NHS: Dentistry Provision

Lord Harris of Haringey Excerpts

Monday 25th November 2024 Lords Chamber

[Baroness Merron (Lab)]

I would like to associate these Benches with the comments made by the noble Lord about the late Lord Colwyn, whose contribution was indeed considerable. I agree that that would be a very appropriate legacy to his memory. The fact is that we are in the position that the previous Government’s dentistry recovery plan did not go far enough and, as we all know, there are too many people struggling to find an NHS appointment. As part of our 10-year plan we are working to assess the need for more dental trainees in areas including the east of England, which the previous noble Lord referred to, because many people continue to struggle. This cannot go on, not least because prevention is absolutely crucial as we move towards making an NHS fit for the future.

[Lord Harris of Haringey (Lab)]

My Lords, I refer to my interests in the register as chair of the General Dental Council. I am grateful to my noble friend the Minister for twice referring to the General Dental Council, but she has, perhaps inadvertently, given the impression that all that is required for a new dental school is that somebody rocks up to the General Dental Council and says they would like to open one. What consideration has she given to where the resources will come from for the training of extra dentists through a new dental school? Can she say what is being done to look at the best use of the number of dental professionals that exist around the country in order to make the best use of the skills mix between dentists and dental care professionals?

[Baroness Merron (Lab)]

My noble friend makes, as ever, very important points, and I am grateful for the opportunity to clarify that it is not a matter of just rocking up to the General Dental Council. However, we may find—I am sure that we will—that, in order to deliver our workforce ambitions, we need to work with partners such as NHS England and the GDC to explore the creation of new dental schools in currently underserved areas of the country. We have already had one such example. Provided that a prospective dental school meets the requirements of the GDC and the Office for Students, it will be considered for future government-funded training places. I absolutely agree with my noble friend that there are a number of layers to this, and I also agree that we need to look at the whole dental team, including dentists. There are a number of people involved in care, and it is crucial that the workforce plan can deliver on that.

Covid-19 Inquiry

Lord Harris of Haringey Excerpts

Tuesday 3rd September 2024 Lords Chamber

[Lord Harris of Haringey (Lab)]

My Lords, I am delighted that the Government have found time for us to debate this very important first report from the Covid-19 inquiry chaired by the noble and learned Baroness, Lady Hallett.

I chair the National Preparedness Commission. This was conceived before Covid struck. Its gestation was dominated by national lockdowns, physical distancing and mask wearing—all overshadowed by nearly 250,000 Covid-related deaths, to say nothing of the toll on physical and mental health across the population.

The report from the noble and learned Baroness, Lady Hallett, necessarily focuses on national pandemic preparedness, but what her report says has a much wider salience. She reminds us that:

“The primary duty of the state is to protect its citizens from harm. It is, therefore, the state’s duty to ensure that the UK is as properly prepared to meet threats from a lethal disease as it is from a hostile force. Both are threats to national security.


That same point applies to most of the other 89 acute risks in the national risk register and the other slow-burn chronic risks that are considered separately by government.

The noble and learned Baroness concludes that there must be “radical reform” as the existing arrangements and structures failed. Her indictment is harsh: the UK was too complacent about its strength in pandemic preparedness. It was boosterism: we were the best in the world, or the second best in the world. We had plans and protocols, but that is not the same as having working systems, particularly if those plans are untested, outdated and over-specific to the wrong kind of pandemic. She says that there was a failure to appreciate long-term risks and an inadequate assessment of cascade and compound risks. Improvements in resilience arising, for example, from previous exercises, were routinely deprioritised. There was a poor use of experts and, in particular, no mechanism for challenging assumptions.

The report draws an important distinction between whole-system preparedness and preparedness for single-domain risks. There are linked and compounding risks that require a cross-government approach. What we need is much stronger systems thinking within government. Departments need to think beyond their own responsibilities and the centre of government must take a grip on the complex nature and interconnectedness of so many of the hazards that we face. But that will only tell us what we face; even more important is that the nation’s resilience and its preparedness to respond to all these different hazards must become a much higher priority.

A resilient and secure nation is the necessary foundation on which all the Government’s missions must be based. To govern is to choose. However, some duties of government are of overriding priority: safeguarding the nation and protecting our citizens from harm. The reality is that those duties must override, where necessary, other shorter-term political choices and objectives. Yet there are practical and institutional biases that have made it difficult for preparedness and resilience to be prioritised, particularly when alternative actions are more visible, provide more immediate gratification and are superficially more crowd-pleasing.

When things go wrong—and I say this to my noble friends who are current Ministers, just as I would say it to those who were Ministers in the past or hope to be Ministers in future—the subsequent inquiries, such as this one or tomorrow’s into the Grenfell fire, always ask what went wrong or why it was not prevented. Looking again at Ministers and former Ministers, I ask: why did those with responsibility not regard the risks as important or pressing enough? Why did they not have the information they needed—or did they fail to ask? Worse still, did they not want to know?

