Integration of Primary and Community Care (Committee Report)

Lord Markham Excerpts

Thursday 9th May 2024 Lords Chamber

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

I too thank the noble Baroness, Lady Pitkeathley, and all the committee, for their work on this report. I hope that noble Lords will see from my speech that this report is appreciated. Directly on the question of the noble Baroness, Lady Finlay: the recommendations are welcome, and I hope that my speech will set out how we are acting on them.

Before I get into the detail, like other noble Lords, I want to acknowledge my noble friend Lord Jamieson’s maiden speech. He brings a wealth of experience to this, both professionally and from local government. I was particularly struck by his passion for housing. I must admit it is one that I share: it is core to so many people’s lives, in terms of well-being, their sense of happiness, security and stability, and, of course, their health. I look forward to discussing further how we can make that the core of so many things. As the noble Baroness, Lady Merron, rightly said, the noble Lord’s mother would be proud of him today.

I will start by recognising the points made by all noble Lords about the importance of primary care and community care integration. The noble Baroness, Lady Pitkeathley, said that nearly all of the four former Ministers strongly made the point that we see more and more resources going to hospitals, and we also know that there are more and more patients who do not need to go there. Around 50% of the people who go to A&E do not really need to be there. We see a lot of children under 12 going in with tooth decay, when better primary care and dental services would avoid that. Unless we change things, we will see the situation set out by the noble Lord, Lord Jamieson: staff levels in healthcare will go from one in seven of the population to one in four, and then one in three.

I think we all agree that we have to get upstream of the problem. The noble Baroness, Lady Tyler, rightly set out the need for prevention. I have seen some excellent examples of that, and Redhill is just one. The noble Lord, Lord Altrincham, and others described the excellent examples we have seen in the work of Professor Sam Everington in east London: making primary care central to care in the community, and assessing how many services can be taken out of acute settings.

As the noble Baroness, Lady Armstrong, said, centring the service around the needs of the individual, in contrast to the existing set-up, needs a shift in resources towards primary care. Our belief is that that can occur only if the ICBs, ICPs and ICSs are equipped with the information and have that helicopter view and the ability to shift resources from one to the other.

The noble Baroness, Lady Merron, asked a very direct and correct question about why we are increasing hospital care resources. I have some lived-in experience of that. It is a gutsy move to say that we will shift resources away from the hospitals. To make the whole equation work, you are often talking about reducing hospital services and the number of hospital beds, and putting them in the community instead, which we all agree is absolutely the right way to go. But we all know the reaction you get from local groups as soon as you try to do something like that. I completely agree that “neighbourhood health service” should be the name. It takes cross-party work to do that, regardless of who is in government after the next election. Speaking candidly, we need to provide each other with air cover during some of those difficult conversations, including with the ICBs and ICSs. For my part, I pledge to play that role, whether I am sitting on this Bench, the Bench opposite or any other bench after the election.

I am sorry that the government response was seen as disappointing. I hope we can address a lot of the issues raised by the noble Baroness, Lady Pitkeathley. We agree with the whole emphasis of the report and its recommendations, the analysis of the problems and the need to focus resources on primary care and prevention. We also agree with the substance of most of the recommendations.

Our main difference is whether we should be mandating the recommendations on the ICBs, ICPs and ICSs, versus enabling them to adopt them. For want of a better word, this is a bet that we are putting on the ICBs, that they are the right bodies to do this, giving them the time and the space to try to do that. I admit that I am naturally resistant—and that is likely to show in the emphasis in many of my replies—on whether we should be mandating them, when we want to give them the flexibilities to do those things at a local level. We should be enabling them to do it, and we should be encouraging them to do it, but where we stop earlier is on whether we should be insisting and mandating them.

I hope that that gives a general sense, but I shall turn to each part, starting with structure and organisation. I agree with the committee’s recommendations to allow the ICSs the appropriate time to mature before introducing any wholesale system reforms. I hear the point of the noble Lord, Lord Allan, that three years is a long time. We need to make sure that we get some of those early indicators as we go along, but at the same time we need to give them time to bed down and accept that some will do a better job than others, which of course is the inevitable consequence of giving people the ability to manage their own local systems.

On the integration, we are giving these bodies the ability to bring together the NHS, the councils, the voluntary sector and the others, with the focus on prevention and better outcomes. The noble Lord, Lord Altrincham, and the noble Baroness, Lady Tyler, emphasised the importance of prevention, and the noble Lord, Lord Jamieson, addressed the raising of life expectancy and quality of life. I am pleased to inform the House that we see the NHS health check as a flagship cardiovascular disease prevention programme. As mentioned, using the app is a key way in which people can engage with that, book their services and have a lot of those type of tests at home.

With respect to the committee’s recommendation relating to a single accountable officer and coterminosity, ICSs have the flexibility to develop accountability arrangements that best meets the need of their local population. We have various successful models of accountability implemented, including as partnerships and committees. Again, where an ICS identifies that its boundary is not meeting local needs, it can request a review. Local authorities are a critical partner here. The NHS has recently published a process for boundary change requests that requires support from all local authority partners in this. At the same time, the noble Baroness, Lady McIntosh, mentioned in her speech some of the challenges around being coterminous with borders, and how that can cut across some of the things that we want to see happening in terms of choice. It is not always a straightforward question. Again, that shows that this should not be something we are mandating, but we are enabling the ICBs to address that, if it is the right thing for their area.

On the question of the noble Baroness, Lady Tyler, on elected officials chairing ICBs, NHS England has set criteria prohibiting all ICB chairs and non-exec members from holding a public office role, or a role in the healthcare organisation within the ICB area. However, the elected local authority, the local government officials, are able to chair the ICP—the partnership—which of course is a very important committee that sets the health and care strategy.

The committee recommends that the CQC pilot ICS assessments are widely disseminated—a point the noble Baroness, Lady Tyler, also raised. I can confirm that the CQC will publish the pilot findings as narrative reports that will be available to the public. The CQC assessments will consider how well health and social care are working together to deliver high-quality care, and the assessment will also score each ICS against the three themes of leadership, integration, quality and safety—I think that is four themes, actually; that is what happens when you try to adjust the brief.

On primary care contracts and funding, as the noble Baroness, Lady Redfern, also mentioned, the primary care contracts are kept under review and we will consult the profession on any proposed changes. As I think noble Lords know, we launched a public consultation in December 2023 on inclusive schemes and expect to publish a government response later this year.

On the co-location point which the noble Baroness, Lady Pitkeathley, raised, the Government agree with the benefits of co-location and multiple disciplinary teams for promoting integration, and we expect the different models of integration to be implemented across the country based on local needs and the availability of estates.

The noble Baroness, Lady Merron, mentioned investing in primary care. We want GPs to deliver the best care to patients, which is why we are backing the NHS with this significant capital investment in this space. That includes the £4.2 billion this year in operational capital for integrated care boards to allocate locally, including to primary care.

The committee outlined a suggestion to better utilise the better care fund and pooling of budgets. The Government encourage local areas to maximise the full potential of the better care fund and to pool budgets. We have seen local areas committing additional money to their better care fund to support joint commissioning and integration. Place-level committees are crucial to delivering integration, and the Government published a toolkit in October 2023 to support the development of shared outcomes as a powerful means of promoting joint working.

As the noble Baroness, Lady Armstrong, raised, proactive care involves providing personalised and co-ordinated care and support for people living with complex health and care needs. A good example of where this works well is the Jean Bishop Integrated Care Centre in Hull, a geriatric-led multidisciplinary service. Measured outcomes show that, between April 2019 and September 2022, the service contributed to a 13.6% reduction in emergency hospital attendance for patients aged over 80. Over the same time, there was a 17.6% reduction in emergency department attendances for patients in care homes. However—this also relates to the point on training later on—where we have fantastic examples such as that one, we need to make sure that that is disseminated and understood as part of the integration sharing.

On systems and data sharing, I have to admit that, like the noble Lord, Lord Allan—this will not be a surprise to many people—I am a fellow data anorak. I understand the importance of the NHS number and common place references in that. I learned about fuzzy data matching the hard way in one of my earlier jobs. You need only to look at what happened to the local Laura Ashley store in Kyiv, funnily enough, to see the consequences of fuzzy data matching and having a misallocation of dress sizes, shapes and colours because I did not fully understand the skew references in terms of fully data matching. Therefore I understood the hard way and the consequences of that.

I think we all understand the point the noble Baroness, Lady Finlay, made about the frustration that many people increasingly express.

The DHSC was called by the report to

“publish high level guidance to standardise the collection of data and portability requirements in commercial data-sharing software, especially for social determinants of health”,

and mandate how clinicians “code” information. The noble Baroness, Lady Barker, raised a key point on responsible handling of data. We already set standards of coding for data and set national standards for data systems to ensure interoperability. The Government have published a plan for digital health and social care that includes milestones for setting standards on interoperability and systems architecture, enabling all relevant health and care data to be accessed by those with a legitimate right to access it at the point of need, no matter where it is held. We are also moving to a system of data access by default for secondary users of NHS data, which will be supported by the implementation of the secure data environments—SDEs—which mean that data from NHS and related services can be used for research without identifying information needing to be shared.

The report also calls for one or more interoperable data systems to be centrally procured, as was rightly flagged as a key issue by the noble Baroness, Lady Barker. We do not believe that the solution lies in the purchase of a single system for the NHS—we have all seen the past problems that has led to—but we believe it involves the need for a common set of standards and cloud-based architecture to ensure that digital records can be shared electronically, that services are interoperable, and that you can connect information based on the NHS number of the individual rather than one organisation. That will improve the provision of safe and personalised care as patients move between different parts of the health service and the social care system. The approach taken seeks to strike an effective balance between central and local initiatives.

On the question from the noble Baroness, Lady McIntosh, about sharing one prescription record, I say that this is where we see that Pharmacy First has been a vital enabler. Making sure that we have the systems right so that the pharmacy can write into the GP records to show what it is prescribing the patient gives a blueprint that we can repeat across all the systems—it gives the writing capability to do that, so to speak. All 42 ICBs have had a connecting care record solution since March 2022, which is fundamental to how services can share their information.

I am coming up to time. I will quickly say that I agree with the point made by the noble Baroness, Lady Merron, on workforce and training, and that integration of training should be part of all that. I conclude by saying that I will follow up in writing, as ever, to make sure I pick up any questions that have not been answered. I thank all noble Lords for their contributions, particularly the noble Baroness, Lady Pitkeathley, and congratulate the noble Lord, Lord Jamieson, once more on his maiden speech.

