General Practitioners: Shortage

Lord Kamall Excerpts

Tuesday 12th July 2022 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

I beg leave to ask the Question standing in my name on the Order Paper and declare my interest with the Dispensing Doctors’ Association.

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

The Government recognise that growing the GP workforce is challenging, particularly in light of pressures from the pandemic. There are over 1,400 more full-time equivalent doctors in general practice in March this year compared with March 2019, showing that there is some movement in the right direction. However, we need to go further, and we are working with NHS England and NHS Improvement, Health Education England and the profession to boost recruitment, address the reasons why doctors leave and encourage them to stay or return to practice.

[Baroness McIntosh of Pickering (Con)]

I am grateful for that Answer, but my noble friend will be aware that by 2030, we will be facing an acute shortage of GPs as more doctors leave the profession than join. There are 9 million people living in remote rural, coastal and island communities, which is more than live in London. Will my noble friend ensure that all health policy is rural-proofed, and that those living in rural areas have equal access to healthcare to those living in urban areas?

[Lord Kamall (Con)]

My noble friend makes a very important point, and she referred continually throughout the passage of the Health and Care Act to practices in rural areas. We have looked at the challenges and have asked GPs about this in surveys, and we know that there are problems about the reduction of working hours, administrative burdens, some stress and burnout, and some issues about equitable distribution. One thing we do have is the Targeted Enhanced Recruitment Scheme launched in 2016, which has attracted hundreds of doctors to train in hard-to-recruit areas by providing a one-off financial incentive.

[Lord Patel (CB)]

My Lords, in 2017, a House of Lords report recommended that the current small business model of primary care is not fit for purpose. The same has been said by the Royal College of General Practitioners, which produced a report; the British Medical Association; two think tanks, the Nuffield Trust and the King’s Fund; and, more recently, Policy Exchange, which produced a report on the model being fit for the future. Is it not time that the Government had plans to look at future models of delivering primary care? If they do not have such an intention, does the Minister agree that the House of Lords should set up a Select Committee to follow on from the excellent report produced on the NHS in 2017?

[Lord Kamall (Con)]

I thank the noble Lord for that question, but I should explain to him that I have been warned for exceeding my powers, as it were, in the past. I think setting up a Select Committee is a bit beyond my powers. The noble Lord and I, and many noble Lords across the House, including previous Health Ministers of all parties, have had this conversation, and we know that the old-fashioned model of a five to 10-minute appointment with your GP, only to be referred elsewhere and into secondary care, is broken in many ways. We need a much more modern model. We have seen primary care take on some of the functions of secondary care, but we have also seen, at the GP level, that the GP does not have to do everything, and that there are other workers such as nurses, physio- therapists and pharmacists who can do more of what the GP has done in the past.

[Lord Winston (Lab)]

My Lords, the figures show that more than half of GPs are considering retirement or are retiring before the age of 60. As the noble Lord has pointed out, there are lots of reasons for this, but he has not told us what he is doing about them. What is he doing constructively to change the attitudes and experience of GPs, which lead to this disillusionment among men who are at the highest point of their career, when they are the most useful to patients in primary care?

[Lord Kamall (Con)]

I assure the noble Lord that the Government are doing lots of things. Not only are we listening but we are looking at potential solutions and discussing them with the relevant bodies. For example, one of the pressures mentioned was the impact of the number of phone calls. There has been investment in handling them and getting them redirected appropriately, and GP practices have been offered money for that. The other issue is pensions: some GPs are worried about taking a hit on their pension if they come back to service. There are discussions about whether they are really worse off and how we can retain staff. Also, having other staff at the GP level who can take on some of those functions that GPs do not necessarily need to do could ease their workload. The administrative burden has added to this, but the digitisation of services should solve a lot of those problems.

[The Lord Speaker (Lord McFall of Alcluith)]

I call the noble Baroness, Lady Brinton, to make a virtual contribution.

[Baroness Brinton (LD) [V]]

My Lords, the Royal College of GPs reports that since 2019, GP clinical administration tasks have risen by a shocking 28%. GPs say that it would make a significant difference if hospital consultants could refer patients directly to other consultants, rather than patients having to come back to GPs and then be redirected. The back-office functions for repeat prescriptions take an ever-increasing amount of their time, and GPs are not in control of either of these processes. As a matter of urgency, will the Minister investigate how to reduce some of this bureaucracy so that GPs have more time to see their patients?

[Lord Kamall (Con)]

As part of the joint NHS England and NHS Improvement and DHSC bureaucracy review—there is such a thing—we have been working across government to reduce unnecessary bureaucratic burdens. There have been a number of key work streams, including a new appraisal process and digitisation of the signing of some notes, along with work to reform who can provide medical evidence and certificates and who can provide notes—nurses, occupational therapists, pharmacists and others. We are continuing to look through the process to engage with GPs to see how we can remove more such administrative burdens.

[Lord Patel of Bradford (Non-Afl)]

My Lords, looking at wider health workforce issues, I understand that we need another 2,000 radiologists in the next five years and that it is highly unlikely that we will be able to produce them. That is the pessimistic note. On an optimistic note, I heard recently that Apollo, the large healthcare provider in India, in partnership with the royal college and the GMC, has been training up 150 high-quality radiologists every year, some of whom are coming to this country. Does the Minister approve of such schemes, and is the department doing more work in places such as India where we can recruit high-quality medical staff?

[Lord Kamall (Con)]

I thank the noble Lord for his question, but also pay tribute to his commitment to tackling racism in our society.

