Anaesthesia Associates and Physician Associates Order 2024

Debate between Lord Allan of Hallam and Baroness Merron

Monday 26th February 2024 Lords Chamber

[Lord Allan of Hallam (LD)]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Baroness Merron (Lab)]

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

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

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

NHS Dentistry: Recovery and Reform

Debate between Lord Allan of Hallam and Baroness Merron

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.

Pharmacy First

Debate between Lord Allan of Hallam and Baroness Merron

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.

NHS Winter Update

Debate between Lord Allan of Hallam and Baroness Merron

Thursday 11th January 2024 Lords Chamber

[Baroness Merron (Lab)]

My Lords, the Government’s urgent and emergency care recovery plan promised the largest and fastest ever improvement in emergency waiting times in the NHS’s history. Yet it has not delivered in preparing the NHS for the winter, which we should remind ourselves is a season that, as sure as eggs are eggs, appears every single year. It should be no surprise to any of us, including the Government.

To take just one shortcoming, the plan talked about lowering bed occupancy rates as “fundamental”, yet in November, at the start of winter, bed occupancy was at its highest level since the start of Covid. It stood at 94.8%, a level which will surely lead to serious issues. Did the Government consider taking any additional action to lower occupancy rates? What steps will they now take to ensure that this is not simply repeated every single year?

Today, there have been a number of reports in the media, and I want to refer to two of them. We have read reports that NHS England has confirmed that the NHS is failing to meet all of its key targets: patients are waiting even longer in A&E, even longer to start routine treatment, even longer for cancer diagnosis and treatment, and even longer to be admitted to hospital or for an ambulance to arrive. This is a damning indictment. Perhaps the Minister could tell us the Government’s response to the reports of NHS England today. Also in the news, the Health Service Journal reported that trusts are being told by service commissioners for Lancashire and South Cumbria that, due to the expected deficit, they should plan for a 10% cut in contract values on top of the annual efficiency savings that they are already planning for next year. What is the Minister’s response to this worrying situation? How will it affect services, not just in winter but all year round? How many other trusts across the country are in a similar position?

I would like to pick up a matter strongly defended by the Secretary of State in the other place when this Statement was first made to Parliament—the matter of 800 new ambulances. These ambulances were promised by the Government to help NHS trusts tackle the crisis of ever-worsening response times. But freedom of information requests found that, across 10 of the 11 ambulance trusts in England, there were plans to order only 51 new ambulances. I would like to give the opportunity to the Minister to share any information that is missing from the responses from ambulance trusts that would show that the information referred to in the FOI request was mistaken in some way. Perhaps the Minister could also provide more detail on what NHS England referred to as a problem in procurement due to the impact of global supply chain pressures, and on whether and when it is expected pressure will subside, so that we will see all the promised new ambulances. What performance improvements are to be expected from the 51 new ambulances that we know have been ordered? How would this compare with the full 800 that were promised, had they been procured?

The Government’s Statement presents as a combination of somewhat selectively chosen numbers and situations that do not recognise the reality of a health service in which patients cannot get appointments with their doctors, dentistry is in crisis, and unprecedented numbers of people are having to wait unduly for surgery, cancer diagnosis and treatment, and their ambulances—and all of this while striking doctors are being blamed for the whole situation. The strike action by junior doctors has been the longest in NHS history, with trusts declaring critical incidents and A&E departments telling some patients to stay away to lessen the load. This is a situation that I am sure the Minister will tell us cannot continue, but it continues to disappoint that the Government do not see it as their responsibility to show leadership and resolve the dispute. Could the Minister advise the House of the steps the Government are now taking, or will take, to ensure that we do not see a continuation of this damaging situation?

Finally, I would be keen to hear from the Minister on an aspect of the winter health situation which was not mentioned in the Statement regarding Covid. In the run-up to Christmas, according to the Office for National Statistics, 2.5 million people were thought to have Covid. What assessment have the Government made of this increased prevalence and what impact has it had on the NHS so far this winter? What assessment have the Government made of how the impact may continue? I look forward to the Minister’s response.

[Lord Allan of Hallam (LD)]

My Lords, we should start by recognising and thanking the nearly 3 million health and care workers whom we depend on all year but who have to work especially hard during the winter months. We should also show our appreciation for the many millions more informal carers who spent the festive period looking after family and friends. That was the nice bit, but I now turn to some questions for the Government on what I thought was a predictably upbeat, “It’s all going swimmingly except for the strike” Statement; yet within it there were some significant gaps, some of which the noble Baroness, Lady Merron, pointed out.

It is notable that the Statement says nothing about primary care but instead focuses very much on hospital beds, which I will come to next. Can the Minister comment on how GP appointment waiting times remain unacceptably long in many parts of the country? This is a poor outcome both of itself and in terms of the knock-on effect it has on emergency services. I hope that the Minister can confirm that the Government have been monitoring GP waiting times during the winter months, and that he can indicate what they are doing about these.

The Government say they have added 3,000 hospital beds as part of their 5,000 target. That target was part of their response to last year’s crisis. Does the Minister have any new data on the utilisation of those beds and whether this matches up with the predictions the Government made when they set the target, and any analysis they made to come up with the 5,000 number in the first place? The Statement also highlights the 11,000 virtual beds that are now available, which instinctively seems like a positive development to me. But the important thing is how a broad range of people experience these and the health outcomes they deliver. What are the Government doing systematically to collect data about those virtual beds and whether they have been able to deliver a comparable level of care for people who are suffering during the winter pressures?

Another key area of delivering emergency care in winter is the availability of ambulances, which was rightly flagged by the noble Baroness, Lady Merron. The Minister may have seen a report in the Health Service Journal from 30 November last year, which said that in some areas there is a mismatch between the number of paramedics recruited and the number of ambulances available. It is great that the paramedics have been recruited, but if they are sitting around in the base stations because the vehicles are not there, that does not deliver the improved waiting times we are all looking for. I hope the Minister can comment on this report and whether the Government are able to deliver the vehicles in lockstep with the newly trained paramedics, which is what we all wish to see.

A further element of the response is the 111 service for less-urgent services, which, again, is not mentioned in the Statement. There are concerns about whether people are being directed to the right place—111, GPs, 999 or accident and emergency departments. Are the Government monitoring the performance of 111 in respect of flu, Covid and other winter respiratory diseases?

Finally, we have often discussed patient flow through hospital and out into the community with the Minister, who I know takes a particular interest in this. We know that some trusts are piloting systems to improve flow that could be described as like hotel booking systems that enable beds to be made available in a much more efficient and timely fashion. Will the Government compare the performance of trusts that have these systems in place with those that do not, as they go through this acute period of pressure in the winter months?

Countess of Chester Hospital Inquiry

Debate between Lord Allan of Hallam and Baroness Merron

Tuesday 5th September 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, the Statement that we consider today reminds us of acts that were so cruel that it is hard to make sense of them. Our thoughts must be with the families who have suffered the worst of ordeals and with the children who were so brutally taken from them. It can only be hoped that the conviction and the sentencing have helped bring some closure, even though the murderer dared not face up to them in person in court. More than this, the extent of the crimes committed by Lucy Letby may not yet be fully known, as Cheshire police have widened the investigation to now cover her entire clinical career.

There are heroes in this story—the doctors who fought to sound the alarm in the face of a hard-headed and stubborn refusal to even consider the evidence that was brought forward. I am sure that the whole House would wish to join me in recognising the courage of Dr Stephen Brearey and Dr Ravi Jayaram.

This killer should and could have been stopped months before. If it had not been for the persistent bravery of the staff who finally forced the hospital to call in the Cheshire police, the lives of even more babies would have been put at risk. The refusal to listen, the failure to approach the unexplained deaths of infants with an open mind, and the failure to properly investigate when the evidence appeared to be so clear, are absolutely unforgivable. There was then the insult of ordering concerned medics to write a letter of apology to a serial killer. It is clear that the allegations that were made and the evidence produced were not met with any respect or regard.

This is a tragic and true story, where events came together and flags were raised and ignored. It is to this point that I would like to take the Minister. I start by saying that we very much welcome that the inquiry has been put on a statutory footing, and it is welcome that the full force of the law will be behind it. However, can the Minister tell your Lordships’ House why it took so long to get to that correct decision? It is right that families have now been listened to, but why were they not consulted before the initial announcement? Will they be consulted ahead of any future decisions?

This is not the first time that whistleblowers in the National Health Service have been ignored. On all the occasions such as these where they have not been listened to, there has been a missed opportunity to save lives. The reality is that nobody thinks that the system of accountability, professional standards and regulation of NHS managers and leaders is good enough. Why were senior leaders at the hospital still employed after the conviction? Regarding the absence of serious regulation, which enables a revolving door of those with records of poor performance or misconduct, does the Minister agree that this is unacceptable, particularly when lives are at stake?

I refer the Minister to the duty of candour. It is 10 years since Sir Robert Francis’s report was published in which he put forward the duty of candour, and yet the duty of candour of a number of consultants was ignored and overridden in this case. As a result of that, will the Minister ensure that there is an independent external route through which concerns can be raised in future? Will he look at the accountability, scrutiny and supervision of clinicians throughout the National Health Service, because the pressures on the service at the moment mean that, sometimes, these vital double-checks can be missed? What review has been conducted into the effectiveness of the duty of candour? What is the conclusion of any review that has taken place about what has gone wrong over the past 10 years?

The terrible events at the Countess of Chester Hospital shine a clear light on a lack of consistent standards. Therefore, it is welcome that the Government are considering a register of NHS executives and the power to disbar, which was recommended by 2019 Kark review. However, the Government should go further. Will they begin the process of bringing in a regulatory system for managers, and standards and quality training, as was recommended by the 2022 Messenger review? Can the Minister indicate how and when there will be progress on bringing together a single set of unified core leadership and management standards for managers, and training and development to meet these standards? What is being done to promote excellence in leadership and to ensure patient support when things go wrong?

I am sure we can all agree—I know that the Minister will join with this—that we owe it to the children who lost their lives and to the families who grieve their loss to do what we can to prevent anything like this ever happening again.

