Stroke Care

Lord Markham Excerpts

Monday 24th July 2023 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government how they are ensuring that integrated care systems across England implement recommended best practice in stroke care in line with the updated National Clinical Guideline for Stroke, published in April.

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

The National Clinical Guideline for Stroke, published in April 2023, is an initiative of the intercollegiate stroke working party made up of representatives from the professional bodies involved in stroke care. National regional SQuIRe managers, who are responsible for managing stroke services, are working with integrated stroke delivery networks and newly formed integrated care systems to implement the NHS integrated community stroke service and improve the provision of community-based stroke rehabilitation.

[Baroness Wheeler (Lab)]

My Lords, the update of the national stroke guidelines is welcome, particularly its now UK-wide remit, with one of its major changes being significant expansion in the number of patients eligible for thrombolysis and thrombectomy. Given that both these powerful clot-busting interventions are most effective the faster they are used following a stroke, what assessment has been made of the impact of the current NHS delays in the expansion of their respective uses and how will the Government ensure that ICSs address the huge regional variations in both thrombectomy and in the vital post-stroke rehabilitation in hospital and at home that is so necessary?

[Lord Markham (Con)]

First, I thank the noble Baroness for the work that she does in this area; I know that it is very close to her heart. I have set up a meeting with the NHS COO David Sloman and with Sarah-Jane Marsh, and would be delighted if the noble Baroness would like to join me. The benefit of these sessions is always the shining of a light on areas.

It is vital that people are seen within the first hour; currently 59% of people are, which is an improvement on the last couple of years when the figure was 55%. However, we would all agree that we want that number to be as high as possible. The SQuIRe managers’ job is to make sure that all the different integrated care boards are delivering best practice in each area.

[Baroness Manzoor (Con)]

My Lords, what role will NHS England play in first collecting information, monitoring it, evaluating it and disseminating it across the UK to ensure best practice, and how often does it undertake to do this?

[Lord Markham (Con)]

I thank my noble friend. The NHS delivery plan set out in January 2023 was trying to set out the best practice in this area. It is then the job of the SQuIRe managers to make sure that that is implemented in each area. One example is that they are trialling having videos in ambulances in certain areas so that paramedics can speak to stroke experts. We all know that getting patients to the right place quickly is vital, so I hope that that is another example of best practice that we can roll out.

[The Lord Bishop of St Albans]

My Lords, these guidelines are very encouraging, and all who work on them should be congratulated. As we keep hearing, the essence is speed if we are to treat effectively, yet this is particularly difficult in rural areas, especially remote rural areas. What additional help is being given to integrated care boards’ care systems to ensure that our rural integrated care boards can deliver these guidelines, which are so vital?

[Lord Markham (Con)]

The job of each integrated care board and the regional SQuIRe managers within it is to make sure that they are catering for the needs of their area. Clearly, rural areas present more challenges in terms of speed of access to the relevant stroke services. At the same time, there has been a rollout of the integrated stroke networks that can perform the clot-busting treatments to make sure that we have more of them located in the right places.

[Lord Allan of Hallam (LD)]

My Lords, we are fortunate to have the Sentinel Stroke National Audit Programme—SSNAP—to help us monitor compliance with the national guideline. In its very good easy access report for the first quarter of this year, it tells us that three out of five stroke patients are not taken to a stroke unit immediately and it calls for urgent action in this area. What are the Government doing to make sure that stroke patients are immediately admitted to stroke units in line with that guideline?

[Lord Markham (Con)]

The noble Lord is absolutely correct. As mentioned, speed to the right place is vital; videos in ambulances are one way of communicating ahead and speaking to the paramedics so that they are ready to receive them, which is really important. The latest data I have seen is that 92% of people are now sent straight to the stroke ward on arrival, which sounds promising but is somewhat at odds with the Sentinel figure he mentioned. I will find out more about that and get back to the noble Lord.

[Lord Woodley (Lab)]

I speak with experience, having seen my wife suffer a very serious stroke more than a decade ago. As the right reverend Prelate said, speed is of the essence. Not one but two ambulances arrived within 15 minutes and she was in hospital within 25 minutes; they saved her life at Chester County Hospital. Does the Minister agree that things have got worse and worse over the last decade and that, unfortunately, people are dying?

[Lord Markham (Con)]

I agree that last winter was particularly difficult; as we all know, ambulance wait times were too long, which undoubtedly caused issues. We have a recovery plan for the emergency services and have invested more in ambulances, but it is all about flow, which we have spoken about many times in this House, and making sure that people can get to where they need to be as soon as possible.

[Lord Kamall (Con)]

My Lords, I will take this opportunity to ask my noble friend a more general question about guidelines. I am sure he receives correspondence about parts of the NHS not meeting guidelines, not only on strokes but on other issues. What are the Government and the NHS doing to make sure that, where there are guidelines, they are followed through and adopted by ICSs and medical practitioners right across the system?

[Lord Markham (Con)]

I thank my noble friend. As we all agree, there are always two steps involved: setting out the guidelines that we believe are best practice and making sure that they are then implemented. ICBs have that responsibility and regional managers look into them. As I think I have mentioned before, each Minister personally takes charge of six or seven ICBs—I will visit a few of them in the next few weeks during Recess—so we can make sure that they are really delivering on the ground.