We know that there are countries that train more people than they have places for in their country. They do that, first, to help those people get a better life elsewhere, but also because remittances are much better than foreign aid for many of those countries. I frequently mention the fact that it was immigrants from the Commonwealth who saved public services in this country after the war. We should remember that and continue to encourage people from the Commonwealth to come to this country. Sadly, for some reason, noble Lords quite often do not want them and make up all sorts of excuses for trying to block non-white people from outside Europe.

[Lord Young of Norwood Green (Lab)]

My Lords, one of the disincentives for both men and women GPs is the quality of accommodation. They are in overcrowded buildings. There is a good example from a care commissioning group in my area which spent £1 million planning a new centralised health centre, which would have provided top-of-the-range facilities and would have encouraged general practitioners to remain in practice. Will the Minister look at the quality of accommodation? What plans are there to introduce new buildings? That is a really important factor in dealing with the shortage of GPs.

[Lord Kamall (Con)]

The noble Lord makes the very important point that GP practices are evolving. Some are moving premises; some are merging in larger premises; some are moving into primary care centres, where they are able to offer not just traditional GP services but some of the services that secondary care currently offers. I am not entirely sure of the specific point that the noble Lord makes. He would be welcome to have a conversation so that I can follow it up with my department.

[Lord Moylan (Con)]

My Lords, does my noble friend agree that an increasing number of GPs prefer to work part-time because they face a marginal tax rate of 62% on earnings over £100,000? Will he consider discussions with his friends at Her Majesty’s Treasury to address those anomalies in the tax system?

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[Lord Kamall (Con)]

There are a number of reasons why some GPs and other health professionals prefer to work part-time as opposed to full-time. Many people, especially given the stresses of the pandemic, want a better work/life balance. Some people have suggested in the past that we should focus on full-time equivalents. We should make sure that current staff who want to go from full-time to part-time can do so within the system, so that we can retain them, while tackling all the barriers to retention as well as recruiting more GPs.

[Baroness Merron (Lab)]

My Lords, the appointments system is not working well for GPs or patients. Healthwatch England reports that complaints about GP services are rising, the main problems being difficulties getting an appointment, exorbitant waits on the phone, about which we all know, and an end to online facilities to book slots. What assessment has been made of the detrimental impact on people struggling to access GP services, particularly those who are more vulnerable, and what is the plan to put this right?

[Lord Kamall (Con)]

The noble Baroness is absolutely right. We know that, for many people, their first entry into the system—their portal, if you like—is trying to get an appointment with their GP. As the noble Lord, Lord Patel, mentioned earlier, we have to look at how we can modernise this service. In the short term, we have made money available to help improve triage for people who phone up for services; this includes how to manage incoming and outgoing calls. In future, we are looking at more digitisation and extending the functionality of the NHS app so that people can book appointments for all sorts of services; if they are waiting for an appointment or secondary care, they will also be able to see how long they will have to wait and where they are in the queue.

Cannabis: Medicinal Use

Lord Kamall Excerpts

Tuesday 12th July 2022 Lords Chamber

[Baroness Meacher]

To ask Her Majesty’s Government what plans they have to amend the Misuse of Drugs (Amendments) (Cannabis and Licence Fees) (England, Wales and Scotland) Regulations 2018 to enable general practitioners to prescribe cannabis medicines to patients whose symptoms are being substantially alleviated by such medicines currently purchased privately.

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

The Government share the aim of NHS funding for licensed medicines that have proved safe and effective, rather than patients paying private subscriptions for unlicensed products that are not assured by our medicines regulator. Broadening who can prescribe these products will not achieve this. For this to happen, we need the cannabis industry to invest in clinical trials. Our medicines regulator—and the National Institute for Health and Care Research—has asked it to do so and is ready to support it when it does.

[Baroness Meacher (CB)]

My Lords, the Minister will be aware of Bailey Williams, aged 20, who has very severe epilepsy and was hospitalised every week throughout his childhood, until the last four years, when he has been on medical cannabis—these have been his best years. His parents are struggling financially and asked Bailey’s consultant to prescribe medical cannabis under the NHS; after all, NICE has approved this in its guidance. The answer was no, but palliative care was an option—palliative care but not a proven medicine that has done so well for this child for four years. The Minister cannot accept that situation. Will he meet MHRA, with me, to discuss the way forward? There has to be a way forward.

[Lord Kamall (Con)]

First, I thank the noble Baroness for meeting with my colleague, my noble friend Lady Penn, yesterday. When I became a Minister, the Permanent Sec recognised a potential conflict of interest, which I have been told means that I cannot meet with people about this particular issue, but I can answer this Question if I declare my interest. So I better quickly declare it: I used to work for a think tank that received some funding from the medicinal cannabis industry, and I shared a round table. That immediately ruled me out as having a conflict of interest. None the less, I am very happy to facilitate meetings with my ministerial colleagues. As the noble Baroness will be aware, there is a new ministerial colleague in place at the moment. The point remains that we have asked the industry, which makes lots of money in this area, to come forward and fund trials, but it has preferred not to do so.

[Baroness Walmsley (LD)]

My Lords, I understand that the MHRA is considering extending its compassionate access scheme, particularly regarding the import of Celixir20 from Israel. A number of children with rare forms of drug-resistant epilepsy rely on this medicine. Given the severity of the crisis of access to NHS prescriptions for medicinal cannabis, can the Minister ensure that there are no barriers to the MHRA acting now to extend this scheme?