[Lord Allan of Hallam (LD)]

My Lords, we have all been appalled at what happened at the Countess of Chester Hospital, and we would also like to extend our sympathy to all those affected, especially those parents of children who were taken from them. Those were losses that we now know that could, and should, have been prevented. I echo the comments of the noble Baroness, Lady Merron, in praise of those doctors who did raise concerns and fought to have them taken seriously. The accounts that we have seen of legitimate concerns either being ignored, or in some cases being actively suppressed, are truly shocking and represent a call to action that we must heed.

The inquiry is welcome, and will cover a lot of important ground, and I will not try to pre-empt their work today. Instead, I want to focus on one aspect where the department could act now without cutting across the work of the inquiry, and that is the role of NHS trust non-executive directors. This is something which the patient safety commissioner also highlighted in her statement on the Letby case. She said of NHS non-executive directors that

“it is vital that they are able to ask the right questions and escalate concerns where needed.”

The relationship between non-executive directors on a board and senior management teams in any organisation involves the delicate balance of responsibilities. Would the Minister agree that NHS trust non-executive directors should see patient safety as a priority responsibility—perhaps the single most important among their broad set of duties? Would he also agree that it is a healthy and positive situation if trust managers feel that they are under scrutiny from their non-executive directors on safety issues and believe that they will be pulled up if they are not fully open with them? We saw in this case claims of management not presenting the full sets of facts to their boards. They must be entirely candid with their non-executive directors and must expect to be challenged; that is the culture we want to see on trust boards, not one of cover-up and misleading.

In this context, could the Minister confirm whether the department will take steps now to reinforce with trust boards the importance of non-executive directors being able to raise safety issues? Importantly, will they be providing non-executive directors with training on how to perform this function effectively, so that they understand the best ways in which to challenge executives where necessary?

As I said at the outset, we welcome the inquiry from these benches, but I hope that the Government will not wait until the inquiry has completed its work to start making changes, and that they will be equally committed to making changes now where these would improve governance, and that the Minister can confirm that they are looking at strengthening the role of non-executive directors on NHS trust boards.

Human Medicines (Amendment Relating to Original Pack Dispensing) (England and Wales and Scotland) Regulations 2023

Debate between Lord Allan of Hallam and Baroness Merron

Monday 24th July 2023 Grand Committee

[Lord Allan of Hallam (LD)]

My Lords, I start with the point made by the noble Lord, Lord Dodds. Reading the Explanatory Memorandum, it was curious that in paragraph 10.2 we are told that the consultation was carried out by all the United Kingdom authorities, including

“the Department of Health in Northern Ireland”

yet the regulations clearly state

“England and Wales and Scotland”.

This does not surprise me. We are dealing with two instruments on the same day, one of them Northern Ireland-only and one England, Wales and Scotland-only.

I was curious about the answer on the Northern Ireland instrument, which is that we would need primary legislation, so it is easier to regulate tobacco products in Northern Ireland than it is in England, Wales and Scotland. I hope the reverse does not apply here, and that Northern Ireland is not included because some kind of legislative barrier means that they would find it harder than we would to regulate something which, on the substance of it, seems eminently sensible. Many people outside here might be surprised that pharmacists did not already have some discretion over how they dispense, given that packs are quite often in odd numbers. Having dealt with the scope point, again, the substance of it seems entirely sensible.

This must be a pre-recess present, as it is rare that people bring before us regulations which are good for patients, pharmacists and GPs. It is not only that everybody wins from the change being promoted; the Government have managed to get a “two for the price of one” by incorporating another change, which I know has come up. The noble Baroness, Lady Cumberlege, and others have campaigned for some time to improve the information given to women who are prescribed sodium valproate. So here we are: we are making two sensible changes in one instrument, and the Government should be congratulated on that.

For once, we have an impact assessment. We have four pages of regulation and 40 pages of impact assessment. My heart always sinks when I see a huge impact assessment but this one was really good. Whoever prepared it should be congratulated. There are lots of really good facts and figures about how prescribing works in the United Kingdom to help support the case, so I thought it was very well worked out. The fact that savings were identified independently for patients, GPs and pharmacists was extremely helpful in trying to assess the impact of the regulations. It highlighted that there is a potential increase in drug costs but that that is far outweighed by the savings that all those other constituencies make.

I would be interested in the Minister’s reaction to one number in it that surprised me. The impact assessment said that the cost of an e-consultation that would be saved—I assume it is for some sort of repeat prescribing —was £1.40. That is a very precise amount, but less than the saving from a patient going to the pharmacist to pick up their drugs. That figure surprised me because it felt low. I would expect a greater saving from reducing the number of e-consultations for people being represcribed drugs. Again, I am curious about where that came from.

I thought the model of trying to price out where the savings are, in a sort of piecework way, was extremely helpful, down to the 45p that will be saved by assistants in pharmacies not spending 90 seconds on splitting packs. That is super precise, but it is the kind of data that we want, and which can be tested to really understand how you are making savings all through the chain.

The other numbers that came out, that were just fascinating, were on the spread of prescriptions of paracetamol. There were two prescriptions for 10,000 paracetamol in there that were checked and found to be correct, which did surprise me. Even more surprising than the two prescriptions for 10,000 were two prescriptions for 1,009 paracetamol each. 1,009 is a very large prime number, so there is no “so many per day”; you cannot divide it by anything to get anything else. I assume that is a mistake, and that they meant to write 1,000 or 100 and stuck a nine on the end, because that is the only way I can think of that any GP would ever prescribe a large prime number of paracetamol.

I welcome more impact assessments like this with fun numbers in them, as they are extraordinarily helpful on a Monday before we head off for our break. More substantively, I genuinely hope that we will see more innovation such as this around prescribing and dispensing, because this is one of the areas that we have talked about a lot with the Minister. If we are to see improvements in primary care, we have to look for the kinds of efficiencies that benefit patients and make everything quicker and easier for the patient, but also make it more cost-efficient, because there are savings to be made that can in turn be ploughed back into the new enhanced services that we want to get from our pharmacists.

Again, as a substantive point, the general sustainability of community pharmacies is a problem. They are not getting the kind of income they need to continue to be present in all our communities. We see that in the closure rates; there are hundreds closing every year. As we look at changes such as this—the Minister talked about things such as the hub and spoke model—we have to bear in mind all the time that if we are making savings and are able to put those savings back into community pharmacies, that will be essential if we are to continue to have the kind of network that we need for the Minister’s ambitious plans.

This is a very welcome development. It is great to get two for the price of one; reducing the risks to pregnant women from sodium valproate is very welcome, but in terms of the scale of the dispensing operation, it is the 10% change that will potentially have a significant impact. As I say, I hope the Minister can commit that savings made through this will go back into that community pharmacy network that we all depend on.

[Baroness Merron (Lab)]

My Lords, as the Minister said in his introduction, this is an important issue. I too express my enthusiasm for this SI. We do not have a lot of SIs for which we have a lot of enthusiasm, so I hope the Minister and his team will be very happy with that. The reason for that is that this is common-sense and practical, and provides savings that can be diverted to benefit elsewhere, but also increases patient safety and is a better service to patients. It also allows pharmacists and their teams to do the job they are there for. That, in itself, is somewhat liberating for members of the healthcare team, so it is very welcome.

I also felt that the Minister had given an extremely detailed and welcome introduction, so I will just focus on a few questions in that regard. The first is about pharmacists. Given the changes and the impetus on pharmacists’ professional judgments, will there be any extra training, checks, reviews or similar put in place? I talk about the review not just to ensure that it is doing the job; are there other innovations that we can welcome in SIs in the future? That would be a very positive outcome.

National Health Service (Performers Lists) (England) (Amendment) Regulations 2023

Debate between Lord Allan of Hallam and Baroness Merron

Thursday 13th July 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, we welcome the debate as an opportunity to look at some of the challenges around the number of GPs, dentists, optometrists and other primary care workers that we have available to us. I welcome the fact that the noble Lord, Lord Hunt, has given us that opportunity.

At the core of the statutory instrument, it seems sensible that we should accept registration from other parts of the United Kingdom where people are on the performers list in another part of the devolved system. To many of us, it is perhaps a surprise that it is not already the case that people on a list in one part of the UK are not automatically passported through to other parts. I am interested to hear from the Minister whether he has any information on how much of an issue this has been and whether there is quantitative or qualitative data around whether we have had significant numbers of practitioners in these fields finding that they had a problem as they moved from London to Edinburgh, Cardiff or Belfast and found that there was a barrier to them restarting their work as a professional because of this performers list issue. Any information he has on that would be helpful.

It would also be very interesting to know whether discussions are ongoing about reciprocal arrangements—whether the constituent parts of the United Kingdom will now plan to do something similar when a doctor on the performers list in England enters their system and whether there will be a similar arrangement for automatic entry to the performers list, subject to later checks, rather than having to apply from scratch.

My second point is to reflect on the user experience of trying to navigate the system, either as a practitioner who wants to work and is thinking about how to get on the performers list or as a member of the public. As the noble Lord, Lord Hunt, pointed out, part of the value—or intended value—of the performers list is that a member of the public can see if somebody who they are going to for treatment has been authorised effectively to offer treatment in their area. We want this to be very simple for everybody concerned, but it is quite confusing at the moment.

As part of my research for this debate, I went to a popular search engine and typed in “NHS performers list”. What I got back was a web page from digital.nhs.uk. The website had .uk at the end, so I assumed it was for the UK; the page was called “National Performers List”, and I assumed “national” meant it was for the United Kingdom. I clicked on that and then, on the next page, it told me that it is only for England. Nowhere in this does it explain to me that there are other performers lists for other parts of the United Kingdom. Nowhere am I given a link to say, “If you are interested in Scotland, go here”. The whole experience is a real confusion between the United Kingdom and England—I speak as a supporter of the devolved settlement, but if we are going to do it, let us do it properly. It seems to me that there is no excuse for not making it clear, given that the .uk bit of the service is not for the UK, that this relates to England and, if you do not want that, here is how to get to the other parts of the United Kingdom.

I note in passing that, if you have a problem with this system, the email address is for the Exeter helpdesk. As I think I have referred to before, I spent many happy years working on the Exeter system—the system for registering GPs—and I am pleased to see it still lives on in the helpdesk for people trying to find out about the performers list.