It is not easy for decision-makers, Ministers and civil servants, who have to balance their immediate priorities against longer-term preparations to deal with what is frankly unpredictable and uncertain. There is, of course, the prevention paradox: the more successfully risks are prevented, or handled if they happen, the less people notice. We live in a democracy. We all find it difficult to respond to novel risks, or to protracted and complex challenges. There is an optimism bias and groupthink, as has been referred to several times today, as well as confirmation bias. We should never forget that unlikely events happen and the cost of putting things right is several orders of magnitude greater than earlier preventive action.

Proper resilience and preparedness are likely to be expensive. It will usually be impossible to prove that the actions taken have prevented something or will do so, particularly if that hypothetical event is at some indeterminate time in the future and long after the decision-maker’s term of office is forgotten. But it is still necessary. As a nation, we have been poor at long- term planning to mitigate threats.

So what would make a difference? I have already mentioned systems thinking, but we also need much better horizon scanning and foresight. There needs to be more diversity of thought, a point picked up by several noble Lords—again, recognised in the inquiry—and there is a need for much more external to government advice. I suspect that we also need to have new ways of accounting and valuing resilience and preparedness expenditure. Treasury Green Book rules should be adjusted to ensure that long-term requirements for preparedness and resilience are given due weight rather than being discounted out of the picture.

We also need to change the wiring at the centre of government. The noble and learned Baroness, Lady Hallett, suggests a single Cabinet-level committee responsible for whole-system civil emergency preparedness and resilience, and she quotes a former Prime Minister, the noble Lord, Lord Cameron, as saying that this needs to be led by a strong Cabinet Minister with the

“ear of the Prime Minister”

so that there is

“the full weight of government behind their decisions”.

That political leadership is vital, but we also need the Civil Service support structures to be in place, perhaps with a new Permanent Secretary for preparedness and resilience, effectively the nation’s chief resilience and risk officer, whose task would be to ensure that issues are pursued systematically and across government. We also need a robust system of parliamentary oversight, as my noble friend has already said.

Then we come to what the noble and learned Baroness, Lady Hallett, described at the report launch as her most important recommendation, which was

“a statutory independent body for whole-system civil emergency preparedness and resilience”

to provide independent strategic advice, consult widely, especially with the voluntary and community sectors, assess the state of planning for preparedness and resilience, and make recommendations. It would be a sort of Climate Change Committee on steroids. I know that some people perhaps do not like the idea of a Climate Change Committee on steroids, but for national preparedness and resilience it is essential.

I would go further and suggest that we need a national resilience Act, again perhaps modelled on the Climate Change Act, placing a legal duty on government departments and public bodies to take account of and prioritise the need for preparedness and resilience in all their actions, requiring government to report on baseline resilience, setting targets for improvements needed and reporting annually on progress. The compelling reason for investing in resilience and preparedness is safeguarding the world that our children and grandchildren will inherit. What the noble and learned Baroness, Lady Hallett, has proposed in her report, perhaps along with a national resilience Act, is a necessary condition for a system that encourages and supports preparedness and resilience.

Ultimately, society as a whole must be behind the change of approach needed. That will require mature political leadership and I am confident that we have that. We live in an increasingly turbulent and uncertain world; we must be prepared for whatever may arise. Every part of society and every part of government needs to be prepared and resilient, with a whole-of-society approach and a whole-of-government approach. I hope that when my noble friend responds she will promise precisely that because, if we fail to invest adequately in preparedness and resilience and if we fail to adapt appropriately for the long-term challenges of the future, that will have been a grotesque abnegation of our obligations to our children and future generations. We must not let it happen.

Northern Ireland Dentists: Amalgam Fillings

Lord Harris of Haringey Excerpts

Monday 22nd July 2024 Lords Chamber

[Baroness Merron (Lab)]

I thank the noble Lord for his kind words of welcome and can assure the House that I will certainly do my best in my new role. On the important issue of what next, which I believe the question raises, this will now be a matter for the Democratic Scrutiny Committee in Stormont. It will look closely at what this new arrangement potentially means and will decide the next step, so I suggest that it is in the right place. Of course, we will continue to work closely with our colleagues in Northern Ireland. I believe there will be next steps after we have had the opportunity to hear what the committee says.

[Lord Harris of Haringey (Lab)]

My Lords, I refer to my interest, as listed in the register, as chair of the General Dental Council. Can the Minister express a view, on behalf of His Majesty’s Government, on the safety of amalgam fillings?