[Lord Kamall (Con)]

The noble Baroness raises an important point about working with the importer of those medicines. The MHRA is exceptionally continuing to allow those medicines and is hoping to work with the importer and the Israeli company itself to see whether they will go through the MHRA approval process. In Israel, there are two ways of supplying the product: one is medicinal and the another is for non-medicinal cannabis uses. It has advised us that this is not a licensed medicine in Israel, and therefore we are asking the company to come forward. In the meantime, we are looking at an interim solution.

[Lord Dubs (Lab)]

My Lords, will the Minister confirm that, for certain very severe forms of epilepsy that affect children, medical cannabis is absolutely appropriate? Can he explain why only three such prescriptions have been issued?

[Lord Kamall (Con)]

Yes, but I should start by saying that I have been warned a number of times that it is inappropriate for Ministers to tell doctors and clinicians what they can prescribe. In certain cases, given that it has not been regulated as a medicine in this country, doctors can make an exception and ask for it to be prescribed on the NHS. They will go to their CCG—and now to their ICS—and ask for that. However, that has been agreed to in only a few cases.

[Lord Farmer (Con)]

My Lords, will the Government heed warnings from respected addiction psychiatrists in US states where cannabis has been legalised that medical marijuana acted as a Trojan horse to get recreational use in, that the upward trend in medical potency means that people get addicted, and that super-strength products are associated with a significant rise in cannabis-related psychosis? Are they aware that states are now tightening restrictions on cannabis prescribing, having previously liberalised it, not least given sharp increases in teenage suicides with marijuana in their systems post-mortem?

[Lord Kamall (Con)]

I thank my noble friend for his question and note his concerns. However, I think we should look at this in two ways: there is medicinal cannabis and there is recreational cannabis, and we must be quite clear on that. Some people clearly want to liberalise both. I cannot comment on my own particular views because I am conflicted on this, but what is really important here is that we take a cautious approach and look at the particular issue of medicinal cannabis. The MHRA is ready to regulate medicinal cannabis; it just needs companies to come forward and spend money on the trials.

[Lord Winston (Lab)]

My Lords, the Science and Technology Select Committee, which I had the honour to chair some 15 or 18 years ago, looked at the medicinal uses of cannabis. One of the things we clearly showed was that the statement we just heard is not true; in fact, there was no evidence then that the medicinal use of cannabis led to addiction in patients. Indeed, patients who were having medicinal cannabis were trying very hard not to become high and trying to use the doses in very limited amounts so that they could cure their symptoms.

[Lord Kamall (Con)]

The noble Lord makes a very important point: whatever our personal views, we must distinguish between recreational and medicinal uses of cannabis. We know from observations and many stories that many people believe that they benefit from medicinal cannabis. We know that there is a barrier because companies have not come forward to have it regulated or go through the clinical trials, but we are trying to work with those companies and encourage them to come forward. In fact, we have also found some NIHR research money available to help with those trials. My request to the industry is: “You make a lot of money out of this—please come forward and go through those trials with the MHRA”.

[Baroness Jones of Moulsecoomb (GP)]

My Lords, there is a suspicion among those of us who think that the Government are being very slow about this that they are arguing it from a medical point of view, just as the Minister has today, but that in fact this is a political decision because the Government’s right wing does not like the idea of cannabis use in this way.

[Lord Kamall (Con)]

I do not know how to respond to that. All I will say to the noble Baroness is that nothing could be further from the truth. This is clearly an issue based on medicinal cannabis. The noble Baroness will know that my party is a coalition; there are quite a number of libertarians in my party who would take a very different view on banning these issues. What is really important is that, to be licensed as a medicine, it has to be approved by the MHRA; to be approved by the MHRA, except in very exceptional circumstances, you have to go through trials. These companies make a lot of money; they can afford to go through the trials; they are just choosing not to.

[Baroness Watkins of Tavistock (CB)]

My Lords, NICE has actually supported the limited use of medical cannabis. It has, over many years, supported the limited use of novel drugs in cancer and heart disease, which have been readily available. Does the Minister agree that it is a national scandal that we are discriminating against some of the most vulnerable people with severe epilepsy in our country by not providing this in limited forms on the NHS pre further clinical trials?

[Lord Kamall (Con)]

What I would say is that it is left up to the doctors, who are able to ask for it to be prescribed on the NHS. In some cases, that has clearly not been accepted and that is why people have to go privately, but the best way to solve this problem is for the industry to come forward and go through trials. The offer is open, the NIHR has money available, but for some reason the companies prefer to sell it unlicensed.

[Baroness Butler-Sloss (CB)]

My Lords, is there not a way around this? It seems to me extraordinary that we cannot cut through this.

[Lord Kamall (Con)]

In simple terms, I completely agree. There should be a way around this and I will take this back to the department. In fact, I was quite provocative when I was getting advice on this, but I have also been warned that I am conflicted on this issue, so I will try to push it as long as I am not seen as being in conflict. It is very difficult, but I want to do the right thing.

[Baroness Merron (Lab)]

My Lords, we look forward to the Minister returning on this point, but to build on the points made by other noble Lords, despite the change in the law, many families are experiencing great anguish in getting treatment for young epilepsy sufferers and are left with little option but to pay thousands of pounds each month. What is the Government’s view on implementing all the recommendations of the recent NHS review of the barriers to accessing prescription cannabis products for medicinal use? If they are not planning to implement all the recommendations, which ones are the Government looking at?

