Adult Social Care: Challenge Procedures

Lord Allan of Hallam Excerpts

Wednesday 19th April 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, Section 72 of the Care Act 2014 empowers the Secretary of State to regulate for an appeals system through which people can challenge social care decisions. It seems odd that we went to the trouble of legislating for this and yet, nearly a decade later, it still has not been implemented. What more evidence do the Government need to come to a decision about whether the benefits of such an appeal mechanism would outweigh the costs?

[Lord Markham (Con)]

The main point is that we already have two levels of appeal. In the first instance, someone can appeal to a local authority and if they are not satisfied with that, they can appeal to the local ombudsman. Thousands of people do this every year, and compliance in terms of replies to them is very high. I must admit that I am not sure whether an additional, third level of appeal is really necessary in this case.

Diphtheria

Lord Allan of Hallam Excerpts

Tuesday 18th April 2023 Lords Chamber

[Lord Markham (Con)]

Absolutely. As the noble Baroness is aware, vaccination take-up is the responsibility of the ICBs in their areas. Like many other places, London has unique demographics. As I mentioned, our record is pretty good in this area, but it needs to be done nationally on a uniform scale.

[Lord Allan of Hallam (LD)]

My Lords, in response to the questions from my noble friend Lord Roberts and the noble Lord, Lord Hunt, the Minister has twice told us how well his department’s officials are working with the Home Office. But his department’s officials are not present in local communities; directors of public health are. Can the Minister undertake to lobby the Home Office on behalf of the public health officials to make sure that they similarly have a good dialogue with the Home Office, which does not seem to be the case to date?

[Lord Markham (Con)]

Clearly, I am always going to support good dialogue—that is common sense, and we should do that. The proof of the pudding is in the eating, and 88% is a very good result. That notwithstanding, clearly it makes sense that they should work closely with local officials as well.

Junior Doctors’ Strikes

Lord Allan of Hallam Excerpts

Monday 17th April 2023 Lords Chamber

[Lord Markham (Con)]

I think we all want fair outcomes and negotiated settlements, and I think we felt that the agreement reached with the Agenda for Change parties was fair and was something, as mentioned in the Statement, that the union leadership recommended to the union members. Of course, we need to wait to see the outcome of the staff council of all the Agenda for Change unions from 2 May to see where we end up on that. Our hope is that, across the majority of those, we will see support. As noted, this is a generous offer; it is higher than the offer made in Wales, for example, and we hope it will be a way forward after 2 May. If that is not the case, we need to sit down and think about next steps.

[Lord Allan of Hallam (LD)]

My Lords, the Secretary of State in the other place rightly referred to the workforce plan as essential to dealing with some of the stress that is contributing to the industrial action. I checked the record, and the Minister first told us that this plan was going to be released “shortly” on 2 February. Yet Valentine’s Day came and went, and there was no plan. Now, Easter has come and gone, and there is no plan. I wonder if the Minister could tell us whether “shortly” is getting shorter or longer? Should we be expecting the plan closer to the Coronation or the 75th anniversary of the NHS in July?

[Lord Markham (Con)]

I am afraid I cannot provide a lot more information to the noble Lord, except that complications now include the purdah for local government elections, so I am trying to find out more details on this very subject as to when a date could be set. I am afraid to say I cannot give much more of an update than to say it will be released shortly. What I will say is that, among all this, we are still seeing increases in staff. I was delighted to see that we now have 5,100 more doctors in place than last year, and we have had an increase over the last few years of 30,000 nurses. So, there are movements in the right direction, but clearly more needs to be done.

Stroke Rehabilitation and Community Services

Lord Allan of Hallam Excerpts

Wednesday 22nd March 2023 Lords Chamber

[Lord Markham (Con)]

I thank the noble Baroness for her question and for her tireless work in this space. I have fortnightly meetings with the NHS chief executive. One of the matters that I regularly raise with her is the timing of the return of physio space for this. As for ensuring that we are properly rolling out the services, the national integrated stroke service guarantees people individualised programmes of work and stroke rehabilitation services, in their homes if need be.

