Thyroid Patients: Liothyronine

Lord Kamall Excerpts

Wednesday 6th July 2022 Lords Chamber

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

My Lords, I am still here. While levothyroxine is the first-line treatment for hypothyroidism, guidance published by NHS England is already clear that prescribing liothyronine is clinically appropriate for individual patients who may not respond to levothyroxine alone. NHS England is currently reviewing its guidance. As part of the engagement exercise, patient groups and other key stakeholders have been contacted to provide feedback and will be involved in this refresh.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am relieved that the noble Lord is still here to answer this Question. I am grateful for what he said, but he will know that, for a certain group of patients, T3 is highly effective and much more effective than the normal medication that is given. There was a huge price hike a few years ago, and as a result the NHS restricted access; the price has come down, but, unfortunately, access is still restricted. In some parts of the country, patients cannot get prescribed it. Will the noble Lord, rather than relying on advisers, intervene and tell the NHS to stop this postcode lottery?

[Lord Kamall (Con)]

NHS England is currently consulting on this revision, for much the same reasons that the noble Lord acknowledges. At the moment, liothyronine is a second-line treatment when the other one cannot be used or is not appropriate. At a local level, doctors should be advised that they are able to prescribe it. Clearly, that is not getting through. When we went to NHS England with this, it recognised this and said that there will be a consultation.

[Lord Borwick (Con)]

My Lords, I declare an interest as a thyroid patient and as patron of several thyroid charities. As my noble friend the Minister is aware, there are many patients suffering a misinterpretation of “routinely” in the advice that

“T3 should not be routinely prescribed”.

“Routinely” could mean either “regularly” or “without thought”. Can my noble friend make it clear that the meaning of “routinely” in this case is “without thought”, rather than “regularly”, as all thyroid medication must be prescribed regularly? If the Minister could make this clear from the Dispatch Box, I believe that the suffering of a lot of patients—notably, Christine Potts, who has written to me and to the Minister—could then be reduced.

[Lord Kamall (Con)]

I thank my noble friend for sending me the question in advance, since it was quite complicated—I sent it to the advisers, and when it came back, I had to ask for further explanation. So here is the advice that I have been given, and I hope that noble Lords will bear with me. The term “routinely” can be defined as “regularly”, as part of the usual way of doing things, rather than for any clinically accepted reason. It is actually regularly because patients should not be given liothyronine as the first-line treatment; the exception to that is when patients have tried the first-line treatment but still have symptoms. In that case, liothyronine is tried. I am assured that, although this may be confusing, the language is known to commissioners, whom the guidance is aimed at. However, they appreciate that others outside the commissioning process may not understand it as clearly.

[The Lord Speaker (Lord McFall of Alcluith)]

The noble Baroness, Lady Brinton, will make a virtual contribution.

[Baroness Brinton (LD) [V]]

My Lords, what assessment has been made of the T3 Prescribing Survey Report, which was published on 13 May, and of the reported failure by clinical commissioning groups to follow NHS England’s national guidance, Prescribing of Liothyronine, published in 2019, which shows that 58% of CCGs are still not complying with the national guidelines? Can the Minister intervene? This seems to be a ridiculous situation.

[Lord Kamall (Con)]

I have had prior notice from other noble Lords about this issue and have organised meetings with my officials in the past on this—I am always happy to do so. Given the concerns about the lack of commissioning for people who have tried the first-line treatment and now want the second-line treatment, NHS England intends to revise its guidelines. It is sorry about the process, but it must consult before it can change those guidelines.

[Baroness Masham of Ilton (CB)]

My Lords, is this not a case of discrimination against those patients who need the drug?

[Lord Kamall (Con)]

The current advice is for them to try the first-line treatment and only if that does not work should they go for the second-line treatment which noble Lords are asking for. In some cases, there may be patients in the other direction, who could go on to the first-line treatment. NHS England clearly understands the problem and the concerns that many noble Lords have raised, and it is consulting on the guidelines.

[Baroness Warsi (Con)]

My Lords, this question does not relate to thyroid drugs, but perhaps the Minister can answer it. If not, I would be obliged if he wrote to me. It relates to HRT drugs. My noble friend will be aware of the ongoing issue relating to supply of HRT medication, both oestrogen gel and patches. The now-departed Secretary of State for Health was due to appoint a menopause tsar. Can my noble friend update the House on the current situation regarding supply of HRT and the appointment of a tsar?

[Lord Kamall (Con)]

I am afraid that I am not able to fully answer my noble friend’s question. However, I know that my right honourable friend the former Secretary of State for Health did organise a round table with some of the relevant charities to discuss this and to discuss where they can source elsewhere, outside of the UK, and whether they could build up UK capacity. My honourable friend Maria Caulfield, the Minister, has also met with a number of organisations on this, and they are determined to get as much as they can. One issue is the stock for the future as opposed to for now, and feeding that through, but I know that the department is on to this.

[Baroness Wheeler (Lab)]

My Lords, the evidence clearly shows that many patients with hypothyroidism would benefit hugely from the declassification of T3 as a high-cost drug back to being a drug that is routinely prescribed in primary care. Can the Minister explain exactly what the Government will do to ensure that the actual NICE guidelines that enable T3 to be prescribed by clinicians according to their judgment reflect this position, are implemented consistently across new NHS structures and stop the current postcode lottery? Would this not be better than repeating the record of the majority of CCGs who ignore the guidelines?

[Lord Kamall (Con)]

The noble Baroness raises a really important point about some of the blockages to patients getting T3. It is both the first and second-line advice from NHS England but also the NICE advice too. NICE always reminds us that it is independent, and that Ministers should not intervene, but we can call for meetings. NICE also recognises that a price change does change the equation. It has told me that it is open to new evidence with people able to consult and contact it about this.

Bread and Flour Regulations: Folic Acid

Lord Kamall Excerpts

Wednesday 6th July 2022 Lords Chamber

[Lord Rooker]

To ask Her Majesty’s Government, further to the answer by Lord Kamall on 6 April (HL Deb col 2076), what progress they have made towards amending the Bread and Flour Regulations to include folic acid fortification.

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

I am grateful to the noble Lord for continuing to promote this important policy. I hope that, following our meeting in May, the noble Lord is sure that the Government share his commitment to getting folic acid fortification done as part of the Bread and Flour Regulations review. The review continues to progress, we are aiming to launch a consultation shortly and I am able to share an indicative timeline for the process.

[Lord Rooker (Lab)]

I am grateful to the Minister for his Answer and confirmation, but just in case there is any backsliding in his department, may I suggest that he asks them a question? Can anybody name any one of the 85 countries that have made fortified folic acid mandatory, some for over 20 years, that has pulled out; and can the Minister name any one of the 85 that has found a bad side-effect? The answer to both questions is no. Then, he can go and face the 18 women last week, this week, next week and the week after who have terminations after the 20-week scan. The department is sitting on a cure to stop 80% of that distress among our fellow citizens. We are going at a glacial pace— I accept it is in the right direction, but it is glacial.

[Lord Kamall (Con)]

I hope the noble Lord appreciates that there is debate here. He has written to me a number of times about Professor Wald’s paper, which has been put before the advisers in the department. I think what we are seeing is scientific contestation: some people say that the science is settled, but others say that you have to be very aware of the unintended consequences. The NHS website advises people with certain conditions not to take folic acid, the worry being that, for people who do have levels of folic acid, we may end up solving one problem and unintentionally creating another.

[Lord Patel (CB)]

My Lords, we have now discussed the scientific validity several times. The Minister arranged a meeting, and I thought we had resolved this issue. Which scientific evidence is confusing the departmental advisers?

--- Later in debate ---

[Lord Kamall (Con)]

The advice still does not accept Professor Wald’s paper. But we did say in the meeting, if the noble Lord remembers, that we should not let the scientific debate be the enemy of progress. We are progressing, and I am able to share an indicative time- frame. We can debate at appropriate levels after that, but we are progressing where there is consensus.

[Lord Cunningham of Felling (Lab)]

My Lords, why does the Minister refuse to implement the regulations when there is abundant evidence internationally in support of this? Even worse, what does he have to say to those 18 women each week who lose a baby because of the Government’s failure to act?

[Lord Kamall (Con)]

The noble Lord has a couple of questions there, and I will try to answer them as quickly as possible. We are hoping to launch a consultation in August/early September, with a close date 12 weeks after that. There should be a government response on the final position in Q1 2023. After that we have to notify the World Trade Organization and the European Commission, because of the Northern Ireland aspect of this issue. After that, we have a notification period of between two and six months. Assuming that that is all cleared as quickly as possible, we will be ready to lay the provision by Q4 2023. It is glacial, but I assure the noble Lord that we are doing this as quickly as we can.

[Lord Addington (LD)]

My Lords, will the Government give us an assurance that they have identified all the checks and balances? That might be a good start. Also, exactly how long did it take some of the other nations that have already done this process to get through it?

[Lord Kamall (Con)]

The Government are clear that we are doing this, but we also have to be aware of the debate regarding high levels of folic acid. We are progressing in areas where the consensus is that there are no unintended consequences or damage. However, the NHS website plainly says that you should not take folic acid if you have had an allergic reaction to it; if you have certain forms of cancer, unless you have folic deficiency anaemia; if you have a type of kidney dialysis called haemodialysis; or if you have a stent in your heart. Let us make sure that this is based on evidence. We have to make sure that we address the worry of unintended consequences; otherwise, what do we tell the relatives of those who have died because of high levels of folic acid?

[Baroness Hayman (CB)]

Does the Minister accept that that sort of advice is given regarding life-saving treatments across the board? In more than a quarter of a century, I have heard Ministers at that Dispatch Box prevaricate and obfuscate on this issue, while the rest of the world has moved on and given us scientific evidence, in 85 countries, that this works—that it saves lives and saves distress. There is scientific evidence, and evidence in practice as well. The Minister has the opportunity not to be one of those prevaricating and obfuscating Ministers; I hope that he will take it.

--- Later in debate ---

[Lord Kamall (Con)]

I hope that the noble Baroness is not mis-stating the fact that we are looking to go through proper processes as our trying to kick this down the road.

[Noble Lords]

Oh!

[Lord Kamall (Con)]

I have been advised on this issue, and I have asked if this could be done quicker. Let us put it this way: I anticipated the reaction that I might well get in this Chamber to some of these answers. Indeed, I had to go back to the department on some of the answers and ask for clarification. The point is that there has to be a consultation. Think back to where there has been improper consultation, or where certain evidence has been ignored—the dash to diesel, for example. That consultation identified that while diesel might have lower levels of CO₂, it has higher levels of other things that damage air quality. But that advice from the consultation was ignored. They pushed ahead, and the situation end up worse as an unintended consequence. We have to be careful on this one.

[Lord Dodds of Duncairn (DUP)]

My Lords, the Government first announced that they were going out to consultation on this issue in October 2018. That was very welcome after many years of delay. Given the number of countries that have implemented this very sensible policy, what on earth are the scientific arguments for not proceeding? Surely, all these other countries have tested this in real terms, in actual practice. Can the Minister give us a target date for when all the consultations will have finished and the regulations will come into force?

