NHS Dentistry: Recovery and Reform

Lord Allan of Hallam Excerpts

Wednesday 7th February 2024 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I associate these Benches with the thoughts and prayers expressed for His Majesty the King. We wish him a full and speedy recovery.

I thank the Minister for this Statement at a time when NHS dentistry is at the most perilous point in its 75-year history. I found yesterday’s scenes in Bristol quite shocking, where the police were called to manage hundreds of people lined up outside a dentist. They had flocked to a newly opened practice, absolutely desperate to secure an NHS appointment. It is a raw illustration of the state of dentistry where more than eight in 10 dental surgeries are refusing to accept adult patients seeking NHS care and where more than seven out of 10 are not accepting under-18s. Tooth decay is the main reason for children between the ages of six and 10 being admitted to hospital.

It is noted that there is some proposed new investment in this plan, although previous funding has not kept pace with inflation. Good practice is to be deployed to improve access to dental care for those who have not seen a dentist for years, through the use of mobile clinics and some preventive measures. But this long-awaited plan which the British Dental Association has described as “sticking plaster” will not address the systemic problems that have led to today’s state of near terminal decline.

In addition to targeting recruitment of dentists to areas most in need and the preventive toothbrushing scheme for three to five year-olds, we have committed to 700,000 extra urgent and emergency appointments. There does not seem to be anything in the plan to address this latter need. This is key, because surveys have shown that 82% of dentists have treated patients who have had to take matters into their own hands since lockdown, by carrying out DIY dentistry. In 2022-23, across England, 52,000 patients were seen in A&E with a dental abscess caused by tooth decay, as well as 15,000 with dental caries. How will this plan work without the provision of more emergency and urgent appointments?

We know that immediate reform of the dental contract is needed. If in government, we will sit down with the British Dental Association in our first week. The Government’s 2010 manifesto made a promise to reform the NHS dental contract. Yet, this Statement confirms that reform will not be on the cards until 2025. Why was progress not made when it could have been? What assessment has been made of the impact of continued delay on dental health?

I turn to some specific points. Dentists are covering costs out of their own pockets, particularly for treatments that require lab work, such as dentures and crowns. This needs to be addressed. What assessment has been made of this situation and what impact does the Minister expect the plan to have in resolving it?

To what extent do the Government expect the new patient premium to make a dent in the scale of the problem of improving access for new patients? As the plan for around a million new patients is time-limited, there are concerns that this risks disincentivising the long-term treatment of the new patients being brought into the NHS. What reassurance can the Government give that this will not happen? The Government state that the plan will deliver care to 2.5 million, but their own data show that 12 million people in England have an unmet need for NHS dentistry. What about the rest?

The plan also includes “golden hellos” to around 240 dentists to work in underserved areas for up to three years. I hope this will help. Across the UK, 90% of dentists are not taking on new, adult NHS patients. In huge parts of the country, new patients are not being taken on at all, while, in others, dentists are refusing to see a child unless a parent is signed up as a private patient. What sort of a dent will 240 dentists make in this? How will these payments be distributed and in what areas? Perhaps the Minister can clarify whether the payments are for new dentists or are they to be used to get existing, qualified ones to move?

The absence of essential NHS dentistry is to the detriment of the health of the nation. As the Nuffield Trust says, this plan appears to be,

“a much-needed scale and polish when what NHS dentistry needs is root canal treatment”.

I look forward to the Minister’s response.

[Lord Allan of Hallam (LD)]

My Lords, from these Benches, I also echo our best wishes to His Majesty the King. We hope that he makes a speedy recovery.

In responding to this Statement, I also reach for that familiar phrase of it being a sticking plaster, before heading in the direction of dental metaphors. Rather than a scale and polish, it seems to me that this is something of a temporary filling when, as the noble Baroness, Lady Merron, says, NHS dentistry needs serious root canal work.

I feel for the Minister because I know he cares about dentistry and understands the scale of the problem. He has to sell the temporary filling hard in the hope that we will trust the Government to deliver on the more comprehensive course of treatment that is in the consulting on and exploring part of the document.

There are three elements in that long-term part of the plan on which I hope the Minister can comment further today or later in writing. First, we are told that the Government will ring-fence the £3 billion of NHS dentistry budgets from 2024-25 which have been underspent because of the lack of dentists willing to work at NHS rates. We cannot see this changing overnight, even with what is announced today. How will this ring-fencing work if an integrated care board has still not been able to get the take-up of the contracts that it wants? What kinds of things could they use these underspends for? Will these include additional local financial incentives on top of the ones we are discussing at a national level today?

Secondly, it is important to realise the benefits of people with dental qualifications moving to the UK. I know that the Minister would wholeheartedly agree. The policy document promotes the idea of a provisional registration of overseas qualified dentists while they are waiting for their full GDC registration. The phrasing in the Statement and in the document is quite hesitant. It talks about the Government working towards introducing legislation. Can the Minister give us more information about the complexity of the legislative changes that will be required and their likely timescale?

Thirdly, failures in emergency care both cause severe patient distress and additional work for NHS hospitals. The noble Baroness, Lady Merron, has already pointed out that many children are referred to hospital for emergency treatment. I looked at the description on the Smile Together website—a good service in Cornwall cited in the plan. It says that:

“Smile Together is commissioned by NHS England to provide urgent and emergency dental care to patients who would otherwise be unable to access treatment. Demand for this service is very high and the criteria set by our commissioners is very strict. We therefore offer emergency appointments that are independent of our NHS service”,


and people who call in who are unable to get an NHS appointment and do not wish to wait and try again the next day can basically go private. I am not sure we want to be in a situation where people needing emergency care are left hanging on the phone day in, day out, or face having to go for the private option. I hope the Minister can explain what the Government intend to do around emergency care. I hope he will agree that making sure people can get NHS emergency care will be better for both the patient and the NHS.

A temporary filling is designed to last a few weeks—or months at most—or perhaps until an election. We are grateful for the temporary relief it provides, but we know that more work is needed, and this has to be done urgently if we are to fix NHS for the long term.

[Lord Markham (Con)]

I thank noble Lords for their comments. First, the thing that brings us together is the desire on all sides to expand capacity. That is something that we are all behind. I hope that I can bring out the themes in this regard—the plans that we are talking about are designed to do exactly that.