[Lord Allan of Hallam (LD)]

My Lords, the Minister told the House yesterday that the long-awaited NHS workforce plan is due “shortly”, which we are reliably informed is sooner than “soon”. We now wait with bated breath. I know that the Minister cannot speak to the specifics of the plan until it is released but I hope he can comment on its structure. Will it have the kind of detail that we need to see how staff shortages in specialist areas such as stroke rehabilitation will be remedied, or will it be so high level that further subplans will need to be developed so that specialist functional needs are not lost in the mix?

[Lord Markham (Con)]

I can confirm that it is a detailed plan. Services such as physio are an important part of that and will be planned accordingly.

Social Care: Workforce Strategy

Lord Allan of Hallam Excerpts

Wednesday 22nd March 2023 Lords Chamber

[Lord Markham (Con)]

The noble Lord is correct, in that this is pivotal to the whole health service and to health and well-being. It is very much the duty of the integrated care boards, and our Ministers are personally holding them to account on this. I have frequent meetings on seven integrated care boards, and this is very much on the agenda. The other six Ministers have 42 in total, seven each, so that we can make sure we hold them to account.

[Lord Allan of Hallam (LD)]

My Lords, the Minister has repeatedly agreed on the need for increased social care funding when replying to questions in debates. His party set out an ambitious plan for making such an investment in the Government’s Build Back Better strategy of September 2021. How have social care needs changed since then, such that the Government now seem comfortable to cut hundreds of millions from the commitments that they made less than 18 months ago? Does he think that we no longer need more supported housing or better digital services, two of the areas that the reports tell us are facing cuts?

[Lord Markham (Con)]

I do not recognise “cuts” in this context. Noble Lords are aware that we have committed to a £7.5 billion increase over the next two years, which amounts to about a 20% increase. We will see record investment and provision in this area.

Health Education England (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Lord Allan of Hallam Excerpts

Tuesday 21st March 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I very much appreciate the opportunity that the noble Baroness, Lady Merron, has given to the House to debate this reorganisation on the back of her regret amendment. In preparation for this, I had a look at Health Education England’s website; it is always good to look at the thing you are abolishing. It is worth quoting in full what it says about itself:

“Health Education England … exists for one reason only: to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place.”


That would perhaps be an appropriate motto for the Minister to have. It is timeless: we want people to be focused on that mission of delivering the right people with the right skills at the right time and in the right place.

Again, I looked at the history of the body. It was set up as a special health authority in 2012. I imagined that it was something we had had for years, but no, it was set up in 2012 and became a non-departmental body in 2014. So in about a decade we have gone from wanting a body with a singular focused mission to saying, “No, that’s a disaster; it needs to now be fully integrated into a much bigger body in order to be able to deliver”. I fear we have seen this again and again; we had it with NHS Digital. A group of people got together a decade or so ago and said that the important thing is that all these functions have a team that is solely dedicated to delivering workforce, digital or whatever, and 10 years later the fashion has changed. The Minister makes a reasonable argument that you would not now have a separate HR function. Clearly, a decade ago, we thought that was exactly what we should do, and we spent time and money constructing this thing. Now we are spending time and money destructing it.

There is a risk that we end up mistaking circular motion for forward motion. It is still motion—we are moving things around—but there is a risk that we are not making progress. I will explain why we need to have really serious measures to understand whether we are doing that; otherwise, I fear we will back here in five or 10 years’ time, with people standing at the Dispatch Box arguing why we need to separate all these functions out, because merging them into NHS England meant that we lost focus.

The one group of people that will continue to make money out of this is the consultants. I note we are told in the Explanatory Memorandum that they were paid £1 million plus VAT to create this reorganisation. I am sure a similar group was paid £1 million plus VAT to spin out HEE when it was originally set up, and we will see this again with all the different parts of the health service. We spend money and we reorganise. Even if we support the latest organisation, we in this House need to continue to hold the Government’s feet to the fire, whoever they are, to say, “Prove that the reorganisation was worth the money”.

The noble Baroness, Lady Merron, is quite right to keep bringing us back to the information in the Explanatory Memorandum and the reports we get from the scrutiny committee. We are given explicit information about the costs. We are told that it is £1 million plus VAT for the consultants and another £1 million for staff costs, so a couple of million pounds here and there for direct costs. The savings are much less clear. We are told they are £1.3 million because we no longer need a separate board; then the big savings are wrapped up in this aspirational 40% for all of these reorgs into NHS England, but we are not given any more detail than that. I know the current body of staff in Health Education England is some 2,000 people, overseeing approximately £5 billion of expenditure, so there is clearly a lot of scope for potential savings.