[Lord Kamall (Con)]

Perhaps I have not made it clear enough that we are proceeding with this; there is no stopping the process or review. We are clear that the scientific debate should not hold up progress, so we want to launch the consultation in August/early September. The closing date will be 12 weeks after that, and we should have a government response on the final position in Q1 2023. We would then notify the WTO and European Commission, and once that is all cleared, it should result in legislation being ready to be laid in Q4 2023, and the transition period for the industry would be discussed after that. When I spoke to the noble Lord, Lord Rooker—I hope he would acknowledge this—he believed that I was one of the few Ministers who is very intent on progressing this.

[Baroness Merron (Lab)]

My Lords, as the noble Lord, Lord Patel, has said, the scientific evidence is readily available and evidenced across the world. Can the Minister tell us what, on this new timeline, he thinks the new consultation and process might reveal that we have not seen so far?

[Lord Kamall (Con)]

The reason we have a consultation is so that we are aware of unforeseen circumstances and that, hopefully, we deal with unintended consequences before they occur. It is all very well saying that the science is settled; we have reached a level of consensus where both sides can agree, and that is what we are progressing from. Once it is implemented, we can start reviewing whether it should be a higher level and whether there are unintended consequences. The history of contestation in science goes back a long way; think of the heliocentrism versus geocentrism debate. People thought that the universe revolved around the earth, but Aristarchus of Samos, al-Battani, Islamic philosophers and others challenged that, and Copernicus proved that heliocentrism was right.

[Lord Cormack (Con)]

My Lords, will it take as long for my noble friend to come to this conclusion? If there were a Nobel prize for prevarication, he would win it.

[Lord Kamall (Con)]

I am not sure that I should thank my noble friend for that question. I really do not mind being heckled, as long as I am not being asked to resign, frankly.

[Noble Lords]

Oh!

[Lord Kamall (Con)]

If I let your Lordships laugh a bit longer, maybe I will run out of time. We are absolutely clear that we will do this; I am sorry that we have to go through this process, but the advice I have been given is that we have to go through the proper consultation and notification process. I apologise if that annoys noble Lords.

[Baroness Symons of Vernham Dean (Lab)]

My Lords, the noble Lord will have followed the argument of my noble friend Lord Rooker for a very long time. Actually, he is one of the very few Ministers that I hope will not resign, because he is always honest and clear with this House and has a level of respect which Ministers in another place perhaps do not have. But I ask him quite sincerely: does he really want the risk of another 500 or 600 babies who are much wanted being lost, on the timetable he has outlined to the House, because that is what will happen?

[Lord Kamall (Con)]

I first express my relief that the noble Baroness does not want me to resign—but, as others say, give it time.

[Noble Lords]

Oh!

[Lord Kamall (Con)]

You always have to be careful what you say at the Dispatch Box. I am afraid that I have to follow a process; I can take it back to the policy team, but they advise that this is the process we have to go through. We have to notify the WTO and others.

Paramedic Services

Lord Kamall Excerpts

Monday 4th July 2022 Lords Chamber

[Lord Young of Norwood Green]

To ask Her Majesty’s Government what steps they are taking to prevent avoidable deaths caused by delays to the arrival of paramedic services.

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

NHS Improvement has allocated £150 million of additional funding to ambulance services to help address pressures, alongside reducing ambulance handover delays. Even though the pandemic placed significant pressure on response times, there have been improvements in all response time categories in both April and May, with average response times to category 2 emergency calls—such as strokes and heart attacks—reduced by about 11 minutes and 24 seconds in May alone. Work continues with the service to restore performance.

[Lord Young of Norwood Green (Lab)]

My Lords, it is difficult to thank the Minister for the Answer because it is a totally unsatisfactory one. I have been raising this question for about the last six months. The reality is that, as the noble Baroness, Lady Uddin, told me when her son had a stroke and 999 was called, it took nearly six hours. He suffered serious consequences as a result of that. People are dying as we sit in this Chamber, literally thousands of them. Why? Because paramedics are waiting with trolleys in hospitals for a bed. There is a simple solution to this problem, which I have been suggesting to the Minister. I have also given him a place—Wolverhampton—where they have solved this problem. Yet, still we do not seem to treat this as a matter of urgency. It is a national disgrace and I want an assurance from the Minister that real action is to be taken—and that does not mean an 11-minute improvement.

[Lord Kamall (Con)]

I begin by thanking the noble Lord for his engagement with me and the department on this issue. When the noble Lord has sent me details or suggestions, I have passed them to the relevant officials within the department. I hope I can assure that noble Lord that I have done that. As the noble Lord will know, within departments we have particular portfolios and I have to hand it on to the person responsible. In terms of the recovery plan, the NHS has published a 10-point action plan for urgent and emergency care. I will not go through the whole action plan, but it includes dealing with paramedics, recruitment and retention, and more space in A&E departments. At the same time, can requests be handled by telephone by clinicians and patients diverted to a more appropriate resource? All these have been looked at. I understand that the noble Lord thinks it is unsatisfactory, but we have been hit by the pandemic, we are trying to recover and there is a plan.

[Baroness Blackwood of North Oxford (Con)]

My Lords, the noble Lord, Lord Young, is right that handover times have a particular impact on ambulance services. I was pleased to hear the Minister mention recruitment and retention in A&E departments. This is a long-standing problem in emergency services. The Royal College of Emergency Medicine states that emergency medicine has a high attrition rate. I know that a number of steps have been set out. Can the Minister state what success they are having and, if they are not succeeding yet, what further steps the Government plan to set out? We need a change in direction as soon as possible.

[Lord Kamall (Con)]

I thank my noble friend for the question and also for the point that this happens at number of different points in the system. Clearly, there are recruitment campaigns for doctors and nurses. In addition, the number of ambulance and support staff has increased by almost 40% since 2010. Call handler numbers have also increased since the start of May 2022; we have 400 more. In addition, there are pledges to increase the training of paramedic graduates nationally by 3,000 per annum. All these will take time to get into the system, which is still recovering from the pandemic.

[The Lord Speaker (Lord McFall of Alcluith)]

My Lords, we have a virtual contribution.

[Baroness Brinton (LD) [V]]

My Lords, when Sandra Francis of Oswestry had a cardiac arrest a few months ago, her son had to do 35 minutes of CPR waiting for an ambulance delayed in handovers at A&E. Sadly, she died. Her son said:

“An ambulance should be a way of getting someone to hospital. It shouldn’t be a waiting room sat at the hospital.”


He is right. Ambulance delays are the very visible part of the A&E crisis and the wider shortage of hospital beds, doctors and other healthcare professionals. Again, I ask the Minister: what are the Government doing to remedy this much wider emergency that is causing preventable deaths right now?

[Lord Kamall (Con)]

The noble Baroness will be aware that there are a number of things going on with the 10-point plan. Maybe I will go through some of the points now. We are supporting 999 and 111 services, making sure that the appropriate person answers the call; supporting primary care and community health services to manage those services; making more use of urgent treatment centres; and providing more support for children and young people. Sometimes people ring 999 but do not need emergency treatment and they can be redirected to another clinician, who can speak to them and that takes pressure off. We are recruiting more staff and looking at more prevention and looking at different rules which prevent the appropriate workflow through the system.

[Lord Winston (Lab)]

My Lords, some months ago, as my wife lay dying in my arms, I phoned the 999 service. The man answering the call asked me a litany of questions and asked me to count her number of heartbeats per minute. That waste of time is critical; with a cardiac arrest you have only a few seconds. I had to interrupt the cardiac massage that I was giving my wife until the emergency services arrived, but of course they had not been called yet. When eventually the man backed down, it was obvious that he had not been trained to ask the right questions. Can the Minister assure the House that there is proper training for people who answer these calls at these critical times, when they are dealing with someone who may recognise that their close relative is dying, and that the latter can hear what they are saying on the telephone? It is highly dangerous and that makes it very difficult. The last thing we hear as we die is usually the voice of someone who is with us.

[Lord Kamall (Con)]

I thank the noble Lord for sharing that very personal story. Clearly, there are too many incidents of this kind. One of the issues that we have to be very careful about as we look to recruit more numbers is to look at the system and at how to divert the less urgent calls. Probably in that case the person was trained to ask particular questions to ascertain how serious or urgent it was but, clearly, that was inappropriate. I will take that case back to the department and see whether I can get some answers.

[The Lord Bishop of Manchester]

My Lords, our prime objective must be to eliminate all these unacceptable delays as quickly as possible. Can the Minister confirm what work is being done in the interim to ensure that effective pastoral care is available for those who are currently waiting for long periods in ambulances, particularly for the many for whom last rites and other rituals that take place at the point of death form an important part of their faith?

[Lord Kamall (Con)]

The right reverend Prelate raises an important issue for those of faith who want to share their last moments of life with someone. I am afraid that I do not have a detailed answer, but I will go back to the department and write to the right reverend Prelate.

[Baroness Merron (Lab)]

My Lords, as other noble Lords have said, ambulance delays are a symptom of pressures elsewhere in the health and care system. At the end of April, 62% of over 20,000 patients in England who were medically fit to be discharged remained in hospital, largely due to a lack of appropriate social care provision. Can the Minister say how and when there will be a fully costed workforce plan to ensure that the relevant staff are in place to urgently tackle this bottleneck?

--- Later in debate ---

[Lord Kamall (Con)]

The noble Baroness will know from the debates that we had during the passage of the Health and Care Bill that there is a 15-year plan; Health Education England has been tasked with that. In addition, significant amounts of things are being done at the local trust level, so it is not just a sort of five-year, top-down Soviet-type plan but is looking at recruitment at a local level. There is also a national discharge task force that works with national and local government and the NHS to identify long-term sustainable changes which could reduce delayed discharges and ensure that patients are in hospital only for as long as they need to be.

[Lord Tugendhat (Con)]

My Lords, what role does the Minister think the police might have to play in this? Last Wednesday I was knocked down in Great George Street by a bicycle and rendered unconscious. Although a paramedic arrived from St Thomas’ by bicycle quite quickly, there was no ambulance. I was very grateful to the police for taking me into St Thomas’ and depositing me at the A&E. That was very helpful, and I wonder whether the Minister thinks that might happen more often.

[Lord Kamall (Con)]

I thank my noble friend for sharing that experience, and it is good to see that he has recovered and is able to ask the question. One interesting thing that is being looked at as part of the overall review—again, we have to be very careful about unintended consequences—is how many of these cases can be treated at the scene without requiring the patient to be taken to hospital. That will need careful thought as it is a difficult trade-off. In this case, clearly, they were looking at the possibility of someone else taking my noble friend to hospital, and he was fortunate that there was a police officer nearby who was able to do that. However, with any of these interventions we have to be careful and make sure that we are fully aware of unintended consequences that could make things worse.

Mental Health: Advertising and Body Image

Lord Kamall Excerpts

Thursday 30th June 2022 Lords Chamber

[The Lord Bishop of Gloucester]

To ask Her Majesty’s Government what assessment they have made of any link between advertising, body image, and mental health.

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

The Government acknowledge the possible link between advertising, body image and mental health, including the potential harms that such a link may cause. The Government intend to use the online advertising programme consultation, which closed on 8 June, to develop the evidence base on this issue. Our priority is to ensure that any intervention is evidence-based and makes a real and positive difference. The Government will set out the exact approach having assessed the evidence.