The noble Baroness, Lady Merron, asked how the golden hellos will work. The idea is that it will be in the 12 most needy areas, and the ICBs will have the flexibility in how they attract people there. It might be existing dentists who they want to take from another area, or it might be private sector dentists or dentists who are just graduating. It is about making sure that they have the ability to bring those people into the areas of most need.

The mobile vans have proved quite successful already in areas such as Cornwall, where they have already been. They are designed to hit exactly those areas where it is hard to seed new dental practices, because there is a dental desert there, for want of a better word. Each of those vans alone should be able to do about 10,000 appointments a year, which is quite a sizeable number. Of course, what that does is put it in the areas of most need. The beauty of it—if beauty is the right word—is that, when you are talking about emergency-type situations, you will be able to tell exactly where they are.

The other thing that is important, with regard to all the payment mechanisms and how that will work, is that the dentists working in these vans are salaried. The idea is that we know that in those instances it is absolutely going to work in terms of the incentives. While we think that the patient premium absolutely will help in terms of access, and we know that the hardest one is getting them to see patients for the first time and that is what the additional £50 is all about, by bringing in these salaried people we can absolutely guarantee that those new people will be seen in those situations.

What I note from all this is that these are very concrete plans to create 2.5 million new treatments. I noticed that the noble Baroness, Lady Merron, mentioned the Labour plan of 700,000 extra, so I shall let noble Lords draw their own conclusions as to which one is more extensive. But to try to answer the question around ring-fencing, what this is all designed to do is to make sure that the contracted number of UDAs that we want to happen is delivered. Noble Lords will have heard me say before that the problem often is that it is not delivered because the dentists then go and try to sell to the private sector instead. So this is all designed to underpin that: first, by making it more attractive for those dentists to offer it to patients, in terms of the patient premium of £50, and the increase in the UDA price; and, secondly, by supplementing that with salaried staff, so you can absolutely make sure that it is being delivered in those circumstances. That is what we are trying to do—because we know that the UDAs are there in terms of the expansion, and we did see a large expansion last year. We increased the number of treatments from 26 million to 33 million, a 23% increase—so we have managed to do it. But we are talking here about wanting to do more of it, of course.

As for whether this is a temporary filling or a long-term fix, of course the long-term workforce plan is all about a long-term fix, making sure that we have the supply in place so we can supply the NHS services needed on a long-term basis. That is where we are talking about the 40% increase, and about making it easier to bring people in from overseas, to answer the question from the noble Lord, Lord Allan. As noble Lords know, I have a personal interest. I would not have a wife—or this particular wife—if she had not managed to become a dentist from overseas. But what I saw from all of that was that it is a two-stage process. It was one thing for her to be allowed to become a private dentist. I had to fill in the forms myself, and it was pretty hard. But it was an altogether new process then to become an NHS dentist. To be honest, the conclusion after all that was, “Why would I bother to do this? If I can already be a private sector dentist, why would I jump through a load more hoops to then become an NHS dentist?” It is designed to try to iron out those differences and not act as a disincentive in those situations.

To answer the question, those mobile vans, in terms of SMILE4LIFE, are there to make sure that they get people off on the right foot. The family hubs are for training would-be mothers about looking after gums and teeth. But also, crucially, it is about using those mobile services in the areas where they are most needed, putting in the fluoride varnish for 165,000 reception-age kids—so aged from four to five. That means really starting to get the right start to life in all this.

I hope that what we are seeing here is a comprehensive set of plans, expanding supply in terms of the golden hellos, mobile vans and increasing treatments, as well as the long-term workforce plan for increasing staffing. We are making it more attractive for dentists to provide NHS dental services in terms of the patient premiums. These will all start very quickly—in March, for instance. It is also about increasing the UDAs and making sure that our children get the right start to life, in terms of SMILE4LIFE, and making sure that their teeth are clean from a very young age.

There is a lot to do—I perfectly accept that—but I believe that what we have here is taking the right steps to achieve it.

Pharmacy First

Lord Allan of Hallam Excerpts

Tuesday 6th February 2024 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I recognise that pharmacies already do far more than just dispense prescriptions and sell items. They are highly trained experts, easily accessible and approachable, with a reach across the entire country. As we saw during the pandemic, they are a highly trusted part of our communities and they are to be commended. But their skills and knowledge are often underutilised, even though pharmacists can take the pressure off GPs and encourage people to seek advice and services that they otherwise might not have sought. That is why we recently announced that we would want to bring NHS out-patient appointments closer to people, and through high street opticians as well.

This announcement will not make up for the 1,000 pharmacies that have closed or the 2,000 GPs that have been cut since 2015. Patients today can be waiting over a month to see a GP, if they can get an appointment at all. When I think back to 2010, I recall that people could get an appointment within 48 hours. Can the Minister update your Lordships’ House on what has happened to the Government’s pledge to deliver 6,000 more GPs this year? What is being done to support community pharmacies, which are already facing a perfect storm with inflationary pressures on running costs, recruitment challenges and an unstable medicines market?

As the Association of Independent Multiple Pharmacies chief exec said, we should not forget that pharmacies are seriously underfunded and that the

“stranglehold of chronic underfunding must be relieved … to ensure our community pharmacies continue to exist and can deliver”

what the Government are expecting. How will the Government ensure that GPs and pharmacies work closely together, given some of the fractured relationships that currently exist over their roles? On delivery, how long will it take to get up to the promised capacity? When will the promised IT systems go fully live across all pharmacies taking part, and how will the public be made aware of the services that they will now be able to get from their local pharmacy?

The Minister will know of concerns regarding the impact on the pharmacy workforce. The concern is that they will just be overwhelmed, which begs the question: why was Pharmacy First not phased in? What is being done to ease the inevitable extra pressure on pharmacies, including in the use of their premises? How will the Government ensure the privacy that we all need? It is not acceptable to be discussing personal matters for all to hear, nor to receive a vaccination that may require the removal or adjustment of clothing for all to see.

Turning to some of the specific services, I note that pharmacists will be able to treat urinary infections, which women suffer frequently, requiring urgent treatment as soon as the signs start to occur. But why is that only up to the age of 64? It is very welcome to get blood pressure checks routinely done at pharmacies, particularly for older people with long-term conditions. At present, many are asked to buy their own assessment machine and report in the results to the surgery, which they cannot do, and not having a blood pressure reading can lead to delays in getting medication. So how will the Government ensure that key data is safely, accurately and speedily exchanged between pharmacies and GPs?