Equally, if you then come back and search for “performers list” for Wales, Scotland and Northern Ireland, you get a real mishmash of results. There is no consistency. Each of the constituent parts of the United Kingdom has some kind of thing that explains the performers list to you; none of them will link to the others or give you consistent information. In fact, the only place you can find it, if you are really lucky, is by stumbling across the website of the National Association of Sessional GPs, which I assume is intended for GPs looking for locum work. It has a really good explainer with links to all of them, but it seems to me that the Government should be at least as good as the National Association of Sessional GPs at signposting people to the right bit of the performers list.

The other significant area of the statutory instrument which is worth looking at is the question of the inclusion of overseas dentists, which I know the Minister is very familiar with and spends time on. Again, the Explanatory Memorandum tells us that this will improve the situation but is not very forthcoming on how. It tells us that one form of EU exemption will be removed and another system put in place. It would be helpful if the Minister could flesh out a bit about why he is confident—I assume—that it will be a genuine improvement. It would be interesting to hear a bit more detail about how he thinks it will be an improvement and how the new assessment process will help.

I have a final couple of questions. One foundational question, which comes back to the point about the impact assessment, is whether anybody has looked at how much value this performers list system actually adds over and above the existing professional registration systems. I do not think we should just take things as read. We have done it like this previously, where we have people registering with a professional body which requires passing all kinds of tests to get on to the register as a practising dentist or doctor within the United Kingdom—then we have this performers list system. I am genuinely interested in whether we have ever thought to ask whether it is useful to have the performers list layer on top of the general registration layer; if so, how useful it is; and whether the cost of having these two layers of registration is justified. It seems to me that we should always ask those questions; otherwise, we will have bureaucracy on top of bureaucracy.

Finally, I cannot miss this opportunity: I noticed today that in the Prime Minister’s announcement about the funding settlement, which is a welcome increase for various public sector professionals, he said that the Government are going to fund it in part by raising visa fee rates. That is critical. Here we are debating a measure which will make registration on the performers list as an overseas professional a little easier—and we all know that we need a continued stream of overseas professionals in this area. However good we are at training people, we are not going to get there for a while. I am interested in and hopeful about the Minister’s views on whether we are not giving with one hand and taking back with the other. We are making registration a bit easier, but we are going to make it a lot more expensive for people to get here in the first place. As I say, I cannot miss the opportunity to flag that there may be some inconsistency in government policy across that piece.

[Baroness Merron (Lab)]

My Lords, I think this debate is all about whether these regulations will do the job they are intended to do. As my noble friend Lord Hunt said at the outset, it is difficult to see whether that is the case in the absence of, for example, an impact assessment. I start by thanking my noble friend for again bringing this issue before the House. NHS dentistry is so important to people’s health and well-being in this country, and it has deteriorated, sadly, over a number of years. This is not an issue with the regulations themselves but whether they assist primary care in the way that it is said they are going to and that we all seek to do.

In terms of the background, there is no doubt—we all know this from our own experience and that of the people we know—that finding an NHS dental practice in the UK which will accept new adult patients for treatment under the health service is something of a rarity. Only one in 10 practices is offering that at present. That situation remains unsustainable.

NHS Long-term Workforce Plan

Debate between Lord Allan of Hallam and Baroness Merron

Tuesday 4th July 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am absolutely sure that the Minister is as relieved as anyone to see this Statement on the NHS workforce plan before your Lordships’ House today, after many years of waiting and promises of it being published shortly, imminently, or at some time in a very extended spring.

The plan promises much, but it is the delivery that will count and the difference it will make to the health and well-being of the nation. But at the heart of it, its effectiveness will stand or fall on how successfully it joins up with other key aspects of the NHS and social care. It is not just about delivery: the commitment to updating the plan every two years is essential in the hope that it will be a lasting way out of the continuing workforce shortages that have blighted the NHS for many years. Ministers have a lot at stake and are investing a lot of hope in this workforce plan, not least because the lurch from crisis to crisis has to come to an end, with proper consideration of the long-term challenges ahead.

This long overdue plan started and continues its life against a backdrop of chronic NHS understaffing. It is long overdue. If it had been launched eight years ago, it would have been enough to fill the NHS vacancy levels—yet we have had to wait. Instead, the NHS is short of 150,000 staff, and this announcement will take years to have an impact, while patients continue to wait longer than ever before for operations, in A&E, or for an ambulance. While the plan is a positive step, it is only the first step. Much more detail is needed on how the plan will be implemented and what measures will be used to judge its success. What attention is being given to training staff and key leaders in what quality management looks like?

Retention is key, and the plan has little to say about that. The overall staff leaving rate increased from 9.6% in 2020 to 12.5% in 2022. The plan acknowledges the importance of retaining workers, offering more flexibility and improving the culture in the NHS, but it is light on detail about how it might do that. We know that more NHS strikes are planned—and that work culture, bullying and harassment continue to be a real issue, and nearly one in 10 staff experience discrimination. When will there be details on retention, pay and working conditions, such that they can add some detail on how retention might be improved in the NHS?

It is a missed opportunity that there is no social care workforce plan, especially as the NHS workforce plan identifies the impact that delayed discharge due to difficulties securing a social care package is having on patients and staff alike. Without such a plan, it will not be possible to enhance the quality of care and support provided by the NHS—they are inextricably linked. There are currently 165,000 vacancies in social care, an increase of 52% and the highest rate on record. Average vacancy rates across the sector are at nearly 11%, which is twice the national average. What assessment has the Minister made of the impact that having an NHS-only plan will have on the social care workforce? Social care workers already seek jobs in the NHS, where pay and conditions are better. Does the Minister share my concern that an NHS-only plan is likely to exacerbate this situation and the number of vacancies in the social care workforce? Does the Minister consider that this will undermine the ambitions of the NHS plan?

As the King’s Fund rightly observed, the projections are likely to be based on ambitious assumptions. Yet there needs to be realism about the investment in buildings, technology and equipment that is needed to realise productivity gains. Can the Minister say whether and when we can expect plans relating to the various and absolutely crucial aspects of investment? Page 121 of the plan sets out a labour productivity rate of 1.5% to 2% per year. That was never achieved by the NHS or any other comparable health system, so what assumptions are being made in relation to achieving that?

The focus of the plan is crucial. It appears on reading to have been seen through a rather hospital-focused lens, so will the Minister ensure that the lens includes healthcare in the community? At the centre of this plan has to be the patient in all their different facets. In the consultations that took place in the lead-up to the development of this plan, could the Minister advise your Lordships’ House on how patient organisations were involved and which ones were consulted?

It appears that the plan seeks to look to the longer term. As happened in 2000, when the Labour Government of the time produced a 10-year plan of investment and reform which included seeking frequent staff increases, we will look to this workforce plan to make a difference to patients and care and the health and well-being of the nation in the same way as we saw come out of the plan in the year 2000. I look forward to the Minister’s response.

[Lord Allan of Hallam (LD)]

My Lords, I shall try not to be too grudging, as we have been calling for this plan for so long. I start by recognising the enormous amount of work that has gone into this from people working in the NHS and the department over a very long period, but the reality is that the plan is too late for those who are waiting for treatment today and are unable to get it, because the investment was not made in the workforce years ago for it to be available now on the front line. However, the plan certainly is substantive and there is much to welcome in it, looking forward. There are several areas where I hope the Minister can explain the Government’s thinking further.

First and perhaps most importantly, we need a similar, sister plan for the social care workforce. As we have discussed many times across these Benches, health and care work in symbiosis and both have seen too little supply to meet demand in recent years. Can the Minister confirm that the Government have no plans to further reduce capacity in social care by acceding to some of the requests from his political colleagues to limit visas being made available for essential social care staff? Can he say when the Government intend to release a sister plan to the NHS plan dealing with the social care workforce?

The plan also depends on ambitious productivity gains, and these will require certain things to be put in place. First, we need technology that will make life easier rather than more difficult for staff. Will the Minister explain what work is being done to understand how front-line staff in the NHS actually experience the technology they are being provided with, to ensure that we are not setting them back? Technology, when implemented well, leads to productivity increases, but technology poorly implemented can simply add to the frustrations of staff and make their jobs more difficult.

Another key factor in productivity is good management. This is a much less fashionable area to comment on than additional doctors and nurses, but the evidence seems to suggest that the National Health Service is actually quite lean in terms of its management. Will the Minister comment on what is in the plan to boost management capacity so that we can make savings on that other kind of consultant, the management consultant? Far too much is still being spent on externalising management expertise rather than building capacity within the service.

The final area I want to comment on is retention. The plan has hard numbers and new targets for getting new people into training but is much less precise on how we can improve staff retention over the long term. This is of course, quite importantly, a matter of pay and working conditions across all grades of staff. I invite the Minister to comment on some of the press stories we have seen saying that there seems to be some reluctance on the part of the Prime Minister to implement pay review body recommendations in full, something that he himself has said we should rely on to resolve issues particularly around junior doctors. Certainly, understanding that pay is important and that review body recommendations are going to be respected is critical for retention.

We can see that the Government have looked very closely at the specific factors that discourage senior doctors, in particular, from staying on as they approach retirement age. I suggest to the Minister that similarly detailed work needs to be done to understand the precise factors that are leading more junior staff at earlier stages in their career to leave the profession. Similar attention must be paid to resolving those specific issues if we are to address the retention problem.

One way we can motivate staff to stay on is through continuous professional development and retraining into more highly skilled roles, yet training opportunities can be constrained by the capacity of those delivering it. Can the Minister assure us that training opportunities will be provided for existing staff as well as new staff, so that we do not end up holding back Peter in order to train Paul? It will be net negative if we lose staff from the existing workforce through missed training opportunities as we bring in new staff. More generally, is there an understanding of how we are going to build up that capacity for training existing and new staff?

When I was younger, I had a teacher who would often write on my essays, “Okay as far as it goes”. This would annoy me, but with the benefit of wisdom and age I have to concede that it was often fair and accurate. Today, we might say that this plan, into which I know a huge amount of work has gone, is okay as far as it goes. We can be confident that it will really make a difference only if it is delivered in full, and in particular if there is a sister plan for the social care workforce and a real effort made on staff retention. I hope the Minister will comment on some of those aspects.