[The Lord Bishop of Gloucester]

My Lords, with my #liedentity campaign, I have spoken to many young people about their worth not coming from how they look. In the other place, the Prime Minister assured the honourable Member for Bosworth, Dr Luke Evans, that he would look at a body image initiative as part of the mental health plan. Given that Norway has recently introduced a retouched images law, what assessment have the Government made of the potential merits of labelling digitally altered body images used for commercial purposes?

[Lord Kamall (Con)]

I pay tribute to the right reverend Prelate and the campaign in which she has been involved. It is an important issue, and we are still learning a lot. As she rightly said, Norway is about to introduce such a law; France and Israel have introduced it in the past. Sadly, the evidence coming from those studies as to the effectiveness of the measures is limited. There is also a debate about whether those images should be stopped in the first place, rather than allowing altered images and then putting a warning on them. We need to see more evidence about the most effective way.

[The Lord Speaker (Lord McFall of Alcluith)]

We have a remote contribution from the noble Baroness, Lady Brinton.

[Baroness Brinton (LD) [V]]

My Lords, the Children’s Society’s Good Childhood Report 2021 shows that one in seven girls and one in eight boys is particularly unhappy about their appearance. Young people who are not happy with their lives at 14 are more likely than others to have symptoms of mental health issues by 17, including instances of self-harm and suicide attempts. Despite the Government’s promises of future funding for mental health support for schools and CAMHS, it is clear that young people are not getting that initial front-line support that they need now. How soon will there be mental health counsellors in every secondary school?

[Lord Kamall (Con)]

When we look at mental health in children and body image, we see that it varies not only among age groups but within age groups. We have identified concerns about poor body image as a risk factor that leads to mental health conditions, but it is not necessarily a mental health condition in itself. We have to look at how much of this was already present in the playground before the age of social media, with people being called nicknames for their appearance. However, that has been amplified by social media. We are working with social media companies and others to find the most effective solution.

[Baroness Bull (CB)]

My Lords, despite the fact that advertising prescription-only medicines like botulinum toxin to the general public is already illegal, Botox is still widely advertised online by providers of cosmetic procedures. Given the risks of amateur and poor procedures to physical and mental health, what steps will the Government take to improve the enforcement of existing rules so that the online environment is free of these illegal adverts?

[Lord Kamall (Con)]

A range of issues were looked at in the online advertising programme, including advertising on social media, where people get messages from in the first place, and what the most effective method is. What do we ban? What do we give advice on? What do we give warnings to? It is an incredibly complicated issue, but we are looking through lots of evidence that came in as a result of the consultation.

[Lord Robathan (Con)]

My Lords, what assessment have Her Majesty’s Government made of the link between body image, obesity, childhood obesity, diabetes, cancer and early death?

[Lord Kamall (Con)]

My noble friend has asked me a very concise question, which will require a less concise answer. Clearly, there is a link between obesity and type 2 diabetes, for example, but one of the difficult things in this area, as with much in healthcare, is getting the right balance. The more emphasis we put on tackling obesity, the more unintended consequences there will be for people with eating disorders. There is now calorie labelling in restaurants and other out-of-home places, but some charities working with people with eating disorders are concerned that this may have a negative impact on them. It is always a difficult balance, but we must try to achieve it.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the Minister and other noble Lords have raised the issue of social media. What assessment has he made—or is he aware of—of the influence of social influencers, particularly in cases where they are supported by commercial deals that pay them in part to promote certain kinds of advertising?

[Lord Kamall (Con)]

The noble Baroness makes a really important point about a contributing factor to people having poor body image. We know that there are influencers who promote certain products, and that they often alter their own image so that it is almost an idealistic image—whatever that means. Young people then feel inadequate when looking at those images. We also must recognise that this issue affects not just young people but a range of people—even older people. For them, it might be as a gentle a thing as a comb-over, but if that makes them feel better, great. We must look at this issue in its entirety, and it has been looked at as part of the online advertising programme.

[Baroness Verma (Con)]

My Lords, what will the Government do to ban or reduce the use of lightening creams? Among the south Asian and black community, we have an issue around the push for lightening creams, which affects the well-being of a lot of young people who desperately want to fit in.

[Lord Kamall (Con)]

If I have been accurately briefed, I will begin by wishing my noble friend a very happy birthday.

This is a really important issue concerning ethnic minorities and people of different colours. First, young people want to see people who look like them on TV and in the media as role models, to show that they are part of everyday society. Also—I am sure my noble friend will be aware of this—sadly, there is the issue of colourism, whereby sometimes there is a preference for people of a lighter colour within certain ethnic minority groups. People who are darker are quite often discriminated against; they are not necessarily abused, but there is this preference for lighter colours. This is all being looked at. What my noble friend says shows what an incredibly complicated area this is. It is really important that we look at all these issues: is it size, is it appearance, is it colour?

[Baroness Merron (Lab)]

Advanced early intervention is crucial. Treatment for mental health conditions such as eating disorders has consistently unacceptable waiting times. At the end of last year, a record 2,100 children and young people were waiting for treatment, with demand continuing to rise. Can the Minister tell your Lordships’ House when the waiting times will mean timely intervention? What are the Government doing to recruit, retain and train the necessary levels of staff to provide the treatment that is so desperately needed?

[Lord Kamall (Con)]

I hope the noble Baroness will recognise that before the pandemic, we were meeting the waiting times targets for many younger people. Clearly, as with many things in our health and social care service, the pandemic has had a huge impact—not only delaying the treatment of people who should have been treated before the pandemic, but increasing the number seeking help with mental health issues. As I am sure noble Lords will recognise, for young people those two years were a massive proportion of their lives compared to us. Those are lost years for them, and it has led to many mental health issues. As the noble Baroness will know, we have announced the draft mental health Bill. The NHS long-term plan will have an additional £2.3 billion a year for mental health services by 2023-24, and an extra 2 million people will be able to access support. This will all take time, and we will have to work through that.

[Baroness Burt of Solihull (LD)]

Noble Lords have rightly been criticising advertising that promotes unrealistic body images, but the Government themselves are not helping. In April last year, the Women and Equalities Committee published a report on body image. According to it, the Government’s own obesity strategy actually

“contributes to eating disorders, and … mental”

ill-health. The Minister is nodding, so in the interests of brevity I ask him: does he agree with the recommendations of this committee, and what are the Government doing to remedy their approach?

--- Later in debate ---

[Lord Kamall (Con)]

I am sure the noble Baroness will acknowledge that many noble Lords and many people in society want to do something about obesity, through healthy eating, for example. This demonstrates what a complex area this is. With any policy position, we must always be aware of unintended consequences. We must be very careful about the impact on people with eating disorders. Also, do the interventions actually work in the first place, or do they lead to more unintended consequences rather than positive results? One example is calorie labelling on menus, about which, as we know, eating disorder charities have concerns. At the same time, we do not know whether the evidence shows that such measures will help to reduce obesity, and we need to wait for that evidence to come through.

Draft Mental Health Bill

Lord Kamall Excerpts

Tuesday 28th June 2022 Lords Chamber

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

I thank the noble Baronesses for their very detailed questions. I will write if I do not cover all the questions.

We want pre-legislative scrutiny to commence at the earliest opportunity, and I understand that this is being discussed by the usual channels. The hope is to appoint the committee if possible before the summer; we want to do this as soon as possible. Our ambition is that once pre-legislative scrutiny has been completed and understood, we can introduce the Bill in the new year, to allow noble Lords the scrutiny that the Bill deserves. That is the indicative timeframe at the moment. As long as things go smoothly, pre-legislative scrutiny will start as soon as possible and we will then, I hope, be in a position to have a better-informed Bill, the new draft of the Bill having been through pre-legislative scrutiny.

We hope to see a lot of potential amendments to the Bill following pre-legislative scrutiny. Having had a baptism of fire in this House, in coming straight into this position and taking up the Heath and Care Bill, I know that there will be many valid points that will no doubt be taken on board as we debate the mental health Bill. As we saw with the debate on the Health and Care Bill, noble Lords across the House were able to improve it. Even though as government Minister I sadly had to disappoint on some of the amendments, I think we made a better job of it.

I am pleased that the important issue that black people are four times more likely to be detained under the Act, and 10 times more likely to be subject to a community treatment order, was raised. Central to addressing this is the patient and carer race equality framework, which is being rolled out by NHS England and NHS Improvement. We hope that this will support NHS mental healthcare providers to work with their local communities to improve the ways in which patients access and experience treatment.

We have already commenced culturally appropriate advocacy pilots, providing improved culturally appropriate services so that people from different backgrounds and their needs can be understood. One thing I would caution is that it is very easy to group people with the same skin colour as having the same needs. There is incredible diversity—I know this myself, coming from one of the immigrant communities—within these communities and in the pressures that arise from one community to another. Overall, it is important that we address those. We are working with Health Education England to undertake programmes on the diversity of the workforce, and to make sure that patients’ voices are represented.

Both noble Baronesses talked about the principles. We felt that the principles informed every decision we have made in developing the draft mental health Bill. Although it has not been possible to create clear overarching principles in primary legislation as recommended by the independent review, the reforms break down the review’s principles into specific duties that appear in the draft Bill—for example, ensuring that people are detained only when absolutely necessary; ensuring that if people are detained this must be for the purpose of, and have a reasonable prospect of, providing them with therapeutic benefit; introducing new patient safeguards to make it harder to override someone’s refusal of a particular treatment; and the creation of a new clinical checklist which will put greater emphasis on tailoring treatment to the individual patient. We believe that, together, these more specific duties deliver much of the intended impact of the review’s principles, but in a better way.

The overall picture of the sector is a mixture of private and state providers, but for us, it matters that the Care Quality Commission has the role of making sure that all providers are regulated properly and that they meet requirements. All providers in receipt of NHS contracts must meet requirements, including those in the NHS provider licence and the NHS standard contract. Contracts to private providers can be and are terminated when these are not met.

We have consulted on the independent review’s recommendations, and less than half the consultees supported the approach of giving patients the ability to appeal treatment at the MHT, the power sitting with a single judge acting alone. I am sure that this will come up in pre-legislative scrutiny and as we debate the Bill itself.

On the workforce, once again, there has been growth, but we all understand that demand is outstripping supply. We are looking at that as part of the long-term plan and the Health Education England review. I do not have an exact date; every time I ask for one, I am always told that it will be soon. I do not think that means it is being kicked down the road—I just think that there is not a proper date yet, given that all the consultations and responses have to be addressed. Work is ongoing to confirm plans to 2024 for integrated care systems.

We are providing more than £90 million of additional funding in 2022-23—£70 million as part of the NHS long-term plan and £21 million through the community discharge grant—to make sure that we reduce in-patient numbers and ensure that people with learning disabilities and autistic people can live in the community.

I am very aware of the issue of children and young people’s mental health. There are a number of different factors, and it is not easy to narrow them down to one. There could be environmental factors; it could be pressure; it could be that some of them are child carers, who feel large amounts of pressure at too young an age. In 2021-22, we provided an additional £79 million in response to the pandemic to expand children’s mental health services in that financial year, but we are very aware of how much more demand there is for mental health services, particularly for children. For us, two years is a relatively small proportion of our life, but for children it is a massive proportion, and they want to get that time back. That has created huge mental health issues for children, so we are tackling that.