Finally, what is the Government’s plan in the longer term to integrate the increase in independent prescribers, who are being trained as part of the long-term workforce plan? Does the Minister agree that we should accelerate the rollout of independent prescribing to establish a community pharmacist prescribing service, covering a wide range of common conditions? That would support patients with chronic conditions, which is one of the biggest challenges facing the NHS. Does he agree that community pharmacies will have an important role to play in supporting GPs in the management of long-term conditions, such as hypertension and asthma, and in tackling the serious issue of overprescribing, which is responsible for thousands of avoidable hospital admissions every year?

Bringing healthcare into the community means that patients will have greater control and be seen faster, while GPs will be freed up to see more complex cases. From these Benches, we have long argued for a greater role for pharmacists and pharmacies. The NHS should work as a neighbourhood health service as much as a National Health Service, and that is a development to which these Benches are wholly committed.

[Lord Allan of Hallam (LD)]

My Lords, the holy grail for health policy is a change which improves the service for patients at the same time as reducing the cost of delivering that service. I think we can all see the potential for Pharmacy First to be such a move, if executed well. I have a few questions for the Minister and his answers will help us to understand whether he is on the right path in this grail quest.

First, I understand that there will be a payment per consultation, if the consultation meets criteria that the Government have set, but that there will be a cap on the total budget. Can the Minister explain how this cap will work? Is it per pharmacy or per integrated care board, and what happens if it is exceeded? I do not think that we want people going back to more costly channels simply because of an accounting feature. Secondly, can he explain how the Government will assess value for money in comparing the cost of the Pharmacy First consultations with the estimated savings on the GP and A&E side?

Thirdly, while we are discussing urgent care today, can the Minister also say whether the Government are looking at using pharmacies for approving repeat prescriptions—this was raised by the noble Baroness, Lady Merron—for drugs such as statins that people may be on for many years? The current protocol requires them to go back to their GP for regular reviews. Are there any plans afoot to move some of that medicine review process for long-term conditions also into the Pharmacy First programme?

Can the Minister also explain how instructions will be given to NHS 111 services so that they can properly direct people, in light of Pharmacy First now being an available option? It could make a real difference to the pressure on A&E services if 111 moved appropriate cases over to pharmacies. There are concerns that 111 has a natural tendency to be risk averse and refer people to A&E. If we are going to ask it to refer people now to pharmacies, we need to understand how that shift in direction will take place.

Finally, I have a digital question. It is not the one about the joined-up records that we discussed earlier at Oral Questions, as I am confident that the Minister will tell us that the Government are on track for that. What I want to raise is, even when the pharmacy has issued a prescription and dispensed it, at present what happens is that it will then print it off and post it to the NHS Business Services Authority for payment. This happens with all the prescriptions in the pharmacy system at present. My understanding is that the business services authority will then scan them into its system to make the payments—which seems quite farcical in 2024. So I would be interested to hear from the Minister what plans the Government have to get rid of that piece of the equation or to make it more efficient, so that, when a prescribing process happens electronically, it happens all the way through, to the point at which the pharmacy is reimbursed for the work that it has done.

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

I thank both noble Lords for their general welcome of what we are trying to do here. My thoughts on this are that anything that we can do to expand supply should be a good thing in this context.

I will pick up on specific questions. As mentioned, we have not managed to achieve 6,000 additional GPs. To specifically answer the question, we have achieved about 2,799. However, through the use of additional staff, we have managed to achieve 50 million additional appointments in GP settings since 2019, so we actually hit our target on that earlier. I think that demonstrates—this goes back to the Question we had earlier today—that we are trying to use people to the top of their professional skills and supplement that with other skilled people coming in. In terms of output, 50 million appointments are a good example.

We are hoping that this will be a boost to community pharmacies. They are, as I mentioned earlier today, seen as a very important asset. They are often the first line in terms of health in the local community. This is intended to not only enhance the health service in an area but give community pharmacies a necessary boost. I think these figures have been reported, but for the sake of completeness I will say that we have had about 10,000 pharmacies sign up—about 95% of them—so clearly it has been welcomed. In the first three days we have had about 3,000 consultations. In answer to the question about pharmacies being overwhelmed, the early indications are that it has been managed well. You could say that the more business they get is a good thing in terms of their viability. Right now, we feel that it is so far, so good.

On privacy—I will try to group the app and IT questions together a bit later—part of the conditions for being available for Pharmacy First is that a pharmacy has a private treatment area available, so that there will not be privacy issues.

My understanding—I will definitely need to write on this—in terms of UTIs is that it applies only up to the age of 64, as they are less complex in those cases. For instance, as you get older UTIs can be a sign of other comorbidities. I think that is the thinking behind the age of 64, but I will follow that up in writing.

The general point was made by both the noble Baroness, Lady Merron, and the noble Lord, Lord Allan, about trying to expand provision. I would say that this is the first step. We have tried to pick the areas that we think suit the situation well. This gives us the ability to expand as the capability increases. Repeat prescriptions is obviously a very good example, as is managing cases such as hypertension and other similar areas. The direction of travel is very much: let us make sure that this works well and then build on that.

I will answer the questions on IT asked by the noble Lord, Lord Allan, together. The overall thinking on the cap is that we are trying to make sure that this does not run out of control—for want of a better word—in some respects, and that goes back to the value for money question. If you can really prove that it is enhancing and substituting for GP appointments, which we all want to boost the availability of, that has to be a good thing. As ever, you need to try to set up budgets at the beginning to make sure that they are sensible in terms of that control.

To give a sense of direction, it is very much the intention that 111—I include the app and other digital approaches in this—will point a person to the right pathway for them. If we then know that they have one of these seven conditions, such as a simple UTI, sinusitis, or something of that ilk, they will be guided towards Pharmacy First. That is very much the intention. I hope that that in some way answers the question. It is intended that more and more volume is put that way.

In terms of trying to make sure that there is a slicker system with the IT generally, obviously it has to be sensible—for example, not printing things off, and that there is an electronic payment mechanism. My understanding is that that is already occurring in some of the digital areas. Noble Lords will be aware of some of the digital pharmacies, which are paperless the whole way. Those sorts of mechanisms are being set up and it is a matter of expanding them, so that there is a complete digital service. I will come back with more detail on that, but I understand that it is happening.