I ask the Minister to make a firm commitment that the Government will come back and that future NHS England reports will give the kind of detail we need in order to understand whether those savings were realised. When these reorgs happen, there is a risk that NHS England’s future reports will be structured in a way that disguises the savings so that we cannot pull them out. It would help the House and the public if, when NHS England reports in a year’s time, there is a separate item that says, “For NHS Digital, we did or did not realise these savings”, and, for Health Education England and the education functions, “This is how many staff we now have working on it and that is why we think we are getting better value for money from the budget”.

From an accountancy point of view, you can go either way: you can either try to hide things by smushing them all up together or try to make them explicit by ensuring that the data is there. I hope that the Minister will commit so that we can come back at this time of year in 2024, 2025 and 2026—I recognise that this will take time to play out—to see whether this reorganisation has had the effect. This would inform the debate next time we are asked to reorganise; I am sure we will be told every time that they will make savings.

Finally, the substantive point raised by the noble Baroness, Lady Merron, is around the workforce plan. We can repeat our previous exhortations: that this is desperately needed; I know the Minister agrees that it is desperately needed. There are concerns that the reason it is being held up is that the funding is not there. Every time we see good news—the pay settlement for nurses and others is good news—a little bit of us asks where they will find the money; we hope they will not find the money by cutting in other areas. We need continual reassurance that the workforce plan will be accompanied by the money that will be needed to deliver it, and that we will not see it shaved away as it goes through the process of finalisation. That might be partly why we want it quickly. Once it is published, it is much harder to step back. The fear is that, the longer it takes, the more likely it is that there will be a process of salami slicing and the bold, ambitious workforce plan, which I am sure the Minister and his colleagues in the department supported, ends up “Treasury-fied” and no longer quite as ambitious as it was.

Finally on the workforce plan, we are talking about the NHS and we are rolling Health Education England into NHS England. As we have discussed many times in this House, health and social care are intimately related in terms of being able to deliver for people out there and being able to run an efficient service. I hope the Minister will at least be able to say that this reorganisation will not negatively impact joined-up workforce planning across both sectors. Ideally, I hope he will be able to say that there will be some positive impact from this reorganisation in terms of making sure that social care staff numbers correspond with the increase in NHS staff that he knows we need.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a relatively new non-executive director of NHS England, appointed together with two expert doctors to give clinical input to the board and tackle the issues that have just been discussed. However, I want to put on record that I think Health Education England has been a success and has set up sound processes that have enabled a good estimation of the workforce needed for the next 15 years.

The workforce plan is in draft and is being considered by the Government, but I want to underline the fact that, without sufficient funding, it will not achieve what everybody wants it to achieve. I believe that making it mainstream in NHS England should mean that, working with the ICBs, we have a sound approach for the future. I am aware that the two previous speakers will be able to hold NHS England to account on whether we get it right or not. I felt that I should be here this afternoon to say that I think it will work, but only because of the sound foundation that NHS Education has left behind.

I also want to echo one concern: that we have to calculate social care needs within the workforce development plan, in particular the needs of leaders of teams in social care, who are often nurses or allied health professionals such as physiotherapists. On that note, I will sit down; I wanted to express my current understanding of the situation.

Medical Devices and Blood Safety and Quality (Fees Amendment) Regulations 2023

Lord Allan of Hallam Excerpts

Monday 20th March 2023 Grand Committee

[Lord Jones (Lab)]

My Lords, I thank the Minister for his concern and his introduction on the very important matter of blood. Much detail is given by the department in the papers that we have, particularly in the Explanatory Memorandum. Clearly, a lot of work has gone into producing what we have before us.

Currently, a lengthy inquiry by a learned judge and his board is drawing to a close. It regards how, a generation ago, contaminated blood was given to unsuspecting patients, resulting in great distress—and worse—for not only the patients affected but their families. I think the learned chair will report soon; the Minister might confirm that.