As I said, I will write to the noble Baronesses on all the questions I have not answered.

[Baroness Chisholm of Owlpen (Con)]

My Lords, the noble Baroness, Lady Merron, talked about patients being detained for too long, particularly those who have been sectioned. My right honourable friend Jeremy Hunt MP, down the other end, talked yesterday about how it would be good to put something in the Bill to say that those who had been sectioned had to be re-evaluated fortnightly, or at least monthly. This is a very good idea, because we know that there are problems with people, particularly those in the autistic community, who are detained for far longer than need be. Could my noble friend the Minister make sure that this is brought up in Bill meetings? I hope that it could go in the Bill.

[Lord Kamall (Con)]

I thank my noble friend for the question and for raising this issue. I am aware that my right honourable friend the Secretary of State intends to meet Jeremy Hunt to discuss this in more detail. In my first week, or first fortnight, as Minister, one of the debates I took part in was led by the noble Baroness, Lady Hollins, about detention. That brought home to me at a very early stage in my ministerial career how shocking some of these events are and the way that young people, particularly those who are autistic or have other conditions, are being treated. My right honourable friend the Secretary of State will meet Jeremy Hunt to discuss this, and I hope that it will also be approached in the pre-legislative stage. If not, I am sure that it will be debated in this Chamber.

[Lord Judge (CB)]

My Lords, I admire the enthusiasm for speed that the Minister expressed earlier from the Dispatch Box. Can he say whether that rules out having detailed pre-legislative scrutiny? This Bill should have no political elements to it at all, except possibly the cost, but all the other issues should be capable of sensible evaluation between intelligent people trying to achieve the same objective, which is improvement in our mental health services. Can the Minister’s enthusiasm for speed please not lead us to the problem identified in this House on the Procurement Bill this afternoon, where, after Report, there are 322 government amendments? That is not the way to legislate.

[Lord Kamall (Con)]

The noble and learned Lord makes an important point. I am very much aware of today’s earlier discussion, when I was smiling, perhaps over-smugly, thinking, “At least we’ve got pre-legislative scrutiny.” However, I accept the noble and learned Lord’s point that it has to be proper pre-legislative scrutiny. I hope he will forgive my lack of experience on this. I am not yet aware of the difference between good and thorough pre-legislative scrutiny and brief pre-legislative scrutiny, so I will have to take this back to the department and will write to him and others.

[Lord Davies of Brixton (Lab)]

We thank the Minister for the draft Bill. Although it is on the law of mental health, it has clear financial implications and so a specific commitment to provide the resources to implement the changes in the law would be valued. In addition, however, given the agreement that there is about what will be in the Bill, what steps are the Government taking to get it implemented straightaway? There are so many proposals in Sir Simon Wessely’s report that could be implemented immediately, so I hope the department is pursuing that proactively.

It is important to understand a bit of the context here. We are heading into financially difficult times. We know that there is a close connection between people’s personal financial problems and mental health and that there will be an increasing level of indebtedness, which automatically means greater need for services. Maybe the Minister can reassure us that the resources will be there to carry out what is in the proposals.

[Lord Kamall (Con)]

The noble Lord makes an incredibly important point. We have seen the impact that the pandemic has had on mental health across all age groups. During the Health and Care Bill, the noble Lord and many others raised the issue of parity between mental health and physical health, and I thank him for that. That brought home that the current legislation is out of date, which is why we really need to update it. I also thank noble Lords who have spoken so far for agreeing that this is not a party-political issue at all. We all want to address this issue, and maybe the issue of funding will come up. The Government remain committed to achieving parity between mental and physical health services to reduce inequalities. We are making good progress; investment in NHS mental health services continues to increase each year, from almost £11 billion in 2015-16 to £14.3 billion in 2020-21. We expect all current CCGs—and ICBs once operational —to continue to meet the mental health standard, and we have made a number of amendments. We are investing more than £400 million over the next four years to eradicate mental health dormitories. Clearly, as we go through the Bill, there will be financial implications, which will be considered as we debate it. I cannot give a clear pledge on which measures will be implemented until we have seen the Bill. Clearly, however, we understand that a lot of this is long overdue, so the quicker we can get this done and come to an agreement satisfactory to all sides of the House, the sooner we can get on with implementing it.

[Baroness Tyler of Enfield (LD)]

My Lords, I welcome many of the proposals contained in the draft Bill, particularly those that give people affected by the Bill more say over their treatment and care. However, as others have said, the Bill is currently worryingly silent on workforce issues, and I think we all agree that they will be critical to the successful implementation of any reforms. My specific question to the Minister is: what assurances can he give that children and young people aged 18 and under will benefit from the reforms at least as much as adults and, specifically, will they be able to access the same treatment safeguards as adults?

[Lord Kamall (Con)]

When I was having initial discussions on the various parts of the Bill, children and young people’s mental health clearly came up. The statistics are staggering. Some 420,000 children and young people were treated through NHS-commissioned mental health services in 2021. That is an increase of 95,000 in just a few years. That is still without us being aware of everyone who needs access to the system, or young people and their parents and families being aware of what support is available.

We are continuing to increase investment into mental health services by at least £2.3 billion a year by 2023-24, as set out in the NHS Long Term Plan. There is also the extra money in response to the pandemic, which saw extra demand. We have 287 mental health support teams in place in around 4,700 schools and colleges across the country but, once again, more needs to be done. It is one of those issues where demand outstrips supply.

We now have mental health support teams covering 26% of the country a year earlier than planned, but we hope to increase this progressively over the years so that as many schools as possible are covered. We have delivered 7 million well-being for education recovery programmes. We understand the tensions and workforce issues that will inevitably arise. The Health Education England review and the Government’s strategic review are considering all the changes in healthcare overall; all the technologies and ways of delivering services; and the change from secondary to primary and down to the community. We are working out in the response what workforce we need for each of those changes.

[Baroness Hollins (CB)]

My Lords, the average stay for people with learning disabilities and autistic people detained under the Act is five and a half years and, shockingly, many people are criminalised during their admission, making their discharge even more difficult. Although removing learning disability and autism from the Act is clearly the right thing to do, does the Minister agree that, unless there is some improvement in the care and support provided in the community to avoid those admissions in the first place, this could put people at risk? That is a concern in the wider community at the moment. We should take them out, but how do we look after people better?

[Lord Kamall (Con)]

I start by paying tribute to all the work the noble Baroness has done in this area, and for educating me more on this issue when I was a relatively new Minister. All I can say at this stage is that patients who have a co-occurring mental illness as well as a learning disability or autism may well be detained under the Act, but we want to make sure that there is support in the community. This is one of the big debates we have seen on a number of issues—for example, on social care. How much of social care will be in homes and how much will be in the community? Does technology improve that? Does constant online communications technology, sensors and the ability to speak to somebody online almost immediately change that equation? A lot of that will be discussed as we debate the Bill and by the experts who, we hope, will be on the pre-legislative scrutiny committee.

[Baroness Armstrong of Hill Top (Lab)]

My Lords, I chair the Public Services Committee and we are currently concluding a report on workforce in the public sector. I hope the Minister will be able to read it and think about it over the recess to make sure that he takes account of it. In my work with women with complex needs, particularly those who have been groomed, it is absolutely clear that their sexual exploitation has led to significant trauma. The NHS will never be able to be the first body they interact with, or able to train enough people in the next 10 years to look after the wide range of people who we know now need mental health care. That means the Bill must link to the work of the voluntary sector and how we address trauma in people first approaching a public service, or any service. I am concerned that the Government think they can do it just by training more people, which will take a long time. They need to be working in a pathway that starts at a very different level.

[Lord Kamall (Con)]

I could not agree more with the noble Baroness. One thing we must be well aware of is that, although there are pressures and we are asked for more funding, the Government alone cannot do all this. Sometimes officials, be they from local or national government or from another state organisation, are mistrusted by vulnerable people. Local civil society groups, voluntary organisations and, often, those who have suffered the same problems themselves and then been inspired to set up their own organisation to support others—who can empathise with the situation many of these poor women are in—are sometimes the best first point of contact. As the Government spend more on this, we must make sure that we are not squeezing out the voluntary sector or local civil society, but working in partnership with them.

[Lord Mawson (CB)]

My Lords, my colleagues and I have been involved in this space for many years. I was in conversation with my colleagues just last week. I agree with the noble Baroness, but one of the challenges we face is the financing when organisations try to create this more integrated environment. The money and the streams coming out of the Treasury are endlessly pulling apart the very services that need to be connected. I encourage the Minister and his colleagues to look at some of that. In Bromley-by-Bow we are still dealing with 62 different funding sources from government, with all the attendant bureaucracy that is trying to deal with this problem.

[Lord Kamall (Con)]

The noble Lord makes a very important point from his own experience. I thank him for all his engagement and for educating me on what happens in the community. We must be careful because often, these issues are not simple or binary but are multi-faceted, and we then have different initiatives from the Government, which overlap. There is probably an incredibly complex Venn diagram of who is responsible, where the funding pots are and at what level you get the funding—is it local government, national government or philanthropy networks, for example? I would love to make it easy—but will I be able to?

Also, whenever you have change there are often winners and losers. Often, those who lose out because of change are very concentrated and make their voices heard, while the winners are dispersed and we do not hear them saying, “This is a great change.” Therefore, we must be very careful with any change in funding. However, the noble Lord makes an incredibly important point. We must ensure that we are not squeezing out civil society and pulling people in many directions, and that it is much easier to access finance. The noble Lord, Lord Glasman, made the point that as a Labour Peer, he is incredibly proud of 1945 and the welfare state, but that he worries that in doing such things, sometimes the state squeezes out local community groups and breaks the bonds in local communities. We must ensure that we get the right balance.

[Lord Stevens of Birmingham (CB)]

My Lords, I welcome the draft mental health Bill. Prime Minister Theresa May was right to ask Sir Simon Wessely to develop these proposals, which command wide support across the sector. It was pleasing to hear the Minister commit to the Bill’s passage through Parliament before, and hopefully well before, the next election. However, as a number of noble Lords have pointed out, to will the end is to will the means. The Minister will know that the Royal College of Psychiatrists and others, in the impact assessment for this draft legislation, have shown that to make this work in practice will require more people working in mental health.

To that end, if the Minister does not mind me banging a familiar drum, it is surely paradoxical that UCAS is reporting that only 16% of applicants for undergraduate medicine and dentistry got an offer this year. We are turning bright and brilliant young people away at precisely the time when the NHS, and indeed our mental health services in the future, will need their services. Deans of medical schools report that this year is the hardest in living memory to enter undergraduate medicine. Can the Minister give us a date by which the Government will declare their hand on the needed expansion of undergraduate medicine?

[Lord Kamall (Con)]

I am sure the noble Lord is aware that one of the things we found when looking at the shortage of doctors—even though we have more doctors than ever before—was that some people are likely to stay close to where they were trained. That is why, for example, we have opened the new medical schools, and we are bringing more doctors into the system. Clearly, that will not happen overnight, since training to be a doctor takes a very long time.