On the IT systems and the holy grail of making sure that they are all connecting—to give everyone the benefit of our conversation in the Corridor—the idea is that it has to be two-way. You want to make sure that pharmacies have access to doctors’ records. That is not ready today, but it will be in the next few months. Likewise, you want to make sure that whatever the pharmacies do gets updated to GP records. Right now, that will be done by a simple PDF. This is not ideal because it involves a rekeying, but in a matter of weeks, it will update the GP records automatically. The value of that is that, obviously, while Pharmacy First is the forerunner, there are all sorts of circumstances it could be replicated for, whether appointments with physios or any other physician relevant to the patient records. I think that will be a positive when it comes in.

I have tried to answer most of the questions about execution. I think we will all freely admit that, as ever with these things, there is a certain amount of bedding in—it is something that I am glad to see everyone welcomes in principle. I hope that in a few months’ time I will be able to update the House on it; I will be happy to do so. If it is executed well, and we believe that this is working well, we will be looking to extend it to further services.

Allied Health Professionals: Prescribing Responsibilities

Lord Allan of Hallam Excerpts

Tuesday 6th February 2024 Lords Chamber

[Lord Markham (Con)]

I agree with my noble friend that not only are they the pillar of communities, but they are the front line in a lot of health services. This is about trying to put more business and activity their way to increase their viability, both in terms of paying for treatments such as these and increasing footfall generally. I completely agree with my noble friend that we want as many of these small businesses thriving in their own right, but also as a vital part of the health ecosystem.

[Lord Allan of Hallam (LD)]

My Lords, increasing the range of health professionals who can prescribe is welcome, but does the Minister agree that this makes it even more important that people are able to see their entire medical record in one place, as the Times Health Commission has proposed? What does the Minister make of that proposal, and what are the Government doing to ensure that, wherever you get a prescription, that record is located in one central point?

Premature Deaths: Heart and Circulatory Conditions

Lord Allan of Hallam Excerpts

Tuesday 6th February 2024 Lords Chamber

[Lord Markham (Con)]

I agree with the noble Lord. We violently agree that it is all about early detection. That is why we have not just put it in pharmacies but have had mobile units going to leisure centres and high streets: so that we can catch people early, whatever their background or ethnicity, because that is the key starting point.

Digital is the way of the future in this. We are introducing digital health checks from the spring. Again, these will open it up to a wider bunch of people. Early detection is key.

[Lord Allan of Hallam (LD)]

My Lords, the relationship between cardiovascular disease and poverty is clear and well documented. What specific steps are the Government taking to encourage take-up of the new screening programmes, which the Minister talked about, in poorer communities where people are at higher risk? Will the Minister commit to publishing data so that we can understand whether the screening programmes are reaching everyone or just people in wealthier communities?

[Lord Markham (Con)]

First, I am happy to commit on the data front, because data and giving results always shine a light and will always help in these situations. On outreach to all these communities, the noble Lord might be aware that, on top of the pharmacies and leisure centres, we have been incentivising GPs. As an example, being in the right age group I have numerous texts and messages from my GP about getting those check-ups done. It is those sorts of measures that we are trying to use.

Medical Devices (In Vitro Diagnostic Devices etc.) (Amendment) Regulations 2023

Lord Allan of Hallam Excerpts

Tuesday 6th February 2024 Grand Committee

[Baroness Finlay of Llandaff (CB)]

My Lords, I should declare that my son is a cardiologist and founder of Rhythm AI and Echopoint Medical—I think those medical devices do not completely fall within the scope of this, but I declare it anyway just in case.

It is notable that the medical devices road map from the MHRA, which set a future regulatory framework for devices and was published on 9 January, talks about four statutory instruments. Does this form part of those four? Are others due to come, and if so, when?

Despite the Government’s warm words about us being an attractive market, the problem is that the UK is becoming an increasingly less attractive market because our application-to-approval time has extended beyond that of other countries such as the US and Australia and, I think, Japan. Clinical trials in general are not being brought to the UK. During the pandemic, we showed that MHRA approval could allow us to be the fastest in the world with vaccine development and, more recently, with treatment of sickle cell disease. However, low numbers of patients are now enrolled in studies. For the life sciences to develop, trial and test new technologies, they need to be able to do so rapidly. How will the MHRA have adequate workforce to deal with an increased workload from Northern Ireland? Has that been factored in?

How will the risk assessment be set? It is important to recognise that some developments will fail and fall by the wayside. A realistic risk assessment recognises that a whole population needs to be studied. That is best done with post-market surveillance, which is key to evaluating the implementation of any new technology in the real world.

There is a view that our regulations have become tighter, making it too hard and burdensome for device development to be brought to the NHS; as the UK market is small, we need to make it particularly attractive for innovation. The eventual market, being small, would allow us to keep our innovations and market them abroad once they had gone through full approval processes. What steps are in place for mutual recognition agreements to be taken forward?

A paper from Birmingham Health Partners, Alternative Routes to Market for Medical Devices, suggests there are three routes. I gather that Switzerland has now undertaken to adopt the Food and Drug Administration approval systems from the US, registering the file—for us, it could be registered with the MHRA—with a post-market surveillance plan in place. Of course, the initial safety standards must be met, but it is in the real world that benefits and risks are revealed.

For our deficits and gaps in the NHS, there are problems that we need to solve by pulling new technology and diagnostics in. But the golden age of innovation will happen only if there is fast approval to evaluate, with good surveillance so that those innovations with problems are rapidly dropped and those with promise and better patient outcomes continue to be developed. This innovation has to happen across primary and community care as well as hospital specialty services. It requires the recognition of intrinsic risk by adjusting the risk threshold, including that not to innovate is also a risk.

The public understands the need to innovate. In the related areas of clinical trials, which I think is an important but salutary comparator, we have dropped from being fourth in the world to being 10th in the world, which is much to the loss of our NHS and our patients, as well as, obviously, innovation business. Our time for the regulatory review is greater, so we are slower than many other countries. How will these regulations strip out unnecessary processes and bureaucracy and speed up processes to make us attractive to innovators? Northern Ireland being in the unique position that it is now in could be a very important market for innovation, with its fast and easy access and attractions for those developing in vitro devices.

[Lord Allan of Hallam (LD)]

My Lords, I was grateful to the Minister for his description of in vitro devices, which is not necessarily obvious from the regulations. I hope that he can confirm that the “in vitro” bit is misleading; we are talking about lots of tests that are done in plastic and no longer glass, so it is a Latin hangover. I think that I am right in thinking that this applies to everything, whether it is a stick test or whatever device it is; it applies to any kind of diagnostic test.