Mental Health In-patient Services: Improving Safety

Debate between Lord Allan of Hallam and Baroness Merron

Monday 3rd July 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I welcome the announcement in this Statement that the inquiry to investigate the deaths of mental health in-patients across Essex between 2000 and 2020, chaired by Dr Strathdee, will now be given vital statutory powers. This is an important and long overdue development. Not only have the grieving families suffered the pain and anguish of bereavement, and how they have felt in their fight for answers over so many years, but all of this has been compounded by an inquiry that lacked the necessary powers to seek the truth. It would be helpful for your Lordships’ House if the Minister could shed some light on why it has taken so long to allow the inquiry to do its job thoroughly.

More broadly, and connected with this issue, are repeated scandals in in-patient mental health settings involving abuse, dehumanising behaviour and needless loss of life, such that more than one in three people say they do not have faith that a loved one would be safe if they needed mental health care in a hospital. How will the Government seek to restore essential public confidence?

The situation set out in the Statement is against a backdrop of some 1.6 million people on waiting lists for mental health treatment. Their condition is deteriorating and can reach crisis point. At the same time, the incidence of poor mental health continues to rise. Those in poverty or financial difficulty are particularly at risk, to mention just one group. With the cost of living crisis continuing unabated and children from the poorest 20% of households four times more likely to develop serious mental health difficulties by the age of 11 when compared with the wealthiest 20%, this is an upward and unequal trend that the Government have to tackle. I hope the Minister can comment on how this will be properly dealt with.

I will pick up some particular aspects. Families of patients in Essex will welcome the news that this inquiry will be put on a statutory footing, but across the country those failed by inadequate mental health services are in desperate need of answers and need change. In March 2022 the CQC released its Out of Sight report to identify what progress the Government have made in addressing the culture, behaviour and design of services for patients in mental health in-patient settings. Will the Minister tell your Lordships’ House what progress has been made in implementing the recommendations in full?

If we are to bring about change, it is very important that the rapid review of data in mental health in-patient settings translates into action and the report does not simply sit on a shelf in the department. Can the Minister tell your Lordships’ House when the Government’s response to the review will be published and whether he will set out a timetable for when the recommendations are to be implemented?

Over the past year there has been a flurry of reports, as we know only too well in this House, of patients being failed in the care of mental health trusts around the country. Have Ministers actually met the leaders of those trusts to find out what has gone wrong? If not, do they plan to meet and when?

The Government have shelved the 10-year mental health strategy and, despite promises first made in 2018 to reform the outdated Mental Health Act, legislation has repeatedly been delayed. The Joint Committee on the Draft Mental Health Bill published recommendations for improving legislation in January, but thus far Ministers have still not responded to the report and the Bill is yet to be introduced to the House of Commons. Will the Minister please update the House on when it can be expected?

When it comes to mental health, taking a preventive approach would mean fewer patients needing to use in-patient services in future. Have the Government considered shifting the system towards prevention by providing mental health support in every school, for example, and a mental health hub for young people in every community? Ensuring that there are enough staff to provide adequate services is vital to improving patient outcomes, so can the Minister say some more about what plans the Government have to retain staff, to recruit new staff and to expand access to mental health treatment? I look forward to hearing from the Minister on these points.

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to have an opportunity to discuss mental health provision, and my comments will very much follow on from those of the noble Baroness, Lady Merron. We are also interested in the Government’s latest thinking about the draft mental health Bill. Now that the workforce plan is out—we will discuss it tomorrow—our new refrain may be, “When will the Government get on with the mental health Bill?”. It is long overdue, and a huge amount of work has gone in that is clearly fundamental to trying to deal with some of the structural issues.

Turning to some of the issues raised in the Statement, I first want to ask about people’s journeys when they are in need of mental health support. The Statement said that 111 will now provide mental health advice, which is very welcome, but can I ask the Minister for his thoughts on what is happening in primary care? My understanding is that at the moment mental health nursing provision is not a requirement of all general practices—some offer it and others do not. Can the Minister, who I know cares about joined-up, seamless services, give us some insights into the Government’s thinking on ensuring that people who present with mental health problems to general practice—which is the first port of call for many of them, before they even get to 111 or 999—see more consistency of support available at that level?

Thinking about the review—a major part of what is in the Statement—a significant proportion of providers of mental health in-patient services are private sector, which has been the case for some time. Can the Minister confirm that they will be included in the review and comment on whether the inspectorate’s powers will be applied equally to the private and public sectors? That is critical to understanding what is happening in all settings.

Will the Minister also talk a little about the input the review may get from related services? Again, we know that the police, local authorities and accident and emergency departments often pick up the pieces where mental health provision has not been made available. Can the Minister assure us that the review will also look at all those other parties to this journey of care that people require? Can he also comment on the data questions? I have seen evidence from freedom of information requests to the Office for National Statistics asking about deaths of people in mental health in-patient settings. My understanding is that the data is not recorded consistently. If we are to have a review and to understand what is happening in the mental health sector, it would be helpful to know what measures the Government will take to improve the consistency of data collection so that, when someone unfortunately suffers a tragic incident, we know where they were at the time and have the data available to build up the national pattern.

The final issue I want to ask for the Minister’s comments on is out-of-area placements. Will he acknowledge that it remains a serious issue that many people with serious mental health conditions are able to get treatment only in places that are far from home and therefore far from their families and support networks? I note from the Statement that the Government are providing three new hospitals. This is of course welcome, but I hope the Minister will also be able to confirm that there is a locality-based strategy, with the Government thinking hard about matching local facilities to local need so that we can end the situation in which people at a time of extreme distress are sent very far away from home, which can only add to the crisis they are facing.

Lung Cancer: Screening

Debate between Lord Allan of Hallam and Baroness Merron

Monday 26th June 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I thank the National Screening Committee for its work and welcome this Statement, which outlines the only response that makes any sense: the establishment of a national targeted lung cancer screening programme. I also pay tribute to the many individuals and organisations that have worked over many years for this, in particular the Roy Castle Lung Cancer Foundation, which, in addition to campaigning, has been delivering its own scans since 2016.

I very much wish to associate these Benches with the thoughts of the late and much-missed MP for Old Bexley and Sidcup, James Brokenshire. I acknowledge the work he did in bringing this cancer screening programme about, which was continued by his wife Cathy. This is a very fitting Statement with which to honour his memory.

There is no doubt that diagnosing more people earlier is absolutely crucial. This programme will certainly improve that, but it does have to go hand in hand with treatment that is available rather quicker than is currently the case. The UK currently lags behind the European average for five-year survival rates for lung cancer. More broadly, since 2010, ever more cancer patients have waited longer than is safe to see a specialist. The target of 85% of patients to start treatment from initial GP referral within 62 days has not been met since 2015.

Can the Minister tell your Lordships’ House whether this extension of screening will be matched by the necessary improvements in access to treatment? If the treatment programme is to be improved—as surely it must be—how will this be done, and when? Will it be new money or a diversion from existing resources that funds the programme and any associated improvements in treatment?

Turning to the areas where lung disease is most prevalent, notably those with the greatest deprivation and health inequality, can the Minister give an assurance that resources for the screening programme will continue to be targeted at the areas that need it most? With existing health structures already worse in these areas, how will they be improved to support the delivery of the lung cancer screening programme?

Despite the Government’s support today, it has taken nearly nine months to act on the recommendation of the National Screening Committee, and there is now a timeline to reach 40% of the eligible population by March 2025, with full coverage by March 2030. Can the Minister say whether work is going on to hasten the timeline of this rollout?

The Health and Social Care Select Committee’s report last year into cancer services concluded that a lack of serious effort on cancer workforce shortages risks a reversal in cancer survival rates. While we have been promised the NHS workforce plan this week, after many years of waiting, I note that the Government’s press release had just one line on the workforce necessary to make the screening programme a reality, saying that additional radiographers are due to be appointed. Can the Minister assure the House that when we do get the workforce plan, it will address the major shortages that were outlined by the British Thoracic Society, whose report identifies workforce shortages as the main challenge in the provision of healthcare to those with lung conditions?

As the Minister rightly pointed out in the Statement, smoking is indeed the leading cause of cancer, causing 150 cancer cases every day and one person’s death every five minutes due to smoking-related ill health. It is therefore important that alongside diagnosis, we work to stop people smoking in the first place and support those who do smoke to quit. Yet the number of people quitting has slumped since 2010 and smoking cessation services have been cut. Can the Minister confirm when we will get the awaited Government response to the review of tobacco control policies, led by Dr Javed Khan?

It is not only smokers who have lung cancer and other lung conditions. The context in which all of this takes place is a range of other factors in addition to smoke and smoking, and that includes air quality. It would be helpful if the Minister indicated what is being done to tackle these broader challenges. Furthermore, it is not the diagnosis of lung cancer only that will improve through the screening programme, but also that of conditions such as cystic fibrosis. What expectation does the Minister have in this regard?

My Lords, I am sure we all want to see this national, targeted lung cancer screening programme save lives, and I hope the Minister can give the reassurances I seek today.

[Lord Allan of Hallam (LD)]

My Lords, I would like to follow the noble Baroness, Lady Merron, in welcoming the Government’s acceptance of the National Screening Committee’s recommendation to introduce a targeted lung cancer screening programme, and echo her tribute to the late James Brokenshire, whom I dealt with in a previous capacity when he was a Minister advocating for child safety online. I found him to be very effective; a firm Minister who was also very pleasant to deal with—the most effective model for all of us.

The new programme is especially welcome as a step towards addressing the glaring health inequalities we face in the United Kingdom. I hope the Minister will reassure us that sufficient data will be collected in order to understand whether it is having the kind of impact the Government intend, as he outlined in the Statement.

I hope the Minister can also provide more information about how it can be delivered, given that we already have dire shortages in capacity to deliver diagnostic tests. This shortfall is reflected in today’s report from the King’s Fund, which shows a serious gap in CT and MRI scanner capacity between the UK and comparable countries. When can we expect to see investment from the Government in additional scanners, to bring us up to something more like the international mean? As well as the lack of machines, we do not have sufficient people to operate them or to assess the test results. I invite the Minister to refresh his formula for when we may see the long-awaited NHS workforce plan, including the element that relates to radiologists, perhaps updating it from “shortly” to “in the next week”, as it surely has to come before the 75th<sup>anniversary of the NHS on 5 July.