We are also looking at what else needs to be done at that level. There are other pathways, such as nurses becoming doctors after a certain amount of time. Clearly, international recruitment plays an important role there. Our aim is to have an additional 27,000 mental health professionals in the NHS workforce by 2023-24. We are investing money to achieve that, but again, it is a question of how long it takes for the money to get through. At the same time, we must ensure that by having this additional workforce in the NHS, we are not squeezing out the voluntary sector but ensuring that we are working in partnership with it.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, I am sure the Minister will agree that if we get to point of having to apply the Mental Health Act to a particular individual, the system has failed because that person is, by definition, in crisis. I entirely accept that this Bill is necessary because the current legislation is no longer fit for purpose—Simon Wessely’s review is a very salutary read in that respect—but it is none the less the case that what we really need is to better equip our preventive services to deal with incipient mental health problems as they emerge, trying to prevent them becoming critical. That has been alluded to, in various ways, during this discussion.

Can the Minister tell the House where the £900 million —I think that is what he said—that is being committed immediately to the improvement of mental health services is to be spent? The real crisis is in the availability of human resource to deliver the service. There simply is not enough of it, as many people in this House, and certainly beyond, know from personal experience.

[Lord Kamall (Con)]

As noble Lords discussed during the Health and Care Bill, prevention is crucial. One thing I became aware of when I became a Minister was, when talking to the NHS and others, how they want to move away from purely curing to prevention. In response to the noble Baroness’s specific question, I commit to write to her on the exact allocation of that, but there is one area that plays an incredibly important role. We know, for example, looking back on the crisis, that when we did not know how long it would last, that created a lot of uncertainty. Uncertainty is very unbalancing for people, and it is a huge factor in them having mental health issues. Clearly, one of the issues that came up during the Bill was the use of civil society organisations, social prescribing, music and art therapy, but also conversations—people being able to talk to someone about the issue they are facing and feeling they are not alone. Clearly, that is something we have looked at, in terms of prevention, but in response to the specific question I commit to write to the noble Baroness.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I am sure that prevention will be part of the new 10-year mental health strategy—or I hope that it will be—and also part of the 10-year suicide strategy. My noble friend asked when we might expect to receive a copy of that strategy, because of the exponential need, which the Minister has recognised, especially in relation to young people. I remind noble Lords of my interests in the register. I urge the Government to produce that strategy as soon as possible.

[Lord Kamall (Con)]

Clearly, there are a number of different facets to mental health and what we are looking at, but suicide is one of those areas. In fact, my right honourable friend the Secretary of State met a very well-known anti-suicide charity, or support group, the other day, to talk about this specific issue. It is a tragedy; we must do all we can and treat it with the same urgency that we would any other major killer. We know about the high percentage of male suicides and what proportion that is of young men’s deaths. We are looking at the drivers linked to suicide, including those that were not necessarily reflected in our previous strategy, such as gambling, domestic abuse and online safety.

We are engaging widely to shape our plan. We have announced a number of commitments for that plan, including a best practice guide, safety plans, et cetera, by early next year. I do not have the exact date yet, but I keep being told it is soon. That is not very helpful, I know, but I will try to get more information for the noble Baroness.

Pharmacy (Responsible Pharmacists, Superintendent Pharmacists etc.) Order 2022

Lord Kamall Excerpts

Tuesday 28th June 2022 Lords Chamber

Moved by

[Lord Kamall]

That the draft Order laid before the House on 28 April be approved.

Relevant document: 1st Report from the Secondary Legislation Scrutiny Committee

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

My Lords, since the outbreak of the coronavirus pandemic, the country has faced its greatest health and economic challenge for decades. Community pharmacies have proven once again that they sit at the centre of our communities and are a vital first port of call for healthcare advice. It is therefore important that we have a strong and flexible governance framework in place to meet the challenges of modern pharmacy and to deliver safe and effective services to patients, for patients.

The purpose of the draft Pharmacy (Responsible Pharmacists, Superintendent Pharmacists etc.) Order 2022 is to define and clarify the core purpose of the responsible pharmacist, who is the person in charge of a particular retail pharmacy premise, and the superintendent pharmacist, who is the person responsible for all retail pharmacies across a retail pharmacy business. The draft order also gives powers to the General Pharmaceutical Council and the Pharmaceutical Society of Northern Ireland to define in professional regulation how the purpose of these roles is fulfilled.

These regulators already have powers to set rules around professional standards. It therefore makes sense that these powers sit with the regulator rather than with the Minister. In doing so, we are putting in place a more flexible regulatory framework and the necessary system governance framework to support maximising the potential of community pharmacy and to make better use of the skill mix of pharmacy teams to deliver more clinical services in the community and support wider NHS capacity. The draft order will apply across the United Kingdom, and I draw your Lordships’ attention to two provisions specific to Northern Ireland, which aim to align the law in Northern Ireland with that in the rest of the UK.

At the request of the Department of Health in Northern Ireland and the Pharmaceutical Society of Northern Ireland, it is proposed to give the Department of Health in Northern Ireland the power to appoint a deputy registrar in respect of duties set out in the Pharmacy (Northern Ireland) Order 1976. This will essentially mean that there is no disruption to maintaining the register of pharmacists and pharmacies in the absence of the registrar, and secondly, it will extend the requirement that a superintendent pharmacist must inform the relevant pharmacy regulator when they stop holding the role in a pharmacy business to include Northern Ireland and the Pharmaceutical Society of Northern Ireland.

I hope that noble Lords will agree that these technical amendments are helpful in aligning pharmacy law in Northern Ireland with that of Great Britain and enhance public safety by ensuring that important functions can be performed in the absence of the registrar.

I also take the opportunity to thank the Secondary Legislation Scrutiny Committee for its welcome scrutiny of this work. I encourage noble Lords to read the committee’s first report, which draws these regulations to the attention of the House. Officials have provided supplementary information to the committee, which I can make available to the House.

In summary, the draft order will clarify and strengthen the organisational governance arrangements of registered pharmacies and make sure that the key roles of the responsible pharmacist and superintendent pharmacist are clear for all pharmacy professionals and owners. It will also ensure that pharmacy practice matters rightly sit with the professional regulators rather than with Ministers, as is the case for other healthcare professionals.

The proposals include safeguards to ensure that any changes the regulators might make are subject to full consultation, in much the same way as is expected from the Government. This will ensure that patients, the public, pharmacy professionals and the pharmacy sector will be able to have their say on what the standards should say, and Parliament will have the opportunity to scrutinise any instrument laid before Parliament by the regulators. I and my colleagues in government look forward to those discussions.

On the amendment in the name of the noble Lord, Lord Hunt, I completely understand the concerns about the pressures on pharmacy teams who are still recovering from the impact of the pandemic. I am sure that noble Lords would like to join me in once again putting on record our thanks for the outstanding work and professionalism of the pharmacy workforce. We recognise that, along with all other staff in the NHS, community pharmacy teams have played an enormous role in the response to the pandemic and that this and other compounding factors are having an impact on the pharmacy workforce.

Employers are concerned about high costs of locums and difficulties in recruitment and retention of staff. For example, some employers are more reliant on locums and therefore more sensitive to increases in locum daily rates. I hope noble Lords will remember that in community pharmacy the employers are often commercial organisations that have a clear role and responsibility in staff recruitment and retention. These issues and the cost of locums cannot really be addressed by the legislation before your Lordships today.

However, that does not mean that the Government and the NHS are being passive on this account. We are monitoring the situation carefully. Analysis undertaken by NHS England shows that any workforce challenges that community pharmacies are facing are limited to geographical areas, and, as with the wider NHS, there are a number of complex and multifactorial issues. NHS England is working closely with employers to provide support and adopt a shared approach, to ensure that the essential NHS services provided by community pharmacy contractors continue to be available to patients.

There remains good access to NHS pharmaceutical services in England overall at the macro level, with 80% of the population within 20 minutes’ walking distance of their nearest pharmacy, and there are two to three times more pharmacies in the most deprived areas. I recognise that in many cases this does not drill down to some of the local difficulties in specific areas which are facing a number of factors. Given that, I beg to move.

Amendment to the Motion

Moved by

--- Later in debate ---

[Baroness Wheeler (Lab)]

My Lords, this debate has been a welcome opportunity to clarify the role of responsible and superintendent pharmacists, as set out in the SI, and to take a closer look at the wider industry, its workforce and, in particular, the support and funding community pharmacies need to enable them to operate effectively and undertake the extended role they need as an integral part of the local primary care team.

I congratulate my noble friend Lord Hunt on his excellent speech and presentation of the strong case for his amendment. All speakers have rightly paid tribute to the role played by community pharmacies during the pandemic, which remained open and continued to offer their full range of services. We all acknowledge the huge contribution they made then and make now to front-line care: the delivery of mass vaccination programmes for both Covid and flu, providing essential preventive programmes, such as blood pressure checks, providing medicine support for patients discharged from hospital, and supporting patients, particularly those with long-term conditions, with their self-care and self-management. All this takes pressure off GPs and ensures better access for patients to healthcare information and advice, and more efficient use of NHS resources. The estimate that the NHS could save £640 million through nationwide treatment of minor ailments by community pharmacists is an example of how their role should be extended.

The new community pharmacy consultation service mentioned by my noble friend Lord Hunt—involving GP surgeries, NHS 111 and pharmacies—for minor illness or medication consultations, and the pilot schemes for NHS Direct cancer referrals to pharmacies for patient scans and checks, are both key developments which we very much welcome.

I also pay tribute to my colleague Peter Dowd MP for his excellent Westminster Hall debate last week, which I commend to your Lordships. It set out a compelling case on the contribution community pharmacists could make with the right support and funding and increased collaboration with GPs, a case which had strong cross-party backing from supporting speakers. However, no part of the extended role we all want to see can be delivered unless the major workforce issues across community pharmacies are acknowledged, and the ongoing discussions with the Pharmaceutical Services Negotiating Committee on the current agreement and future funding acknowledge the scale of the resources needed.

On the SI, we support and welcome the aim of clarifying and strengthening the governance requirements of responsible and superintendent pharmacists. I thank the General Pharmaceutical Council for the reassurances in the note it prepared for this debate on extensive public consultation and engagement with patients, the public and the pharmacy and health sector on the rules and standards to operate under the extended remit the SI gives them.

Like my noble friend and the noble Baroness, Lady Brinton, I await the Minister’s response to the concerns of the Secondary Legislation Scrutiny Committee on the profession’s general distrust of the council on the setting of appropriate standards and concerns about patient safety if the pharmacist is absent from the pharmacy. As the committee rightly stressed, the Government need to improve on the reassurances they offered the committee. How are the profession’s concerns and reservations to be addressed? How will the Minister address the Pharmacists’ Defence Association’s deep worry that the new focus of the GPC in exercising its rule-making powers, minimising the burden on businesses, could lead to less focus on patient safety, which surely must be the council’s number one concern?

On workforce, all the excellent stakeholder briefings we received for this debate point to a crisis across the pharmacy industry. While the numbers of pharmacists on the register and of pharmacy technicians have increased, there has been a serious reduction in the numbers of students in training and of dispensary and counter staff. As we have heard, the primary care networks, with pharmacists working in GPs’ surgeries and away from pharmacies, have had a significant impact on staffing levels in high-street pharmacies, which to cover vacancies have to make increasing use of locums, the cost of which is spiralling. The Company Chemists’ Association’s estimate of a shortfall of 3,000 community pharmacies in England is not the setting or context in which any newly extended role for community pharmacies can develop strongly and flourish.