On the regulations, I shall offer a one-sentence Brexit whinge, which is just to say: “Oven-ready, ha ha ha!” Looking at these regulations, we are now in legislative spaghetti territory, where to do something quite small and simple requires pages and pages of legislation to enact it. We are in a very messy regulatory situation, and it is only going to multiply over time. That was the first point that I wanted to raise.

It would be helpful if the Minister could say, for the health area for which he is responsible, the extent to which the Government have assessed how far there will now be divergence between Northern Ireland and Great Britain in the relevant health areas. There are two different scenarios. In one, the UK stands still, but the EU moves on, which is effectively what has happened here: the EU has updated its law, and we are now having to respond, because it will apply in Northern Ireland. So even if we do nothing, there will be change, and we should be reasonably capable of extrapolating that by looking at past behaviour and the EU’s legislative programme. Of course, the other scenario is where we actively diverge from the EU.

I hope that, in both scenarios, the Minister will be able to confirm that there is somebody—or a team somewhere in DHSC—who has all this mapped out. It may not have been possible before Brexit, when we were still living in la-la land—but, since we have had the experience of the retained EU law Bill, where the number of laws that we found tripled from the first exercise to the current iteration, it is important for businesses out there that we understand how much retained EU law there is in the health area, how much of it will be relevant and how much will require this kind of statutory instrument to ensure that we can respect both the Northern Ireland and the Great Britain settlement.

I am also curious: the Minister referred to the fact that the EU’s updated law was implemented as a regulation, which of course applies directly, rather than a directive, which needs transposition. He said that it applied from May 2022, but we are regulating only now. I am genuinely curious as to what happened in the intervening period. Is it the case that if somebody had been selling non-conforming devices, they would get away with it for that period because the law did not catch up? I am curious to hear what the Government’s intention is. Presumably, this scenario is going to be repeated: there will be new bits of EU law and we have to follow on and make sure that they are implemented for Northern Ireland. I am genuinely interested in the Minister’s comments on the Government’s strategy: are they concerned at all that there may be these gaps, or is it something we just have to live with now?

--- Later in debate ---

[Lord Markham (Con)]

I thank noble Lords for their contributions and the spirit in which they were made in terms of helpfulness and trying to make the market as open and productive as possible.

I shall try to answer the questions in turn. To the noble Baroness, Lady Finlay, I say, yes, this is part of the four SIs.

On the noble Baroness’s whole question about making the UK market attractive to innovation, that is exactly what this is all about. On her point about clinical trials, my understanding is that there was a period when we slipped down the league on timings. I am told that a lot of that was because we were trying to prioritise Covid issues but, as I understand it today, we are now back within the timeframes. While we slipped down to 10th place in the league, the understanding from recent business coming in is that we think that we are making our way back up into the champions league spots, for want of a better phrase. I am assured that we have seen quite an improvement in the time taken in clinical trials.

On the noble Baroness’s question about what this means for the MHRA—the noble Baroness, Lady Merron, asked a similar question—we do not believe that this should have a significant impact. At the same time, I am totally with the sentiment that we do not want the MHRA to be a bottleneck, not just in this area but generally because speed to market is important here. In the last Budget, we agreed quite an increase in the MHRA’s budget, exactly so that it is able to pass such things through more quickly.

On the points about mutual recognition, it is absolutely our direction of travel. We are looking to do that with other authorities. Again—this also goes to the question of the noble Lord, Lord Allan—we are recognising the “CE” marks until 2030. That is probably a good example of mutual recognition.

[Lord Allan of Hallam (LD)]

The “CE” mark recognition is an example of one-way recognition, not mutual recognition, because it does not go the other way.

[Lord Markham (Con)]

Absolutely. Clearly, we would like it both ways, for obvious reasons. There are a number of areas where we are still being open about our rules—not just to the EU but to other countries as well, with the hope that there is some reciprocation down the line. That is definitely the intention. Talking to the regulators, I know that the situation is crazy. We know that the Australian, Canadian or Singapore regulators are top-notch, so we should be satisfied with their work in many cases. The feeling often is that stage one towards that recognition is that, while we might have slightly different standards, recognising that where they have conducted tests, rather than reconducting those tests, we should at least recognise that each other has done the tests correctly. We should take that data and that should speed things up.

In answer to the question of the noble Lord, Lord Allan, we are talking about any type of diagnostic test—

--- Later in debate ---

[Lord Markham (Con)]

I am probably not qualified to speak specifically about the Orbis project read-across but, at the general level, that is definitely the direction of travel, if you speak to the MHRA. As I said, there are almost two levels to it. The complete level is where you just take it lock, stock and barrel. That is the slightly harder one, but at least the preliminary step towards that is recognising when they have done a batch of tests. I know from a previous life—during Covid, for instance, when a lot of tests were about—that you have to do a number of samples, test them against a control group and see where they come out against that. Those were internationally recognised tests, so if the US, Canada or Australia have done tests on those devices, rather than doing our own tests, let us at least accept them. Those are the two stages of that.

On the point about divergence, this SI tries to make sure that the GB and Northern Ireland markets are as similar as possible. My understanding of how we used to regulate EU “CE” devices was that we would take the “CE” marks and then often tweak them slightly to make them relevant for the domestic market. Apparently, France, Germany and all the countries do that. With this SI, as I mentioned, we are recognising “CE” marks generally until 2030 on a voluntary basis—so, obviously, we can tweak them as much as we like. Northern Ireland generally has to accept those devices because of the Windsor agreement, but it still has that tweaking ability, for want of a better word, that we always used to have when we were in the EU. The idea behind this SI is to allow us to tweak it from both ends—the GB end and the Northern Ireland end—so that it is common, and we have read-across so that the product will work under the “CE” mark in both Northern Ireland and across in GB.

This was explained to me this morning, so my officials can tell me later whether I have been a decent student. For general clarity, as ever, I will happily write this all down, but I hope that makes sense.

[Lord Allan of Hallam (LD)]

It does; that was a helpful and clear explanation. However, if somebody has tweaked their test for Northern Ireland and they also want to sell to the EU, are they able to do so? For example, can they send it south of the border into the EU? Or would that require an untweaked “CE” mark, and, if so, who gives them that? That is really the heart of it.

[Lord Markham (Con)]

My understanding of all this—again, I will tell the noble Lord to the best of my knowledge and correct it if I am wrong—is that we always used to tweak it when we were part of the EU. It was generally accepted that we would tweak a bit, and so would France and Germany. That did not stop products being sold across, so I do not believe that they will need to untweak it, for want of a better word. Again, if I am wrong about any of that, I will clarify it.