[Baroness Merron (Lab)]

Yes, I can confirm that amalgam is safe. The reason for this phase-down of the use of mercury, which is in amalgam fillings, is related to the environment. When mercury is released into the environment—for example, through emissions from crematoria—it can get into the food chain, where it accumulates mainly in fish such as shark and tuna. That can affect those who have a fish-rich diet, in countries such as Greenland, Brazil, Japan and China. However, there is no evidence whatsoever that amalgam is unsafe, and it is with that in mind that we have sought this arrangement for Northern Ireland.

Anaesthesia Associates and Physician Associates Order 2024

Lord Harris of Haringey Excerpts

Monday 26th February 2024 Lords Chamber

[Lord Lansley (Con)]

I am very glad to follow the noble Lord, Lord Winston, because he directs us to the central issue, of how we seek to ensure the safety of patients in all circumstances. What he was describing illustrates the essence of the relationship of a physician associate—or, for that matter, an anaesthesia associate—to the supervising doctor. That is a central issue as well. In the circumstances that we were just hearing about, the responsibility of the doctor or the consultant in charge of the patient is the central responsibility. It would be wrong to think that the devolution of tasks to an associate removes the responsibility of the doctor in charge of that patient.

I hope we agree that proceeding with the order is necessary because we want to bring physician associates and anaesthesia associates within the scope of regulation. This process has been very useful, not least because my noble friend and his colleagues have given us considerable time and energy in discussing the order and how it is to be implemented.

I confess to the House that when I was Secretary of State back in 2010 to 2012, and as the noble Lord, Lord Markham, made clear, there were relatively few physician associates. I remember them as physician assistants. I remember the desire on the part of physicians to have additional resources available to support them in that role. It was never to replace doctors; it was always to enable physicians to focus on where their responsibilities lie. That is still the purpose and the point of physician associates. I am less familiar with anaesthesia associates, and in those days, I do not remember understanding that they were there in the form in which we now have a number.

None of this debate is about trying to criticise physician associates, anaesthesia associates or the profession as a whole. We are setting out to make sure that as they are brought into regulation, that regulation works most effectively. From my point of view, the simple fact of being brought under the regulation of the General Medical Council was not a problem, because the General Medical Council was clearly addressing all the issues very efficiently and professionally. However, because the GMC regulates doctors, I confess that there is a worry about the idea of another profession being regulated by it. If one says, “I am GMC registered”, what do people assume by that phrase? They assume that one is a doctor. The distinction that needs to be made between the medical register, the specialist registers and the register that is to be established for physician associates and anaesthesia associates is critical.

As for myself, I am perfectly clear in my mind and would have started out by assuming that PAs and AAs would be regulated by the Health and Care Professions Council. That clearly was not the route that was chosen. In my view, it is too late to revisit that. However, the distinction in the registers under the GMC must be very clear.

Equally, the scope of practice and what the noble Lord, Lord Hunt of Kings Heath, said about the governance of the trusts and the bodies responsible needs to be absolutely clear. In particular, the scope of practice is the essence of how we can ensure the safety of patients, so that the whole multidisciplinary team understands what their respective roles are. I am not sure that there is any merit in trying to understand which professions are responsible for which mistakes. Let us look at outcomes. The outcomes are the product of the multidisciplinary team and a group of professionals working together—they are not the results of individual professionals. Let us put that slightly to one side.

The only other thing that I feel very strongly about—which has been referred to in a number of respects—is that patients and the public need to understand who the professionals responsible for them or providing the service to them are. Let us be clear: we start from a point where I suspect that most patients in most circumstances where they are looked after by PAs or AAs do not know who they are and how they fit into the professional scene. It is not that we are looking to ensure that everybody needs to be educated about that—that is probably too hard a task—but I urge my noble friend the Minister, the regulators and the professionals involved to recognise that PAs or AAs do themselves and patients the greatest service by being absolutely clear at any moment—including proactively—that they are not the doctor in charge of that patient but that they are providing care under the supervision of the doctor for the given purpose. If anybody appears to be in any confusion whatever, it is important that that confusion is remedied. For patients, understanding who is doing what to them and why is an essential part of “no decision about me without me”.

While the order enables the regulation to proceed, I hope that our debates on it are not “fire and forget”. This is about a process that we should be looking at very carefully to understand whether the problems that we have referred to, and the difficulties and worries that we entertain while the order goes through, are dealt with in the subsequent regulation.

[Lord Harris of Haringey (Lab)]

My Lords, I declare my interest as the chair of the General Dental Council. It is not for me to comment extensively on matters affecting a fellow healthcare professional regulator, but I will say one thing directly in response to what the noble Lord, Lord Lansley, said about the substance of the order. Unlike the GMC, the GDC is responsible for all dental professionals, including dentists, dental nurses, dental technicians and so on in the four nations of the UK. I believe that it is helpful to the public to be assured that all the professionals they encounter when they enter a dental surgery will be registered as professionals by the same regulator and that they will have equal levels of assurance about the training and standards they can expect—and within a framework that indicates what the limits are of each of their professional responsibilities, what can and cannot be done, and how they are appropriately supervised.