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[Lord Kamall (Con)]

The department has been reviewing the Hodges review and has been looking at the method of data collection. At the moment, I cannot comment on the significance of the statistics in the report, but the important thing here, I think, is that once again we are asking the industry to come forward. It can fund the trials—it can afford this—but for some reason it prefers to sell it unlicensed.

[Lord Watts (Lab)]

My Lords, just to clarify the point that the Minister made, that it is not for him to tell doctors what medicines to prescribe, is he really saying that if doctors are failing to give their patients the proper and adequate medicines—the only medicines that work—there is nothing he can do?

[Lord Kamall (Con)]

These are left to clinical decisions, and it is up to individual doctors. Some doctors believe that the evidence is not there to prescribe it; other doctors believe that it is there and they would like to prescribe but they go to their local CCG or elsewhere and they are not given permission or access. What we are trying to do is make sure that there is sufficient evidence, but we really need the companies to come forward. If I can make one appeal to noble Lords, if anyone contacts them from the industry, ask them to come forward and go through the trials.

Coronavirus: New Cases

Lord Kamall Excerpts

Monday 11th July 2022 Lords Chamber

[Baroness Merron]

To ask Her Majesty’s Government what assessment they have made of the recent rise in Covid cases across the UK to 2.7 million infections over the last week.

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

We continue to see Covid-19 case rates and hospitalisations rise in all age groups, with the largest increases in hospitalisations and ICU admissions in those aged 75 and older. A large proportion of those hospitalised are admitted for reasons other than Covid. However, Covid is identified due to the increase in case rates in the community and the high rates of testing in hospital, including among those with no respiratory symptoms. Current data does not point to cases becoming more severe.

[Baroness Merron (Lab)]

My Lords, with a stark rise in infections, many people—particularly the clinically vulnerable, carers and older people—are feeling anxious, yet the Government have been noticeably silent, perhaps being somewhat distracted. We might be through the worst of Covid but evidently it has not gone away; individuals, organisation and businesses still want guidance. I have two questions for the Minister. Are the Government planning any campaigns, perhaps involving scientists and others, to highlight current risks and to encourage the take up of booster jabs? Are there plans to reintroduce mandatory mask wearing in hospitals, which the chair of the JCVI considers sensible?

[Lord Kamall (Con)]

I have to strongly disagree with the noble Baroness when she says that the Government are doing nothing. We are reliant on the UKHSA, which monitors rates and gives us advice, along with the JCVI. In my briefing from the UKHSA, it said it is continuing to monitor cases. As many noble Lords will remember, when we announced the living with Covid strategy we said that we are always ready to stand up measures should case rates rise so much that our health system was under pressure. We managed to break the link between infections and hospitalisations and hospitalisations and death; if that gets out of control then of course we will stand up the measures that we had previously.

[Lord Paddick (LD)]

My Lords, why do the Government not reintroduce free Covid tests for everyone in England and financial support for those who do the right thing and self-isolate, especially in the face of the cost of living crisis?

[Lord Kamall (Con)]

The noble Lord will be aware of the different balances and trade-offs that the Government have to consider. At one stage, I think we spent £2 billion in a short period on testing, and a number of people in the health system said that surely that money would be better spent elsewhere, given the backlog due to lockdown. It is always a difficult trade-off on where you spend the money. At the moment, there are people who are still eligible for free tests: certain social and healthcare workers, and also people visiting and some carers. All this will continue to be monitored. Should the number of cases spiral out of control, clearly we would look to reintroduce free testing at some stage, should that be needed.

[Lord Cormack (Con)]

My Lords, Covid is clearly here to stay. As we will be into autumn within two months or thereabouts, what plans do Her Majesty’s Government have to give a dose of the vaccine to everyone in autumn along with the flu vaccine?

[Lord Kamall (Con)]

My noble friend raises a very important question. We are waiting for advice from the JCVI, coming later this week, on the autumn programme. There have been various reports, but we are waiting for confirmation of whether it will be the existing cohort of 75 and over, 70 and over, or whether it will be given to wider groups. That is being considered and will be announced later this week.

[Lord Bilimoria (CB)]

My Lords, the Minister mentioned £2 billion being spent in a month on Covid tests, which includes PCR tests as well. What proportion of that £2 billion was spent on lateral flow tests? If necessary, looking down the road to this winter, are the Government prepared with vaccines, free lateral flow tests for businesses and citizens, and the antiviral programme? Are we ready just in case?

[Lord Kamall (Con)]

We continue to monitor the situation. The Secretary of State and I have regular meetings with the UKHSA, which tells us about the various issues of concern. Noble Lords will know about the outbreak of monkeypox in certain communities and the discovery of the polio vaccine in sewage, though not leading to cases. Clearly, we constantly talk about Covid cases. We are monitoring numbers, and the UKHSA looks at the ONS numbers as well. We are planning for the autumn, but we also have plans should the number of infections start leading to hospitalisations and possibly deaths.

[Lord Foulkes of Cumnock (Lab Co-op)]

My Lords, my noble friend Lady Merron is absolutely right: this appears to be creeping up on the Government unawares. The level is going up and is particularly high in Scotland. The last time around, there was a lot of confusion, because different reactions were evident in Scotland, Wales, Northern Ireland and England. In order to deal with this quickly and in a co-ordinated way, can I ask the Minister to get together the Chief Medical Officers of all four countries as quickly as possible to come up with a plan?