On the question of what happens between March 2022 and now, I will let the noble Lord know in writing about what happens during that period.

My understanding is that the MHRA is neither a notified body nor an approved body. It does not set “CE” marks or “UKCA” marks itself; it tests them and looks at the conformity, but it does not establish any, for want of a better word.

On the questions raised by the noble Baroness, Lady Merron, that I did not pick up on before, we do not think the fee structure will have much impact on the MHRA.

The noble Baroness also asked what the opportunities are and what kinds of visions will come from this. I freely admit that this is a complicated space. However, one area where I have seen an opportunity is around the precision medicine space. For example, for the next set of cancer treatments, it will be possible to take a sample of the malignant tissue or cells and adjust the messenger RNA to, effectively, get your own body to attack those cells. The problem is that each one of those medicines you produce is individual to you, so it becomes difficult to regulate each individual medicine under the regulatory framework, as it would take ages and destroy the point of the exercise. The MHRA, however, has developed an umbrella mechanism, allowing it to treat all the individual medicines as regulated and approved. That is a major opportunity. My understanding is that the EU has not managed to be quite as fleet of foot, so it is not there yet. That is just one example I have seen; it is very important, as it allows us to charge ahead in terms of the precision medicine space. Moving forward, that will help us establish ourselves in the clinical trials and life sciences fields. I understand the points the noble Lord makes about all the complications due to some of these post-Brexit situations, but, actually, this is one area that is very positive. It will be a huge benefit for us going forward.

On the question asked by the noble Baroness, Lady Merron, about the future vision, I think it is sensible to agree a baseline based upon what we see in reputable countries with standards—such as Canada and Australia —making it as easy as possible to regulate. It would not be ideal if that meant we had to do it just one way, as we would prefer to do it both ways. However, it would still make us attractive as it would be possible to do clinical trials for our products here and know that it will work. However, where we can forge ahead in areas such as precision medicine, where you need tailored and expert help, let us really try and do that. So I think there are some really exciting possibilities.

I hope that gives a flavour of our vision and how we are trying to progress matters in this space. I realise I have not answered every question, but it has been quite a useful debate. I have definitely found it useful to tease out the details. If I may, I will go back to my notes.

I trust that I have provided sufficient answers to the questions and, as I said, I will write to follow up. I hope and trust that I have demonstrated the necessity of these regulations to honour our current commitments under the Windsor Framework agreement. With that, I commend this instrument to the Committee.

NHS: Fracture Liaison Services

Lord Allan of Hallam Excerpts

Monday 5th February 2024 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, the noble Lord, Lord Black, and the Better Bones campaign have done an excellent job in raising the public profile of fracture liaison services, so I was a little surprised that searching for them on the NHS website returned some general articles about fractures and advice about the Patient Advice and Liaison Service but nothing about fracture liaison services as such. Will the Minister look into this to ensure that people trying to find information about FLSs are given it and directed to their local service?

[Lord Markham (Con)]

I thank the noble Lord. His interventions around the communications side are always welcome, because we recognise that it is one thing having a service and another thing making sure that the world knows about it. I will go and find out more and write to the noble Lord.

Care of Critically Ill Children

Lord Allan of Hallam Excerpts

Monday 29th January 2024 Lords Chamber

[Lord Markham (Con)]

Clearly, the processes on these terrible cases have got to be as transparent as possible. As noble Lords probably know, legal aid is automatically available in all these types of cases to make sure that there is a level playing field. I also think we all believe that there is a case for seeing whether we can use mediation more as, obviously, courts should only ever be a last resort.

[Lord Allan of Hallam (LD)]

My Lords, the Minister has already flagged communication as one of the key areas that comes through in the report, around both palliative care and care more generally. Can the Minister assure us that the task force will have the skills it needs to ensure that that communication can take place with parents from a variety of different backgrounds—educational, with different levels of medical knowledge and in different linguistic and cultural contexts?

[Lord Markham (Con)]

Yes, the noble Lord is quite correct. We know that, in many walks of life, so to speak, there are certain sectors of society that do not get the same level of provision and sometimes miss out. We had the debate last week on maternity provision and saw instances in relation to ethnic minorities as well as people with learning difficulties. We need to make sure that all the communications are there and that everyone is armed to provide the right levels of interface and communication in what are some really difficult cases.

Maternity Services

Lord Allan of Hallam Excerpts

Thursday 25th January 2024 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am also grateful to the noble Baroness, Lady Taylor of Bolton, for the debate, and to all speakers, whose points will inform my contribution. Like the noble Baroness, Lady Donaghy, I was moved by the description of a new mother’s experience from the noble Lord, Lord Patel, which brought back memories of the birth of my twins across the river at St Thomas’, where the labour room has a splendid view of this building. I offer a tip to partners who are present during labour: pointing out interesting features of the Palace of Westminster and taking photos may not endear yourself to the mother, who is doing all the work. On a more serious note, it is good to be able to offer a belated and public thank you to the staff at St Thomas’, who were superb—particularly at dealing with multiple births, which I know is a much more specialist and complex procedure.

I am grateful to all noble Lords for the expertise they have shared. I will largely focus on the digital aspects, which is something that I have more hands-on experience of than medicine or giving birth. I also want to pick up the point about the workforce and the student experience. Although my children are not at the taxpayer stage, unlike those of the noble Baroness, Lady Watkins, I observe them and their peers going through the process of making their higher education choices and the kinds of calculations they make. The debt figures presented by the Royal College of Midwives that we have heard about from the noble Baroness, Lady Bennett, and others in the debate are alarming. It seems blindingly obvious that they are putting people off going into the profession, causing enormous stress for students during the process of learning and contributing to drop-out rates that are higher than any of us would like.

I hope that the Minister has something to offer in this area around how we can make sure that training to be a midwife, as well as training in other medical professions, is something that an 18 year-old, when they make those calculations, thinks is worth their while. However well-motivated they are inside, you cannot ignore the economics of being saddled with huge amounts of debt.

My first digital point is also a workforce point to a certain extent. It is about people’s changing expectations as they come into the workforce. Having survived the training and debt, as they move into work, that has to be workable for the individual based on how they live their lives today. The noble Baroness, Lady Watkins, touched earlier on scheduling and rostering, and flexibility at work. It is an issue across the wider health and care workforce, but is especially acute for roles dependent on a safety-critical presence in the workforce. These are not roles that can be moved around; people have to be present at a certain time, on a certain date and in certain numbers for safety to be maintained.