My reason for intervening, however, is separate. The DHSC has made it clear that this order is the first step in the reform of the way that all the healthcare professionals are to be regulated. Indeed, it told the Secondary Legislation Scrutiny Committee that the intent is to provide all regulators with “broadly equivalent powers”. While the GDC is some way down the queue—it is after the NMC, the Health and Care Professions Council and so on; although it is still helpful to get in early—this is potentially a template that will apply to all the regulated professions.

I make it clear that regulatory reform is welcome and long overdue. The GDC’s framework was set out in the Dentists Act 1984—that legislation is 40 years old, with only limited updating since then; somehow, the GMC is slightly more prominent and gets more updating than some of the other professions. The Government first consulted about the scope of reform in 2017, following Law Commission recommendations three years earlier. It has taken a decade to get even to this stage, and we are still a very long way off from orders being prepared to cover the dental professions. By the time the orders for all the other professionals are agreed, the model in today’s order may be outdated.

The GDC welcomes the intention to give the regulatory bodies more authority to update their procedures and processes without recourse to Privy Council approval and the delays inherent in waiting for the DHSC to draft regulations and lay them before Parliament. Such updating would of course be subject to full consultation in each case by the regulators concerned and would be only in the framework laid out in orders such as the one we are debating. We need such reforms to enable regulators to operate as effectively as possible to protect the public better in the light of changes in the way the professions deliver their services.

--- Later in debate ---

As my noble friend Lord Lansley, said, this needs to be an ongoing process policed by the CQC. As part of that, I take the point made by the noble Lord, Lord Harris, that you should not need the caveat about the intent to deceive. The fact that you are not using your correct title in the right place is enough in itself.

[Lord Harris of Haringey (Lab)]

It is in your order.

[Lord Markham (Con)]

That is something I will pick up on. On the point raised by the noble Baroness, Lady Fox, I say that the GMC, with the CQC, should be able to give the ongoing quality assurance.

The noble Lord, Lord Hunt, said very well that the discussion on mistakes has not been useful. We are all aware that, regrettably, mistakes happen in all areas, and we need to make sure that we understand and learn from them, rather than using them to point fingers. Moving into the regulated space, where there is duty of candour, is useful.

I do not think anyone could be failed to be moved by the passion with which the noble Lord, Lord Winston, spoke about his experience. It was a very telling story. As reassurance I cite the noble Lord, Lord Patel, on the scope of the practice: it is one anaesthetist to two AAs, and the role of the AA is very much to maintain, as he explained well. In a similar way, the PAs really do need to work under GP supervision. The numbers are set out in the long-term workforce plan. We have a foot on the throttle for those training places, particularly in regulating them. We will make sure that things are properly managed so they cannot get out of control.

I absolutely agree with the points made by the noble Baronesses, Lady Watkins, Lady Harding and Lady Bloomfield, that this is a people management issue, and a lot of the heat from this debate is a feeling from junior doctors and others that they are unloved and uncared for. I freely admit that there is a wider issue that we need to look at, concerning things like hot meals; clearly, it is something trusts need to look at it as well.

I echo the points made by the noble Lord, Lord Hunt, that passing this order is the best way to ensure the safety of patients. As we develop, there is perhaps scope to be more ambitious, but let us try to do this step by step, to make sure we really are happy and that the scope of practice works. As ever in a debate as long as this—it has been a very thorough one—I will write to fill in any details that I have not managed to cover. At this point, I hope and trust I have provided sufficient answers to the questions, and have demonstrated—

NHS Dentistry: Recovery and Reform

Lord Harris of Haringey Excerpts

Wednesday 7th February 2024 Lords Chamber

[Lord Markham (Con)]

I thank my noble friend. He is absolutely correct that the benefits of water fluoridation are well proven. The consultation for the north-east of England, which will bring in 1.6 million people to this, is starting very shortly. The idea behind that is that we can really try to get moving quite quickly on that. I was surprised to learn that the level of water fluoridation in England today is only at about 6 million people. I know that a lot of people think that their water supply has fluoridation, but there is obviously a long way to go on that. The 1.6 million in the north-east is a good extension to that, but there is a lot more that we plan to do in this space.