Immunisation: Children

Lord Markham Excerpts

Wednesday 8th May 2024 Lords Chamber

[The Lord Bishop of St Albans]

To ask His Majesty’s Government what plans they have to address the decline in uptake of childhood immunisations.

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

NHS England’s 2023 vaccination strategy set a range of ambitions, including to improve uptake of children’s vaccines across the board. On mumps, measles and rubella in particular, between January and March the NHS and partners administered around four times as many MMR vaccinations to those aged five to 25 as last year and focused on engaging groups with historically lower vaccination rates. We intend to build on these experiences to further improve uptake.

[The Lord Bishop of St Albans]

I thank the Minister for his reply and pay tribute to the NHS for its sterling work in this area. I have a couple of points. First, I wonder what consideration His Majesty’s Government have given to working with leaders of harder-to-reach groups, some of the smaller groups and some of the faith groups, where messaging can be more powerful when it is done by a local leader. Secondly, there is a worrying increase in the level of whooping cough. Indeed, I believe there has been a childhood death recently. Can the Minister update us on what is being done about this worrying development?

[Lord Markham (Con)]

I thank the right reverend Prelate. First, I completely agree that using faith leaders is often a very good way to reach hard-to-reach communities, particularly as it is often ethnic-minority communities that have lower rates of vaccine uptake. Whooping cough has been a concern; we had about 850 cases in January 2024 compared with about 550 for the whole of 2023. We are deploying a number of strategies that have been proven to work in areas such as MMR: using outreach groups, having leaflets in 15 languages and having recall programmes. In the case of whooping cough, if we can get pregnant mothers vaccinated, that is 97% effective.

[Lord Allan of Hallam (LD)]

My Lords, I know the Minister agrees that it would help if parents had online access to their children’s vaccination records and, with his customary efficiency, he kindly wrote to me following a previous exchange on the digital red book to say that parental access to baby records is being piloted in 70 general practices. Can I ask the Minister to give us a ballpark date for when it might be rolled out to the other 6,000-odd GP practices in the United Kingdom? Will it be shortly, soon or in due course?

[Lord Markham (Con)]

Or “none of the above”. The noble Lord is quite correct. Of course, data is vital in this whole area, and getting that sharing of data and understanding with people is vital. I will come back on the precise date, but I hope it will be soon.

[Baroness Finlay of Llandaff (CB)]

My Lords, there have been more than 1,000 cases of measles in the last six months. What action are the Government taking to make sure that mothers are given options, which maximise convenience, of places to go and times when they could take their children for vaccination, rather than tying them to appointments that may clash with the working day when they cannot get childcare for other children?

[Lord Markham (Con)]

That is an important point. We must try to make sure that vaccination clinics are widespread. We have used pop-up clinics successfully in many locations, particularly around London, and that has helped get 25,000 more jabs into unvaccinated people’s arms in the last few months.

[Baroness Manzoor (Con)]

My Lords, I welcome the action that the Government are taking to ensure that MMR vaccinations are going up in underrepresented groups. Can my noble friend the Minister say what action the Government are taking for people seeking asylum? What kind of service are they being offered, and what access do they have to vaccination?

[Lord Markham (Con)]

I thank my noble friend for the question. Actually, it is not just asylum seekers; it is often migrant groups full stop. Their communities or the countries they have come from often do not have the same level of vaccination programmes. It is part of the check we try to give people as they come into the country, and something we ask GPs to look out for, so that we can get them in a catch-up programme. A lot of the work we are doing on outreach is also particularly focused on those communities.

[Lord Watts (Lab)]

My Lords, is it not the case that we need to make the case for public health, and that our public health policy is determined by parents getting their children vaccinated? Do we not need to make the case that they put their own and other people’s children in danger unless they comply with vaccination?

[Lord Markham (Con)]

Yes, absolutely. Unfortunately, we are all aware of the Wakefield effect on the MMR vaccine. That knock of confidence was completely unjustified and irresponsible, but we know the impact it had. Clearly, a lot of the anti-vax sentiment around Covid has not helped either. We need to overcome all these messages.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, on the Wakefield effect, as the Minister called it, he will remember that the impact it had on a lot of people was very profound. In particular, some of that was associated with incidence of autism, which again was completely unjustified. Can he tell the House whether any work has been done, in the interests of public information, on what happened to the children who were not vaccinated at that time, and what the outcomes were for them? As a deterrent, it might be useful for people to know what the worst that can happen is if you do not get your children vaccinated.

[Lord Markham (Con)]

The noble Baroness is quite right. I had two young sons at around that time, and it was a concern. Of course, we did go ahead, but it was a consideration. It is an excellent question. I have not seen the study of those various cohort groups but I will go back, because it is something we need to bring out.

[Baroness Merron (Lab)]

My Lords, it is concerning that measles cases continue to rise, with a particular spike in London, where certain areas have low vaccination rates. With the advent of microarray patch technology, can the Minister confirm that this is being looked at? Does he agree that the chance to dispense with using needles and special storage, and the opportunity to use less of professionals’ time, could present an opportunity to drive up vaccination rates?

[Lord Markham (Con)]

It has to make sense to take more measures that are easy for people, including maybe less skilled people, to operate. Funnily enough, I was talking just today to the head of Moderna about how it is packing syringes, or has planned to for vaccinations going forward, rather than vials, to take that step out of the process. The easier we can make it, the better.

[Lord Kamall (Con)]

My Lords, the right reverend Prelate rightly spoke about the role of faith communities in reaching those hard-to-reach communities. I know that my noble friend the Minister has answered these questions previously, but I wonder what lessons the department has learned from previous vaccination campaigns—Covid, MMR, et cetera—to make sure that the initiatives it is using to reach those hard-to-reach communities are more effective.

[Lord Markham (Con)]

It really is about having the whole toolkit. Clearly, it is about making sure that we are using communications in 15 different languages. It is about the outreach groups and, particularly, the catch-up programmes. We have been doing one for 17 to 25 year-olds for polio and MMR. It is about all those strategies and the pop-up clinics, so that it is very easy to catch people in places that are convenient for them.

[Baroness Hollins (CB)]

Does the Minister agree that the anti-vax sentiment is a powerful deterrent with some of the misinformation on social media? Is there anything more that can be done to try to counter that misinformation?

--- Later in debate ---

[Lord Markham (Con)]

We are trying to get the facts out there. I appreciate the efforts of all noble Lords in doing that. I welcome any ideas on what more action we could be taking. The UK measures at the highest level internationally in terms of parents who believe that vaccines should be used. The level is 97%. That is high, but the trouble is that 3% in concentrated areas can still be quite dangerous.

[Lord Geddes (Con)]

My Lords, further to my noble friend’s question about asylum seekers and immigrants and the Minister’s answer, how are GPs going to check whether such children have been immunised? They will not be carrying any paper proof, and they will certainly not have an app on their phones.

[Lord Markham (Con)]

It is often a case of asking them and seeing what they recall. There are a lot of vaccinations, such as the six-in-one ones. Often, they might not have had any vaccinations. My noble friend is correct that it is not easy to find out that information, but in many cases, where we can, it is good to apply the precautionary principle and offer vaccinations anyway.

International Health Regulations: Amendments

Lord Markham Excerpts

Tuesday 7th May 2024 Lords Chamber

[Lord Strathcarron]

To ask His Majesty’s Government what assessment they have made of the warning by independent WHO experts at the Brownstone Institute that amendments to the International Health Regulations to be made at its forthcoming meeting in May 2024 may contravene Article 55 of those Regulations.

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

The Government are satisfied that negotiations on amendments to the International Health Regulations comply with Article 55 of those regulations. Member states proposed amendments, which were communicated to all member states in December 2022 and then posted online. Since then, member states have been negotiating the proposals. As per Article 55, the timeline is well in advance of the World Health Assembly this May, where they are due to be considered for agreement.

[Lord Strathcarron (Con)]

I thank my noble friend the Minister for the reply. Irrespective of the WHO’s current interpretation of its own rules, the fact remains that Article 55(2) clearly says it is required to give member states four months’ written notice before the amendments are agreed at the end of this month, and it has clearly failed to do so. Bearing this in mind, and that the Government have been less than transparent about the UK’s aims in these negotiations, and bearing in mind the WHO’s woeful performance in the Covid pandemic, does the Minister agree that, regardless of the legal position, it would be wise to delay the votes until the next WHA so that we can have proper parliamentary scrutiny of what the Government are signing us up to?

[Lord Markham (Con)]

The key thing that we are looking at here, which I would hope that all of us could agree on, is that we will not agree to anything in this process which impacts our sovereignty as a country and our ability to react to a pandemic in a way that is appropriate for this country and this Government. I hope that we can all rely on that, and that is very much our approach to these negotiations.

[Lord Allan of Hallam (LD)]

My Lords, objective 2 of the UK’s Global Health Framework says that the Government will:

“Reform global health architecture, including through a strengthened World Health Organization, driving more coherent governance and collaboration across the international system”.


Aside from producing a winning sentence for policy buzzword bingo, can the Minister point to any specific global health architecture wins that the Government have had in the year since that policy was published?

[Lord Markham (Con)]

I am not sure in what year that policy was published. However, I can talk about how, when we were president of the G7 in 2021, we led the calls to donate vaccines on a worldwide basis, which led to 1.2 billion doses being donated to countries all around the world, led by Britain’s initiative with AstraZeneca. That was great global co-operation and we can feel very proud of it.

[Lord Watts (Lab)]

My Lords, the Government said that they would learn the lessons from the Covid problems. How have they tackled the issue of production of equipment that was needed for Covid but which we did not have? The Government promised to make sure that we will have it next time. Can he give us an update on that?

[Lord Markham (Con)]

Of course, we covered much of this when we had a Question on 15 April around this. This is about making sure that we have the diagnostic capability—which we have—and the ability to scale up. We have made a £125 million-fund available for precisely the issue that the noble Lord mentions, so we have the mothballed capacity ready to operate at quick notice.

[Lord Hannan of Kingsclere (Con)]

My Lords, on 14 January 2020 the World Health Organization declared that there was no evidence of person-to-person transmission of the Covid virus. It was parroting the line of the Chinese Government, which at that time were terrified of any investigation of the lab leak theory. Does my noble friend the Minister worry that giving more powers of co-ordination and control to this body will mean less diversity, more homogeneity and the suppression of any attempt to be a Sweden or a Florida, or anyone else who might buck the consensus and thereby, God forbid, suggest that these extreme and draconian lockdowns may not have been the best policy response?