There is also the PDA’s serious concern about the pressures on staff in some pharmacies, such as unsafe staffing levels, poor pay and working conditions, long hours and suffering physical abuse from customers, which cause them to want to change jobs or leave the profession. What are the Government doing to ensure that risk assessment and preventive safety measures are in place, as well as a zero-tolerance approach when incidents occur? How can the welcome development of primary care networks and pharmacy services in GP surgeries develop hand in hand with ensuring enough staff and resources for community pharmacies to provide the quality of professional care that they want to deliver and we all want to see? How will the Government help pharmacies invest in staff training and development?

On funding, the Minister will have heard the concerns from across the House. The CCA’s estimate of funding last being increased for the sector eight years ago, in 2014, and the cuts of £200 million that it had to find two years later, paint a sobering picture of how the industry has fared. The current community pharmacy contractual framework agreed in 2019 has not been adjusted despite the pandemic and rising inflation and costs. The £370 million from the Government to meet pandemic costs was a loan, as we know from valiant attempts in this House to ensure that the industry did not have to repay it. I understand that it was repaid and then a separate admin process was established for the industry to claim back the extra costs incurred during Covid. Does the Minister have any further information on the sums reclaimed under this procedure? Can he reassure the House that the current negotiations with the PSNC on year 4 of the five-year funding agreement will include funding recognition for the extended and full role that community pharmacies need to play?

The need for an overall strategy for the primary care workforce across GPs, pharmacies and community services becomes ever more urgent, as this debate and the questions from noble Lords have clearly demonstrated. I look forward to the Minister’s response. We will fully support my noble friend’s amendment, should he put it to the vote, highlighting the vital importance of having the clear, long-term strategy and vision for community pharmacies that we have all been calling for.

[Lord Kamall (Con)]

My Lords, I thank all noble Lords for their contributions and once again apologise for the delay in bringing this matter before the House. I welcome the essential role that your Lordships play in scrutinising measures. I experienced that during the passage of the Health and Care Bill, and I think we have a better Act as a result of the scrutiny from across the House. I will try to address as many as possible of the points raised before I conclude. I will try to cover most of the points but I pledge to write to noble Lords if I have missed any specific points.

If we look at the overall picture of the NHS, I am sure noble Lords recognise that we seem to have more doctors, nurses and pharmacists than ever before. As someone said to me the other day, that is all very well but the supply is not keeping up with the demand. If we consider our whole understanding of health, some of the things we ignored many years ago are now things we deem as needing treatment. For example, the whole area of mental health was ignored for many years. PTSM, which people talk about now, was officially recognised only in the 1980s. I know that we will probably talk about that in the next debate.

Before a debate the other day about neurological conditions, I asked my officials to give me a list of all the conditions. They said, “Minister, there are 600 of them.” Let us think about this. We were not even aware of that previously. It shows the great complexity as we become more aware of conditions and issues, putting even more pressure on our health service and health professionals, even though we have more health professionals than ever before.

The Secretary of State recently pledged to start with pharmacies when it came to overall primary care. The community pharmacy contractual framework, to which the noble Baroness, Lady Wheeler, referred—the 2019 to 2024 five-year deal—set out a joint vision for the sector, and an ambition for community pharmacies to be better integrated in the NHS and provide more clinical services. We saw this during the pandemic when pharmacies provided vaccines and we have seen recently that they will be providing more initial advice on issues such as cancer—and they welcome this.

At the same time, we are seeing an overhaul of the overall model. It is time to move away from the old model, in which you see your GP for five minutes and then hope for a referral somewhere else. Services previously considered part of secondary care are now being taken over by primary care centres. Areas previously considered the work of GPs are now being taken over by nurses and physiotherapists, as well as by pharmacists in the community.

Despite the challenges of the last few years, we have jointly delivered the introduction of a new range of clinical services at the community level. These are important in their own right and we are negotiating with the Pharmaceutical Services Negotiating Committee on the expansion of additional services to be introduced in the fourth year of the five-year deal. I very much hope that my right honourable friend the Secretary of State will be able to make an announcement soon. Longer term, we want to build on what has already been achieved and make better use of existing skill sets and those that are developing; for example, the prescribing and assessment skills that all pharmacists graduating from 2026 will have acquired during their training.

I turn to some specific points. We now have more pharmacists than ever before. Data from Health Education England shows that we now have an additional 4,122 pharmacists employed in the community compared with 2017, and the number of registered pharmacists has increased year on year. The number of primary care pharmacy education pathway trainees coming from community pharmacy increased by nearly 2,500. Reforms to initial education and training of pharmacists means that pharmacists qualified from 2026 will be qualified to prescribe at the point of registration. On top of the £2.5 billion that we are spending on the sector, Health Education England is investing £15.9 million over the next four years to support the expansion of front-line pharmacy staff in primary and community care.

We are also supporting a significant expansion in primary care capacity through the additional roles reimbursement scheme, enabling primary care networks to recruit clinical pharmacists and pharmacy technicians, two of 15 roles that PCNs can choose to recruit to. We saw the strength and potential of community pharmacies —many noble Lords referred to it—during the Covid vaccination campaign and the role that community pharmacies played in it. It is not yet known whether recurrent boosters will be required annually. We are looking into that and whether pharmacies will be once again called on.

Noble Lords will recognise—we had this debate many times during the stages of the Health and Care Bill—that to support long-term workforce planning, we are looking first at the long-term strategic drivers of workforce demand and supply. Building on this work, we have commissioned NHS England and NHS Improvement to develop a long-term plan for the workforce for the next 15 years, including long-term supply projections. Once this work is ready, we will share the conclusions and start to home in on what it means for recruitment, skills needed and skill gaps.

A number of noble Lords raised fears or concerns about what the regulators will do with their new powers. This is understandable: community pharmacies are private businesses and increased regulatory burden will be a concern for many of them. However, once again, we have to get the right balance between regulation and making sure of safety. The proposals include safeguards to ensure that any changes the regulators make are subject to full consultation, in much the same way as is expected from the Government. This will ensure that patients, the public, pharmacy professionals and the pharmacy sector have their say on what the standards should say.

There were some concerns about remote supervision. It is important to emphasise that a lot of the issues raised today do not affect this legislation, but I completely understand the point about taking advantage of the situation to debate the wider issues.

National Health Service (Integrated Care Boards: Exceptions to Core Responsibility) Regulations 2022

Lord Kamall Excerpts

Monday 27th June 2022 Lords Chamber

Moved by

[Lord Kamall]

That the draft Regulations laid before the House on 11 May be approved. Considered in Grand Committee on 20 June.

Motion agreed.

Polio

Lord Kamall Excerpts

Thursday 23rd June 2022 Lords Chamber

[Baroness Merron]

To ask Her Majesty’s Government what action they have taken in response to the national incident declared due to the polio virus being found in London sewerage systems.

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

The established UKHSA public health response mechanism has been stood up in line with national polio guidelines. This national incident means that a national team has been set up to manage and co-ordinate these actions across areas, which is standard procedure for many of the health threats that the UKHSA foresees and manages. Although samples have been detected in London, the UKHSA is working to ensure that other areas are aware and are taking actions necessary to protect populations, including encouraging people to take the vaccine.

[Baroness Merron (Lab)]

My Lords, while the risk to the public is considered low, the declaration of a national incident will of course give cause for concern, so the Government need to communicate swiftly and clearly about the situation and to ensure that children in particular are vaccinated against polio, especially as there is lower vaccine coverage in London among younger children. What is being done to address this situation and how will the Government roll out their messaging, working with local authorities, schools, the NHS and GPs, who already have added pressure from being contacted in greater numbers by the public who are concerned about vaccinations? Can the Minister reassure your Lordships’ House that he is working closely with the Treasury to ensure a properly funded communications and vaccination campaign?

[Lord Kamall (Con)]

We should start by being clear about what has been found. As part of routine surveillance, the MHRA analyses sewage from a number of treatment works and looks at what may be identified—it is world-leading in this. We should pay tribute to the UKHSA for its world-leading work and for being ahead of the game in spotting potential health risks early. It is normal for one to three vaccine-like polio viruses to be detected each year in UK sewage samples, but those are usually one-off findings. In this case, a vaccine has been detected; it is probably related to someone having had the polio vaccine and having shed it as part of their faeces. A couple of things will now happen. First, the MHRA will go further down the system to see whether it can isolate where that came from. Secondly, the messaging is quite clear: you must get your vaccine. Most people get their vaccines as part of a routine. They get it twice in preschool and then at school at 14 as their final booster. However, there are some areas of low vaccination, and we are making sure that we are rolling out that message along all the channels mentioned by the noble Baroness.

[Lord Herbert of South Downs (Con)]

My Lords, the World Health Organization pronounced Europe free of polio 20 years ago, but that was clearly not the case globally. Its emergence here is surely a reminder that a highly infectious disease anywhere can become a highly infectious disease everywhere. Is it not also a reminder of the need therefore for vigilance against such infectious diseases, which are not beaten until they are fully beaten globally? There are other diseases such as TB where there is not even a vaccine. Will my noble friend consider the importance therefore of renewing the UK’s commitment to the Global Polio Eradication Initiative to ensure that, once and for all, this beatable disease is beaten?

[Lord Kamall (Con)]

My noble friend makes a very important point. Even though a number of countries have been declared polio-free, including the UK because of our high level of polio vaccination, we should be clear that it has been detected and it has derived from someone having had a polio vaccine, probably an oral vaccine—the sugar cube that many of us will remember from our youth, rather than the injection that a person receives now as part of their 6-in-1. That has the potential to spread, and it is why the UKHSA is monitoring it. The important message is to remind everyone: check your red book, check your medical records, check your vaccination record. If you have not been vaccinated against polio or have not had the booster, go to your GP and get it as quickly as possible.

[Baroness Jolly (LD)]

My Lords, what is unusual about these detections is that several positive ones have come from the same sewage facility over a few months. It is worth noting that this kind of polio virus community transmission in London has not been detected since the 1980s. Genomic testing has subsequently revealed that these positive samples are all related, suggesting the virus has been spreading through one or more individuals in London over recent months. Can the Minister give us more detail and tell us what action is being taken by local public health scientists and local authorities? Does the department consider it may be part of a trend? Many noble Lords can remember polio vaccinations—I had a vaccination and then my younger brother had a sugar lump, which I thought was distinctly unfair. Is there a plan to start vaccinations in the area?

[Lord Kamall (Con)]

Vaccination is already part of a national plan. People should be vaccinated at certain ages—I think it is in the first few months, and then in preschool and then at about the age of 14, when they get their booster at school. A couple of things could have happened. Someone may have travelled overseas, had the oral polio vaccine and then excreted it into the system—and it has happened on more than one occasion. On top of that, the important message is: check your records and make sure that you are vaccinated. It is not a matter of trying to get a new vaccine; it is already part of NHS routine. We encourage more people to come forward.

[Baroness Watkins of Tavistock (CB)]

Can the Minister clarify further what we will do to encourage vaccinations, while schools are still open, for 14 year-olds and for the 11% of under-twos in Greater London who are not vaccinated at the moment?