[Lord Harris of Haringey (Lab)]

My Lords, I declare my interests as chair of the General Dental Council. I welcome the fact that this plan has now arrived—it has been a very long time coming. Of course, the council’s role is to maintain a register of dentists and ensure that all the dentists on that list are of an appropriate standard and fit to practise in this country. I am not going to comment on the level of investment, but I make the point that increasing the number of dentists on the register does not in itself increase the number of people who practise in the NHS. I think that the British Dental Association uses an analogy about a bucket with a hole in it. The point is that, if the situation is one in which dentists, whether they qualified here or abroad, feel that the rewards that they get from being an NHS dentist are insufficient, we will continue to see that drift away from NHS dentistry.

My specific point is about the question of overseas registration. The Statement highlighted the fact that 30% of those on the register are qualified from overseas. I should say that nearly 50% of those who joined the register in 2022 are from overseas, so that gives some idea of the direction of travel. To facilitate that, the GDC has trebled the number of places for people taking their ORE part 1 examinations. On the specific proposal about provisional registration, which the General Dental Council will welcome, I hope it is recognised that, if somebody is provisionally registered, they must be supervised. This will require a structure within both the NHS and private practice to make sure that there are adequate levels of supervision available and an adequate number of dentists to do that. Can the Minister tell us how that will happen?

[Lord Markham (Con)]

I thank the noble Lord, particularly for his great knowledge and work with the GDC. I absolutely accept the basic point about the leaky bucket, for want of a better phrase; we are losing a lot of dentists to private. At the end of the day it is about the economics, and clearly we need to make sure that doing NHS work pays. In part that is what the patient premium is designed to do, as is increasing the value of UDAs to £28. There is also an acceptance that we need to look at some of the more long-term measures to make sure that it is economic to do that. The salaried staff I mentioned earlier will help with that as well.

The noble Lord is absolutely correct—again, I have some personal experience of all this—about having that mentoring scheme. Even if a dentist has been operating overseas for a number of years, learning a lot of the techniques and methods here is very beneficial. It is absolutely recognised that such mentoring is required. On the detail of how that is being planned, I will set out in my letter to everyone how exactly that will be achieved.

NHS Long-term Workforce Plan

Lord Harris of Haringey Excerpts

Tuesday 4th July 2023 Lords Chamber

[Lord Markham (Con)]

As for the A-level point and those people not being able to go on to universities, that is what the different routes are about. The different pathways that we are talking about include nursing associate training places, which we want to see increased to 10,000, and similarly with physician associates. While we all understand that having a university education is a fantastic medical grounding, there are many other ways to get there. I am sure we all have very good examples of fantastic clinicians who did not have a degree.

[Lord Harris of Haringey (Lab)]

I refer to my interest as chair of the General Dental Council. I welcome not only the whole document but the specific commitment within it to increase the number of dental training places by 40% by the beginning of the next decade. Does the Minister accept that simply increasing the number of dentists will not solve the problems of NHS dentistry if dentists decide that it is more lucrative for them to practise privately rather than through the NHS? This is only part of the process. If the solution to dealing with the problems of NHS dentistry is to essentially create a tied class of dentists who have trained and are therefore expected to work in the NHS, I am not sure that this will be sufficient.

I also raise a more general point which is nothing to do with dentistry specifically. Could the Minister tell the House what proportion in any one year of the number of people entering the workforce are expected to go into the NHS? My calculation suggests that they are expecting the figure to go up from 10% of those entering the workforce to 15%. What will incentivise that, and will it be addressed through the various pay processes that we have already referred to?

[Lord Markham (Con)]

I thank the noble Lord for the work he does as chair of the GDC. He will know that this is something that is quite close to my heart, given that my better half is a dentist. I completely agree that it is about far more than just the training places. I think the House has heard me discuss this before, but if we are serious about dentists who have been in practice for 10 years setting up their own clinic, maybe in an NHS Digital desert, we must give them guidance and support, as it is quite an ask to do that. We plan to produce and publish a dental plan in the not-too-distant future, in which I hope and trust that a lot of these points will be covered.

The noble Lord is correct; I do not know the exact maths behind it, but we spend roughly 12% of our economy on the health sector and so it is not surprising that roughly that number would be expected to go into the NHS workforce. In some ways, that shows the magnitude of everything we are talking about today. Probably one in eight of all people leaving school will end up in this sector—that really is a number worth thinking about and pondering over. As we all agree, it shows why this plan is timely and why it must be a living document that is continually adjusted as we go forward.

Mental Health In-patient Services: Improving Safety

Lord Harris of Haringey Excerpts

Monday 3rd July 2023 Lords Chamber

[Lord Markham (Con)]

As I am sure the noble Lord is aware, the second thing that the HSSIB is being asked to look at is exactly the point about how people are cared for as in-patients and how we can improve that approach. On staffing—again, we will debate this more tomorrow night following the Statement repeat—it is vital that there is a feedback loop in terms of the long-term workforce plan. That feedback loop, as I am sure noble Lords are aware, is built into it, so that when new data comes along, as will potentially be the case with the HSSIB, there is a way for that to feed back in again.