[Lord Markham (Con)]

We are talking about two very different things here. One is ensuring that, as a country, we are armed with the information as quickly as possible so that we can act; getting the genomic sequencing of the original strain was vital for us to be able to prepare a vaccine so quickly, so that information sharing is vital. In terms of the impact on our ability to act as a sovereign Government, that is something very different; it is key and understood, and the Covid inquiry now is all about learning lessons. As my noble friend knows, I have personal views about that second lockdown: we need to be looking at the wider impact of that second lockdown in areas such as mental health and other areas in which there was an impact on children, but that is a matter that will always be for the UK Government to decide on.

[Lord Hannay of Chiswick (CB)]

My Lords, the problems that arose during the Covid pandemic in respect of the WHO were because the WHO was let down by one of its members and not properly informed quickly enough of the symptoms that were occurring in that country. There is no point in blaming it when the blame rests with the collective membership of the WHO, which now needs to be repaired. Does the Minister not agree that postponing that repair work will not serve our or anyone else’s purpose?

[Lord Markham (Con)]

I do agree: I do not think that it would help to postpone it. I had this exact conversation with the American Health Secretary, who is very aware that we are getting nearer and nearer to an American election and, for all the countries to be able to co-operate fully, the timing is right to reach a solution now. However, we will not reach an agreement at any cost or anything which might impact our sovereignty.

[Baroness Merron (Lab)]

My Lords, the Brownstone Institute, to which the noble Lord’s Question refers, was set up to work against Covid restrictions and lists articles which argue that Covid-19 vaccines do not work, that children should not be vaccinated and that vaccine mandates compare with the crimes of the Soviet gulag. On this basis, perhaps the Minister would like to comment on what note he should be taking of the Brownstone Institute, if any. What assessment has been made of the impact of dangerous propaganda like this on the low take-up rates of vaccinations that we see among minority ethnic groups and where there are regional and social disparities?

[Lord Markham (Con)]

I thank the noble Baroness. All Members of the House, when we had a good Question on the take-up of Covid vaccines, agreed that information supporting the take-up is a vital health message to get across. To any detractors, I say very firmly that it is not the view of the Government, and I know that it is not the view of nearly all noble Lords.

[Lord Moylan (Con)]

My Lords, returning to the treaty, am I right in thinking that it contains provision that envisages a role for the WHO in vaccine certification? If that is the case, how would that have played out when we wished to roll out our own vaccine very speedily? Would we have had to wait for WHO certification?

[Lord Markham (Con)]

Again, my noble friend will agree with me that our ability to assess the vaccine more quickly than any other country and roll it out very quickly was a key asset for the UK. Clearly, we will not do anything that will put that at risk.

Homecare Medicines Services (Public Services Committee Report)

Lord Markham Excerpts

Thursday 2nd May 2024 Lords Chamber

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

My Lords, I am a bit slow in getting up. I will blame my son Xavi, who is in the Gallery. I was playing with him a bit too much this weekend, so I apologise. Now I am up, I will be fine.

I start by thanking noble Lords, and particularly the noble Baroness, Lady Morris. This is a very important area about which, I freely admit, 10 days ago I knew very little. I guess it was my noble friend Lord Blencathra who raised awareness in the first place, but I think this has been an excellent example of what the House of Lords does really well, which is to realise that there is an area that needs looking at.

On the question from the noble Lord, Lord Carter, about whether we found a report useful: yes, definitely. I have a couple of ideas and I think the noble Baroness, Lady Wheeler, has some good ideas on some of the next steps. I thank all noble Lords on the committee for their contributions and I am pleased that it is felt that the department has responded positively. I must admit that, in briefings, you can always tell when officials get it, are keen and have the bit between their teeth—and that is definitely the feeling I got here.

I will spend a few minutes unpacking something that impressed me: it really came home to me just how important this is, not just in terms of patient treatment today but for how we all want to deliver the service in the future. I call it the four Ps, on why I think this is important. First, there is prevention. I think we all agree that more prevention needs to begin at home, with home treatments and home testing services, to create a fantastic service in this area.

The second P is primary care: we want more care in the community and that is going to happen only if we have these sorts of services working really well. Noble Lords have heard me say it many times, but Bromley-by-Bow is a perfect example: they are treating patients with type 2 diabetes and CBT patients in their home rather than in hospital. But that can happen only if we have a really gold-plated homecare service, which they are able to provide in that very small instance. What we are really talking about today is the professionalisation of that type of service, so we can offer it much more widely.

My third P is of course patient care, brilliantly described through his own personal experiences by my noble friend Lord Blencathra, and the effect that that had on him, but also with the Crohn’s disease example set out by my noble friend Lord Mott, and the realisation that, as annoyed as we all often are when we wait all day for a delivery that does not turn up, in these cases we know that there are real-life consequences. Those consequences do not impact only the individual involved; they have knock-on consequences for the rest of the health service if patients have to go into hospital for that treatment instead.

Fourthly, I see the future in the area of precision medicine. I have started to understand that, by seeing what the likes of BioNTech and Moderna are doing, using mRNA to fight cancers on your behalf. This is personalised treatment, which moves away from the model of mass manufacturing in big pharma factories to a point-of-care delivery of services. That is why it is so vital to get this right.

The report’s title, An Opportunity Lost, is a perfect way to capture what we are trying to do here. We all understand that it is a complicated area, and there are very clear reasons why a lot of it is delivered through the pharmaceutical industry. It makes sense to have that service connected to it all, particularly as a lot of their treatments become more complex.

I think all noble Lords would agree with the point of the noble Lord, Lord Blencathra, that we do not want the NHS to deliver on these areas, and that it has enough on its plate already. As the noble Baroness, Lady Morris, said, we need someone who is going to grab hold of this. Leadership and management 101 is that you need someone to lead a business, and that is clear here. We will be appointing and announcing that person very shortly. I cannot say it yet but, from some of the comments made today, I think that noble Lords will agree that it is a logical appointment. I probably should not go further than that. NHSE and its service delivery will be included in all of this. To the point of the noble Baroness, Lady Wheeler, all of this should absolutely begin now. A lot of this job is to make a fragmented service coherent.

As to what their job list should be, noble Lords set this out very clearly, and it is set out very clearly in the recommendations. I hope that that is clear in some of our responses, but I shall try to add some flesh to those bones. Number one on the job list is clearly data, and a common set of KPIs is fundamental to this. I was completely unclear on the sentence that the noble Lord, Lord Shipley, read out—it was probably more than one sentence. I was none the wiser, so there is definitely a mark of “could do better” there. As the noble Lord, Lord Mott, said, we need clarity, a common system of measurements and complete transparency all the way through, accompanied by a clear complaints system. No business in the world would get anywhere without that fundamental data, in as close to real time as possible.

Secondly, I completely understand why the regulatory lead has evolved in this way. It is natural that the MHRA looks after the medicines aspect, such as efficacy and any side effects. It makes sense that the General Pharmaceutical Council looks after some of the dispensing aspects, but at the core of these homecare services is the delivery of treatment. As the noble Lord, Lord Willis, suggested, that is why the CQC is the natural lead for doing that. I will not comment on the assessment of noble Lord, Lord Blencathra, on its involvement in this to date, but it is about making it very clear that it is a priority. That is key: what we have tried to do will be the future, so it should be a priority.

On the question from the noble Baroness, Lady Wheeler, my understanding is that meaningful conversations have begun towards that. It is quite clear that the CQC would be the natural lead because this is mainly about treatment and the delivery of healthcare services.

The third important thing on the job list is digital. It is amazing just how basic things are there. I am completely with the noble Lord, Lord Allan, that we should expect an Amazon-style delivery. We are all very used to that these days, where you get a message that your delivery is on the way. Providing that sort of information is not rocket science. We should definitely look at that, so that the service is at least as good as his cat’s service, if not—I hope—a lot better.

The fourth job is to provide clarity on the costings. As the noble Lord, Lord Willis, and others have said, the commercial confidentiality aspect should not be an issue. All we are saying is that, if they are charging £100 for an item, which includes both the medicine and the service delivery, there is an element—£20 or whatever it is—associated with the service delivery. My suspicion is that the power is with the pharma company here—that goes to some of the points raised by the noble Lord, Lord Carter. Often, the service is the tail-end Charlie in the whole set-up. As the noble Lord, Lord Carter, said, this is just basic operational and service delivery. We need to make sure that it is a very clear part of it in the contractual sense that the noble Lord, Lord Allan, referred to.

We need to do some training with our contractual negotiators. This is not just about driving down the price of the medicine—which I think we would all guess is the primary part of the negotiation—but, where there is a treatment component, is about making sure that the delivery is key. If the noble Lord, Lord Hunt, were here, that is exactly what he would say about value-based procurement. Small things going wrong with that can have huge consequences not just for the patients, as we have seen with the examples raised today, but through knock-on costs for the rest of the service.

For what I hope will be a constructive way forward, I propose that the senior responsible officer—the leader for all this—will be appointed soon. With noble Lords’ permission, I would like to invite him or her and the relevant NHS people to a round table with the noble Baroness’s committee. With them having had a bit of time to get their feet under the table, but not so much that they have already gone down the path too much, it would be excellent to have a hopeful round-table conversation. I hope that will be a constructive way forward to make sure that they are setting off on the right track.

As ever, when we finalise this all, I will write on any points that I have not covered, particularly on blister packs. We probably have been talking at cross purposes, so I will make sure that the point is understood and taken back.

In conclusion, this is definitely useful. As I say, I will come back to the committee with more thoughts, but one thing off the top of my head is that in the whole area of precision medicine there is just such an opportunity there for a whole new way of treating cancer—I hope that one day it will replace chemo, which we know is a blunt tool. There is a whole mechanism there for delivering which we will need to build on in these homecare-type areas, and that could be a very interesting area for the committee to look at.

I have learned a lot from this area, and I thank your Lordships for shining a light on it. I hope that noble Lords feel that we are getting the right attention paid to all of it. However, we absolutely need to continue to hold feet to the fire, and I know we can rely on all noble Lords, quite rightly, to make sure that we do that.

NHS England: Ovarian Cancer

Lord Markham Excerpts

Thursday 2nd May 2024 Lords Chamber

[Baroness Hayter of Kentish Town]

To ask His Majesty’s Government what assessment they have made of NHS England London stating that “anyone with ovaries can get ovarian cancer” in a social media post rather than referring to “women”, whereas at other times NHS England refers to “men” in relation to prostate cancer; and whether this wording has been market tested with women, including those for whom English is a second language, to ensure that it is fully understood.

