Strikes (Minimum Service Levels: NHS Ambulance Services and the NHS Patient Transport Service) Regulations 2023

Debate between Lord Allan of Hallam and Baroness Bennett of Manor Castle

Wednesday 6th December 2023 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, in speaking after the noble Baroness, Lady Merron, I must respectfully disagree with and indeed correct her on one point. I do not now accept that your Lordships’ House does not have the responsibility, in exceptional circumstances that I have set out before, to act to stop statutory instruments that should not go through. However, your Lordships will be pleased to know that I will not rehearse all the arguments I referenced in my earlier speech.

I also correct the noble Baroness on her suggestion that there has to be a Labour Government to protect the rights of working people. We have to get rid of the Conservative Government, but other options are available. The see-saw of politics that we have had for the past century has not served this country well, and its people are increasingly aware of that fact.

I am aware of the desire to move quickly to a vote, so I will be brief, but I will pick up a point from the Minister. Again, it is important in this debate to reference the briefing from the Royal College of Nursing, which stresses that the regulations seek to make trade unions responsible for breaking their own strikes. As the Royal College of Nursing makes clear, the Government had claimed this is not about nurses, but there are nurses working for the services that we are now talking about. It seems so long ago that we were all standing on doorsteps clapping, cheering and banging pots for our nurses and other medical workers who were putting their lives on the line. Look where we are now.

The RCN briefing also makes the important point, as the Joint Committee on Human Rights noted, that the minimum service level requirements may impact more severely on certain protected groups—most obviously women in respect of nursing. This is a gendered attack on the freedom of members of the RCN. As the RCN says, and as others have said before, this whole approach makes strikes more likely, not less likely.

In a recent survey of RCN members, 83% of nursing staff said that the staffing levels on their most recent shift were not sufficient to meet the needs of patients safely and effectively. I, and I think all medical workers, strongly believe in minimum service levels. We need to have them every day, and the Government have not created a situation in which that is possible.

For the avoidance of doubt—we want to move on to other votes—I am not planning to divide the House on this but, in the meantime, to allow the debate, I beg to move.

[Lord Allan of Hallam (LD)]

My Lords, it is good that this instrument applies only to ambulance trusts in England. That is the last time I will use the word “good” in association with this statutory instrument, but it certainly reflects a lot of feedback, particularly by the noble and learned Lord, Lord Thomas of Cwmgiedd, and others, that we had during the debate on the primary legislation, when we felt we had to remind the Government that the health service is devolved and that it was inappropriate to seek to interfere too far. It was interesting to hear the Minister say that the Government have made an offer of assistance to the Governments in Wales and Scotland in respect of giving them these wonderful minimum service levels. I would love to be a fly on the wall for those conversations, which I am sure are very short.

I turn to the substance of the requirements. The people running local health services are like watchmakers looking after very complex mechanisms with many different moving parts. From time to time, we work with those professionals on health and care legislation that provides tools for them to tune and improve their services. What is before us today is not such an instrument but rather reflects that the Government have decided unilaterally to give local health authority managers a hammer, because that is what the Government think they need. Yet the feedback we have had from all those who work in the National Health Service, as cited by the noble Baroness, Lady Merron, is that they clearly believe that this is the wrong tool for the job. Given that feedback, it seems quite likely that many trusts will choose not to use the powers to issue work notices. If that is the case, perhaps little harm will ultimately have been done other than wasting parliamentary time on creating the law and the regulations.

But there is a worrying scenario, which we explored during the legislative process, that was not sufficiently addressed—where trusts that do not want to issue work notices nevertheless feel compelled to use them for legal reasons. I would like the Minister to come back to this today and provide some more compelling assurances. If an ambulance trust, after the passing of these regulations, wishes not to use this mechanism but instead to negotiate voluntary agreements, as the Minister said that he would like them to do, will it truly be free to make that choice? If politicians want to urge trusts to use the hammer of work notices that they have given them, that is one thing. They can deal with the political pressure. But if, by declining to use these notices, they will expose themselves to new legal risks, that is much more problematic. Trusts may then feel that they have to use the hammer, even where they believe it will cause more damage, because they cannot risk being sued for not doing so. Can the Minister give a clear guarantee that his department has looked into this thoroughly and determined that trusts will continue to be able to use their best judgment on what will cause least harm to the communities they serve?