[Lord Harris of Haringey (Lab)]

My Lords, I will follow on from the point made by the noble Baroness, Lady Berridge. Until 2015, I chaired the Independent Advisory Panel on Deaths in Custody, which covered the more high-profile areas of deaths in police and prison custody. However, the largest number of deaths under the care of the state was in mental health institutions. The noble Baroness, Lady Berridge, asked about independent investigations and the Minister said that the review will look at what lessons can be drawn. The point is, however, that over the last 20 to 30 years, there have not been independent investigations into the individual deaths, so how will there be an evidence base to decide whether proper lessons were drawn at the time and whether those were acted on?

Secondly, my noble friend Lord Hunt of Kings Heath talked about the difficulties with CAMHS. There is a gulf at age 18 between people being treated under CAMHS and then going into adult mental health services. What are the Government doing to bridge that gap? People who may have received some support from CAMHS then lose it when they go into the adult sector.

Finally—I know I should not ask three questions, but I want to—one of the striking things about the number of deaths that occurred in mental health institutions is that many arose from physical causes. It was not about people committing suicide or their mental health crisis; it was the fact that in a hospital, a place of medical provision, they were not getting adequate physical healthcare. What are the Government doing about that?

[Lord Markham (Con)]

I thank the noble Lord for his commitment in this area over the years. With regard to the first question about past evidence, clearly the HSSIB will be looking at what evidence exists. As the noble Lord said, some investigations go back 30 years, so there will not always be circumstances where it can pick out that evidence, unfortunately. However, where there is that information, we are trying to make sure that we pull it out and learn from it. That is very much the direction of travel. Clearly, if part of the HSSIB’s findings is that we need to make sure that every death in such circumstances is investigated under a certain pathway, then I am sure that will come into its recommendations. In terms of the other questions, I think it is best that I write to the noble Lord, if I may.

Hospitals: Maintenance

Lord Harris of Haringey Excerpts

Thursday 9th February 2023 Lords Chamber

[Lord Markham (Con)]

The noble Lord makes an excellent point. As he knows, we are investing heavily in a federated data platform, which is precisely about stopping storing paper and making such savings. Even more importantly, it is about improving patient care so that we can ensure that records are transferred instantaneously and really build on the knowledge that will bring.

[Lord Harris of Haringey (Lab)]

My Lords, I am not sure that the Minister really addressed the question my noble friend raised about the number of hospitals. He said that it was substantially more than three, then tailed off without giving us a number. He promised us a virtual reality opportunity to look at “the hospital of the future”, but I do not know whether that exhibition will show exactly which hospitals the 40 in question are, what is going to happen and how many of them a normal person in the street would regard as new. While he is on his feet, can he tell us what feedback Ministers have had from NHS staff working in hospitals about the physical state of those buildings and the extent to which that impedes their daily activities supporting patients?

[Lord Markham (Con)]

We have eight cohort 1 hospitals, which all have full planning permission and are in various stages of construction. We have 10 cohort 2 hospitals, of which two have full planning permission, seven have outline planning permission and one is awaiting approval of outline permission. All have had the preparation works done. So that is 17 where massive progress is being made. We then have cohort 3 schemes: the new hospital 2.0 projects, which are introducing modern methods of construction to standardise production and get cheaper and more efficient hospitals at a quicker rate of output. That is what I invite noble Lords to come and see for themselves over the coming weeks. This programme is very real and I will happily take people through whatever detail they want because, believe me, it is all there.

PPE Expenditure

Lord Harris of Haringey Excerpts

Wednesday 25th January 2023 Lords Chamber

Asked by

[Lord Harris of Haringey]

To ask His Majesty’s Government what is their latest estimate of expenditure incurred in purchasing faulty personal protective equipment (PPE) during the COVID-19 pandemic; how much had been recovered by 31 December 2022; and how much they forecast to recover by 31 December 2023.

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

The department’s Annual Report and Accounts 2020-21 confirm that 817 million items of PPE worth £673 million were not fit for any use. By December 2022, the department had reduced the number of contested PPE contracts from 176 to 60, with an associated recovery of value for the taxpayer of around £1 billion. Given commercial sensitivities, we cannot comment on our forecast for further recovery.

[Lord Harris of Haringey (Lab)]

My Lords, I am grateful to the Minister for that reply, but when I look at the National Audit Office report it produces some slightly different figures from those that he has given. It says that his department had identified 3.6 billion PPE items that were not suitable for use, at a cost of £2.9 billion. The point I want the Minister to comment on is that 53% of those suppliers who came through the VIP route provided materials which were not fit for use. Does that raise any questions about the procurement processes operated during the pandemic?