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

We are writing to NHS England about NHS London’s social media post, to reiterate the expectation that biological sex should be front and centre of all health-related information. Removing language around biological sex has the potential for unintended health consequences. The Government are committed to upholding the rights of women and girls, which is why we are consulting on updates to the NHS constitution, including the use of clear language based on biological sex.

[Baroness Hayter of Kentish Town (Lab)]

I warmly welcome the Minister’s response, which is probably welcomed across the House. Given the Government’s welcome assurance that “single-sex wards” means “biologically single-sex wards”, will he also discuss with the GMC the video on its website that advises doctors to ask trans patients which wards they would prefer to go in? Perhaps he could also talk to the GMC about its practice of allowing doctors to change their gender on the register without any advice that they should inform patients of their biological sex. Although I approve of the Government saying so, it is very hard for patients to ask for a doctor of a particular sex for intimate care if they do not know the sex of their doctor.

[Lord Markham (Con)]

First, I thank the noble Baroness for all her work in this space. I will continue to work closely with her, including by writing to and meeting the GMC as necessary on all these matters. On her second point, while I respect that many clinicians may wish to keep their information private, we have to understand that, for many people, it is the patient’s right to be treated by someone of a particular biological sex and to know what that is. We have to make sure that those feelings and understandable sensitivities—which are sometimes religious—are catered for.

[Baroness Burt of Solihull (LD)]

My Lords, I totally agree that the wording looks a bit odd, to say the least, and that we should give special consideration to the wording for people for whom English is not their first language. However, there are tens of thousands of trans and non-binary people who would be missed out if we did not spell out that trans men can still get ovarian cancer and trans women can get prostate cancer. Does the Minister agree that what we need is clear, incisive language, so that everyone can be aware of the health risks that apply to them?

[Lord Markham (Con)]

Yes, absolutely. We all come at this from the perspective of making sure that health is front and centre, which is why the primary descriptors should be “man” and “woman”, as I think we all agree. Beyond that, we should clarify that “woman” may mean a “person with ovaries”—but the primary descriptor is “woman”. I hope that we can all agree on that.

[Baroness Meyer (Con)]

My Lords, given the lack of specific data on the consequences of NHS England’s adoption of gender-neutral language and services, does my noble friend the Minister agree that the millions of women who have been affected should have been consulted before such measures were implemented? Does he agree that, if medical records fail to document patients’ biological sex, clinicians would be at risk of giving trans people the wrong medication?

[Lord Markham (Con)]

Yes. Once again, I come at this from the perspective that health is the primary factor here. Clearly, a person’s biological sex is a key part of the information on their record that any clinician needs to know, so that absolutely needs to be primary.

[Lord Cashman (Lab)]

My Lords, I will make a simple point with which I hope the Minister agrees. Is it not to be welcomed that we come up with language that is inclusive and reaches as many people as possible, as the noble Baroness, Lady Burt, suggested, and as is indicated in the framing of the information we are discussing?

[Lord Markham (Con)]

Yes. To reiterate, I think that we should always use “man” or “woman” as the primary descriptor. For people with English as a second language, “woman” is very understandable. We can then be inclusive by saying a “person with ovaries”, so that we are absolutely clear. My remit here is health, so I want to make sure that most people, especially if English is their second language, understand who we are referring to when we say “woman”.

[Lord Patel (CB)]

My Lords, I am slightly reluctant to stand up and get involved, but I have done so previously, and I will continue to support the campaign led by the noble Baroness, Lady Hayter, to make sure that the words “woman” and “mother” are not removed from our language—I absolutely support that. I will muddy the waters a bit. There is, in medical terms, a syndrome called androgen insensitivity syndrome, which occurs in about two to five per 100,000 births. The person born is registered at birth as a female, because they have the phenotype of a female and external genitalia that resemble those of a female. They grow up as female, and the diagnosis is often not made until puberty, when they do not menstruate—but they develop breasts. They do not have ovaries. They often identify themselves as female for the rest of their lives, and they occasionally get married. I have looked after such a person myself. They are registered as female, they do not have ovaries and they sometimes have internal testes, which can become cancerous. So it is correct that only people with ovaries can develop ovarian diseases, including ovarian cancer. As I said, I have muddied the waters.

[Lord Markham (Con)]

I am not sure that there was a question there, so I might take the easy option of thanking the noble Lord for his comments—and for maybe muddying the waters—and moving on.

[Lord Collins of Highbury (Lab)]

My Lords, all noble Lords have raised the issue and the Minister has put it quite rightly: health has to be the primary consideration, language is quite important, and how do we reach difficult communities who are isolated, whether for community or religious reasons, and so on? On a visit to Kenya last year, I was able to see innovative practices. Women living with HIV are 60% more likely to get cervical cancer, so local treatment centres were being used as a way of testing and screening so that comorbidity was properly addressed. The success of these campaigns was because they were backed up by using individuals trained in the community to empower and educate their community. They provide a critical service by building trust and confidence, because many people are reluctant to be tested and screened in the way that noble Lords have been talking about. That innovation has been incredibly successful in Kenya. Does the Minister agree that we can learn from that sort of thing and start doing it in this country?

[Lord Markham (Con)]

Absolutely, and I hope noble Lords have seen that I am keen to learn from wherever. I would be interested to understand more in this case. As I think we are all saying in these arguments, it is about making sure that we are being sensitive and inclusive in language, but that we are also being very clear in our language about what we mean so that health always comes first.

[Lord Allan of Hallam (LD)]

My Lords, I recently looked at the prostate-specific antigen screening programme advice, which was very good and met the requirements that the Minister has set out. However, I got there only because of a Peer-to-Peer networking episode, where I bumped into another Peer who said, “You really need to go and look at the PSA screening”. It struck me then that this journey into screening programmes is still very confused and ad hoc. Will the Minister look at that and at how we can make sure that whoever you are and whatever your gender, your age and your other risk factors, you get the direction you need into the right screening programme?

[Lord Markham (Con)]

I thank the noble Lord; he is always very good at bringing up some of those cases. I will look into it and make sure that we do that.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I welcome the untangling of linguistic confusion and the implications for policy. However, when the Minister says, “When we say ‘woman’, we all know what we mean”, I am not convinced that that is true in policy circles. Increasingly, inclusive linguistic demands are that “women” includes men who self-identify as women, which means that by-women and for-women provision, such as rape crisis centres, domestic abuse support and so on, is actually not women-only at all. When the Minister says, “We all know what we mean by ‘woman’”, can he make it absolutely clear that he means “woman” as in “natal woman” and not those who identify as women?

[Lord Markham (Con)]

I guess what I am trying to say here—again, always with my health hat firmly on—is that I want to make sure that when we describe something in a health sense, I want that person to know that we mean them because we are doing something which applies to them, often in the case of ovarian or cervical cancer. By saying “woman”, obviously in most cases that will make it very clear that it applies to them—particularly to those with English as a second language—and they know what that means. To make sure we are covering all the bases, I am very happy that we have that secondary descriptor of a “person with ovaries”. I am trying to cover all the bases in an inclusive way so that the health message gets through.

Covid-19 Vaccination: Coronary Disease

Lord Markham Excerpts

Tuesday 23rd April 2024 Lords Chamber

[Lord Farmer]

To ask His Majesty’s Government what assessment they have made of the connection between COVID-19 vaccination and increased prevalence of coronary disease.

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

The Government are taking action to tackle cardiovascular disease and coronary heart disease, including through supporting improved uptake of the NHS Health Check England cardiovascular disease prevention programme. There is no evidence linking Covid-19 vaccines to increased levels of coronary heart disease. All vaccines used in the UK are authorised only once they have met robust standards of effectiveness, safety and quality set by the UK independent regulator, the Medicines and Healthcare products Regulatory Agency.

[Lord Farmer (Con)]

I thank the Minister for his reply. A considerable number of cardiologists, other medical practitioners and scientists have raised concerns about a link, especially among younger people, amid a pervasive sense of a lack of transparency. A reluctance to disclose the full gamut of information sits uneasily with the Government’s ongoing encouragement for people to get vaccinated. To resolve this, can the Government at least publish data on cardiac deaths in the ever vaccinated and never vaccinated by age group for 2022, 2023 and onwards?

[Lord Markham (Con)]

I thank my noble friend for this question. The ONS has provided this information and made it available for research purposes to make absolutely sure that we get to the bottom of this issue. For the understanding of noble Lords, every medical vaccine has side-effects, but the MHRA has investigated this, and the side-effect that people are worried about is heart inflammation. One to two people per 100,000 who have had a vaccine experienced side-effects, but, for people who have had Covid, it is 150 per 100,000. Having these vaccines is a much safer route to go.

[Lord Allan of Hallam (LD)]

My Lords, there is one substance that we put into our bodies during Covid that has been clearly linked to thousands of excess deaths: alcohol. Are the Government carrying out studies into what happened with alcohol consumption during the pandemic, who was most at risk and how we can ensure that in any future pandemics we do not see excess deaths? We are talking about 2,500 excess deaths during 2022.

[Lord Markham (Con)]

The noble Lord is quite right. There were much wider effects and impacts in the lockdown, and alcohol intake was one of them; mental health, particularly of our children, was another. My sincere hope is that these are the kinds of issues that the Covid inquiry should really be investigating: the wider impacts on society caused by lockdown.

[Lord Patel (CB)]

My Lords, a recent study published in Vaccine of a cohort of 99 million people who were vaccinated with one of the vaccines—either vector or messenger RNA vaccines—showed an increased risk related to myocarditis and pericarditis. The incidence, particularly among the younger people, was about one in 10 in a 1 million population, as opposed to the non-vaccinated who got Covid. That should be the comparison, not the non-vaccinated who did not get Covid. In those cases, things such as Guillain-Barré syndrome, which is a long-term viral fatigue syndrome, occurred at a higher incidence in non-vaccinated people than in vaccinated people, particularly with the Oxford/AstraZeneca number 1 vaccine, which was withdrawn. Therefore, it is a balance of whether the disease or the vaccine will make you more sick. With any treatment in any branch of medicine, there is always a risk to the treatment. There has to be a balance.

[Lord Markham (Con)]

I am sure I speak for the whole House when thanking the noble Lord for his expert understanding and insights. As he said, the evidence is very clear that while no vaccine is risk-free, what it saves you from is much greater. The very firm advice is that you are much better off having the vaccine.

[Lord Hannan of Kingsclere (Con)]

My Lords, may I ask my noble friend the Minister about the efficacy of the vaccine in preventing transmission? It does seem to be very good at keeping people out of hospital and keeping people alive, but we built the most immense edifice of restrictions around the idea that it was preventing the transmission of Covid. We had vaccine passports and travel bans, and it now seems that both the WHO and Pfizer knew at the time that its efficacy when it came to preventing transmission was negligible. Can my noble friend the Minister tell the House what his department’s latest assessment is of the vaccine’s ability to prevent giving Covid to other people?