[Lord Kamall (Con)]

Part of the public health message has been focused on making sure that people come forward, even before this was detected in the sewage works. One thing we saw as a result of lockdown was that some parents in some areas had not taken their young children to their doctor to have the vaccine. Let me be clear: at eight, 12 and 16 weeks, a child gets a 6-in-1 vaccine; at three years and four months, as part of the 4-in-1 preschool booster, they get it; and at 14 years they get one at school as a teenage booster. Some of those are pre school. We are encouraging people to check their red book, check their vaccination record and make sure they take their child in for their vaccine.

[Lord Reid of Cardowan (Lab)]

My Lords, one of the paradoxes of ministerial Statements on issues such as this is that the more transparent Ministers are, the more the risk that it will create a sense of concern in the public. The history of public health problems over the past 50 years gives us the knowledge that the best way to deal with these issues is the maximum transparency at the most regular and immediate opportunities. That is the way ultimately to relieve concern and I recommend it to the Minister. On a specific issue, can the Minister give a little more detail on the decline in vaccinations throughout the country, particularly in London, during the Covid pandemic? I assume that the natural concern with vaccination for Covid led to a fairly substantial decline in vaccinations for other diseases. Can he give us a little more information on that?

[Lord Kamall (Con)]

First, I thank the noble Lord for his recognition of one of the challenges of ministerial office, as he will know from his own experience. It is important that we recognise that vaccine-derived polio has the potential to spread, but it is rare and the risk to the public overall is limited. The majority of Londoners are fully protected against polio and will not need to take any more action, but the NHS will begin reaching out to parents of children under five in London who are not up to date. But we are asking for it both ways and for parents to check their records. Let us be clear that the UK is considered to be free from polio, but we recognise a potential risk given our world-leading surveillance of sewage.

On the noble Lord’s specific question, we are quite clear that people must come forward for all vaccines. Sometimes during lockdown people were unable to see a doctor or nurse in person, and the NHS is catching up with that anyway, but the NHS will keep sending the message to try to identify people who have not been vaccinated. At the same time, we are encouraging people to check their records. Let us be clear: we detected this very early in the chain, and it has perhaps come from someone who took an oral vaccine overseas and has excreted it into the system.

[Baroness McIntosh of Pickering (Con)]

I congratulate the UKHSA and the Environment Agency on the investment they have made. When was the polio first detected—there are reports that it was detected as early as February—and when might they be able to narrow down the area in which it has been found?

[Lord Kamall (Con)]

I thank my noble friend for that question. There is routine surveillance that happens anyway. However, in this case they have detected it in more than one surveillance. Quite often, it is seen as a one-off and then not seen again for some time; in this case, it has been detected at each interval of the surveillance. We know it is from the Beckton Sewage Treatment Works—in that part of London. I must be careful about the words I use here: clearly, it is mixed up with a lot of other stuff, and we must now work out how we go along the pipe, as it were, and investigate individual pipes to see whether we can locate the source. In theory, it might be possible to find individual households or streets but it is too early to do so. What we are doing here is really world-beating: it is a first and shows that we are ahead. However, one issue in being ahead is that we detect things that would not have been detected earlier, and people are worried about them.

[Lord Walney (CB)]

My Lords, does the Minister recognise the stark difference at the moment in the quality of vaccine records’ availability? I declare an interest in that a consultancy of which I am a director works with Palantir, which has been part of the extraordinary change in the Covid vaccine records. Does he recognise the need to update the rest of the NHS so that the information on hand to patients, which has been so valuable in the system here, is more widely available for polio and other vaccines?

[Lord Kamall (Con)]

The noble Lord makes a really important about the future of the NHS and our health services. Last week, the Government published the Data Saves Lives strategy, which is what it says on the cover. One of the first issues we must tackle is digitising the NHS as much as possible. Digitisation is one of my three priorities, alongside sharing data. First, this will ensure that we can identify population health issues and patterns in conjunction with AI; secondly, giving appropriate access to researchers allows us to continue to be world-beating in identifying such issues. In future, it may well be that we can get a sample, use a bit of AI—thanks to other data sets—and locate more accurately. At the moment, we are really at the cutting edge of this. What will be vital to it is the digitisation, sharing of and access to data across the system.

[Baroness Masham of Ilton (CB)]

My Lords, is it known how many countries are using the live vaccine, which is different from the vaccine we are using?

[Lord Kamall (Con)]

I am aware that there are still some countries that use the oral polio vaccine, as opposed to the IPV we use in this country. I do not have the exact numbers with me. If the noble Baroness with allow me, I will go back to the department, see if that information is available and then write to her.

[Baroness Uddin (Non-Afl)]

My Lords, water quality in east London is appalling enough without this scare. I spoke with three of my neighbours yesterday, all with very young children, and not one was aware of this campaign. What steps are being taken to ensure sufficient and urgent awareness is created among East End multilingual communities, who are already struggling with a daunting array of health and well=being information?

[Lord Kamall (Con)]

As it happens, I was at an event yesterday at which a GP from east London was present; we were talking about the whole range of issues, not just this specific issue. Let us be clear: no one has got polio and no cases have been identified. We have found it in the sewage, and it probably came from someone who had the oral vaccine overseas, came to the UK and excreted it into the system. there are no cases of polio at the moment—we should be absolutely clear about that—but we are saying that this is a warning that people should ensure that they get vaccinated and check their records.

The noble Baroness makes a really important point about health disparities and there are lots of issues we must tackle. I have said many times that we must see how we can work on a community-led solution, rather than having someone in Westminster or Whitehall who thinks they have all the answers. To be honest, we have to show due humility and say that people sitting in this House can sometimes be out of touch with those communities.

[Lord Sterling of Plaistow (Con)]

My Lords, as my noble friend has said, the polio disease still exists in other parts of the world. When immigrants come from different parts of the world—not just from Europe—are they examined, checked and given polio injections immediately, or does it take time?

[Lord Kamall (Con)]

I thank my noble friend for that question. I am not sure of the exact details on when they are informed but let me go back to the department and ask. What I do know is that, when immigrants come to this country and register with their local GP, there is a health check and, quite often, a questionnaire to raise awareness about what vaccines or treatments they may have had and to ensure that they are as up to date with their vaccinations as the existing populations.

Diabetic Prevention Programme

Lord Kamall Excerpts

Thursday 23rd June 2022 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask Her Majesty’s Government what was the business case for not recording the percentage of patients who joined the Diabetic Prevention Programme between 2018 and 2019 but failed to complete the course; and whether this information is now recorded.

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

Data on completion rates is collected for specific reference periods. Rather than looking just at a yearly comparison, completion is analysed to understand the impact of changes to the programme, such as providing a digital option for consumers. Data collected at specific reference points, such as from January 2017 to March 2019, shows a completion rate of 53%.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful to the Minister for that. He may not know it, but I have been on the diabetes prevention courses, as I am on the cusp of diabetes. I was amazed by the rate of drop-out on the course that I was on. It ran for nine months. I wondered about the cost and so asked a Written Question on the details, which the Minister has now given me. With a nearly 50% drop-out rate, surely there is something wrong with the course. I want to see more courses but they should be run properly. Can we get the NAO to look at this to see if we can have some improvements and get better returns?

[Lord Kamall (Con)]

I thank the noble Lord for the question and pay tribute to him for his work in this area over many years. He is absolutely right. One of the challenges of this programme is that it is a nine-month course. Clearly, like many things, it was impacted by Covid, with a lack of in-person consultations and appointments. However, the silver lining to the cloud was the digital service. The course was able to move some patients on to digital services and to self-referring. One impact of that has been more people signing up to this programme.

[Lord Hamilton of Epsom (Con)]

My Lords, is it possible that it is not the course that is at fault but the people who go on it? Has the department not considered charging people a refundable attendance fee to ensure that they roll up?

[Lord Kamall (Con)]

I thank the noble Lord for his question but what is more important is that we get people who have diabetes on to the programme in the first place. As we adjust the programme to take account of the pandemic, for example, and digital offers, we are also looking at different ways to work with different communities. For example, I was talking to a young girl of Bengali origin in my department the other day. I said, “What do we do about getting to the heart of the communities, given that we are in Westminster and Whitehall?” She said that one of the problems in her community is that, “We love ghee—we love clarified butter, in our curries and our rotis.” We are looking at alternative recipes and menus so that people can still have the same food but it can be healthier.

[The Lord Speaker (Lord McFall of Alcluith)]

The noble Baroness, Lady Brinton, is contributing remotely.

[Baroness Brinton (LD) [V]]

My Lords, the observational study by academics of the 2018-19 wave of the NHS diabetes prevention programme, published by BMC Health Services Research, observed disengagement within sessions when patients reported that information was difficult to understand, and when there were very large group sizes and problems with session scheduling. This is all before Covid. Problems with the course will inevitably make patients more likely to drop out but 50% is shocking. Now that this diabetes prevention programme has been rolled out across England, have these specific problems been addressed?

[Lord Kamall (Con)]

The noble Baroness makes an important point about what we have to learn from these programmes. In many of these programmes we are in a process of discovery. You try things—some will work and some will not. Those which do not work, we want to learn the lessons from. Clearly, the length of the programme, nine months, has put some people off and led to the dropout rate. We are looking at shorter programmes, digital access and self-assessment, and at community-led initiatives rather than top-down government initiatives. To give another example, I met someone at a meeting yesterday who told me that his mosque in Accrington was running healthier-diet programmes for worshippers. We need to see a lot more of those programmes as well.

[Baroness Merron (Lab)]

My Lords, the national paediatric diabetes audit shows that the impact of type 2 diabetes and the cost-of-living crisis is disproportionately felt by children living in the most deprived areas. What preventive measures specifically geared towards children are in place so that they may avoid type 2 diabetes? What are the Government doing for the almost 4 million children, and their households, who are struggling to access and afford enough fruit, vegetables and other healthy foods to meet official and basic nutrition guidelines?

[Lord Kamall (Con)]

One of the NHS programmes that will be repeated by integrated care boards when we have them is the eight annual diabetes checks for people of all ages. Certain factors—HbA1c, which is your average blood glucose level, or your glycated haemoglobin; blood pressure; cholesterol; serum creatinine; urine albumin; foot surveillance; BMI; and smoking—are checked for patients of all ages to identify early onset of diabetes.

[Lord Grocott (Lab)]

My Lords, further to my noble friend Lord Brooke’s Question about the drop-out rate and his suggestion of an independent review, what mechanism is there for assessing courses that clearly are not as successful as they might be if there is such a high drop-out rate?

[Lord Kamall (Con)]

The point is about what we learn. For example, some noble Lords will have seen stories about the impact of minimum alcohol pricing in Scotland. Clearly, it did not turn out as intended because the review found that people from poor communities were spending more on alcohol, rather than the alcoholism rate being affected. In this case, we have learned that the nine-month programme and some of the other processes behind it clearly lead to a drop-out rate. We are looking at other programmes. One of the great stories we have seen is the use of digital and other forms of access. If we can roll that out as well with community programmes, it might be a better way of doing things.

[Lord McNicol of West Kilbride (Lab)]

My Lords, following my noble friend Lady Merron’s question regarding children, could the Minister say a little more about schools and what work the Government are doing to raise these issues there? We all know that the earlier we can prevent onset the better. Schools are a great place for this to be done.