[Lord Kamall (Con)]

The noble Lord will be aware that health policy is devolved. There are times when the devolved Administrations want to go their own way and not follow England—

[Lord Foulkes of Cumnock (Lab Co-op)]

That does not matter.

[Lord Kamall (Con)]

I am sure the noble Lord will have been in meetings with the devolved Administrations; sometimes they want to go their own way. For example, when we reduced some of the measures in England, the devolved Administrations were sceptical of what we had done. When the data showed that the measures left in place in Scotland were no more effective than us removing some of those restrictions, it demonstrated exactly why, although we talk to the devolved Administrations all the time, we also respect the devolved settlements. We have to agree to disagree at times.

[Baroness Altmann (Con)]

My Lords, does my noble friend agree that we have lived with flu all our lives? I completely agree with his assertion that if this illness is not proving more deadly than illnesses we have lived with for a long time, what would be the purpose of upsetting the economic recovery and causing so much extra cost to the public purse—unless, as he rightly says, serious hospitalisation cases and deaths were to increase suddenly?

[Lord Kamall (Con)]

My noble friend makes a very important point. You always have to look at these things in the round and you have to look at the trade-offs. Many noble Lords will recognise that, when we went into lockdown, there were build-ups in many parts of the NHS backlog and an increase in people suffering from mental health issues—the numbers were even larger than they were before—so clearly, we have to look at this as a trade-off. We have a living with Covid strategy. We constantly get updated by the UKHSA, which is looking at all this data. We are ready to stand up should we need to.

[Lord Stirrup (CB)]

My Lords, the recent welcome inroads into NHS waiting lists are now being reversed. What plans do the Government have to ensure that, as Covid pressures mount, over the winter in particular, crucial NHS services and diagnoses are sustained—particularly, for example, early diagnoses of cancers?

[Lord Kamall (Con)]

The noble and gallant Lord makes a very important point: we have to continue with the living with Covid strategy, and keep an eye on the Covid cases, but also be aware that we need to clear the backlog, and that people have missed appointments. One of the things we are doing is looking more at diagnostics. Many noble Lords will be aware that about 80% of the waiting list is people waiting for diagnosis. Of those waiting for surgery, about 80% of them do not need to stay overnight in hospital. We want to make sure that we get the right balance between monitoring what is going on with Covid and at the same time clearing the backlog.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord just talked about clearing the backlog. He said earlier that the incidence rise is now leading to increased hospitalisations. What impact is that having on the backlog?

[Lord Kamall (Con)]

I asked that very same question when I had the briefing with UKHSA officials earlier, and they said they are still focusing on the backlog. If it gets to a point where it is affecting the backlog, clearly measures may well have to be introduced.

[Lord Scriven (LD)]

My Lords, I declare my interest as in the register as a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust. Following on from the last two questions, last year, the Government awarded £6 billion extra to the NHS to deal with Covid cost pressures. There was an assumption that there would be no Covid in the NHS by June, and all funding stopped. In the light of rising cases and the issues caused by the pressures, will the Government reinstate NHS Covid money? If not, this will eat into the day-to-day budgets of our NHS.

[Lord Kamall (Con)]

As I said, we are keeping everything under review. We called our strategy Living with Covid-19 as opposed to “We’ve Got Over Covid-19” because we knew it could come back at any time. We have seen that, with the omicron variant, some medication is less effective. We continue to monitor that, and we are ready to stand up the measures that may be needed if the number of cases dictates that, on the advice of the JCVI and the UKHSA.

[Lord Patel (CB)]

My Lords, we all agree that the numbers are increasing by the day. Can the Minister say what is driving this rise in numbers? Are particular groups driving the rise, and if so, is the policy based on that information?

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[Lord Kamall (Con)]

We are finding that vaccination is clearly the best way to break the link between catching Covid and hospitalisation. Sadly, a large part of our population still has not been vaccinated. Even with the third booster, 80% of that age group have come forward but 20% of the older age group still have not done so. We are trying to target groups that have not yet been vaccinated to make sure that we offer them the best protection possible.

[Lord Hamilton of Epsom (Con)]

My Lords, does my noble friend think that an inquiry will be carried out into the Covid pandemic, and if there is one, does he think that it will prove that every mutation has made this virus more transmissible but less lethal?

[Lord Kamall (Con)]

Undoubtedly there will be an inquiry; in fact, the Government announced that there would be one. There will also be lots of independent inquiries and academics writing about what different countries got right and got wrong. When speaking to my friends who are Health Ministers in other countries, we all say that, looking back, there are things that we could have done differently, in various ways, if we had had that knowledge. But we also have to be very careful about the fallacy of hindsight, and of saying that we would have acted differently had we been in that situation. We can learn from hindsight, and we need to make sure that we do so for future pandemics.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, will the Minister take up the offer made by the noble Lord, Lord Foulkes, of a meeting of the four chief medical officers of the regions and nations of the UK to explore further possibilities and solutions in relation to Covid? Only last week in Northern Ireland I heard two separate virologists indicating that to reduce the advisory limit for self-isolation to five days was a dangerous precedent because many people in that group would remain positive, thereby spreading Covid in their local area. In view of that and the rising levels of Covid and other respiratory viruses, will the Minister immediately talk to his ministerial colleagues and set up such a meeting?