--- Later in debate ---

[Lord Markham (Con)]

The main thing that the vaccine did was prevent any bad effects if you did get Covid. While it might not have reduced transmission much, its main benefit was that it reduced the effects if you had it, as well as hospitalisations and deaths. Making Covid a less serious disease, basically, enabled us to open up the country and we were one of the first to get going again because we knew that the disease no longer posed the high risk that it did before we had the vaccines.

[Lord Davies of Brixton (Lab)]

My Lords, I have some personal experience here. One week after I had my first course of Covid vaccination, I had an attack of pericarditis and ended up in St Thomas’ Hospital. I am convinced that there is a link, but it is important to look at the longer-term effects—having an attack of Covid causes more heart problems, as well as having a long-term impact on your general health.

[Lord Markham (Con)]

The noble Lord is absolutely correct. The MHRA study on heart inflammation, which he mentioned, said that there is that side-effect for one to two people per 100,000—unfortunately, the noble Lord seems to have been one of them. However, if you get Covid it affects 150 people per 100,000. On balance, if you have not had the vaccination, your risk is 22 per 100,000. The statistics are very clear.

[Lord Watts (Lab)]

My Lords, does the Minister think that we need to do far more on public awareness of vaccines and their benefits? All sorts of people out there are spreading malicious tales about the implications of taking them, whether for mumps or Covid.

[Lord Markham (Con)]

Absolutely. We are all very aware of the damage done by all the myths around the MMR vaccine 20 to 30 years ago and the impact that has had on people. The more we can get the message out, the better. As the noble Baroness, Lady Merron, asked me yesterday, we have learned that it is about making sure that we communicate to all groups so that we can make sure that ethnic minorities and other minority groups get that information.

[Baroness Merron (Lab)]

My Lords, after many years of stalled progress, the rate of premature deaths from cardiovascular disease continues to increase, for reasons that the British Heart Foundation describes as “multiple and complex”. The warning signs of this have been present for over a decade. As this phenomenon did not start with Covid, what assessment has been made of the contributory factors of government policy pre Covid and what steps are being taken to turn this around?

[Lord Markham (Con)]

Deaths from heart disease among those under 75 are down by about 20% compared with 2010, which is a clear trend. Notwithstanding that, we are very aware—Sir Chris Whitty is concerned about this—that Covid meant that a lot of people did not get basic heart and blood pressure checks. That is why we have introduced the Midlife MoT, which is designed to give people a 10-year risk analysis; have put blood pressure devices in pharmacies and all sorts of other places to get 2 million checks; and have a workplace heart disease strategy check. All this is designed to get that prevention in place so that people are aware of and understand the risks.

[Baroness Finlay of Llandaff (CB)]

My Lords, does the Minister agree that, although we are talking about heart disease, we must also remember pulmonary embolism from clotting disorders, which can persist for up to six months after even a mild Covid infection? A massive pulmonary embolus is another cause of mortality in people who have Covid. One of the problems with the virus is its ability to mutate, but the evidence is that vaccination, even if it does not give you complete protection, moves you from obtaining serious Covid to having milder Covid. That risk of thromboembolism also needs to be monitored in the long term in relation to Covid infections, including for those who have had a mild infection and those who have long Covid.

[Lord Markham (Con)]

The noble Baroness is absolutely correct: a vaccine helped you avoid not just heart disease but all the other impacts of Covid that she mentioned, including long Covid and a whole list of other things. Again, the undeniable advice is that it is much better to have the Covid vaccine.

NHS: Long-term Sustainability

Lord Markham Excerpts

Thursday 18th April 2024 Lords Chamber

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

I also thank the noble Lord, Lord Patel, for initiating this debate today. I am very happy to start off by answering the question of the noble Lord, Lord Hacking, by praising the NHS. The very ethos of the debate that the noble Lord, Lord Patel, brought up today is that, as critical friends, we know that we need to look at the challenges that the NHS is facing if it is going to be sustainable for the next 75 years.

I welcome the noble Baroness, Lady Ramsey. I enjoyed her journey and I shared some of her difficulties in finding her way around this building. I think I sum up the views of the whole House by saying that we are delighted that she has found her way to be with us here today and, generally, in the House of Lords.

I also thank all noble Lords for the constructive way in which this debate has taken place. Again, I praise the noble Lord, Lord Patel, for the way he framed this whole debate to bring that about. There were a lot of very thoughtful contributions, and in many ways we built on the debate that the noble Lord, Lord Scriven, called about six or nine months ago—this debate was very much in keeping with that. I particularly enjoyed the passion that the noble Baroness, Lady Boycott, brought to it all. I thought that at this stage I probably should not declare an interest in Costa Coffee—which I do not have, by the way. There were very many thoughtful contributions which I hope I will be able to build on, but I single out those by the noble Baroness, Lady Murphy, and the noble Lord, Lord Warner.

I want to avoid this being a political debate. Maybe contrary to some of the points of the noble Lord, Lord Hunt, we are seeing similar challenges across all four NHSs—across all four nations. I am afraid to say that maybe the worst-performing of those, from the records that many noble Lords will remember, whether we are looking at waiting lists or a number of other records, was Wales. These are challenges that we are all facing at this point. However, I want to be united in this debate in looking at the positive way forward.

I recognise that many noble Lords, including the noble Lords, Lord Hunt and Lord Warner, and the noble Baroness, Lady Murphy, brought up the overcentralised nature of the NHS. However, I disagree with the noble Lord, Lord Hunt, that this is due to direction from Ministers. The whole point of trying to set up the ICBs, as referenced by the noble Lord, Lord Carter, is to reverse that and put more power at a local level. These are early days in the life of ICBs but we definitely see them as the way forward.

I hope to answer the points made by the noble Lord, Lord Kakkar, and the noble Baroness, Lady Cavendish, on trying to make this into a long-term conversation. I freely accept that probably at this part of the political cycle we can have only so much of a conversation. However, on my part, whichever role I may or may not be in post election, I undertake to take part with whoever is in power in what I hope will be a constructive conversation. It needs to be the sort of environment where, as the noble Lord, Lord Allan, says, code wins the argument, and people are coming from all around and can have those sorts of constructive conversations. I think that will include a new contract between the NHS and the people, as the noble Baroness, Lady Hollins, says.

I will start by echoing some of the financial realities that the noble Lords, Lord Bethell, Lord Mawson and Lord St John, brought up. The reality of the situation is that we spend about 10% of our GDP on the NHS right now. It is going up as a proportion year after year, and it will go only one way. At the same time, no one is proposing major injections of cash. I think we all recognise the financial situation; the proposals that Labour made, for instance, amount to less than 1% of the NHS budget. Therefore, I think that what we can all unite on right now is that this is an argument not about pumping in lots more money but about finding other ways to try to make the NHS more sustainable, in many ways using, as the noble Lord, Lord Warner, says, a “tough love” approach where that is appropriate.

I want to talk about the things we are doing in terms of the infrastructure and capacity, as the noble Baroness, Lady Murphy, mentioned. When I talk about infrastructure and capacity I am talking about the labour supply, the productivity plan and the capital estate, and I then want to combine that with the new way we need to engage, whether it is around technology, prevention or primary community care, which to my mind are the ways in which we will create a sustainable NHS going forward.

Starting with the labour supply, I completely agree with the point made by the noble Lord, Lord Hacking, that staff are at the heart of every successful organisation. That begins with making sure that we have the right number of staff, which is what the long-term workforce plan is all about—trying to make sure that we have the proper recruitment, training and long-term resources.

However, more important than any of that are the points about retention and the right culture, made by the noble Baronesses, Lady Hollins and Lady Finlay, respectively, so that people feel that they are valued and are in a caring and supportive environment rather than the bullying environment we have seen all too often. In answer to the questions from the noble Lord, Lord Carter, and the noble Baroness, Lady Cavendish, I say that the Messenger report is vital.

The role of management is fundamental. In answer to the question from the noble Lord, Lord St John, I can say that when I first came into this, I did a lot of work trying to look at hospital performance. I did all sorts of analysis, looking at demographics in a local area and the relative funding. No matter what I did, there was always at least 50% unanswered in the multiple regression analysis and so on. The conclusion I came to, which is probably not earth-shattering, was that that 50% performance is all about the management, leadership and culture that drives it.

As the noble Lord, Lord Kakkar, said, a lot of that is allowing people to work at the top of their profession. If you allow them to do that, that is when they can make the new developments and innovations. That means using technology and AI to help reduce administration, which I will come to later when I talk about the productivity plan. It will also mean some uncomfortable conversations, using other staff to do some more of the administrative parts. Again, I totally support, welcome and appreciate the moves that the noble Lords, Lord Hunt and Lord Scriven, are making in the use of things such as physician associates, which is about trying to take away a lot of that burden so that doctors really can practise at the top of their profession.

In response to the point made by the noble Baroness, Lady Tyler, about productivity, that needs to be and is being put into a detailed plan that we can all review. We will have the opportunity to do so around July. As the noble Baroness, Lady Merron, said, we absolutely identify that we need to replace the inefficient IT estate, among other things. It is doing a lot of the basics in PCs, wifi and all the things mentioned by Joe Harrison, whom I know well; I work with him every week. It is about systems, EPR and arming the staff and clinicians with the basic equipment. You can start small, as the noble Lord, Lord Mawson, said. As well as electronic patient records and the FDP, those are the things from which we will get productivity improvements. When I talk about figures such as the £35 billion, I am talking about increased output, not savings. I am talking about how we can get increased treatments and output—and definitely by using the things mentioned by the noble Lords, Lord Reid and Lord Carter: payment by results and the right incentive systems; and, as the noble Lord, Lord Crisp, said, the use of the independent sector to supply, where relevant.

Of course, vital to all this is the capital estate. That is why the new hospital plan is a vital part of this. The work shows that if you put the right digital instruments in place and the infrastructure into hospitals, you get 10% more productivity. In answer to some of the questions from the noble Lord, Lord Warner, I say that if you put the right real estate in as well, the combination gives you 20% more productivity. That is not just time output but reductions in the length of stays. We all know that the sooner you can get people home, they are more likely to go on and live successfully in their environment.