[Lord Kamall (Con)]

The noble Lord makes an important point. When I speak to experts, policy officials and people working on diabetes, one of the things they say is that the Government cannot reduce obesity alone; efforts also have to include businesses, health professionals, schools, local authorities, families, individuals, community groups and civil society. We all have to come together collectively. There clearly are programmes in schools to encourage people to eat more healthily, but I am sure the noble Lord would recognise that, when we were children, we had programmes about not smoking, sex education and people not drinking alcohol. We would come out of them and say, “I’m never going to drink alcohol or smoke cigarettes again.” Two years later, we were all at parties and what were we doing? We have to make sure that it is impactful all the way through life, not just at that time.

[Lord McColl of Dulwich (Con)]

My Lords, does the Minister agree with the recently published scientific evidence that fasting is actually good for you and that missing an occasional meal would be a good thing, especially for preventing diabetes?

[Lord Kamall (Con)]

As my noble friend will be aware, there are always debates in scientific circles on this. There are different types of fasting regime as well. For example, during Ramadan lots of mosques expounded it as a great example of something that is not only spiritual but good for your physical health. It does depend. Other studies show that it depends on who is doing it and their other circumstances.

[Lord Scriven (LD)]

My Lords, could the Minister say what is being done regarding the latest statistics, which showed that just 34% of people in the north of England who have diabetes have access to the eight health checks that they should have?

--- Later in debate ---

[Lord Kamall (Con)]

The noble Lord makes an important point. The Office for Health Improvement and Disparities is looking at a number of these areas and where the health service or the ICS locally has to target more resources. Clearly, one of the big concerns is disparities. The noble Lord has given the example of the north-east; as he rightly said, there will be parts of the country where those checks are not happening. It is vital that we tackle those disparities.

[Lord Brooke of Alverthorpe (Lab)]

I am sorry to be so persistent, but we are spending millions on these programmes. Since some work is being done to try to improve them, could the Minister give the House a report in six months’ time to tell us what progress is being made and give us some targets that are being delivered?

[Lord Kamall (Con)]

I am not entirely sure that I can give the noble Lord what he asks for, but I suggest that he asks me a Question about progress in six months’ time. Given that the noble Lord asked this Question, I will go back to the department and see what answers we can give.

[Lord Hain (Lab)]

My Lords, is there any link between patients with diabetes and other ailments and the drop-out rate? Can the Minister give any evidence for that?

[Lord Kamall (Con)]

I apologise, I did not hear what the link was: between diabetes and what, sorry?

[Lord Hain (Lab)]

Patients with other ailments or conditions and the drop-out rate.

[Lord Kamall (Con)]

I am not entirely sure of the answer to that. I will check and write to the noble Lord.

Social Care: Adults

Lord Kamall Excerpts

Wednesday 22nd June 2022 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what assessment they have made of the survey by the Association of Directors of Adult Social Services, published on 13 May, which found that more than 500,000 people in England were waiting (1) for a social care assessment, (2) for their care package to begin, or (3) for a review of their care.

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

Local authorities are responsible for meeting the needs of those who require care and support under the Care Act. The ADASS survey highlights that their waiting lists are increasing, which is why we are investing to support improved outcomes and experiences of care for people and their families, including through an additional £5.4 billion over three years to begin a comprehensive programme of reform.

[Baroness Wheeler (Lab)]

My Lords, both the ADASS survey on social care waiting lists of 500,000 and Age UK’s estimate of 1.6 million people with unmet care needs are a stark wake-up call for the Government’s mantra of having fixed social care. The Minister knows that the official figures that he always quotes and quotes today are nowhere near enough to meet current and future demands, as key stakeholders and the expert think tanks routinely remind him. What are the Government doing to prioritise care and support in people’s homes and local communities? Does the Minister not recognise that the situation is getting worse, not better?

[Lord Kamall (Con)]

Many noble Lords recognise the challenges faced by not just this sector but all sectors, during Covid. One issue we have been looking at for many years, over subsequent Governments—we discussed this during the Health and Care Bill—is that social care was seen as a Cinderella service for many years. For the first time, thanks to noble Lords’ support, we managed to get the Health and Care Bill through to have a properly integrated health and care system. We are also looking at how we can make sure that we properly understand the health and care landscape, with the register and the hub, and that it is a vocation that more people find attractive.

[Baroness Altmann (Con)]

My Lords, I urge my noble friend, in light of the extraordinary number of vacancies in the social care sector—more and more staff are leaving to join other sectors—to urge the Government to revisit the Immigration Rules that do not allow overseas care workers, who could fill those gaps, to come in. We have a special system for agricultural workers; surely my noble friend agrees that we must not put picking fruit and vegetables above the needs of the most vulnerable in our society.

[Lord Kamall (Con)]

I thank my noble friend for the question, but make the point that it is important that we look not only to our domestic workforce but to recruit people from far and wide to fill those gaps. We have always done that. As I often say from this place, we must remember that public services in this country were saved by people from the Commonwealth after the war. They played a very important role in making sure that this country and its public services recovered after the war. On recruitment from overseas, on 15 February, we added care workers to the health and care visa and shortage occupation list, allowing these roles to be recruited from overseas. We hope that will enable us to fill thousands of eligible vacancies.

[The Lord Speaker (Lord McFall of Alcluith)]

My Lords, the noble Baroness, Lady Brinton, is participating remotely.

[Baroness Brinton (LD) [V]]

My Lords, I go back to the previous question: this ADASS survey shows that almost 170,000 hours of homecare a week could not be delivered for the first three months of this year, because of a shortage of care workers. This is a sevenfold increase on the previous year. The changes proposed to the social care system will not increase the rates of pay for social care workers, at the moment, to make it attractive to others, who can work in hospitality. But there is a dire need for people now. What will the Government do right now to help solve this crisis?

[Lord Kamall (Con)]

As the noble Baroness will acknowledge, some of the problems have been in evidence for a long time. Sometimes, we are tackling the legacy of this neglect of the social care system. At the same time, we have to remember that many social care providers are not run by the state; they are private providers. Following the People at the Heart of Care White Paper, we want to make sure that, first, we encourage better conditions for workers. We also want to make sure that local authorities determine a fair rate of pay based on local market conditions. We have seen an increase in the national living wage, which means care workers will get an increase. But we are looking at all this as part of the overview of the social care landscape.

[Baroness Bull (CB)]

My Lords, could the Minister comment on the March 2022 progress report on the Out of Sight – Who Cares? report, which came out in October 2020? It found that of the 17 recommendations, none had been fully achieved and only four had been partially achieved. Can the Minister say when Government will address these recommendations and end the excessive use of the dehumanising isolation, segregation and seclusion within adult social care?

[Lord Kamall (Con)]

On that specific question, I will have to go back to the department and get an answer. I will commit to write to the noble Baroness.

[Baroness Uddin (Non-Afl)]

My Lords, 500,000 is a staggering number, but the number experiencing the deepest emotional and physical impact on families may be in the millions. Is the noble Lord and his department aware of the costs associated with neglecting these people and how many may have lost their lives while waiting for these services?

[Lord Kamall (Con)]

When we look at the 500,000 number, we are talking about an assessment of any kind. These are not people who are outside the system; sometimes they may be in the system but waiting for another assessment within the system. For example, they could be waiting for Care Act deprivation of liberty safeguards, occupational therapy assessments, the beginning of direct payments or a review of their care. It means they are in the system but just waiting for another part of the system to work. The other thing about the report was that there was a 61% response rate, and it was extrapolated from that. Anyone who has read behavioural economists Daniel Ariely or Daniel Kahneman will know that people are more likely to focus on losses rather than gains and, similarly, in surveys people are more likely to report bad things than things that are going well.

[Lord Forsyth of Drumlean (Con)]

My Lords, does my noble friend accept that what these figures show is that local authorities with insufficient resources are introducing rationing of services to some of the most vulnerable people in the country? Why did we pay more in national insurance if the money was not to be made available to social care until three years down the line and the crisis is now?

[Lord Kamall (Con)]

I wonder if I could correct my noble friend. The Government implemented a comprehensive review of the programme on adult social care with a £5.4 billion investment over three years from April 2022, of which £1.7 billion will be used to begin major improvements across adult social care in England, including but not limited to £500 million investment in the workforce and £150 million to improve technology. As many noble Lords recognise, for too long this sector has been neglected. In some cases, there is a lack of understanding about the breadth of the sector. We are trying to understand it and get people to register, and then we can improve it.

[Lord Scriven (LD)]

My Lords, I declare my interests as set out in the register. Some hospital NHS trusts have a third to a quarter of their beds bed-blocked by people who are clinically ready for discharge but cannot leave because of no social package being available. What are the Government doing now to deal with this problem? It undermines the NHS waiting list backlog as well.

[Lord Kamall (Con)]

The noble Lord makes an important point, and the fact is that if some patients do stay in hospital too long, they can lose control of certain faculties and see muscular deterioration. So it is our priority to ensure that people discharge safely, as quickly as possible, to the most appropriate place. Local areas should work together to plan and deliver hospital discharge, and the department is working with NHS England, NHS Improvement, local government and social care providers to monitor and understand the underlying causes and do something about them.

[Lord Watts (Lab)]

My Lords, the Government say this is a long-term problem, but they have been in power now for 10 years. What have the Government been doing to address this issue, bearing in mind that Andy Burnham identified this as a problem and was attacked by the Front Benches when he put forward some suggestions on how they could deal with it? This is a crisis made by this Government.

[Lord Kamall (Con)]

I am afraid I will have to humbly disagree with the noble Lord, because this has been a problem for subsequent Governments, as we discussed during the passage of the Health and Care Bill. In some cases we can see reports going back 50 years. What has happened over the years is that Labour, Conservative and coalition Governments have put those reports on shelves to gather dust. We were the first Government to introduce an integrated health and care system and to grasp the nettle.

[Baroness Manzoor (Con)]

My Lords, there is some anecdotal evidence that patients are being discharged from hospital without having a full care package in place. Could my noble friend say exactly what the Government’s policy is to ensure this does not happen? These are some of the most vulnerable people, such as individuals who have had a stroke. On occasions, they are sent home with no support mechanism at all.

[Lord Kamall (Con)]

I thank my noble friend for the question. It is a really important issue that we discussed many times not only during the passage of the Health and Care Bill but subsequently. We have to make sure that everyone in the system is working together to make sure that a hospital knows who it is discharging to and that the carer who will receive or help that person has not only the support but the facilities and capabilities at home, or wherever that person is being discharged to, to work with that person. There are gaps in the system; it is not perfect in all places. We are working with local authorities and others to make sure we improve the system.

[Viscount Waverley (CB)]

My Lords, would the Minister care to associate himself with today’s celebration of the arrival of the HMT “Empire Windrush” in 1948, whereby a statue has been unveiled at Waterloo station to remember that it was Caribbean citizens who, frankly, came to the rescue of the National Health Service? Are there lessons to be learned that the Minister might wish to apply to today’s situation?

[Lord Kamall (Con)]

I am so keen to answer that question because of my own Caribbean background. In fact, my father was part of that Windrush generation. He travelled from Guyana to Trinidad in 1952, and then from Trinidad to the United Kingdom, where he worked first on the railways and then as a bus driver. His brother worked in a post office and his sister was a nurse. That shows the vital contribution that people from the Caribbean made to this country post war.