[Lord Kamall (Con)]

One of the things we do in the Department of Health and Social Care is to have regular meetings with our counterparts in the devolved Administrations—all the Ministers do. The noble Lord, Lord Foulkes, shakes his head, but I can tell him that we regularly have meetings with the devolved Administrations. I commit to go back to the department and see who is next due to have a meeting with their devolved counterparts, and ask whether we can put Covid on the agenda.

[Lord Winston (Lab)]

Does the Minister agree that his dismissal of hindsight is one of the most useless ways of looking at this? Surely with continuing infection like this, hindsight is really important, and we should be looking all the time to see how we can change our practice.

[Lord Kamall (Con)]

I was making the point that there is the benefit of hindsight but also the fallacy of hindsight. The benefit is that we learn from mistakes we made in the past. We learn from previous actions what worked and did not work, particularly in a local context. Some of my friends in other countries tell me that what we did in England may not necessarily have worked in their country, and vice versa. There is also the fallacy of hindsight, when people say that in the same situation, 18 months or two years ago, they would have done something completely different with the information we had then. That is what is known in social sciences as the fallacy of hindsight.

[Lord Morse (CB)]

My Lords, I just want to be clear about something. One mistake we made before was not paying attention earlier to predictive modelling from the NHS. Are we sitting on any information that we are getting from the NHS now about what exponential rate may occur in this virus? Please can the Minister reassure me on that.

[Lord Kamall (Con)]

We rely on data from the UK Health Security Agency. It monitors this, and looks at ONS data, data on hospitalisations and the capacity of the NHS to absorb the increase in patient numbers if there is one. That is where we take our advice from and that is what would trigger future action, should it be needed.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I confirm that there is anxiety about the rise in Covid cases, but less about the virus itself than a worry that politicians might reintroduce some of the over-the-top restrictions that led to such collateral damage during the past two years. Hindsight or not, I make the point that people are nervous. Very specifically, will the Minister comment on the fact that, for example, some care homes are using the rise in Covid cases to lock down homes and carry on restricting visits with relatives—which we now know is damaging the mental and physical health of so many elderly care home residents, who suffered so inhumanely, not from Covid but from our response to it? Will he encourage those care homes to open up and be a bit more confident?

[Lord Kamall (Con)]

I start by paying tribute to the noble Baroness for her championing of civil liberties issues and making sure there was a debate on them. I will, with pleasure, take back her point on care homes to my ministerial colleagues who are in charge of social care.

Health Improvement and Food Production

Lord Kamall Excerpts

Thursday 7th July 2022 Lords Chamber

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

My Lords, I also congratulate the noble Baroness, Lady Walmsley, on securing this debate. I am also grateful to all noble Lords for their considered and thoughtful contributions. It is a self-evident truth that we all need food to survive. However, as with many things in life, it is not enough simply to restate this. As noble Lords have rightly said, there are many factors to be considered. How is the food produced? Is it done sustainably? How affordable is it, and what is its impact on our health?

We know that access to good-quality, healthy food is essential to achieving our ambition to halve childhood obesity by 2030, to reduce the gap in healthy life expectancy and to reduce the number of people living with diet and weight-related illnesses. The Government are committed to supporting the production and availability of good food to help improve the nation’s health.

As noble Lords have referred to, our recently published food strategy puts food security at the heart of our vision for the food sector. Our aim is to maintain broadly the current level of food that we produce domestically and to boost production in sectors where there are the largest opportunities. It sets out our ambitions to create a sustainable and accessible food system, with quality products that support healthier and homegrown diets for all. Our farming reforms are designed to support farmers to produce food sustainably and productively and in a more environmentally friendly way, from which we will all benefit. I am sure we all want to see a sustainable and healthy food system, from farm to fork and catch to plate, seizing the opportunities before us and levelling up every part of the country so that everyone, wherever they live and whatever their background, has access to nutritious and healthier food.

We all know that the food we consume plays a role in our overall health. Covid-19 highlights the risks of poor diet and obesity, driving home the importance of better diets and maintaining a healthy weight. As noble Lords have referred to, the Eatwell Guide outlines the Government’s advice on a healthy, balanced diet. It shows the proportions in which different types of food are needed to have a well-balanced and healthy diet, to help meet nutrient requirements and reduce the risk of chronic disease. We know that too many of us are eating too many calories, too much salt and saturated fat and too many large portions, and are snacking too frequently.

While some parts of the food and drink industry are leading the way, by reformulating products or reducing portion sizes, and I think we should pay credit to those parts of the industry that have done so and sometimes met targets in advance of target dates, the challenge to go further remains.

We know that obesity does not develop overnight. When you look at the behavioural contributions, it builds over time through frequent excessive calorie consumption and insufficient physical activity. It is not the stereotype of Billy Bunter stuffing his face with 75 cream cakes. Even eating small amounts of excess calories over time can add up for both adults and children. It catches up with many people over time.

As noble Lords have rightly said, obesity is associated with reduced healthy life expectancy. It is a leading cause of serious non-communicable diseases, such as type 2 diabetes and heart disease, and it is often associated with poorer mental health. We also know now that it increases the risk of serious illness and death from Covid-19.

Helping people to achieve and maintain a healthy weight and a heathier diet is one of the most important things we can do to improve our nation’s health. We all have a role to play in meeting this challenge: government, industry, the health service and many other partners across the country. As a government, we can play our role in enabling healthier food choices by making a greater range of healthier food more accessible; by empowering people with more information to make informed decisions about the foods that they eat; and by incentivising healthier behaviours.