Regarding the points around adult social care and the training and qualifications of the staff, which were made by the right reverend Prelate the Bishop of Newcastle, the noble Baroness, Lady Warwick, and the noble Lord, Lord Turnberg, I totally agree. That is what we are trying to do. We have for the first time introduced a qualification for adult social care staff and training. We have put 18,000 different adult social care providers into a system where they can put up training and get easy management of payments for it all. More needs to be done long term for a fundamental funding model; that goes to the points raised by the noble Baronesses, Lady Warwick and Lady Cavendish. That will involve a covenant of care but, honestly, we need to do more work on long-term funding solutions.

I cannot say enough about prevention. My noble friend Lord Bethell said to me, “Very simple, your speech today: prevention, prevention, prevention”. There are a few more things but I will definitely add a few “preventions”. The long-term workforce plan and productivity plan are designed towards that. The screening programme that we are doing is because Chris Whitty’s biggest concern is that simple things such as blood pressure which were missed during Covid will now lead to excess deaths in heart disease. As the noble Lord, Lord Patel, mentions, those simple blood pressure measures and mid-life MoTs are fundamental to what we are trying to do. I will take a leaf from the book of the noble Lord, Lord Allan, because it is right: we need the champions in that space.

I agree with the points made by the noble Baroness, Lady Boycott, on the importance of dentistry and early check-ups being needed for the prevention agenda. Our new plan regarding school checks and water fluoridation is all to help with that. I see a future world, of which I will talk more later on, where you have a much more targeted screening programme. In addition to our mid-life MoTs, which are blanket programmes, AI needs to be used to help target screenings so that we can really help people in prevention.

I agree on the ever-increasing use and funding of acute hospitals, which none of us has solved, as raised by many noble Lords. There is a need to rebalance this towards primary and community care. I look forward to the report of the committee of the noble Baroness, Lady Pitkeathley, on the integration of it all and what we can learn from its points. Things such as Pharmacy First are good ways ahead. We have seen 98% of pharmacies sign up and already there have been 125,000 consultations. With the dental plan, we have had 500 new surgeries and a 50% increase in the numbers taking adult NHS patients. However, we need the new model of care mentioned by the noble Lords, Lord Scriven and Lord Crisp, care that is away from the acute hospital and in the community. I cannot speak more highly of the Bromley by Bow Centre, which I visited. The noble Lord, Lord Mawson, should be very proud of everything that I saw there. Of all the visits that I have done in almost two years in this job, it was one of the ones that I enjoyed the most and was most impressed by. That is the model we should take going forward.

That centre is doing exactly what the noble Baroness, Lady Chisholm, mentioned, in looking at the whole health of the person and seeing how it can really care for them in the community. Of course, that requires community nursing. My mother was a community nurse, so I realise that. It needs to be backed by technology. I am proud to say that I have been responsible for the app for the last 18 months and we have gone from 10% of people having their medical records to over 90%. As the noble Baroness, Lady Merron, said, we now have 33 million people using the app for digital prescriptions, medical records and appointments, which the noble Baroness, Lady Pitkeathley, had an example of just the other day.

We do need to broaden things out, so more people realise all the features that are on the app, but we really do see the app as the front door of access to the NHS. It will deal with future therapies, whether musculoskeletal, as many noble Lords have mentioned, or mental health. That gives opportunity for it all. On the point made by the noble Lord, Lord Parekh, the app does allow people to take control and to take power away, sometimes, from the experts, giving them control and putting the power in their own fingertips.

Data and AI are fundamental to this, to enable the sort of precision medicines my noble friend Lady Blackwood mentioned. I thank her, and Genomics England for all the work it is doing to lead on this. It is an institution we should rightly be proud of. That is the future of medicine, but it is all underpinned by the data. Funnily enough, I have kicked off cataloguing of that, because it is fundamental.

On adult care, we have increased digitisation from 20% to 60% quite quickly. Having the data at the heart of this will allow competition and innovation to take place. But we need to make sure that that conversation happens in the right way, so that we bring the public with us on that journey.

I hope that gives a vision of the things we are trying to do to put the infrastructure in place—the supply, workforce, technology, IT and capital—accompanying that with new ways of working, whether it is a focus on prevention, more input into primary and community care, or using AI, technology and genomics to lead the way forward. I think we all agree that that is the only way we will get a sustainable health service going forward.

I thank the noble Lord, Lord Patel, and all noble Lords who have contributed for the spirit of the debate and its thoughtfulness. I give special thanks again to the noble Baroness, Lady Ramsey, for choosing this debate for her maiden speech, and I thank the noble Baroness, Lady D’Souza, for joining us on her 80th birthday. As ever, I apologise to those whose contributions I have not managed to cover completely, and I promise to write giving a thorough wrap-up.

Cass Review

Lord Markham Excerpts

Wednesday 17th April 2024 Lords Chamber

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

I thank the noble Baronesses for their important points and for their sensitivity.

First, I echo the Secretary of State’s gratitude to Dr Cass and her team for undertaking a considered, comprehensive and courageous review into an extremely contentious area of healthcare. Officials have described this to me as probably the best report they have seen, in its excellence, thoroughness and sensitivity. Since NHS England commissioned the review in 2020, it has meticulously unpicked what went wrong, what the evidence really shows and how to design a fundamentally different service that better serves the needs of children.

Noble Lords and Baronesses will be aware of why this review was commissioned, but it is worth repeating here. The statistics are startling. As recently as 2009, the NHS’s sole gender identity development service at the Tavistock and Portman trust received fewer than 60 referrals for children and young people, with just 15 being adolescent girls. Since then, demand has surged. In 2022, more than 5,000 children and young people were referred to gender identity clinics, almost three-quarters of whom were female. The near uniform prescription of an irreversible medical pathway on the basis of sometimes very minimal evidence was imposed on these children and young people with complex needs without full and thoughtful consideration of their wider needs, including neurodiversity, trauma, mental health conditions or who they loved.

In her Statement in the other place, the Secretary of State outlined the immediate priorities for taking forward the recommendations from Dr Cass’s report. This includes looking closely at what needs to be done to curtail loopholes in the prescribing practices of private or online providers to ensure that they fall in line with Dr Cass’s recommendations. In answer to the noble Baroness, Lady Merron, the CQC is on this, and made it clear to all providers straightaway. We hope that legislation will not be required, but we are prepared to table it if necessary, because we need to send out a very clear message.

Private providers have been put on notice. Prescribing is a highly regulated activity and the CQC has not licensed any gender clinic to prescribe hormone blockers or cross-sex hormones to people under the age of 16. Any clinic that does may be committing extremely serious regulatory offences, for which it can have its licence revoked and its clinicians struck off.

On the point made by the noble Baroness, Lady Merron, I share the view of Dr Cass and the Secretary of State—I know that noble Lords share it, too—that it is completely unacceptable that all bar one adult gender clinics refused to co-operate with the University of York research into the long-term consequences of treatment received at the Tavistock centre. To be completely honest, I do not understand how they could be allowed to do that and I think we all are united in saying that that is simply not acceptable. That is why we have gone back so strongly on exactly that point.

Since the publication of Dr Cass’s interim report in 2022, NHS England has made a series of important changes. On 31 March, the Tavistock clinic finally closed, having stopped seeing new patients a year earlier. To answer the points made about new services, two new regional hubs have been opened in partnership with the country’s most prestigious children’s hospitals to ensure that children are supported by specialist multidisciplinary teams, and another will follow in Bristol later this year. In the last few weeks, NHS England has made the landmark decision to end the routine prescription to children of puberty blockers for gender dysphoria. On the day of publication of Dr Cass’s final report, NHS England announced it was stopping children under 18 receiving adult gender services with immediate effect, and an urgent review on clinical policy for cross-sex hormones will now follow without delay.

Children are at the heart of this debate. Dr Cass’s report demonstrates that they deserve healthcare that is compassionate, caring and careful. Their safety and well-being must come above any other concern. That is why the Government will work with NHS England to root out the ideology that has caused so much unnecessary harm, and to give the next generation access to holistic care and protect our children’s future.

I turn to the other points raised. In addition to the three clinics mentioned, eight regional clinics will also be set up to make sure we can provide services on this. Within all that, the point about providing continuity of care up to 25 will be a key part of that. On mental health treatments generally and helping people on that, that is what the £2.3 billion investment has all been about in terms of developing the hundreds or thousands of extra places.

With regard to clinical trial timings, that is a difficult one. I think all noble Lords agree—this was very much a feature of the round table we held after we had the question on gender identity—that there is a general feeling that of course you do not want to settle on any course of treatment for a young person while they are still at that stage of life, in terms of puberty, where they have not had a chance to discover their own feelings. We all know that it is a complicated time and so, more than anything, we want to make sure that people are not set on a course of action that is irreversible before they really know their own minds and bodies and what is appropriate in that situation. That is why we are so firm in trying to follow the Cass guidelines to make sure that that is not available in those circumstances. To be open and honest on that point, I am not absolutely sure whether those clinical trials are compatible with that, but I will come back in more detail on that point. I hope that that answers the points for now, and I look forward to answering other points raised.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, this is a deplorable situation. It is a formidably good report and I commend the Government on their firm action following its publication. I question why it took the NHS quite so long to stop the routine prescription of puberty blockers to children under 18—that seems rather slow off the mark.

However, I have a more important point. I fear that one of the great damages from all this is to one of our national and international centres of excellence. The Tavistock clinic has been in existence for over 100 years. It was started by Hugh Crichton-Miller for the treatment of soldiers with shellshock. It has been the home of John Bowlby, Lily Pincus and RD Laing. It has done incredibly important work in terms of mental distress, mental health and emotional well-being. It is a national and international centre of training, with about 2,000 students a year. If I may take up the Minister, for whom, as he knows, I have an inordinate regard, I think he said that the Tavistock clinic had closed. It has not closed; the gender reassignment clinic has closed for ever. I ask the Minister and everyone in this House to try to help reclaim the reputation and the respect that the Tavistock clinic rightly deserves.

[Lord Markham (Con)]

Yes, absolutely, and I thank my noble friend for correcting me and giving me the opportunity to correct that. Again being very honest, this shows that part of the challenge in setting up the new services is that this has become such a difficult, toxic space, and finding and recruiting staff who want to work in this area is a real challenge as well.

[Baroness Hayter of Kentish Town (Lab)]

I thank the Government, the Minister and indeed the Opposition for their very robust response and welcome to the report. I am really sorry that the Lib Dems have chosen to use Stonewall’s briefing in what we have heard tonight; I hope that is not the whole of the Lib Dem position.

I note that the Government have already met with the GMC over the weekend, and they have been in contact with the CQC. However, just last month, the Royal College of General Practitioners tried to cancel a conference posing exactly the questions covered by Dr Cass in her excellent report. It allowed this conference—it was called “First Do No Harm” and I had the privilege to open it—only after an enormous amount of persuasion; it did it under duress, with bad grace and some hostility. That was the Royal College of General Practitioners.