The concern we continually have with announcements of new services by the NHS in the current context is that they will come at the expense of existing services; the noble Baroness, Lady Merron, also referred to this. I believe this is a rational and reasonable concern to have, given the evidence of missed targets and unacceptable wait times that is all around us. I hope the Minister can give us further assurances that, as the Government will the end of catching more cancers earlier, they will also be willing to will the means to deliver on this promise.

Anyone with eyes in their head can see that vaping is being cynically promoted to young teenagers; it is all around us in high street shops and in the evidence from the litter around schools. The Statement refers to the role of vaping as a tool to help existing smokers give up their harmful habit, but there is increasing evidence that vaping is creating new nicotine addicts, with associated risks. The Australian Government have found that young people who vape are three times as likely to take up smoking, and they have plans to bring in a range of measures to suppress vaping among young non-smokers. Can the Minister explain what assessment the UK Government have made of the Australian evidence of vaping leading to higher smoking prevalence among young people, and are the UK Government considering similar measures to reduce vaping use here? It took us five years to follow Australia in introducing plain packaging for cigarettes. I hope we can follow faster here, on vaping.

The new screening programme is welcome, but it must be properly resourced with both machines and people. I hope the Minister can give us some insights into how that will happen, and at the same time explain what action the Government intend to take to reduce vaping among non-smokers, so that we do not end up creating a new wave of people who are at risk of lung cancer.</sup>

National Health Service (Dental Charges) (Amendment) Regulations 2023

Debate between Lord Allan of Hallam and Baroness Merron

Monday 5th June 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am very grateful to the noble Lord, Lord Hunt of Kings Heath, for giving us the opportunity to have this debate. I think he is having an even busier day than the Minister, given his contribution to the Illegal Migration Bill debate that we just had.

There are two real questions that people are asking about access to NHS dental services. The first is whether they can get an NHS dentist. That is something that we have debated in the context of other regulations along similar lines discussing the way in which the remuneration scheme works. The second question is about how much will it cost if they do get one—if they are the lucky few who can navigate through the system and find an NHS dentist, and that is what we are primarily discussing today.

It is also important to touch on dental deserts, particularly in rural and coastal areas. I hope that the Minister may also have some to say on availability. He has assured us in this House previously that the Government have ideas to try to improve the ability of NHS dentists generally, and I know he had some creative ideas about attracting dentists into under-served areas.

Having got through the barrier of finding an NHS dentist, we now need to think about the question of charges—a question that is entirely academic if you are unable to get one in the first place. The Government are proposing in these regulations an uplift—in common language, an increase, but they prefer to use “uplift”, which I think is supposed to sound a little softer— of 8.5%. I find that curious language. When I go to supermarkets they do not tell me that they are applying an uplift value to their prices; they apply an increase to their prices, but here we are told it is an uplift value.

In paragraphs 7.8 and 7.9 of the Explanatory Memorandum we get a lengthy and quite convoluted explanation of where that money goes, which makes it clear that patient charges make no direct contribution to the remuneration that the dentist receives. People out there may think that the payment they are making to the NHS goes to the dentist, but it does not. Again the Explanatory Memorandum makes it clear that there is intentionally no link between the contract price paid to the dentist and the contribution that the individual pays. Paragraph 7.8 states that the money is essential to improve access challenges, and that current and future work to improve NHS dentistry would be undermined by the risk of reduced funding if the patient charge revenue was lower. Yet, as we heard from the noble Lord, Lord Hunt, it is reported that there was a £400 million underspend in the NHS dentistry budget for last year, so I have a couple of questions for the Minister, a maths question and a logic question. The maths question is: will he confirm that £400 million is approximately five times as much as the £78 million in extra revenue that we are told that this 8.5% increase will achieve? In other words, if we were not to have the increase but were simply to roll the underspend into dentistry, we could cover five years of that additional revenue-raising from the underspend that already exists. The logic question is simply: how can we say logically in this paragraph that these charges are essential to improve NHS dentistry when we are not spending the money that is already available? Perhaps the Minister is going to make us all happy by confirming that that £400 million underspend is all going to be spent on NHS dentistry, in addition to the extra £78 million, but I suspect that is not going to be the case. Listening to the noble Lord, Lord Hunt, I wondered whether one of the solutions might be that the new charges should not be allowed to be levied unless and until all the existing budget has been spent. If there is going to be a £400 million underspend, perhaps the patient should benefit from that if the money is not going to be rolled back into NHS dentistry.

The overriding concern is one that the noble Lord, Lord Hunt, also referred to: that the long-term commitment from this Government to provide dentistry within the National Health Service just is not there. The right words are being spoken, but the actions are telling us a different story.

The Government’s own impact assessment notes, at paragraph 37, tell us:

“There remains uncertainty about whether higher patient dental charges would lead to lower levels of patient access”.


They say that, although the research is not clear,

“it is very likely that higher charges will reduce the number of patients seeking NHS dentistry services, relative to there being no patient charge uplift.”.

So, again, the Government’s own notes tell us that it is likely there will be reduced demand for NHS dentistry as a result of the charges that we are discussing today.

Paragraph 32 very tellingly talks about the relationship between NHS and private dentistry, which, of course, is an alternative in most parts of the country. It says:

“There is also a risk that increases in NHS charges could mean that the cost of NHS dental treatment becomes closer to prices of private dental care. Some patients may choose to receive private care if the cost differential is lower”.


It seems logical that, if a patient is confronted with real difficulty in getting an NHS dentist compared with getting a private dentist and if they understand that there is no real price differential, those two forces combined will act to steer people away from NHS dentistry towards private dentistry.

As I know the Minister and I have heard him speak on these issues before, I suspect he will say that this is not the Government’s intention—but we need more than words. We need evidence that we are not seeing a succession of measures leading inexorably in one direction: a direction in which dentistry ceases to be available on the NHS at a fair NHS price for people in large swathes of this country.

[Baroness Merron (Lab)]

My Lords, I am grateful to my noble friend Lord Hunt for tabling this regret Motion and speaking so clearly to it, describing for your Lordships’ House what this actually means for people by its effect on NHS dentistry.

I am glad to follow the noble Lord, Lord Allan, and I absolutely associate myself with his remarks about the word “uplift”. It is a very positive way of describing an increase in costs to those who need NHS dentistry. We should remind ourselves that this is why we are having this debate, not only about the costs but about the sorry reality of the state of NHS dentistry at present—and bearing in mind that all this takes place in the context of a cost of living crisis.

It is incumbent on us this evening to remind ourselves that poor oral health—which is where we end up when people do not look after their teeth because they cannot afford and/or cannot access NHS dentistry—does not just affect the teeth. It impacts on our general health and well-being; it affects what we can eat, how we communicate, and how and whether we can work, study and socialise with ease, and it affects our self-confidence. Yet it is right to say that tooth decay is largely preventable.

There is also a significant public health problem linked with considerable regional variation and inequality. A three year-old living in Yorkshire and the Humber is more than twice as likely to have dental decay as a three year-old who lives in the east of England; and one in three five year-olds in the north-west has experience of dental decay, compared to nearly one in five in the south-east of England. It would be helpful if the Minister could tell us: what is the Government’s aspiration in respect of NHS dentistry? That aspiration and the practical means to achieve it seem to have got rather lost on the way.

As we heard from my noble friend Lord Hunt, the last 13 years have seen dentists quitting in very considerable numbers. In 2021 alone, 2,000 quit the NHS, which represents almost 10% of all dentists employed in England. An estimated 4 million people cannot access NHS care, with some parts of the country now described as dental deserts, where remaining NHS dentists are not taking on new patients.

To secure a future, we need staff, which I will refer to later, and the equipment, technology and access to ensure that patients get the treatment they need. This raises a number of wider questions. We are spending less on dentistry per head of the population in the areas with the highest levels of deprivation. Statistics from the British Dental Association suggest, for example, that 1 million new or expectant mothers have lost access to dental care since the start of the pandemic. Could the Minister say what the Government are doing to prevent those on low incomes or in more vulnerable groups being disproportionately impacted?

Tooth extraction in hospital due to tooth decay remains the most common reason for hospital admissions in the six to 10 year-old age group, with an estimated cost of hospital admissions for children aged between nought and 19 for this intervention being some £33 million per year. What steps are being taken on early preventive action to reduce what has become a shameful situation?

We know that 91% of dental practices are not able to accept new adult patients in England and 80% are not able to accept new child patients. Millions are having to face the unpalatable options of waiting for months in agony, resorting to their own DIY dentistry, or stumping up for private dental fees they simply cannot afford. My question to the Minister is not just about what the Government are doing to tackle this crisis, but how did they allow it to get to this situation? From inadequate support for the prevention of oral ill health in childhood to dental deserts, net government spend on general dental practices in England has been cut by over one-third over the past decade. Again, perhaps the Minister could explain how the situation has been allowed to deteriorate to this extent.

We know that not enough is being done to recruit and retain dentists and dental care professionals. A recent British Dental Association member survey showed that more than nine in 10 owners of dental practices with a high NHS commitment found it difficult to recruit a dentist, with 43% of vacancies unfilled for more than six months.

On the workforce, there is a point I want to underline following the points raised by my noble friend Lord Hunt. In June last year the House of Commons Health and Social Care Committee reported the findings of its inquiry into the health and social care workforce. It found that the headcount—to underline this—of primary care dentists in England providing NHS treatment or otherwise conducting NHS activity in 2020-21 was at its lowest level since 2013-14. While the register has the highest number of dentists, the number doing NHS work is decreasing. In 2021 alone there was a decrease of 951 dentists with NHS activity in England. That is the near equivalent of the whole intake target of dental students for the whole year. Perhaps the Minister could explain how this all stacks up.

On the matter of substance—we have heard much about this from the noble Lord, Lord Allan, as well as my noble friend Lord Hunt—at almost 500 practices across England the British Dental Association tells us that the amount paid by NHS patients was greater than the amount paid to that practice to provide NHS services. The analysis suggests that patients at those surgeries were topping up government funding by an estimated £2 million last year. It would be helpful to hear from the Minister how and in what way this makes sense.