As noble Lords have acknowledged, the food industry supplies most of the food and drink that we consume. Therefore, it plays a critical role in supporting the aims that we want to see, such as selling healthier food and drink. Through our reduction and reformulation programmes, we are working with the food industry to encourage it to make everyday food and drink lower in sugar, salt and calories. The programme applies across all sectors of the food industry: retailers, manufacturers, restaurants, cafés, pubs, takeaways and delivered food. We have seen some progress since the publication of chapter one of the childhood obesity plan in 2016, with the average sugar content of breakfast cereals and yoghurts decreasing by 13%, and drinks subject to the soft drinks levy decreasing by 44% between 2015 and 2019. These statistics are very welcome, but we know there is more to be done.

However, we also need to be careful about the unintended consequences. As an example, when the sugar content of Irn-Bru was reduced, customers complained about the taste. How did the company respond? By claiming to rediscover an old recipe from 1901, which contained even more sugar. It was a huge hit with Irn-Bru drinkers. How do we address these unintended consequences?

[Baroness Bennett of Manor Castle (GP)]

I thank the Minister for giving way. He referred to “everyday food and drink” and the formulation thereof. Will he acknowledge that, if we are talking about everyday foods, we should not be talking about formulation? You do not talk in that way about fruit and vegetables, and unprocessed food.

[Lord Kamall (Con)]

The noble Baroness makes an important point, but we have to recognise the reality: not where we want to get to, but where we are at the moment. People do eat food that will need to be reformulated if we want to make it healthier. Of course, we know that fruit and vegetables are healthy, but not everyone, as we help them transition, will eat fruit and vegetables, or make stuff from the raw products. They will buy products in supermarkets, and therefore if they are buying them, we have to make sure that they are healthier and reformulated. We do not yet live in that ideal world where everyone buys fruit and vegetables, and cooks everything for themselves.

Given that, we also need new regulations on out-of-home calorie labelling. As we know, many people go to restaurants, buy takeaways or have their food delivered. It is important that we have calorie labelling for food sold in large businesses, including restaurants, cafés and takeaways, which came into force on 6 April 2022. As noble Lords are aware, there will be further legislation, on restricting the promotion and advertising of products high in fat, salt and sugar, which will come into effect in the next few years. I know that many noble Lords disagreed with the Government’s views on delaying some of those measures. We will continue to have the end-of-aisle promotion on the target date, but others, such as “buy one, get one free”, are delayed because of the trade-off with the cost of living crisis, but will come. It is delayed, but we have set target dates.

Once again, we have to be open—

[Baroness Merron (Lab)]

I thank the Minister for referring to the delay, which I accept is a delay, to the restrictions on advertising. Can he explain what that has to do with the cost of living crisis, because I have heard that before?

--- Later in debate ---

[Lord Kamall (Con)]

The delay on “buy one get one free” was a cost of living delay. The delay on advertising was because the Act did not come in as originally intended. There was a delay in getting it on to the statute book and with the statutory consultation period. The industry has asked for some time. I know there was a debate among noble Lords about whether we should give in to industry requests, but in the end we will get there. It is important that we have as many people as we can on side. As the noble Baroness, Lady Walmsley, indicated in a previous debate, some companies actually met those targets in advance of the new target. That is to be welcomed and encouraged.

Once again, we also have to be open to potential unintended consequences. Mental health charities and experts—and some noble Lords who have worked in this area—have expressed concerns about the potential effect of anti-obesity measures on those with eating disorders. We must be careful and make sure that we learn and address those unintended consequences. We know that we have imperfect knowledge as humans and should not fall for the fatal conceit of knowledge. We have to rely on the discovery process. Not all pilots will work, but some evidence-led pilots will. We have seen some of the reductions but think, for example, about the minimum alcohol price in Scotland, which has been recently reviewed. The study found that there was

“a marked increase in the prices paid for alcohol by people with alcohol dependence”

and those drinking at harmful levels, but no clear evidence of any change in consumption or severity of dependence. Although such an effect cannot be ruled out, it demonstrates that we cannot assume that every intervention will work. Future interventions will need to be evidence-based. It is important not just to think that something will work; we have to see that it works.

To help ensure that all children have access to healthy diets, the Government provide a nutritional safety net to those who need it the most through the healthy food schemes. These are: Healthy Start, the nursery milk scheme and the school fruit and vegetable scheme. Together, these schemes help more than 3 million children. The schemes also help to support women through pregnancy, and babies and children when they are at home, in childcare and in early years at school. The schemes contribute to our priorities on obesity and levelling up.

Let us talk about some of the partnerships that we need to see if we are all to play a role in this. Schools have an important role to play. The school food standards are designed to restrict foods high in fat, salt or sugar, as well as low-quality, reformed or reconstituted foods. I have heard many noble Lords refer to ultra-processed or very highly processed foods. These standards are meant to ensure that pupils always have healthy options for their school lunch. They state that schools must provide fruit and vegetables every day—at least three different types each week—and no more than two portions of deep-fried food a week. There are also standards on the amount of salt, fruit juice and food cooked in oil. We hope these standards will play an important role in helping children get healthy options and the energy and nutrition they need throughout the school day.