[Lord Markham (Con)]

I thank the noble Lord. Given the recent press, I want to start by setting out the position of Cignpost, the private sector Covid testing company in which, as many noble Lords will be aware, I own a stake. To be clear, Cignpost did not bid for any government PPE contracts and has only private sector clients. None the less, upon taking up the role as an unpaid Minister of Health, I resigned my directorships, made an undertaking to sell my stake, and in conjunction with the Permanent Secretary, ensured that I was not engaged in any areas where there could be perceived to be a conflict—I just wanted to make that clear.

Turning to the question, I was giving the most up-to-date figures. The £1 billion reflects the money that we have continued to recover. Right now, the only amount that has been written off is the £600-odd million that I have mentioned, and we are continuing to pursue the other amounts. When we close the accounts, we will have an update on where that will go. On the VIP lane, I think we accept that, given our time again, we would conduct that in a different way. I will check but I do not recognise those figures as to the level of faults.

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

Lord Harris of Haringey Excerpts

Monday 9th January 2023 Grand Committee

[Lord Harris of Haringey (Lab)]

My Lords, the noble Lord, Lord Hunt, has effectively declared my interest for me. However, just for the record, I declare that I am chair of the General Dental Council and have been for the last 15 months or so. I am grateful to the Minister for introducing and bringing forward this order. I think we will all benefit from the fact that he has some familial insight into the issues that we are looking at here and in other matters.

I hope that the Minister will accept that this order has been quite a long time coming. It was already long awaited when I was appointed 15 months ago, and the discussion has been going on since at least 2017. This particular order has been introduced twice in the past few months, before the present order; it had to be withdrawn and introduced again, for various technical reasons.

I start by saying clearly that the General Dental Council welcomes this order. However, I want to take this opportunity, in Grand Committee, to make it clear what this order does and does not do. As I think has been said by all noble Lords who have spoken so far, internationally qualified dental professionals make a vital contribution to the UK dental workforce. In recent years, more than one-third of newly registered dentists have qualified overseas, and current workforce pressures would be immeasurably greater without the contribution that they make. However, the current processes for international registration are cumbersome and inefficient. Existing legislation imposes considerable constraints on the GDC’s ability effectively and efficiently to assess the skill and knowledge of internationally qualified dental professionals. For dentists, there is an overseas registration examination with a very rigid structure and, because of the statutory framework, a very limited range of providers. This results in places not always being available for candidates who want to sit the exam.

Quite properly, nothing in this order reduces the high standards required of international candidates seeking to join the UK register. I am sure that the Minister will want to reaffirm that that remains the Government’s priority. Certainly, public protection is, and remains, central to the purpose of the General Dental Council. The standard applied to international candidates is, and should be, equivalent to that applied to people who register based on UK qualifications. Nobody will want to see those standards compromised, least of all the GDC, and the changes made by this order protect those standards but will enable modernised and more flexible approaches for assessing whether candidates have met them.

The order brings in some immediate changes, 21 days after it has been made—so we are probably talking about March this year. From that point, a number of changes will happen immediately. At the moment, the overseas registration examination is in two parts: the first is effectively a written process, and the second a practical test of skills. It is a requirement of the existing legislation that the second part must be concluded within five years of the first part. During the Covid pandemic, part 2 exams had to be suspended and, through no fault of their own, some candidates missed the opportunity to take part 2 because the five-year time limit had expired and therefore lost the opportunity to be registered, because you cannot simply start again. Those affected will now have restored to them the opportunity to sit the second part of the ORE. That is welcome, and it addresses an injustice for those affected as a consequence of the pandemic.

The second immediate change, which my noble friend Lord Hunt of Kings Heath has referred to, is that new applications to the dental care professional register must be based on the primary qualification appropriate for the professional title being applied for. That stops a loophole whereby applicants who are qualified only as dentists have been seeking to register as a DCP. The Committee needs to know that there has been a flood of such applications in the last year: some 1,075 international candidates for registration as DCPs have been approved, which is more than the total number currently on the DCP register from any source. That enables them to practise in this country without going through the more appropriate ORE process for registration as a dentist. There is also now a considerable backlog of applications all seeking to make use of the loophole before it is closed to new applicants 21 days after the order is made. This change is important and overdue. The lack of clarity about what individuals are qualified to carry out in terms of their professional duties is not helpful, and therefore the loophole needs to be closed. The delays and the flood of applications to try to avoid the deadline are causing considerable operational issues for the GDC in managing all overseas registration, and indeed registrations of UK-qualified dentists.