Urgent and Emergency Care Recovery Plan

Debate between Lord Allan of Hallam and Baroness Merron

Thursday 2nd February 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, this plan, interesting in parts though it is, misses the point. We find ourselves in yet another debate over another short-term cash injection to deal with a continuing acute crisis in the health service. It would certainly be helpful if, in replying, the Minister could indicate to your Lordships’ House whether this is in fact new money and, if not, where it is coming from. Furthermore, can the Minister say in his response whether he feels, from his experience, that the better way forward would in fact have been to have a sustainable and long-term plan for the NHS and social care with a laser-like focus on having the necessary workforce in place? The absolutely core point here is this: do we have the staff with which to provide the right level of service? At present, we do not.

We know that more than 7 million people are waiting for NHS treatment; that the four-hour A&E waiting time target has not been met since 2015; and that heart attack and stroke victims and others are waiting inordinate amounts of time for an ambulance. Similarly, we know that those waiting for more than five hours in A&E are more likely to lose their lives, as are heart attack and stroke victims waiting more than 18 minutes for an ambulance.

I am concerned that this plan waters down standards for patients rather than trying to recover the baseline services that are needed to meet them. For example, while the target is for 95% of patients to be seen within four hours at A&E, the Secretary of State has said that the best that can be managed is 76%. Yet outcomes are poorer if patients wait longer than five hours, so can the Minister say what plan there is to return to this all-important target? More generally, can the Minister indicate when patients will see a return to safe waiting times throughout all services?

It is important to see this in the round because too many people find it impossible to get a GP appointment so they end up in A&E, putting more pressure on the service. At the same time, the right care is not available in the community; patients find themselves kept in hospitals, sometimes for months, when they should not be there. As I have said, the gaping hole in this Statement and the Government’s plans is the lack of any sustainable solution to having the right workforce in place, both now and in future. After all, good care in the community, in people’s homes or in hospital cannot be provided without the staff to care for people. As we have lost two in five district nurses since 2010, can the Minister say how more “hospital at home” services will be delivered for patients if there are not the staff to visit them?

As I raised this in a recent question to the Minister, I wonder whether he is now in a position to comment on why the Universities Minister wrote to medical schools telling them not to train any more doctors. It would be helpful to have some light shed on this action.

With regard to virtual wards, NHS providers have rightly pointed out that progress will be dependent on NHS staff continuing to go above and beyond. Does the Minister share my view that this is not what exhausted health and care staff need to hear? Rather, they will want to know when they can expect to have a more sustainable job to go to and when there will be further support from the extended workforce.

In the other place, the former Health Secretary, Sajid Javid, pointed out that successive Governments have not focused enough on prevention, which would take much of the pressure off more expensive emergency care. This intervention came in the context of the Government’s latest announcement that they will not be publishing individual cancer, dementia and mental health plans, which has troubled many patients and stakeholder groups. Can the Minister assure your Lordships’ House that the Government’s new major conditions strategy will give prevention the focus it deserves? When can we expect this strategy? Also, the plan does involve more mental health ambulances, but can the Minister say how we can look forward to a plan that will prevent those with mental ill-health needing an ambulance in the first place?

Lastly, on children, the Royal College of Paediatrics and Child Health has heard how footfall in paediatric emergency departments has doubled across the country, with some children waiting more than 10 hours to be seen by a doctor and surgeries cancelled to free up beds on paediatric wards. As children can deteriorate very quickly, a timely assessment and response is absolutely essential to providing safe and effective care. Will the Minister commit to ensuring that a proportion of the dedicated fund will be used for paediatric services? Will he also commit to writing to every local area to remind them of the solutions that are included in this plan in order to improve urgent and emergency paediatric care?

I look forward to hearing the Minister’s response, in particular with regard to the need for a workforce plan. Perhaps he might also be able to tell us today when we can look forward to the strategy being put before your Lordships’ House.

[Lord Allan of Hallam (LD)]

My Lords, as is usual for this kind of Statement, it is peppered with promises of more of everything. I hope the Minister will help us to dig into the numbers we have been given to see how much lies behind them. First, on the new hospital beds, this seems to come from a process of making winter surge beds permanent. For a real long-term increase in capacity, we need the promised 40 new hospitals. How many of these will be on stream by next winter?

The Statement also tells us that there will be 800 new ambulances, which I think most people would interpret as fully staffed, blue-light vehicles. Can the Minister offer a more detailed breakdown of the different types and capabilities of what is being offered here? The Statement itself said that, for example, 100 of these will be mental health emergency vehicles rather than classic blue-light ambulances.

Of course, staffing these beds and ambulances and the other measures in the Statement will depend on good workforce planning. Here, I echo the comments made by the noble Baroness, Lady Merron, and by these Benches over many months. The Statement tells us that the plan will come this year; can the Minister offer any more precision on when this year we might expect it?

The Statement also talks about data and transparency. We are told that integrated care boards will now have to focus much more on data about patient flow. Can the Minister commit to making more of those statistics public, as well as the ambulance wait time statistics?

Finally, the promised new care hubs can add value only if care services are actually there. This brings us back to workforce limitations. I end with three questions for the Minister: where is the staffing for the beds, where is the staffing for the ambulances, and where is the staffing for the care services?

Health and Social Care Information Centre (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Debate between Lord Allan of Hallam and Baroness Merron

Wednesday 25th January 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to the noble Lord, Lord Hunt, for ensuring that we have an opportunity to debate this statutory instrument. I am also grateful to the Minister for both his initial response to the amendment and the time that he and his officials have spent responding to queries from me and my noble friends Lady Brinton and Lord Clement-Jones.

I revealed in yesterday’s debate how I started my tech career in the Avon Family Health Services Authority. From there, I moved to the FHS Computer Unit and worked on national NHS IT, so this reorganisation has a special interest for me. The subsequent path of the system that I worked with, which was called the Exeter system because the developer hub was in Exeter, is illustrative of the constant reorganisation of NHS IT, of which the latest example is in front of us today; I note in passing that early versions of the Exeter system were written in a language called MUMPS, like the disease but in capital letters, proving that geeks do have a sense of humour. The FHSCU was incorporated into something called the NHS Information Authority, which was then split between the National Programme for IT—NPfIT—and the Health and Social Care Information Centre. NPfIT was later rebadged as Connecting for Health, while the Health and Social Care Information Centre found its way, via a couple more name changes, into NHS Digital; this was referred to by the noble Baroness, Lady Finlay of Llandaff.

It can feel like the architects of these reorganisations have drawn inspiration from peristalsis, the process that moves food through the body by contracting and expanding the gut. The belief seems to be that we can make progress with NHS IT by pulling everything to the centre then pushing it out again to the edges in a cycle of rinse and repeat. I fully expect us to be back here in a few years’ time being told that we have lost focus by pulling everything into NHS England and that we need to create some kind of new stand-alone agency. We might call that new body the Unified Trust Operational Process Information Agency, or UTOPIA for short—there is some free branding advice for the Government.

The serious point here is that, in spite of—or perhaps because of—these reorganisations, the NHS still has information systems that fall well short of what is possible and desirable. There are many excellent people who work in NHS IT, and there are examples of great systems being developed, but we cannot say that there is consistent excellence, which is what the service needs and deserves, as noble Lords have said. I sincerely hope that we might get it right in the public interest this time, but experience suggests that we should remain cautious and test thoroughly what we are being offered.

An early test for this new structure will be the mega contract that has just been opened up for bids to provide a federated data platform, to which my noble friend Lady Brinton referred and which looks like it will cost the taxpayer at least £500 million; that is the number on the face of the contract, and God knows what else will need be spent by trusts on ancillary services. We will be asking searching questions of the Minister at all stages of the development of this project, as some elements are already triggering the spidey-sense of those of us who have seen too many big NHS IT projects go south—by which I do not mean going to Exeter but further than that.

As well as the structural questions about whether this reorganisation will achieve its core purpose of improving IT support for health and social care, there are concerns about what it will mean for the treatment of personal data. The noble Lord, Lord Hunt, and my noble friend Lady Brinton have done a thorough job in describing those concerns so I will not repeat their arguments in detail. However, I want to reinforce their emphasis on the importance of independent oversight. I have worked in technology organisations and have huge admiration for the way in which software engineers, researchers and data scientists tackle problems using data, but their deep focus on addressing problems is not always accompanied by the same level of interest in documenting and getting approvals for all of their uses of data. This is not usually because they are doing anything wrong but because they are in a hurry to explore a task that we have given them. Given this tendency, it is essential that we put in place good governance systems that do not get in the way of necessary uses of data but ensure both that these are properly considered and that any risks are surfaced and mitigated.

As other noble Lords have argued, the IGARD system, which worked for NHS Digital, has broad support. We need something equivalent in this new structure. I ask for the Minister also to consider additional forms of transparency that will help people have confidence that data is being used appropriately. The overriding principle here is that you do not want people to feel surprised that particular kinds of data are being collected or used for particular purposes. A healthy discipline that will help avoid surprises is to ensure that the data schema and software code are made public, as this allows third parties to see for themselves what is going on inside the black box. This is not about publishing all the data held in the databases, which needs to be managed separately; it is about showing the kinds of data that sit in different systems and informing us what the systems are doing with them.

There is a common trope that Governments like to trot out to reassure the public and show that something is safe: putting in place a triple lock. This is part of the Government’s rhetoric around the Online Safety Bill, for example. I invite the Minister tonight to commit to a quadruple lock in this case, given the importance and sensitivity of health and social care data. Lock 1 is the commitment to meeting fully all the data protection standards that are already in place for NHS Digital and in the general data protection regulation. Lock 2 is to ensure there is a truly independent body assessing and authorising requests to use data. Lock 3 is the publication of data schema so that we can see the full extent of what is being held, and where. Lock 4 is the publication of code that will allow people to check that what was authorised is what has actually happened.

I hope that this reorganisation will both lead to positive technology outcomes and avoid negative data outcomes. The NHS needs success in these areas more than ever. I also hope that the Minister will agree that our scepticism on these Benches is healthy and makes it more, not less, likely that we will see those outcomes. Onward to UTOPIA.