To build on the points made by the noble Baroness, Lady Watkins, this is really difficult for employers. They have to know that the right staff will be on-site to cover each shift. There is no way around that, but where this leads to inflexible rostering, that can clash with other staff needs. These may be other caring responsibilities—caring either for younger or older family members—or personal goals, such as travel, which people do have now as they enter the workforce. They may look for extended breaks—sabbaticals were mentioned—or they may want a month to go travelling. That may be a reasonable expectation people have today that they might not have had 15 or 20 years ago. Where rostering systems do not allow sufficient flexibility, staff may either leave the profession altogether, as it just does not add up, or may not accept a trust contract but move into agency work. The NHS then ends up paying more for the same person to do the job. Simply because they did not have the flexibility to take a month off, they have now moved to agency work from a full-time NHS contract. That seems to me to be an absurd outcome.

We talk a lot these days about whizzy technology, such as artificial intelligence, but what we need here are much more straightforward, efficient scheduling systems that enable staff levels to be met while giving individuals more control over the way rostering occurs. That is the expectation they have today. We need a willingness from trust management to change with the times and allow that flexibility to happen. I hope the Minister can look into the question of how we could improve staff retention through improved rostering systems—for all NHS staff, but particularly midwives in the context of today’s debate. This is basic and cheap technology that, used well, could prove to be enormously beneficial in the cost-benefit equation.

The second area I will touch on is information to mothers. This comes out as a key area of concern for respondents to the CQC maternity survey, which was referenced by the noble Baroness, Lady Cumberlege. It seems to be getting worse. In this wonderful information age, we find mothers saying that the information provision they get from maternity services is getting worse, and that seems extraordinary to me.

A key tool in improving that is offering self-help systems, where people can access information themselves. This is better for those who prefer direct access to information, but it should also lead to improvements for those who want to talk to somebody directly, because it frees up staff time to be available for those who need that direct access. Self-help access to information about your own care is critical; it can also be a benefit with language issues, as providing translation and interpretation at scale can often be done more effectively when enabled by technology than if you are reliant on getting somebody with a particular language to a particular location at a certain time.

I would also be very interested in the Minister’s thoughts on accessibility, a point rightly raised by the noble Baroness, Lady Bull. Again, if we want to make information available, it needs to be truly accessible to people, whether they have learning disabilities or any other particular requirement that means that a standard provision of language may not be as useful as something tailored to their needs.

The Government recognise this need, and they gave us a commitment. In the debate today, people have said that we need more than commitments; we need action. The commitment was very clear. The NHS Long Term Plan said: “By 2023/24”—which I think is now—

“all women will be able to access their maternity notes and information through their smart phones or other devices”.

I hope that the Minister can update us on where we are with this target, whether we are likely to reach it and what issues are surfacing. It is normal that things surface during the rollout process, but I would be interested to hear what issues are surfacing and what action the Government are taking to address those.

The third area I will address is maternity electronic health records. I have been looking at this because of an alert issued by NHS England at the end of last year about one of the systems used for managing patient records across several NHS maternity units. It was found that the system could overwrite records, which produces significant safety risks. Here is an area where I praise NHS England—as a board member, the noble Baroness, Lady Watkins, can take this back to it—as the issue was picked up, due processes were followed and an alert was issued to every trust using the system, warning them about it and making sure they put remedial measures in place. I also thank the Minister and his staff for producing a very comprehensive response to queries I made around this.

This prompted questions about the information flow in maternity care generally between GPs, hospital trusts’ general systems and these specialist maternity systems. It seems that we have ended up with a complex jigsaw of different systems handling patient records, which makes life more difficult. I would be interested in whether the Minister thinks information is flowing effectively in the context of maternity services, given that we often seem to have created dedicated systems for maternity services that may not be connected to the other systems. From the patient’s point of view, you want one integrated view of your care—before you became pregnant, during your pregnancy and postnatally—yet because we have different systems, that integration may not be taking place. That is a special challenge because the data is held by different entities. It is the classic NHS challenge that different entities have bought their own bits of this jigsaw puzzle and nobody is responsible, as far as I can understand it, for putting the pieces together.

I was also interested in this in the context of the question raised by the noble Baroness, Lady Gohir, about data collection. I suspect that some bits of this jigsaw will be collecting the data that we are looking for, but other bits may not be, yet because of the way the systems are structured, that may not be joined up, which would be a real shame. It is one thing if we have not collected the data, but it is quite something else if we have collected it but we cannot use it because it is in the wrong bit and has not been connected to the right bit.

I appreciated hearing all the experiences that noble Lords have brought to this debate and I hope my somewhat geeky contribution has flagged some issues that could contribute positively to keeping up the standards of our maternity services. If noble Lords in future find me on the Terrace staring wistfully across the river at St Thomas’, they will know that I am just having a moment.

Smoking

Lord Allan of Hallam Excerpts

Thursday 25th January 2024 Lords Chamber

[Lord Markham (Con)]

Hopefully, my previous answer shows that we are investing major money in cessation services. I must admit to not being that familiar with the drug the noble Baroness mentions, so I will follow up in writing to give her the details.

[Lord Allan of Hallam (LD)]

My Lords, does the Minister agree that reducing the number of outlets that sell tobacco products does in fact have a positive effect on the prevalence of smoking? In this respect, can he indicate whether the Government are having any conversations with large supermarket chains, either individually or collectively, about voluntary reductions in the number of tobacco counters in their outlets? If that is not already happening, would he agree that it would be a good use of government time to do so?

[Lord Markham (Con)]

Again, we are mindful of trying to get the balance right. Inevitably, by taking away a major market, which the over-18s will become as we go into it, smoking sales through retail units will go down more and more. We expect them to reduce as a result of that. We think that is probably getting the balance right, rather than trying to be overburdensome by saying, “No, you shall not be licensed to do that any more”. We think that will happen naturally through the market, because we are of course taking out a whole segment of future customers.

