteria in mind for assessing whether this change has been successful? For example, have they looked at the cost and speed of applying to register before and after the additional flexibility is granted and after the new processes are brought in? The noble Lord, Lord Harris, correctly reminds us that this will not be immediately, but certainly over this multiyear process, if we are to make this change, it would make sense to look at the situation before and after. I note that paragraph 14.1 of the Explanatory Memorandum points out that the instrument itself has no monitoring provisions, but with any legislative change it is helpful for that to be the case, and I hope that the Minister will be able to describe some criteria that the Government have internally for deciding whether this has been successful.
Finally, I end on a note of caution about the safety standards. Sadly, something will go wrong; somebody will be registered in future who should not be registered. When that happens, the fact that we are all supportive of this today means that we will all own that decision, and we should not say that this is wrong because of a single bad case. Overall, we are making the correct decision. The correct risk assessment is that we trust bodies such as the General Dental Council and the Nursing and Midwifery Council to make decisions.
As the noble Lord, Lord Hunt, correctly pointed out, this is part of a process; we will be going further, and other professional bodies will be given similar flexibility. That is the right decision now and will be the right decision in future. Even if and when something sadly goes wrong under the new procedures, as I said, we will need to remember that, overall, we took this decision because we wanted to see more of those people—the kinds of people from whom I have certainly benefited—on the registers in the UK providing the professional services that they can.
Baroness Merron (Lab)
My Lords, I thank the Minister for bringing this order before us. On these Benches, as across your Lordships’ House, these changes are welcomed as sensible and as part of a suite of measures that we will continue to consider. Certainly, the increased flexibility that they bring to the work of the General Dental Council and the Nursing and Midwifery Council by amending the registration and examination processes and procedures so that they are as effective and practical as possible is very welcome. This is about harnessing the capacity and meeting the standards that are needed so that we can ensure that we have the right professionals in place. The noble Lord, Lord Patel, raised important points that I hope the Minister will consider on how the practicalities of this need to be done.
I am grateful to my noble friend Lord Harris, who laid out what the order does but also what it does not do—in our deliberations it is important that we understand that. I noted his comment that there was no ministerial claim that this will solve a workforce crisis, but, as my noble friend Lord Hunt said, we have a challenge in getting a workforce in place to provide the services that we need. In that regard, it is important that we consider the changes today in the current context of the health system in the United Kingdom.
It is important to say that, sadly, in 2021 alone, 2,000 dentists and over 7,000 nurses quit the NHS. There are more than 46,000 empty nursing posts across hospitals, mental health, community care and other services, which means that one in 10 nursing roles is unfilled across the service overall. As we have spoken about many times in your Lordships’ House, the number of NHS dental practices fell by more than 1,200 in the five years before the pandemic, and there are 800 fewer midwives than just three years ago. That is the context in which we are discussing this.
I turn specifically to the order. If, as expected, the GDC begins recouping costs incurred around international registration, including charging applicants more to take the overseas registration exam, could the Minister give an indication of what effect this might have on the number of dentists operating in the UK? I am sure he understands that, given the number of dental deserts that we already face, we cannot afford to lose the capacity of any further dental professionals.
As well as the overseas registration exam, non-EEA dentists also have to go through the performers list validation by experience process to practise here. The Minister will be aware that stakeholders expressed concern about dentists’ PLVEs being disrupted—for example, by being endlessly rearranged or cancelled—and that that is acting as something of a deterrent to working here. Can the Minister confirm whether there is recognition of that difficulty, and whether the department is looking at what needs to be done to make the process as coherent and smoothly run as possible?
In the other place, the Minister of State committed to write further on the breakdown of positive and negative responses to the consultation that was carried out. Can the Minister of State’s response be made available to Members of your Lordships’ House so that we might also better know what stakeholders were thinking when they responded to the consultation on these changes?
The Government’s Explanatory Memorandum states that policy changes that the regulations make following this order
“may potentially impact international applicants and existing registrants with different protected characteristics, particularly with regards to age, sex and race”
but does not provide detail on what that impact might be. Can the Minister offer any insight into this, if the department has correctly forecast what the regulators are planning?
As we have discussed today, the intent of the order is that there will be changes to application processes and so on. Can the Minister indicate what plans there are to review and audit changes to ensure that there is consistency of decision-making, fair treatment of all applicants and the achievement of the right standards?
In conclusion, while we all support the substance of the order, I hope the Minister can give an assurance that its impact and implementation will not be beset with logistical hitches and unforeseen consequences, because we are keen to ensure that changes are made to deliver the right result to get the workforce more into place than it has been hitherto. I look forward to hearing what the Minister has to say about how the order may assist that, if not entirely cure it.
Lord Markham (Con)
I thank noble Lords for their contributions to the debate. I shall attempt to answer the questions set. As ever, I will happily follow up in detail afterwards.
I accept the premise that no one believes that this is a silver bullet that answers all the issues around recruitment and workforce needs. At the same time, I think there is a belief that this is one of many things that can, hopefully, help increase access at the end of the day. I reiterate our commitment to independence, in answer to the question from the noble Lord, Lord Hunt. That is fundamental to this issue and, hopefully, something that the noble Lord, Lord Harris, has recognised through this process.
Probably the point I would like to devote most time to is the one about the DCP register. I must admit that it is something I brought up specifically and wanted to go around the houses on. I absolutely understand the issue: are we cutting off our nose to spite our face? On the equivalence argument—our dentists cannot apply overseas—part of that, as it was described to me, was also the feeling that even in the UK our dentists cannot use the DCP route, so to speak, in that they might be a qualified dentist but want to use some other qualifications, rather than be a dentist. So it was felt that there was no consistency there either.