At the same time, the order is going to give the GDC some new powers, although they will take some time to have practical effect. The requirement for assessments of international dentist applications to be conducted by a dental authority—effectively, a dental school—will be removed. Over time, that will give the GDC much greater flexibility in procuring providers and potentially in designing new assessment models. For example, it might be possible to look at the question of whether the first stage of the overseas registration examination has to be taken in this country or whether it could be taken overseas. That flexibility will be sensible, given the current problems in finding suitable providers. However, it is important to stress that this will not have an immediate effect while current contracts remain in place.

The GDC will also gain the power to make detailed rules about how applicants should be assessed. There will be a requirement to consult on these rules and, critically, the current requirement for Privy Council approval will be removed. The practical effect is that the rules can be more flexible and responsive to changing environments, not the least of which is that the fee can reflect the cost, which at the moment is not necessarily the case until it has received Privy Council approval.

The point is that the order is a vital enabler of reform but does not in itself deliver it. Removing the overly prescriptive constraints is a vital first step towards creating a more effective system but it does not and cannot provide an immediate increase in the dental workforce. The rule-making powers in the order do not come fully into effect for 12 months, and even then it will take time to develop new approaches, consult on new draft rules and procure the supply of the necessary services. Alongside that we have the continuing uncertainty about the different provisions that currently apply to people who can currently benefit from the continuing recognition of EU qualifications. If the Government choose to close that route as a result of the review that they are required to undertake this year, significant additional capacity will be required in the GDC’s assessment processes. Any indication today from the Minister as to whether the existing arrangements for applicants from the EEA will continue would be most welcome.

The order provides provisions for the GDC to explore alternative processes for the recognition of international qualifications. Incidentally, it should not be confused with the powers included in the Professional Qualifications Act that allow for the mutual recognition of qualifications through international agreements: they are outside the scope of this order.

Enabling the recognition of international qualifications is not as straightforward as it might at first appear—and there is certainly no quick solution. New processes for the quality assurance of education and training to secure public protection will be needed, alongside new fee structures. This type of recognition may need to be specific to an institution and qualification. It is not, therefore, a quick solution to workforce challenges. The approach taken would have to be fair to those who undertake the UK qualifications, and indeed to the institutions providing them. Also, any route to recognition would need to be applicable globally and take into account the very different standards and approaches to qualifications around the world.

The key point is that none of these changes will solve the wider problems of access to NHS dentistry. The role of the GDC is to register dentists and dental care professionals who are fit to practise in the UK. But there is a separate process before they can work in the NHS. They still need to go through the performers list validation by experience process to practise in the NHS for each UK nation in which they want to practise. So streamlining the ORE process does not in itself deliver more NHS dentistry. I appreciate that the Minister did not assert that that would be the case, but I have heard that view expressed in various quarters, perhaps by former Ministers, which makes it necessary to reinforce the point.

More significantly, if the NHS dental contract fails sufficiently to incentivise UK-qualified dentists to provide NHS dental services, it is not immediately obvious that overseas-qualified individuals faced with the same set of incentives will choose differently from their UK-qualified counterparts. The BDA in a recent briefing warned that

“NHS dentistry is facing existential threat”,

that even before the pandemic

“only enough dentistry was commissioned for half the population in England”

and that the proposed package of changes to the NHS contract announced by the Government in November was “modest” and “marginal” and would

“do little to arrest the exodus of dentists from the service, or address the crisis in patient access.”

Those were the BDA’s words, but I hope that the Minister will be able to give us some assurance on the nature of the discussions that will take place on the future of NHS dentistry and the NHS contract.

To conclude, these changes in the international registrations order are welcome, but they will not address the fundamental issues.

[Lord Patel (CB)]

My Lords, I will be very brief, because many of the points I might have made were more eloquently made by the noble Lord who just spoke.

The only thing I will say is that, from my experience when I chaired the previous assessor of postgraduate medical training, the Specialist Training Authority, which was established following the EU rules, the same problems occur in recognising equivalence of training. It is easier to recognise a qualification, but when you recognise equivalence of training, it has to take into account, as already elucidated, not just the knowledge but the experience and skills that practitioners can have.

It is even more difficult when you try to certify somebody or accredit somebody with a qualification that is highly specialised—including in dentistry. For instance, they might not be a general dentist but you might want to recruit them because they have specific, high-quality training in a very specialised area. Assessing their equivalence is then made that much more difficult. So the points are well made about an order that I welcome for its simplicity—but it does have drawbacks that need to be addressed, and one way to do that would be to give the General Dental Council more authority to implement its own processes to assess qualifications, experience and training.

I turn now to the nursing and midwifery side, which is a slightly different issue. We should distinguish between qualifications and certifications. While we train nurses as graduate nurses—and that applies to midwives too—not all countries have graduate programmes in nursing and midwifery. They are trained and certified to be fully trained midwives, and having the Nursing and Midwifery Council to assess qualifications, experience and training makes it that much more difficult.