My basic question is: can the Minister say what sort of people are involved in the receipt of these fees? One presumes that they are medical professionals or ancillaries who perhaps deal with the details of making available what is required. Can he give examples of the status, titles and work of those who receive the fees? He might agree that, on the face of it, the fee rise is steep.

Clearly, time has gone by, so I intend my interjection to be very brief, but I think I have raised a pertinent question. I rise in this Committee fairly often because I believe that many important regulations come to us, but debates are thinly attended. In many cases, what we consider in our debates here would be better taken on the Floor of your Lordships’ House. That is an opinion, but what we are debating now is very important, and I look forward to the Minister’s reply.

[Lord Allan of Hallam (LD)]

My Lords, we echo the Minister’s comments in praise of the agency for the valuable work that it does in the United Kingdom. Of course, we also want to make sure that it is effectively funded for that work, but we have a few questions on the instrument before us.

First, if we look through the Explanatory Memorandum, the Minister has already explained the item referred to in Paragraph 7.6, that

“the Office for National Statistics reclassified the MHRA from a Trading Fund to a Market Regulatory Agency”,

and said that this affected the way in which it can use cash reserves. In exchanges with the Minister prior to the Committee we talked about the fact that we do nerdy regulation in here. I am curious to know whether any more detail might be made available in writing or otherwise about the way in which that classification or reclassification can take place and the effect that it has, as clearly it may be relevant to other agencies in this space. Understanding what it means to move from being a trading fund to a market regulatory agency is quite important for our work more generally.

Specifically on the cost increases, paragraph 10.2 tells us that there was “a general acceptance” of the need for increased fees in the responses, noting that people said that there was an understanding of the need for an increase in the fees but that they expected to see corresponding consistency in the service that they were given. Again, I hope that the Minister can come back to that later and talk about the assurances that the industry is looking for with regard to the service. However, if we look in detail at the consultation responses, we see that they were not uniformly positive. If we look at the category 1 increases, which was the simple 10% indexation, it was 61% for and 39% against. However, if we look at category 2, where there are some cost-based increases—they are significant and we will touch on those—it was 56% against to 44% for, so clearly, people were more uncomfortable with that. When we come to the third category of new fees, opinion was just in favour but was more balanced: 55% for and 45% against. Importantly, the consultees were then asked whether they thought there would be some impact of the new fees structure on particular kinds of businesses, and 89% said yes and only 11% said no, so a significant number of the consultees felt that in particular small and medium-sized enterprises might be disproportionately affected. We should not gloss over that. I know that officials are trying to summarise things when they produce an Explanatory Memorandum but if you summarise, sometimes you lose these important nuances where there was a much more mixed picture in the response to the proposals.

Paragraph 12.1 of the Explanatory Memorandum tells us that the anticipated costs that will fall on businesses, charities and voluntary bodies will be £1.9 million per year, which is echoed in paragraph 25 of the impact assessment, where it says that these costs will fall on businesses. Of course, the direct costs do, but those businesses will in turn have to pass those costs on to someone, and in most cases the eventual purchasers will be NHS bodies. Therefore again, at one level, it will fall on the business; I do not think that the businesses will simply absorb that cost, and there will be an impact on the taxpayer which does not necessarily come out. I hope that the Government will look at that and at whether, perhaps by increasing the regulatory costs, perhaps for good reasons, we end up increasing the cost base of the equipment. The noble Baroness, Lady Merron, and I were just in the Chamber talking to a Question about the cost pressures on medical equipment and devices and the need to replace significant amounts of outdated equipment with more modern equipment. In many cases, that more modern equipment will go through this approvals process, which will add on cost, so we need to be mindful of that cost base impact.

That brings me to my last point, which was about the impact of the new costs—again, we should not lose sight of them. We get the detailed figures in the annex to the instrument, which is extremely helpful. However, certainly for medical devices, if we look at the status quo ante and the status quo post the adoption of the regulations—these are my rough calculations and I am sure that the people who advise the Minister will be able to do it in more detail—there are costs potentially of £40,000 or of that order under the current regime for somebody to get a new medical device through the designation process, the audit process, and so on. In many cases, those costs are increasing three or fourfold, so you are talking about somebody potentially having to find £150,000 and numbers north of that now to get a medical device through the process.