National Immunisation Programme

Lord Allan of Hallam Excerpts

Thursday 18th January 2024 Grand Committee

[Lord Allan of Hallam (LD)]

My Lords, I am extremely grateful to the noble Baroness, Lady Ritchie, for both the opportunities she has provided us with to debate vaccination this week. The bulk of my remarks will follow closely the comments made by the noble Baroness, Lady Twycross, but first I want to follow up on the RSV Question yesterday. The Minister’s Answer made me rather more nervous than reassured. I asked who was going to be responsible for the RSV vaccination programme and he described a landscape in which there are different teams dealing with infants, children, old people and so on. I do not want to be mean to the Minister because I know he is struggling through a cold while turning up to debate these issues and I am hesitant to correct him, but I wonder whether the correct answer actually is that Steve Russell, the chief delivery officer of NHS England and the person responsible for vaccination screening, is the person whom we should praise if the RSV programme is rolled out well or hold accountable if it is not. It seemed to me as I looked at it that Steve Russell may be the name I was looking for as the single responsible owner for that programme.

In terms of my broader comments, there are three areas that I want to touch on. The first is access to vaccination and immunisation records where any individual wants to understand what they or their children have had and where the gaps are. This still leaves a huge amount to be desired. Again, we saw an example during Covid of how this can work well. Everybody had an immediate interest, not least related to travel and access to facilities, in getting hold of those records; we produced them in double-quick time, and they are still there today. However, if you go beyond that and try to find your broader vaccination and immunisation records, it is a mess. I went online to look for it and found Connected Nottinghamshire, which helpfully offered some advice. That advice is multiple screenshots saying go into the NHS app and click on “consultations and events” or “medicines” and various other routes through, and they all basically end up telling you to go back and ask your GP. That is a super inefficient use of a GP’s time.

We have done all this work with the NHS app—take-up was boosted dramatically though the Covid vaccination certificate programme, we have invested a huge amount in it, and we now have medical records accessible through it—but, unless the Minister can correct me, it seems that, in most of the country, if an individual says, “I want to see what vaccinations I have had and what is missing”, they will not be able to do that. There is no simple, straightforward way to do it. I hope that the Minister can talk about whether the Government have a programme to enable that to happen, as it seems a very basic and fundamental thing. Knowing that information can help to boost take-up rates, which is what we are looking for. If people can see the gaps, they are much more likely to try to fill them.

The other part of that is integration with other sources of vaccination and immunisation. Obviously, there are travel vaccines, most of which are, correctly, not offered by the NHS; they are seen as a voluntary thing that individuals should pay for. However, if they have paid for a travel vaccine, there is an interest for the individual and a broader public health interest to make sure that that is integrated into their medical records. That is not the case today. There may also be workplace vaccinations. A lot of workplaces offer flu programmes. Other noble Lords may have had this experience: I took up the flu vaccine here, at our workplace, and was then pinged every few weeks by a reminder from my GP practice to come in for a flu vaccine, and I would go back to it saying, “I’ve had it”, and it would say “We don’t know that you’ve had it”. There is clearly a lack of joined-up connection there. This year, I went to have it done by the GP just to make sure I did not get those reminders every week. If workplaces have gone to the trouble of putting in place vaccination programmes, the least that we could do is to integrate those into NHS records. There are models, such as Patients Know Best, that allow you to integrate your own personal health data, and I hope that the Minister can indicate that there is some work going on in government to make sure that we follow that kind of model and bring this all together.

The second area that I am interested in is around invitations to participate in programmes and how those information flows work. Again, Covid was a model of clarity: you knew what you were getting and why you were getting it. The invitations went out to people using lots of modern channels, which made it very easy. People learned the language of Covid vaccination—“Are you getting a Spikevax or a Pfizer?”—but it was a very rare and exceptional situation. If you look back at the norm, the norm is that it is very confusing. The NHS produces a nice chart of all the vaccinations that you will get, but it uses jargon and abbreviations. I understand why—those are the accurate terms—but, for an ordinary person coming across this, they really are not very clear about what they are getting, why they are getting it and why it is important for them.

Again, I do not think that this is just in the area of vaccinations. I cite my personal experience: I got a text message from my practice asking if I wanted to come in for AF screening. As I am a health spokesperson in this place, I thought “I should know what AF is”. I looked it up and it stands for atrial fibrillation. If it had sent me a message that said, “We want to check that your heart is ticking over as it should; please pop in”, it would have been a lot more attractive than one asking if I wanted to come in for AF screening. I think most people will not have bothered to look it up and decide whether they should have it. I hope that the Minister can say who is looking at both the language of and the distribution channels for all these invitations for vaccinations and immunisations to make sure that they are optimised. To people working in the tech sector, this is known as UX—user experience—and they understand that changing the language on something changes the click-through rate dramatically. Similar discipline is needed here to make sure that all the invitations to vaccinations and immunisations are optimised for the target audiences and make them as likely as possible to click and to go and get that vaccination.

There is a generalised problem with distribution channels in the NHS that each screening programme has its own systems for call and recall, and they are not co-ordinated or joined up. If we want take-up of screening, vaccination and immunisation, the least we can do is to join up those programmes, have consistency around language and channels and some kind of pattern and schedule so that people understand what they are being invited for and when. I hope the Minister comments on consistency and co-ordination.

The final area on which I will touch is that of risk. This again follows the comments of the noble Baroness, Lady Twycross, and this is critical to take-up. MMR showed us how this can go off course. People weighed a risk that turned out to be false against a genuine and much more significant risk of suffering from a real disease. The noble Baroness’s personal comments showed us just how important it is that people take up these kinds of vaccinations. The result was a situation in which children have been harmed and not benefitted, which is still ongoing today. There will be children catching measles now, some of whom will, sadly, have very serious complications, essentially because of a false assessment of risk: the risk of MMR against the so-called, supposed risk that people presented on the other side. In some ways, this is comparable to people switching to driving every time there is a train crash. The data is clear: the train is safer than the car at all times. People often react to a single incidence of a problem. With a vaccine, as we saw with Covid, there will be somebody who has a heart attack following a vaccination, but that does not mean that the risk of not having the vaccination is better than the risk of having it. It just means that one person, sadly, had a heart attack.

There is a lot to be done on communicating risk. We need continually to help people to understand the rationale for each vaccination programme, not just the new ones but existing ones, as MMR has shown. I would be interested in understanding what the Government are doing to address this challenge, particularly considering the different levels of trust that different messengers have. We all understand that doctors, for example, are far more trusted than politicians like us. Pharmacists have a very trusted role within the community. We need to think carefully about how we communicate risk and use the most trusted sources.

I again thank the noble Baroness, Lady Ritchie, for this opportunity, and I hope that the Minister will refer to the points I have raised, perhaps in writing, to spare his voice, if he cannot respond to everything verbally today.