Where a trust has exercised its judgment not to issue work notices and things go wrong, as inevitably may happen from time to time, for a variety of reasons, we need to know that the trust will not face action either from the department or from any other third party. Absent that assurance, the safe option may be to issue the work notices, for the trust to take the hammer to the watch, whether or not it thinks it is a good idea. This is the crucial point. If we are to believe the Minister’s reassuring words, that this will still create the scope for trusts to negotiate voluntary agreements and they will not have to issue these work notices, we need to know that the department has looked at this and can give us that kind of copper-bottomed guarantee, rather than simply saying it will not be a problem.

National Health Service (Primary Dental Services) (Amendment) Regulations 2022

Debate between Lord Allan of Hallam and Baroness Bennett of Manor Castle

Tuesday 24th January 2023 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to follow the noble Lord, Lord Hunt of Kings Heath. I thank him for securing this debate and for so clearly setting out the pressing issues around dental treatment. He set out the massive, chronic underfunding—a quarter down since 2010—and the workforce problems. As he said, the regulations we are debating are an extremely modest, if welcome, step to address that to a very small degree.

I will take this opportunity to take a somewhat broader view of dental health and raise a couple of issues that are arising from the crisis of the lack of NHS dental provision. My first point draws on the WHO Global Oral Health Status Report, which was published in November 2022. It stressed that most oral diseases are fundamentally preventable through addressing the social and behavioural determinants, with risk factors such as tobacco, alcohol and sugars that are shared with many other non-communicable diseases. So the first question I put to the Minister is: are the Government really taking seriously the issue of addressing good oral health and public health conditions, which would have so many other positives in terms of issues such as obesity, diabetes, et cetera? Are the Government looking at this in this kind of way?

Secondly, the WHO global strategy on oral health says:

“Achieving the highest attainable standard of oral health is a fundamental right of every human being.”


I will refer here to an article published in the Lancet Public Health on 11 December last year by Winkelmann and other authors, which looked around the world at the different classes of oral health coverage available. There are four: no coverage at all, limited coverage, partial coverage, and comprehensive coverage. The UK, I am afraid, falls in the second of those four increasing levels of coverage: limited coverage. We know that the Government like to claim to be world-leading in many contexts, so do they have an aspiration at least to reach the comprehensive or advanced level of coverage identified in that study, which would mean making dental treatment available to all and ensuing a high quality of preventive public health provision?

My third point is on the issue of dental health tourism. This was prompted to the front of my head again this morning by sitting in a Tube carriage in which I was facing adverts saying, “Get your teeth fixed—go to Turkey”. A couple of days ago, there were a number of horror stories about this across the tabloid newspapers. I am not picking on Turkey in particular, because I do not have the stats on how many people are going where and what problems are arising—but I do not believe that the Government have stats on what is happening with dental health tourism or those problems, either.

As I understand it, there is no reliable source of data on all outbound UK medical tourism, whether it be dental or other forms, but the ONS has estimated that 248,000 UK residents went abroad for medical treatment in 2019. I assume that quite a number of those treatments were probably dental. Indeed, in a recent article the Guardian quoted the editor-in-chief of the International Medical Travel Journal—it is interesting that there is a journal on such a thing—saying that this was going up fast. Are the Government going to collect any stats on both dental tourism and other forms of medical tourism? Are they going to publish those? Are they going to look into whether this is an issue, in which case the stats would clearly be a starting point? Does the Minister agree with me that when these operations go wrong overseas, we will end up seeing the UK dental health system and general health system ultimately having to pick up the pieces?

I come now to my final point. Your Lordships’ House will shortly be engaging, I suspect at some considerable length, with the Levelling-up and Regeneration Bill. It is worth stressing how much dental health issues are a levelling-up issue. The south-west of England, Yorkshire and Humber and the north-west have the largest shortage of provision of NHS dental services, with 98% of practices in these areas refusing to accept new adult NHS patients, according to the latest figures I have been able to find.

I have raised a number of points, and I understand that the Minister may need to write to me on some of those. We sometimes have this sense that there is health, and then there is dental health. Indeed, the article I cited earlier stressed that the WHO is concerned that dental health is often seen as something that is done by private clinics in private places—but, of course, dental health is crucial to the health and well-being of a healthy population. We have, in so many different areas, a public health crisis in the UK. Dental health is one more of those areas, and it must not be left behind or neglected because of historic structural factors.