Patient Deaths: Ambulance Waiting Times

Lord Allan of Hallam Excerpts

Tuesday 14th March 2023 Lords Chamber

[Lord Markham (Con)]

Clearly, we regret any circumstances where capacity is taken out of the system, and this is a clear example. Patient care is primary, and we hope to sit down and resolve the differences. I am glad to say that we are now having good conversations with the nurses’ unions and other unions, and I hope we can have similar productive conversations with the doctors.

[Lord Allan of Hallam (LD)]

My Lords, NHS data shows that there are significant variations in ambulance response times in different areas of England, and we see especially long response times in areas like the east of England, where some category 4 patients were waiting for over eight hours in February. Can the Minister explain how we got into this situation with what are supposed to be national targets? What are the Government doing specifically to help areas that are currently missing the targets by a country mile?

[Lord Markham (Con)]

Local ICBs—integrated care boards—are integral to this, understanding the need for ambulances in each of their areas. As noble Lords have heard me say before, often, having a fall does not require an ambulance response at all, but it is much better to have a full service. Now, it is the responsibility of every ICB to set up a full service so it can respond more appropriately. Additionally, we are tasking each ICB with getting on top of ambulance wait times.

Covid Pandemic: Testing of Care Home Residents

Lord Allan of Hallam Excerpts

Monday 6th March 2023 Lords Chamber

[Lord Markham (Con)]

The first major finding was setting up the UK Health Security Agency, because of a feeling that the bodies that were there at the time were not best placed. That was the first learning. From that, things such as the 100-day vaccine challenge were set up to make sure that we are well placed should another pandemic occur. We have tried to learn lessons all the way through and have made sure that testing capacity is still in place, so that we are able to react quickly, and stocks are there. I like to think that sensible measures are being taken and that we are not waiting for the inquiry, but I am sure we will learn more as the inquiry is fully engaged and when it makes its own findings.

[Lord Allan of Hallam (LD)]

My Lords, the Government’s defence of their entire testing strategy has been that we should trust them but, based on all that we have seen of the former Health Secretary over recent months—far too much, would be many people’s reaction—can the Minister say whether he is a person who displays consistent good judgment or is he capable of making some quite serious mistakes?

[Lord Markham (Con)]

I do not know the said ex-Minister, so cannot comment on that. If we cast our minds back, it was a very pressurised environment in which lots of decisions had to be made very quickly. Mistakes were undoubtedly made as part of that. As to how we did overall, it is best for the inquiry to make findings rather than for me to give my opinion.

Communications Act 2003 (Restrictions on the Advertising of Less Healthy Food) (Effective Date) (Amendment) Regulations 2022

Lord Allan of Hallam Excerpts

Monday 27th February 2023 Lords Chamber

Moved by

[Lord Allan of Hallam]

That this House regrets that the Communications Act 2003 (Restrictions on the Advertising of Less Healthy Food) (Effective Date) (Amendment) Regulations 2022 (SI 2022/1311) will delay for 33 months, until 1 October 2025, the implementation of the ban on advertising less healthy foods and drinks before the 9pm watershed on television, on radio and on online media.

Relevant documents: 24th Report of the Secondary Legislation Scrutiny Committee. Special attention drawn to the instrument

[Lord Allan of Hallam (LD)]

My Lords, the increasing level of obesity represents a clear and present danger to the health of our nation. I will not recite all the issues caused by obesity, but I direct anyone wanting to learn more to the Obesity Health Alliance.

Recognising this risk, Parliament has agreed on a number of tools to try to arrest, and ideally reverse, that increase, including restrictions on advertising less healthy foods which were agreed to in the Health and Care Act 2022. But while Parliament can will the ends as well as the means, in the shape of the proposed new advertising restrictions, it depends on the Executive to bring them into effect and to do so in a timely fashion, and yet we are faced here with the Government telling us that they cannot implement what we have asked them to do for the best part of two years. This makes the Government look powerless to respond to a public health crisis that needs action right now, and their defence seems to be that they are not impotent but merely incompetent.