Will the Government also meet the Royal College of General Practitioners and indeed the Royal College of Psychiatrists, the Royal College of Nursing, the Professional Standards Authority and all the other regulators, many of which seem to have been blind when all this was going on, and ensure that they all engage with the conclusions and the recommendations of Cass, whether those professionals over which they have oversight are working in the NHS or in the private health sector? These puberty blockers were being prescribed years after we knew they were irreversible, when Stonewall still said they were reversible, and when the doctors should have known but still prescribed them. Will the Government therefore engage with all those regulators to ensure that Cass is implemented in full?

[Lord Markham (Con)]

Yes, and that is an excellent point. Again, I thank the noble Baroness in this area. The questions that she raised earlier in the year in terms of some of the language from the GMC really added to the debate and represented a step forward. Therefore, although I am sure it is happening already, I will doubly check that it is.

[Lord Sandhurst (Con)]

My Lords, my focus is on the misuse of drugs for unlicensed purposes. It is perfectly proper and sensible that drugs are used for unlicensed purposes in the right circumstances. For example, in the case of children, drugs are not tested on them; they have been tested and licensed for use on adults, and they are used quite properly—it is called “off-label”—for children for the same purposes. However, in this case, as Cass has found at paragraphs 20.11 and 20.12 of her report, in the case of puberty blockers there was what she describes as a “system weakness” in that off-label use. It went beyond the usual level of permissiveness in extending use to a very different indication. So she has recommended, in recommendation 32:

“Wider guidance applicable to all NHS services should be developed to support providers and commissioners to ensure that innovation is encouraged but that there is appropriate scrutiny and clinical governance to avoid incremental creep of practice in the absence of evidence”.


I have two questions. What steps are the Government taking to implement this important recommendation as a matter of urgency? It will not just be puberty blockers; there will be drugs used in a range of fields. Who will be charged with the responsibility for creating this guidance and then implementing it?

[Lord Markham (Con)]

With the wonders of modern technology, I hope I can answer two questions in one. On the previous question, yes, the regulators have been communicated with about making sure that it is very clear. On that point, I say to my noble friend that the regulators have been charged with making sure that very clear guidelines are put out on the drug use that he mentions; those are being set right now. While I am clearing stuff up, to be clear and to save me correcting it later, it will be eight clinics in total when they are all there; I might have said that it was eight additional clinics.

[Lord Young of Norwood Green (Lab)]

My Lords, I too pay tribute to the Government, and to Dr Cass especially, for a magnificent report that took both determination and courage; let us not underestimate that. She has achieved a huge amount: we now have four clinics up and running with people who understand the need to counsel young people. What we do not know is how many thousands of lives have been wrecked by the indiscriminate use of puberty blockers and hormones; it may eventually be uncovered. I also pay tribute to our party and our shadow Health Minister Wes Streeting for unequivocally backing the Cass report and committing the next Labour Government, should that be the case, to an evidence-based situation.

I put it to the Minister that puberty is not something that ends at 18. Dr Cass rightly defines it as a process that could go up to 25. She recommends that those services should include that kind of counselling, and I would welcome some confirmation from the Minister that that will be the case. There is still more work to be done on this. I have said on previous occasions that this is a cult that has invaded a lot of the institutions of government and other institutions. It is not going to just lie down quietly; there will be attempts to evade this legislation, and we should be on our guard against that.

I want to end on a positive note. I welcome the Statement. I pay a further tribute to Dr Cass, a woman who came out of retirement and was probably looking for a nicer and easier thing than this to deal with. This Chamber owes her and her civil servants a real debt of gratitude.

[Lord Markham (Con)]

I remember that it was the noble Lord who, in the round table that we had on this, made very clearly the same point I was making earlier about puberty and age. It is only when you are right the way through it that you really are in a position where you start to know your own mind and your own body. I agree with the noble Lord that it can be as late as 25, and that is why that is definitely the intention behind the eight clinics that are being set up—that they can provide that continuity right up to the age of 25, given that there is such a state of flux in a young person’s life.

[Baroness Finlay of Llandaff (CB)]

My Lords, I thank the Government for giving us this opportunity. Dr Cass’s report is incredibly important. She has taken a scientific, as well as a kind, humane and humanitarian, approach to the children affected and to the way the report is written. In the recommendations, as well as the discussion over puberty blockers there is the importance of ongoing research, research capacity and data. One finding that emerged for her was that there was a lack of consistent collection of data, which means that for many of these children, the people who were looking after them were, in effect, flying blind. That cannot be allowed to continue in future.

Her recommendation 17 is that:

“A core national data set should be defined for both specialist and designated local specialist services”.


Recommendation 18 is that:

“The national infrastructure should be put in place to manage data collection and audit and this should be used … to drive continuous quality improvement and research in an active learning environment”.


My question to the Government is whether, among the organisations listed, there are also discussions with the Royal College of Surgeons, because there is also surgical intervention undertaken in some of the processes. Without a database of the numbers that undergo a surgical intervention, the type of intervention and the complication rates, and monitoring the effect of that surgery on quality of life, we risk carrying on flying blind with clinical treatments that are literally life changing.

[Lord Markham (Con)]

I thank the noble Baroness. She is absolutely right: it is only in that lack of data environment that, dare I say it, ideology can fill in the vacuum and start to drive the sorts of behaviours that we see. Data is always the best way to cut through and provide light when there is a lot of heat in an argument. She makes an excellent point about the Royal College of Surgeons. I am sure that it has been contacted along with all the other bodies, but we need to make sure that is covered off. As ever, I will come back in detail in writing to all noble Lords who have raised points. I will make sure that point is addressed as well.

[Baroness Deech (CB)]

My Lords, my gratitude to Dr Cass is that the report has given the rest of us the strength to challenge something that we knew was irredeemably harmful. I have two questions for the Government. First, will they remind the NHS of the law? Gillick competence—I am abbreviating it—states that:

“Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment”.


It is simply impossible for any child under the age of 16 to understand what is meant by sex change or puberty delay. They cannot get their heads around it or possibly comprehend what it will mean for them in future, so Gillick competence has to be remembered.

Secondly, will the Government also remind the NHS that young people and others are confused and possibly endangered by the ridiculous use of phrases saying that “people who have ovaries” or “people who have cervixes” should come forward for treatment and so on? Can we please restore the word woman, or indeed girl, when it comes to medical treatment?

[Lord Markham (Con)]

To take the second point first—it was also made by the noble Baroness opposite—that is absolutely right; it can be a real danger. People with English as a second language might not understand that a “person with ovaries” refers to them. It needs to be very clear. It is fundamental that the first description has to be “male” or “female”; you can then put additional parentheses after that.

The noble Baroness’s first point is exactly right. Until young people are through the age of puberty and its effects, they are not in a real position to make up their own minds. That does not mean that they should not be supported during that process, but it does mean that we should not be doing anything irreversible.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I watched the Secretary of State’s introduction to this Statement on Monday, live from my office. She asked the other place to

“bear the sensitivities of this debate in mind”.—[Official Report, Commons, 15/4/24; col. 55.]

I am afraid that it is clear from the printed record before us, and was even clearer watching the Secretary of State speaking, that it was delivered in a triumphalist, dogmatic tone, which meant that she did not follow her own prescription.

The Statement speaks of “myths” but fails to acknowledge the agency and lived experience of children and young people. I have two questions for the Minister. Can he reassure me that we are not going to lose, in this ideological debate, the need for massively more investment in services for children and young people in the NHS? The noble Baroness, Lady Burt, referred to the huge waiting lists that are behind the report we are discussing today.

The Statement also did not mention—and I think we have to acknowledge this—that hate crime against transgender people hit a record high in figures out last October. I hope that the Minister will agree with me that children and young people seeking gender identity services should not have to live in a society where their experiences are used as a political football. They should not be treated as a weapon in the culture war. They should not have to live in a hostile society.

[Lord Markham (Con)]

First, I think I speak for the whole House in agreeing that no one, under any circumstances, should feel that they live in a hostile society —whatever case it is, whether it is transgender, race, sex or whatever. I totally agree with the noble Baroness there. I will absolutely clarify this in the follow-up in writing, but I know that, in this specific area, the NHS has already committed £18 million in this space. Of course, this is quite separate from the £2.3 billion that I mentioned before in the mental health space generally, which, from memory—and I will absolutely clarify this—is the provision of 350,000 extra places for young people, because we know how much the demand is out there.

[Baroness Jenkin of Kennington (Con)]

My Lords, I am grateful to the Noble Baroness for clarifying the Lib Dem position because, unfortunately, the page on the website has disappeared this afternoon. May I ask my noble friend whether the Government acknowledge that a conversion practices Bill would have a detrimental effect on the recruitment of clinicians to the new children’s services, as highlighted in the Cass Review?

[Lord Markham (Con)]

I must admit that I am not sure that I quite understood the question from my noble friend.

[Baroness Jenkin of Kennington (Con)]

There are a number of conversion practices Bills currently in play, and Cass has said that such a Bill would have a detrimental effect on the recruitment of clinicians, because they would feel a chilling effect before they would apply.

[Lord Markham (Con)]

Understood. Again, I will come back in detail on that point. One of the points made to me about the difficulties of trying to recruit to these eight new services was that, when this is such a toxic space, how do you get good-quality people? I think we agree we need that more than ever, because it is such an essential and sensitive area. So I will take that back and make sure that nothing we are doing, such as that legislation, should have that sort of chilling effect.

[Lord Allan of Hallam (LD)]

My Lords, if I could add to the Minister’s correspondence list, this is really following up the point made by the noble Baroness, Lady Finlay. Dr Cass rightly highlights that we need data about all the young people who present to the services—what service they received and what happened to them over time. Can the Minister include in his letter the measures that the Government will be taking to encourage those young people to participate? If they feel intimidated or that the data is going to be used against them, they are going to opt out, and then we are not going to have the dataset we need to understand the best treatment.

[Lord Markham (Con)]

That is an excellent point—yes.

Midwives: Bullying

Lord Markham Excerpts

Tuesday 16th April 2024 Lords Chamber

[Lord Hunt of Kings Heath]

To ask His Majesty’s Government what assessment they have made of the impact of bullying of students and newly qualified midwives in the NHS on (1) retention of staff, and (2) the treatment of pregnant women, as highlighted in the #Saynotobullyinginmidwifery report published on 12 November 2023.