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to the noble Lord, Lord Hunt, for ensuring that we have an opportunity to debate this important statutory instrument today. We benefit from his detailed analysis of problems in the dental sector.

The facts are laid bare in the Government’s own impact assessment, which says:

“NHS dentistry was a challenging area prior to the COVID-19 pandemic, with patient access proving difficult in some areas of the country … The COVID-19 pandemic exacerbated problems with patient access and created a backlog of patients seeking access to NHS dentistry.”


There is a recognition in that analysis that people being unable to access NHS dentistry is a long-standing problem. As other noble Lords have said, the statutory instrument is correctly aimed at addressing some aspects of that shortfall, and we would not oppose it as a contribution to solving the problem. However, we would ask the Minister, “Is this all you’ve got?”, given the clear and enormous gap between demand and supply.

The figures are dire. Again, the Government’s own impact assessment shows that the success rate for patients seeking an NHS dental appointment has fallen from 97% in 2012 to 82% in 2022 for people with an existing relationship with a dentist—so one in five of those who already have an NHS dentist relationship are not being seen. But for those trying to get their first NHS dental appointment, this has become almost impossible in many areas, with only 31% of those who had not been seen before successfully getting an appointment, compared with 77% of the same group in 2012. When we drill down into these national figures, we also see significant variation around the country, with some areas having become known as “dental deserts” because of the lack of dentists offering NHS treatments.

Turning again to the impact assessment, we see that it tells us that

“the North West has generally good access (but with pockets of poor access in rural areas), compared to the South West and East of England where access is generally poor, particularly in rural and coastal areas.”

This is a terrible indictment of what is supposed to be a nationally available essential service—one that is likely to have a disproportionate effect on deprived people who often need intensive dental care. The noble Baroness, Lady Bennett, also raised this point, quite rightly, in the context of the levelling-up agenda—or is it the gauging-up agenda? In any case, the agenda to deliver better services to people in historically deprived areas is critical to this understanding of the disparate access to dental care.

These changes are supposed to incentivise better provision of these intensive treatments but I note that again there is no statutory review clause in the instrument requiring the Government to produce data that will show their actual impact. I hope the Minister will want to commit to producing such a post-implementation evaluation in due course, even if that is not a statutory requirement. I am sure he will talk up the benefit of making these changes but the proof will be when we come back in a year or two and we can see whether there has been a change in the number of people able to access NHS dentistry and the number of treatments that were given.

As well as amending the payment scheme, this regulation places new requirements on dental practices to update information about their services for publication on the NHS website. This may seem weird, but I experienced a twinge of fond nostalgia as I read up on this section. It took me back to my first technology job, where I was responsible for producing the directories of primary care practitioners for what was then the Avon Family Health Services Authority. These consisted of papers in ring binders that listed each dental practice and its services for distribution to libraries and other public information points.

That was in the mid-1990s before the massive growth of the public internet, but I managed to get hold of some software called the NCSA HTTPd, an early web server, and I produced an HTML version of our directory for people in the local authority. All of those products are now long discontinued, as indeed is the country of Avon itself, so this is of historical rather than current interest. However, that may have been version 0.001 of the public directory that we now have on the NHS website.

Fast-forwarding to the present day, it will be no surprise that we support improvements to provision of information to the public such as those in the statutory instrument. However, that has to be complemented by improvements to the availability of services or we will simply see increased frustration as people are given better information about what they cannot have. Does the Minister have a response to people who will go to the NHS website and find that there are no dentists taking on NHS patients in their area?

I hope that the Minister will not think it churlish if we say, “Thanks but not enough” in response to this instrument, and that he may have some additional remarks to make about what more the Government plan to do, especially in respect of creating the NHS dental workforce. I emphasise “NHS”; there are many areas where there is no shortage of dentists, but there is a shortage of dentists who are willing to work for the rates that the NHS is prepared to offer them. I hope that by making those improvements, we will be able to move on from where we are today, where seven out of 10 people in this country who try to get into the NHS dentistry system for the first time cannot find anyone to take them on.