We can expect the Minister’s response to explain the challenges of all the different processes that they have to go through to introduce the restrictions and why these all take time. While I am generally sympathetic to the need to regulate properly by consulting with affected organisations, I am afraid that my response on this occasion has to be that my heart bleeds custard for the Government. The need to go through these various steps was entirely predictable, as these measures have been under discussion since 2018 and were formally consulted on after the Government’s much-heralded tackling obesity strategy of 2020. With the additional delay proposed today, we are looking at these measures taking seven years to get from farm to table. The Minister can have a go at explaining this, but I hope that he will not try too hard to defend it.

I expect to hear about the challenges with Ofcom’s workload. Again, I certainly understand that it is stretched by all the new work coming under the Online Safety Bill, but this delay on these regulations now risks making matters worse. It would have been better to have had this all in place before the wave of new demands comes along. I fear that we may be back here again being told that, unfortunately, there has to be a further delay while more important online safety measures take up all of Ofcom’s bandwidth. We need to ask if there is more to this delay, and if the Government are backsliding on their commitments to anti-obesity measures; they are happy to announce and reannounce them but less willing to get the job done.

We can see that there are mixed views about giving advice to people among leading Conservative Party figures, which we might describe as, “Private nannies good, nanny state bad”. But this is not a nanny-state measure, as it does not stop anyone buying or selling any food products. Rather, it is aimed at changing the environment in which people make their own choices, so that they will be, to borrow language from election law, free from coercion and undue influence.

We also have to ask cui bono—who benefits—from any policy shift, and I hope that the Minister can tell us today who from the food or advertising industries has been lobbying for the delay. If we want to consider cui malo—who is harmed—we find that the Government have just not done their homework to look into the effects of the delay, as pointed out by the Secondary Legislation Scrutiny Committee in its 24th report, to which the noble Baroness, Lady Merron, refers in her Motion. The Explanatory Memorandum tells us in paragraph 12.3:

“A full Impact Assessment has not been prepared … because this instrument is being made only to delay the implementation date of the advertising restrictions by 33 months.”


Only 33 months—just in time for the third birthday of children being born today, whose lifetime health chances will be set during those critical early years. I wonder how long the Minister thinks a delay in legislation has to be for its impact to be worth assessing.

Even without the Government’s assessment, I do not think that any serious commentator would agree that there is no harm from this delay, as it means that there will be a longer period in which people trying to make healthier choices are exposed to messages pushing them in the opposite direction. We may not be able to quantify precisely the effect of those messages, but the promoters of less healthy foods are not stupid; they advertise only because it helps them to sell more.

This debate is obviously an opportunity for us to have a go at the Government for appearing to back-track on a measure which they said they were committed to and have previously agreed is in the public interest. I look forward to hearing other noble Lords kick their balls into this open goal.

--- Later in debate ---

I hope I have reassured noble Lords that the Government are committed to this overarching aim through greater restrictions on advertising less healthy foods and reducing childhood obesity through a number of well-thought-out measures to encourage the consumption of healthier foods.

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to all noble Lords who have taken part in the debate. The noble Baroness, Lady Bull, gave us an important reminder that we need to think holistically about our entire relationship with food, including eating disorders as well as obesity. That is helpful, and something I am sure we will return to.

The noble Baroness, Lady Bennett, and the noble Lord, Lord Brooke, reminded us of other regulations in this area which seem to be having some success: the soft drinks levy and the information provided on restaurant menus. My noble friend Lady Walmsley’s institutional memory is extraordinarily helpful in explaining much of what has already been debated and agreed, undermining the Government’s argument that so much still needs to be done. The noble Baroness, Lady Merron, was right to criticise the process of presenting regulations, and I suggest a carrot and stick approach to the Minister. The carrot is a friendly, gentle debate in the Moses Room and the stick is to come here for another ball-kicking exercise.

Finally, on the substance of the regulation, the Minister has explained that the Government’s real goal is reformulation. This could be done perhaps more urgently than the Government are suggesting if they put their mind to it. If we can shift from being tomato eaters to turnip eaters in the space of a few months, I think we can shift from being unhealthy burger eaters to healthier burger eaters in less than two years. With that and the other contributions, I seek the leave of the House to withdraw the Motion.

Motion withdrawn.