[Baroness Merron (Lab)]

My Lords, I thank the Minister for introducing these regulations and for the assurances he has given your Lordships’ House. I also express my appreciation to my noble friend Lord Hunt for what, as other noble Lords have said, was an extremely detailed and helpful examination of the challenges that these regulations present. I hope that the Minister will take his amendment and this debate in the spirit which I know is intended.

I share the view of all noble Lords who have spoken this evening that digital transformation of the NHS is a good thing; on that we are agreed. We all support the use of information to make things better for patients. However, this is about getting it right, and I hope that the debate this evening has contributed greatly to that. It is about confidence. As the noble Lord, Lord Allan, just said, people should not be surprised. They should also not find themselves compromised, uncertain or in any way undermined by the use or misuse of data. That is the challenge before us.

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

Debate between Lord Allan of Hallam and Baroness Merron

Tuesday 24th January 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

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

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

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


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

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

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

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

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

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

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

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

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

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

[Baroness Merron (Lab)]

My Lords, I commend my noble friend Lord Hunt for such a thorough analysis and for bringing this debate before your Lordships’ House this evening. As ever, he brings his expertise, knowledge and incisive approach to this important subject: the provision, or lack of provision, of dentistry.

As we have heard, we have seen a quarter of the budget cut since 2010 and with dentistry, a complete failure to provide a proper service to the population of this country. We know that dentists suffer burnout and that there is difficulty in retaining and recruiting the dentists that we need, while insufficient numbers are in training. This is a toxic mix. We also know that even under the existing budget, even if it was utilised fully, funding is available to provide NHS dental services for only around half the population. We find ourselves in considerable difficulty.

Let us remind ourselves about this statutory instrument. It was drawn to the special attention of the House by the Joint Committee on Statutory Instruments in its report because the regulations are

“defectively drafted in two related respects.”

To look at the specifics of those, as the noble Lord, Lord Allan, also raised, I ask the Minister why it was not felt necessary in respect of primary dental service agreement changes to give a timeframe for dental practice profiles to be provided for the NHS website. Does this not, as the Joint Committee on Statutory Instruments criticised, insert a somewhat unacceptable level of uncertainty into the statute book? I look forward to the Minister’s comments on that point. Furthermore, in respect of the criticisms of this statutory instrument, can the Minister say why NHS England has received no steer within this as to what a “reasonable timeframe” is to take action against non-compliant contractors, which the JCSI concludes

“leaves this law unacceptably uncertain”?

National Health Service Pension Schemes (Member Contributions etc.) (Amendment) (No. 3) Regulations 2022

Debate between Lord Allan of Hallam and Baroness Merron

Wednesday 11th January 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, regrettably I do not have an interest to declare in respect of the NHS Pension Scheme. I say regrettably because I was an NHS employee during much of my 20s but foolishly opted out of the pension scheme. Older me would have words to say to younger me about the lack of foresight in that decision, because the NHS pension was and is an excellent support in retirement, as the noble Baroness, Lady Altmann, has pointed out. If only I had had someone like her to advise me back then, I would be in a better position today.

Apart from that reminder of personal grief, I am grateful to the noble Lord, Lord Davies of Brixton, for enabling us to have this debate today, as it allows us to return to a key topic that we rightly discuss regularly in this House—the issue of staff shortages in the health and social care sector. He and the noble Baroness, Lady Altmann, have described some of the really quite profound structural challenges related to NHS pensions and taxation, and I hope that the Minister will agree to look at them in some detail.

On the narrower subject of the regulations themselves, the response to the consultation on this instrument is enlightening in describing the nature of the staffing pressures that the NHS faces, which brought around the original changes made in the Covid legislation that have then been prolonged in a series of statutory instruments, and especially in describing those that relate to staff sickness absence rates. I note that the consultation response was written last autumn but accurately predicted the fact that those staff sickness absence rates would continue through the winter. If anything, they have been worse than anyone anticipated, through the combination of Covid and flu. That makes the case for us not disincentivising experienced staff who are past retirement age from returning to help us out at a time of national crisis. It is of special note that, in this consultation, 98% of respondents said that, yes, this should go ahead and we should continue to offer some relief to those who are coming back into work, with only 2% against. That is quite a majority for any consultation.

If the consultees had any criticism, it was that the easements did not go far enough. I note that the Government have agreed to remove the 16-hour rule permanently from 1 April this year, and I hope that the Minister will confirm that this is the case. It was the pension scheme board itself that said that there was no rationale for requiring people who agreed to work past retirement to stick to a 16-hour limit.

The response also goes into some detail about the position of special class status members who can retire at 55, and what happens if they return to work before the age of 60. It included a graph that showed how much a nurse in this category could work before abatement applied. I understand that the word “abatement” in this case means that there is a limit to the number of additional hours that a nurse could work before losing, pound for pound, some of their pension entitlement. In other words, if they work past that amount of time, effectively they are working for free. The Minister may correct me if I have misunderstood, but the chart implied that there would be a straightforward loss.

The chart tells us that the most experienced nurses, those with 35 years of pension entitlement, would be able to work around 0.5 of a full-time equivalent before the pension ceiling kicked in. The Government in their consultation, because they were not lifting the abatement permanently, put a glass-half-full spin on it, saying, “Look, these people can come back and work half time”. But of course there is a glass-half-empty angle on it as well, which is that we are potentially losing half the time that those experienced staff could give to us if they did not feel that, by working those extra hours, they would lose out on their pension entitlement. I note that the abatement for this group has been extended to 2025, acknowledging that concern, but that there is still no permanent solution. Again, I hope that the Minister today has some ideas for how we may go further and ensure that the NHS can persuade retired staff of all classes to put in as many hours as they feel fit to do. We do not want to be in the position whereby someone is willing to work more but, purely for financial reasons, feels unable to do so.

I am sure that we will return to the theme of the impact of NHS Pension Scheme rules on staffing levels over the coming months. As the noble Baroness, Lady Altmann, pointed out, it is clear that there are unforeseen and unwelcome consequences of some of these rules, which I suspect is because they were crafted in a different climate for NHS staffing, at a time when people would retire and plenty more people were coming in. Today we are in quite a different situation where, frankly, we are desperate for those people who can still work, who are at retirement age, to postpone in many cases well-earned retirements to come back and assist us. In that climate, it is essential that the Government commit to revising rules where that would make a material difference to staffing levels and therefore to the health of the nation.

[Baroness Merron (Lab)]

My Lords, I thank my noble friend Lord Davies for tabling this regret Motion and for comprehensively setting out the issues before us this evening. As the noble Baroness, Lady Altmann, said, this is a real problem because we see workplace penalties incentivising staff not to work, which cannot be a state of affairs that is allowed to continue.

I will start by making a general point of context. I have great concerns at how many regret Motions concerning regulations produced by the Department for Health and Social Care have been tabled in recent months, with more to come. Is this a concern that the Minister also shares? If so, I wonder whether he has a view on what action needs to be taken within the department in order to stem this flow. I suggest to your Lordships’ House that perhaps the reasons for justified dissatisfaction with a number of regulations that are being brought forward have roots in both procedure and policy that are falling short. I will return to that point later. I hope that the Minister will act swiftly and systematically to deal with this continuing problem.

As we heard in contributions from across the House, inadequate numbers of staff underscore the crisis in the National Health Service, which is creating a situation of irrevocable damage being done to the lives of people who experience record delays across the whole of the system. We have a crisis of failure in getting and keeping a workforce in place to provide the services that we need. This has not just happened by accident. It is evidenced as predating the pandemic and it is the result of nearly 13 years of very particular choices that have been made by this Government.

In 2021 alone, 2,000 dentists and over 7,000 nurses quit the NHS. There are more than 46,000 empty nursing posts across hospitals, mental health, community care and other services, which means that around one in 10 nursing roles is unfilled across the service overall. That is the context in which we are discussing this regret Motion. As noble Lords on all sides of the House have asked repeatedly—as the noble Lord, Lord Allan, rightly reminded us, and as I and other noble Lords asked on yesterday’s Statement—where is the comprehensive and detailed workforce plan to retain, recruit and train the doctors, nurses and other health professionals whom the NHS so desperately needs? Will this plan take account of NHS pension arrangements?

With specific reference to NHS pensions, we have long been calling for the Government to sort them out and to remove the deterrents in the system to NHS staff staying in post or returning to work. This includes, for example, the cap on doctors’ pensions as, under the current rules, many experienced doctors are deterred from working later into their career because they are unable to opt out of paying into their NHS pension even if they have reached the cap. The result is that GPs are taking early retirement, which they would not have done otherwise, as the noble Baroness, Lady Masham, referred to.

We also know that record numbers of GPs are indicating that they will retire or leave the profession, with burnout and low morale at an all-time high. Can the Minister say how the numbers will stack up, when 4,700 GPs have been cut over the past decade and the long-promised 6,000 GPs are not on course to be delivered? How will the current pension arrangements assist in keeping GPs from wanting to retire and leave the profession? What action will be taken?

I turn to the specific comments of the Secondary Legislation Scrutiny Committee that form the basis of this regret Motion. I understand why my noble friend Lord Davies has seen fit to table this Motion. The committee’s report on this statutory instrument laments the short-term approach taken by the Government. The SLSC has drawn these regulations to the special attention of the House because

“some of the extensions proposed are quite short term and may not give re-employed retired staff or their employers the certainty first to encourage and then to retain staff to deal with the current NHS backlogs.”

National Health Service (NHS Payment Scheme—Consultation) (No. 2) Regulations 2022

Debate between Lord Allan of Hallam and Baroness Merron

Monday 9th January 2023 Grand Committee

[Lord Allan of Hallam (LD)]

My Lords, I am pleased to be able to take the reins from my noble friend Lady Brinton, starting with this short but important statutory instrument. I echo the happy new year wishes and thank the Minister for his welcome. I understand that a key function that we perform in this House is to ensure that legislation is implemented in the way that Parliament intended as we put flesh on the bones of primary legislation through statutory instruments such as the one we are considering today.

Today’s statutory instrument is a small element of an important part of our modern health service infrastructure: the mechanism for pricing services within the NHS’s internal market. It was a prompt for me to read more pages of tariffs and rules than I ever intended or wished to do, which is mind-boggling and fascinating in equal measure. The subject of our debate today is not the substance of the payment scheme but rather the trigger for when the scheme might be reviewed if there are objections.