One thing I feel very strongly about, as noble Lords will know, are the grave disparities we see across this country. Others have expressed concerns about this. One of the gravest inequalities faced by our most disadvantaged communities is poor health. The Covid-19 pandemic powerfully underlined the disparities in health across this country. As part of our wider ambition to level up health across the UK, we announced that the Department of Health and Social Care will publish a health disparities White Paper. This will set out a series of impactful measures, including legislation if required, to address health disparities at each stage when they arise. In addition, the Office for Health Improvement and Disparities is looking at many areas of disparity and making recommendations. The review will look at the biggest preventable killers, such as obesity, as well as the wider causes of ill health and access to the services needed to diagnose and treat ill health in a timely and accessible way.

I remind noble Lords that we also have to show some humility. I think my noble friend Lord Kirkham referred to this. As someone who comes from an immigrant working-class community, I say to noble Lords there is a limit to what any Government can achieve with the attitude of Westminster or Whitehall knows best, or by Soviet-style, top-down central planning. I am sure many noble Lords have seen television programmes about how we can eat well for less. The challenge is in how we get those messages from the living room—or the TV room—into people’s kitchens. The noble Baroness, Lady Bennett, talked about the empowerment of local communities and local people. I completely agree: we need to empower local communities through non-state civil society organisations, local community centres, local mosques, temples, gurdwaras, synagogues and churches, which are trusted by some of the hard-to-reach communities, to help them cook and eat more healthily.

I was talking to an official in my department the other day who comes from a Bengali background. She said, “One of the problems I see in my community is that we all love ghee—we think it’s delicious but we know it’s unhealthy.” I said, “How do we in the Department of Health and others encourage people to eat healthily?” She answered, “You’re not going to do it—it has to be from the grass roots up.” We have to work with local civil society organisations. Maybe there could be a national programme across the country, but it is about the local civil society people who are trusted in those local communities. We can call for it and ask for it here, but how do we get that message into people’s homes and kitchens?

I am slightly concerned by some of the anti-import sentiment that noble Lords expressed in this debate. As a development economist once said to me, “You either take our goods or you take our people.” I know that many noble Lords prefer white Europe to non-white, non-Europe, but on this particular issue we have to be quite clear about that. We will not produce everything we need and will have to import some food, and some of it will be healthy. We should not be against food just because it comes from overseas.

I hope to be able to address some of the other specific points made. I am afraid that I do not have all the details on some of the programmes, and I will ask my noble friend the Defra Minister to respond to some of the points that I am unable to at the moment.

Some specific questions were asked about seasonal labour shortages. Seasonal labour plays an important role in the agricultural sector each year. Since 2019, the Government have provided a seasonal worker visa route for horticultural workers in recognition of the highly seasonal nature of that work. To address the near-term need, we will release the additional provision of 10,000 visas under the seasonal worker visa route, including 2,000 for the poultry sector. That means that in total, 40,000 visas will be available for seasonal workers in 2022, providing labour for food businesses across the UK. We will also work with industry to support the upcoming Migration Advisory Committee review of the shortage occupation list. In addition, we will commission an independent review to ensure the quantity and quality of the food sector workforce; it will encompass the worlds of automation, domestic employment and migration routes.

The noble Baroness, Lady Bennett, asked about the agriculture sector growing more fruit and veg. We will bring forward a horticultural strategy for England which will examine the diverse worlds of small, large and emerging growing models and drive high-tech, controlled environmental horticulture to increase domestic production. We will work with growers during development of this strategy, and there will be an opportunity for those in the industry to feed into this, including potentially through a call for evidence, later this year.

A number of noble Lords asked about free school meals. The view from Defra is that a threshold has to be set somewhere. There will always be a debate about the level that you select, but the right one enables more children to benefit while remaining affordable and deliverable for schools. From 24 March this year, the Government have extended free school meals eligibility to include some children who have no recourse to public funds, subject to specified income thresholds; this permanent extension has been in place since the start of the summer term. We also have the school fruit and vegetable scheme, which is designed to benefit children at a vital stage of their development, providing a wide range of fruit and vegetables to children. The food strategy sets out our aim broadly to maintain domestic food production at current levels, in line with our environmental and climate goals. However, we are not asking anyone to choose between food and the environment; our view is that food production, farm businesses and the environment must work together hand in hand.

The noble Baroness, Lady Walmsley, asked about the Future Farming Resilience Fund, which provides free business support to farmers and land managers during the early years of agricultural transition. It does this by awarding grants to organisations, and it helps farmers and land managers to understand the changes that are happening and to identify how and what they may need to adapt their business models, and it gives tailored support to adapt. In July 2021 we awarded grants to 19 organisations so that they can deliver the interim phase of this resilience support. The organisations are listed on the GOV.UK website but I am sure that my noble friend the relevant Defra Minister will want to write about this.

Noble Lords also asked about food labelling. When I was in the European Parliament, we had constant debates about GDA labels versus traffic lights, and how sometimes food that may appear healthy under certain criteria shows a red light. We also debated the pros and cons of both systems. No system is perfect, but we agree that there has to be a system, and it is being consulted on.

I apologise to noble Lords if I have not addressed all the questions that were thrown at me. I know that I, my officials and Defra officials will look through Hansard and respond accordingly. I end by once again thanking the noble Baroness, Lady Walmsley, and all noble Lords who spoke on this important topic. Even though may not always agree on the merits of different approaches, I hope that we have shown anyone watching today that noble Lords share a commitment to improving the health of our nation, wherever people come from, wherever they live and whatever their background. This is a shared goal that the Government cannot achieve alone. We all have a role to play in this important mission, and I look forward to working with noble Lords, national, devolved and local government, industry and local civil society groups to improve the health of our great nation.

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.

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.

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.

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.

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.