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

This report makes difficult reading, highlighting unacceptable levels of bullying in midwifery. We know that culture and leadership have a significant impact on retention and staff experience. NHS organisations should have robust policies in place to tackle bullying and harassment. Through the NHS long-term workforce plan and the NHS equality, diversity and inclusion plan, we are seeking to expand the workforce and make the NHS a better place to work.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister. As he says, all NHS trusts have those robust policies. The problem is that they are not coming out into practice. This report describes the experience of midwives working in a toxic culture. One newly qualified midwife is quoted as saying that they were left

“burnt out by bullying and the terror of working on understaffed wards”.

Another said:

“I would return home crying most days and became suicidal from the fear and treatment at this trust”.


Does the Minister accept that much more fundamental change is required to deal with understaffed maternity units, NHS trusts preoccupied with reputation management over patient safety, and a reluctance to take whistleblowers seriously?

[Lord Markham (Con)]

I thank the noble Lord for his work in this whole area. That is genuine appreciation, because I know that he looks not just at bullying in this area. He is a very important conduit and I am personally grateful for the work he does on this and how much he cares. It is a combination of all the things that he mentioned. I had a meeting with the chief midwife on this subject this morning because of it being brought to my attention. I was actually quite reassured. Each trust now has what is called a quad leadership team, where the chief midwife, a neonatologist, an obstetrician and the general manager spend time together in a six-month process where they work together as a team on how they will address all these vital cultural issues.

[Baroness Burt of Solihull (LD)]

My Lords, among the very disturbing elements in this report is the way that midwives are bearing the brunt of the toxic culture and dangerously low staffing levels, which are causing over half of midwives to consider leaving their organisation. Despite what the Minister just said, the Ockenden report was over two years ago. Is he satisfied with this rate of progress? Should we not consider a statutory inquiry—a recommendation of this report—before more midwives leave and more babies die?

[Lord Markham (Con)]

We have the highest level of staffing ever in midwifery, 5% up on last year and 21% up on 2010, against a background of static births. I want to address that point on staffing; staffing levels are high. However, as the noble Baroness says, there are issues around culture. On the national inquiry, again, every one of those 150 trusts was visited by the CQC in the last year or so and action plans made on how to address this. We know what we need to do; we just need to get on and implement it.

[Lord Lucas (Con)]

My Lords, I am grateful to my noble friend for his replies. I am much more grateful to the many midwives who have helped my family over the years. They give an extraordinary service. If we are not to have an inquiry, will my noble friend make sure that his ears and doors continue to be open when things are not going as well as they should? The NHS has a habit of closing doors on things and making it difficult to interact with it. Bullying is not the only problem. There is a succession of problems which need bringing out into the air, such as overmedicalisation, the failure to implement the better births policy, and the regulatory culture overseen by the NMC. The Minister could help with that.

[Lord Markham (Con)]

I agree with my noble friend. Over the last 18 months, I have appreciated the power of this House and of these Questions. Each time I get one, it sets off a process. In this case, I undertook to meet the Chief Midwifery Officer to make sure that feet are being held to the fire. I know that Minister Caulfield is doing this. It is to the credit of the House that it has this scrutiny role.

[Lord Mackenzie of Framwellgate (Non-Afl)]

My Lords, my maiden speech in this House was on bullying in schools. Can the Minister tell me whether there is an anonymous hotline for whistleblowers to report unbecoming conduct in the health service? It is so important to have one.

[Lord Markham (Con)]

The noble Lord is absolutely correct. It is crucial. We have a whistleblowing system. It has had over 100,000 reported instances. We are trying to inculcate a culture where people feel able and free to stand up and point out an issue.

[Lord Allan of Hallam (LD)]

My Lords, workplace bullying is particularly toxic where managers are involved. This is where non-executive members of the NHS trust boards may come into their own if complaints involve executive members. What is being done to help non-executive members of trust boards be more responsive and able to deal with bullying complaints?

[Lord Markham (Con)]

The noble Lord is absolutely correct. This is the role of non-execs. Having done a bit of work on the Lucy Letby case, I understand that the non-execs should have said something. Obviously, the executives should have found out, but the non-execs clearly had a role. This is an excellent question. I have to be honest and say that I need to come back on it, if I may, so that I can give the noble Lord a full answer and make sure that this is happening.

[Baroness O’Grady of Upper Holloway (Lab)]

My Lords, does the Minister agree that we also need to tackle the conditions in which bullying can sometimes flourish? The Royal College of Midwives—the union representing midwives—published a report last week showing that over 100,000 hours of unpaid overtime are performed by midwives every week. Some 60% of midwives believe that staffing at their workplace is unsafe. Three-quarters of student midwives are expecting to graduate with £40,000 of debt. Surely it is time that we gave midwives the respect and the pay rise that they deserve.

[Lord Markham (Con)]

I agree. As ever with these things, there are a number of issues, of which pay is one. The introduction of the £5,000 a year support that we now give to all students is an important help with regard to debt. Work conditions are important, but key to it all is the culture. I have seen many examples where that has not been great. I was quite impressed by the Chief Midwifery Officer saying that every trust now has a midwife retention person whose job is to get into all these issues and make sure that they are addressed.

[Lord Boateng (Lab)]

My Lords, how many of the midwives recruited to deal with the current midwifery crisis in the NHS were trained and qualified in the United Kingdom? On a recent visit to Ghana, I visited a child oncology unit, which, in the past year, had lost a fifth of its clinical nursing staff, who were trained, qualified and paid for by the Ghanian taxpayer—to the benefit of the NHS. How is that ethical or right?

[Lord Markham (Con)]

I will come back to the noble Lord with the exact number, but he is correct: the long-term workforce plan is all about making sure that we have the right resources and infrastructure to train the required number of people. Behind that, we have funded an extra 150 spaces this year and we have a target to increase them by 1,000 by 2026. It is absolutely as the noble Lord maintains: we are putting training in place domestically, as well.

[Baroness Cumberlege (Con)]

My Lords, does my noble friend share my view about the evidence that, when midwives and other clinical staff understand the importance of continuity, it leads to safer care and better outcomes for both the mother and the baby? One of the midwives quoted in chapter 2 of the report that was sent to us—I thank my noble friend for that—says that working in a continuity team was the best, most rewarding time in their career. Continuity is absolutely critical; it comes up in a number of reports, some of which I have had a part in writing. We know that you need continuity if you are going to make a real impression on the midwifery service and that the women who are party to it must really understand what continuity does and can achieve.

[Lord Markham (Con)]

I thank my noble friend, who has been a tireless campaigner on continuity of care. I challenged the chief midwife on this just this morning, and the objective behind the long-term workforce plan is to make sure that we have the resources in place to maintain that, starting with ethnic minorities. We all know that there is a disparity of outcomes in terms of inequality, so the first priority for continuity of care is that setting, but the objective is to spread that across the whole system.

Immunisation: RSV

Lord Markham Excerpts

Tuesday 16th April 2024 Lords Chamber

[Baroness Ritchie of Downpatrick]

To ask His Majesty’s Government when a decision on eligibility for a potential 2024 respiratory syncytial virus immunisation programme will be confirmed, and whether this will be aligned to the Joint Committee on Vaccination and Immunisation’s September 2023 advice.

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

The Government have made a policy decision on the eligibility of a potential RSV programme, which is in line with the JCVI’s September 2023 advice. We are working through the full business case, with costing and operational delivery, for final agreement in line with an autumn start.

[Baroness Ritchie of Downpatrick (Lab)]

I thank the Minister for his Answer, but what plans and resources, both staff and finance, are in place to enable the immediate implementation of any RSV immunisation programme for young infants and older adults, in line with the JCVI’s advice, once the ongoing market engagement and tender process is complete?

[Lord Markham (Con)]

That process is absolutely going on at the moment, as well as operational delivery aspects. For infants, it depends on whether we choose a vaccine that goes into the pregnant mother or the infant, as the delivery mechanisms are obviously different. We are looking at the effectiveness of not just one vaccination versus the other but the delivery mechanism. There is a different delivery mechanism for the group aged 75-plus. The full programme business case is considering exactly that to make sure that we can deliver in the autumn.

[Lord Allan of Hallam (LD)]

My Lords, will the Minister commit to making the vaccination records for new programmes such as RSV available through the NHS app from the outset? I ask this as a parent who has just had to verify his teenage children’s MMR status by hunting down the red books last seen a decade ago to find the tatty piece of paper that is the only record of it. I now have a digital copy through my camera phone, but it would be much more useful to have this kind of record in the NHS app.

[Lord Markham (Con)]

It will not surprise the noble Lord to learn that I totally agree. It is absolutely on the road map. I cannot promise it is there today; it is more there for adults. The child digital red book is another objective we are working on, but that is taking slightly longer. But in terms of direction of travel—yes, absolutely.

[Lord Patel (CB)]

My Lords, I congratulate the noble Baroness, Lady Ritchie of Downpatrick, on pursuing this even before we had vaccines available. Now we have succeeded in getting the vaccine, but why has 75 years been chosen for adult immunisation, when we know that the incidence and prevalence of RSV infections is much more common for over-65s?

[Lord Markham (Con)]

I too add my thanks; the noble Baroness is very good at holding our feet to the fire, and it is very important and appreciated. Regarding the age group, we are being guided by the scientific advice on what is most cost-effective.

[Baroness Merron (Lab)]

My Lords, earlier this year we discussed the busy pipeline of new vaccines, including those for RSV, which, coupled with the concerning decline in the uptake of immunisation, does point to the need for a fresh look at delivery mechanisms. What steps are being taken to move beyond traditional arrangements, and when can we hope to see an improvement plan in place, in readiness for the RSV immunisation programme?

[Lord Markham (Con)]

Of course, the communication needed for each one is different, and that is a vital consideration. As I said, we found that, often, it is easier to put RSV in the infant rather than the pregnant mother. It is a question of considering which is the most effective way to get the best outcome and the highest take-up rate. That is one of the key criteria we are looking at. Regarding general communication, the noble Baroness will be aware that, on MMR, we have challenges in both London and the West Midlands. That has shown that you need other communication routes to get to some ethnic minority groups, using technology such as the app. There is no one silver bullet —you need a series of measures in place.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, is the Minister confident that the implementation programme will take place before the 2024-25 winter period, as promised in previous iterations of this Question?

--- Later in debate ---

[Lord Markham (Con)]

The goal is absolutely to make sure that the JCVI advice is there for the key winter period the noble Baroness mentions. That is the programme we are working towards, and this is where the logistics come in. It is not just about the effectiveness of each vaccine but, in terms of the maternal versus infant vaccination to which I referred, being confident of getting it in people’s bodies in time.