As the Minister pointed out, the Government’s intention is to maintain a 66% objection rate for triggering a further consultation period, which is unexceptional as it maintains the previous level. However, like the noble Lord, Lord Patel, I am curious as to why 66% was picked, particularly as I understand that it will not trigger a referral to the Competition and Markets Authority, which would have been a major step, but simply a further consultation period. There may be an argument for why a 51% or 60% threshold would not be appropriate, given that the threshold triggers something less significant than the previous regime.

I am also curious about the experience that we have had over the last decade or so while the other tariff scheme has been in place. Does the Minister have data on the levels of objections received in previous consultations? I suspect that they were much lower than the level we are talking about here but, as we review the scheme, it would be interesting for us to understand whether we were previously getting 10% objection levels, or 50%. I assume that there must be some experience of that within the National Health Service.

Like the noble Lord, Lord Patel, I would like more words about why 66% remains the effective level, and some information about objection levels we have experienced previously. That would be helpful to put our minds at rest, but I think we are all broadly supportive of the instrument as it stands.

[Baroness Merron (Lab)]

I thank the Minister for introducing this statutory instrument. It is a great pleasure to follow the noble Lord, Lord Allan, for the first time in his new role. I am sure there will be many more times, and we all wish him well. Of course, from these Benches, I echo the happy new year greetings. The new year gift to the Minister is that on no side are we opposing these regulations today. I am sure that will make him absolutely delighted as he starts 2023.

The consultation that we are talking about here is important because, as noble Lords have said, the NHS payments scheme governs how billions of pounds of taxpayers’ money is spent. Of course, quality of care and value for money have always to be at the core of our health service and its decision-making, and we need financial management within the health service to be able to deliver both quality of care and value for money in parallel—they are not an either/or. We saw during the pandemic what happens when the NHS strays from these principles, and we do not want to allow such events to happen again.

The former tariff system which these regulations form part of replacing sought to deliver a more competitive environment to drive up quality and to improve outcomes for patients yet, regrettably, it was often something of a rather rigid system that did not allow for the flexibility that individual commissioners actually needed. Therefore, giving local decision-makers the tools that they need to improve services in their areas is absolutely vital to ensuring that the NHS meets the needs of patients where they are, not where the system thinks they should be. The noble Lord, Lord Patel, raised an important point about meeting the needs of patients where there is variability across the country, and it would be helpful if the Minister could offer us some comment on that. With that in mind, a rigorous and effective consultation on changes is absolutely vital, because we know that, when done properly, payment schemes can deliver a meaningful impact on patient outcomes.

The payment by results incentives that were used by the last Labour Government made a significant impact on the elective waiting lists. We know that this may not be the appropriate way forward in every case and that options have to be carefully considered, but we are now in a situation where elective waiting lists are at record levels. So, given the reports that Ministers are considering bringing back payment by results incentives in some form or another, perhaps the Minister could give some comment on what plans are in place to do that.

I will ask a further question to get a sense on this. As we are talking about billions of pounds of public money—of course I believe that this SI and other discussions that we have treat this point with the gravity that it warrants—it would be helpful to hear from the Minister whether he considers that there is enough input through the Secretary of State into this process. I am of course not suggesting that Ministers should be setting payment levels for various treatments, but it would be helpful to have a sense about whether there is enough political input into how we might ensure that the extraordinary purchasing power of the NHS might incentivise innovation, prevention or, for example, buying British.

Furthermore, in previous consultations on the national tariff, such as in 2014, the objection percentage was met, but how have the NHS and the department worked since then and engaged with stakeholders to prevent that from happening again, as far as possible? I was also pleased to read that the department will be monitoring and reviewing the implementation of this legislation. Can the Minister give us some more detail on what form this will take and whether the analysis could be made public? That follows on from the point made by the noble Lord, Lord Allan.

It is important that we get right these changes that we are considering today, and effective consultation is absolutely key. It is in the interests of everyone, because it will ensure better outcomes for patients. I therefore look forward to hearing from the Minister how this will be delivered.

Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022

Debate between Lord Allan of Hallam and Baroness Merron

Monday 9th January 2023 Grand Committee

[Lord Allan of Hallam (LD)]

My Lords, I do not have any direct professional interest in the subject at hand, but as somebody who lives in London and needs dental care, and as a parent, I am grateful to those dentists and midwives from all over the world who have provided me with excellent service through the years. We should be grateful to them all.

From these Benches we also broadly welcome the order the Minister is putting forward. It is clear that we should make it possible for all suitably qualified healthcare professionals to practise in the UK and it is, frankly, a waste of an individual’s talent and a detriment to public interest if there are unnecessary delays or barriers to registration. The noble Lord, Lord Hunt of Kings Heath, described dentists coming here from countries such as Ukraine and Afghanistan who can make a significant contribution, and we need to enable them to do so rather than disabling them from doing so.

Of course, there are necessary checks to protect patient safety, but what we are saying with this statutory instrument is that we believe that the professional bodies, such as the General Dental Council and the Nursing and Midwifery Council, are the bodies most competent to determine what those checks should be and to set out the right testing and assessment processes to allow applicants with overseas training and experience to apply their skills here. In this debate I have learned a lot from the detailed experiences of the noble Lords, Lord Hunt of Kings Heath, Lord Harris of Haringey and Lord Patel, about what this means in practice. It seems to me to be the right decision that we should empower those bodies even further and give them the flexibility that they need to be able to adapt over time as circumstances allow, balancing out the need for safety but also the need to get people on to the register as quickly and reasonably as possible. We agree with the Government on the broad thrust of these provisions and that the additional flexibility is important.

I raise one question with the Minister. Do the Government have any criteria in mind for assessing whether this change has been successful? For example, have they looked at the cost and speed of applying to register before and after the additional flexibility is granted and after the new processes are brought in? The noble Lord, Lord Harris, correctly reminds us that this will not be immediately, but certainly over this multiyear process, if we are to make this change, it would make sense to look at the situation before and after. I note that paragraph 14.1 of the Explanatory Memorandum points out that the instrument itself has no monitoring provisions, but with any legislative change it is helpful for that to be the case, and I hope that the Minister will be able to describe some criteria that the Government have internally for deciding whether this has been successful.

Finally, I end on a note of caution about the safety standards. Sadly, something will go wrong; somebody will be registered in future who should not be registered. When that happens, the fact that we are all supportive of this today means that we will all own that decision, and we should not say that this is wrong because of a single bad case. Overall, we are making the correct decision. The correct risk assessment is that we trust bodies such as the General Dental Council and the Nursing and Midwifery Council to make decisions.

As the noble Lord, Lord Hunt, correctly pointed out, this is part of a process; we will be going further, and other professional bodies will be given similar flexibility. That is the right decision now and will be the right decision in future. Even if and when something sadly goes wrong under the new procedures, as I said, we will need to remember that, overall, we took this decision because we wanted to see more of those people—the kinds of people from whom I have certainly benefited—on the registers in the UK providing the professional services that they can.

[Baroness Merron (Lab)]

My Lords, I thank the Minister for bringing this order before us. On these Benches, as across your Lordships’ House, these changes are welcomed as sensible and as part of a suite of measures that we will continue to consider. Certainly, the increased flexibility that they bring to the work of the General Dental Council and the Nursing and Midwifery Council by amending the registration and examination processes and procedures so that they are as effective and practical as possible is very welcome. This is about harnessing the capacity and meeting the standards that are needed so that we can ensure that we have the right professionals in place. The noble Lord, Lord Patel, raised important points that I hope the Minister will consider on how the practicalities of this need to be done.

I am grateful to my noble friend Lord Harris, who laid out what the order does but also what it does not do—in our deliberations it is important that we understand that. I noted his comment that there was no ministerial claim that this will solve a workforce crisis, but, as my noble friend Lord Hunt said, we have a challenge in getting a workforce in place to provide the services that we need. In that regard, it is important that we consider the changes today in the current context of the health system in the United Kingdom.

It is important to say that, sadly, in 2021 alone, 2,000 dentists and over 7,000 nurses quit the NHS. There are more than 46,000 empty nursing posts across hospitals, mental health, community care and other services, which means that one in 10 nursing roles is unfilled across the service overall. As we have spoken about many times in your Lordships’ House, the number of NHS dental practices fell by more than 1,200 in the five years before the pandemic, and there are 800 fewer midwives than just three years ago. That is the context in which we are discussing this.

I turn specifically to the order. If, as expected, the GDC begins recouping costs incurred around international registration, including charging applicants more to take the overseas registration exam, could the Minister give an indication of what effect this might have on the number of dentists operating in the UK? I am sure he understands that, given the number of dental deserts that we already face, we cannot afford to lose the capacity of any further dental professionals.

As well as the overseas registration exam, non-EEA dentists also have to go through the performers list validation by experience process to practise here. The Minister will be aware that stakeholders expressed concern about dentists’ PLVEs being disrupted—for example, by being endlessly rearranged or cancelled—and that that is acting as something of a deterrent to working here. Can the Minister confirm whether there is recognition of that difficulty, and whether the department is looking at what needs to be done to make the process as coherent and smoothly run as possible?

In the other place, the Minister of State committed to write further on the breakdown of positive and negative responses to the consultation that was carried out. Can the Minister of State’s response be made available to Members of your Lordships’ House so that we might also better know what stakeholders were thinking when they responded to the consultation on these changes?

The Government’s Explanatory Memorandum states that policy changes that the regulations make following this order

“may potentially impact international applicants and existing registrants with different protected characteristics, particularly with regards to age, sex and race”

but does not provide detail on what that impact might be. Can the Minister offer any insight into this, if the department has correctly forecast what the regulators are planning?

As we have discussed today, the intent of the order is that there will be changes to application processes and so on. Can the Minister indicate what plans there are to review and audit changes to ensure that there is consistency of decision-making, fair treatment of all applicants and the achievement of the right standards?

In conclusion, while we all support the substance of the order, I hope the Minister can give an assurance that its impact and implementation will not be beset with logistical hitches and unforeseen consequences, because we are keen to ensure that changes are made to deliver the right result to get the workforce more into place than it has been hitherto. I look forward to hearing what the Minister has to say about how the order may assist that, if not entirely cure it.