[Lord Scriven (LD)]

My Lords, the Getting It Right First Time report has shown that 29 recommendations are needed for strokes and its wider programme has shown what works in the healthcare system to improve care and save lives. What levers do the Government have when integrated care boards do not implement best practice to save lives and improve health in an area?

[Lord Markham (Con)]

There are a number of things. For want of a better phrase, we have a tier rating for the different trusts and hospitals and they can be put into the equivalent of special measures—that is not the right term, but the noble Lord knows what I am referring to. Ultimately, the NHS and Ministers also have the ability to hire and fire, as we know that leadership is vital in all these areas.

[Lord Kakkar (CB)]

My Lords, I draw noble Lords’ attention to my registered interests. It is clearly important that stroke networks are properly supported to deliver clinical care efficiently and effectively but, beyond the capacity to do that, there must also be ongoing capacity to participate in further research and development and to provide the opportunity for appropriate clinical evaluation of innovations that will yet further improve outcomes for those suffering ischemic stroke. Is the Minister content that there is sufficient support for that activity in stroke networks?

[Lord Markham (Con)]

A lot of good work is being done. AI is often used to analyse brain scans very quickly in a lot of these centres that the noble Lord mentions. One of the very good things about trusts is that they have a lot of independence to develop their own initiatives, but sometimes the challenge—which I have really taken up—is getting that innovation adopted widely. I and the Secretary of State are great believers in that but, candidly, we need to work harder on it.

[Lord Sikka (Lab)]

My Lords, I invite the Minister to visit A&E departments and note the chronic lack of resources and capacity. I will give a personal example. I took my son to the local A&E as he had some life-threatening issues. We arrived at 12.13 pm on a Wednesday and a bed was found at 2.30 am the next morning; no spare bed could be found in any of the adjacent hospitals at all. When was the last time the Minister visited an A&E department and what did he notice?

[Lord Markham (Con)]

In the last few weeks, I have been in A&E departments most weeks. Over the Recess, I will be visiting another 15 or so hospitals—I cannot remember the exact number, but it is a big one. That will be to see the A&E and the new hospital programme that I am responsible for. I agree with the noble Lord that there is nothing like visiting a place to really understand the problems and get on top of them.

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

Lord Markham Excerpts

Monday 24th July 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Human Medicines (Amendment Relating to Original Pack Dispensing) (England and Wales and Scotland) Regulations 2023.

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

I am grateful to be here today, as is right, to debate such an important issue. The Human Medicines Regulations 2012—the HMRs—set out when medicines need to be prescription only and requirements for pharmacists selling or supplying prescription-only medicines. This SI will make two amendments to the HMRs to enable original-pack dispensing of medicine—OPD—and to require whole-pack dispensing of medicines containing valproate.

The first amendment, on OPD, is to enable pharmacists and pharmacy staff under their supervision the flexibility to dispense up to 10% more or less of the medicine compared to the quantity prescribed if it means that the medicine can be dispensed in the manufacturer’s original packaging. The second amendment requires medicines containing valproate always to be dispensed in the manufacturer’s original packaging, supplying a quantity as close to the quantity prescribed as possible, with exceptions in specific circumstances when the prescribed quantity must be dispensed.

The aims of enabling OPD and requiring whole-pack dispensing of medicines containing valproate are to increase patient safety by ensuring that patients receive the necessary information that is included on, as well as inside, the manufacturer’s original packaging about the safe and effective use of a product. A further aim of OPD is to support efficiencies in community pharmacies.

The Human Medicines Regulations require that a pharmacy may not sell or supply prescription-only medicine except in accordance with a prescription given by an appropriate practitioner. Currently, we interpret dispensing

“in accordance with a prescription”

to mean that pharmacists must supply the exact quantity of medicine prescribed, with a few exceptions where it is practically impossible or very difficult to split the original pack. This means that, where the quantity prescribed on a prescription is not equal to or multiples of a pack size, pharmacy staff need to split the manufacturer’s original pack. In order to dispense the prescribed quantity, the medicine may be supplied in a plain dispensing box or bottle or in the manufacturer’s original packaging but with some taken out. In the case of tablets and capsules, this usually means snipping the strip of medicines.

When supplying in plain dispensing packaging, pharmacies look to provide patient information leaflets but this may not always happen. Patients certainly will not receive or have the opportunity to read the safety information printed on the manufacturer’s original packaging. Further, they may get a collection of snipped strips in a plain dispensing box, which makes it difficult to know whether they have taken their tablet that day or how many tablets they have left and therefore when they need to reorder their medicines. Where patients get the manufacturer’s original pack but with some tablets taken out, and where any tamper-evident seal is broken, they may be concerned that their medicines have been interfered with.

In the case of medicines containing valproate, these amendments will mean that they must always be dispensed in whole packs in the manufacturer’s original packaging, regardless of the conditions that we set around other products for original package dispensing. The requirement is that the nearest number of whole packs to the quantity prescribed—either rounding up or down—will be supplied so that the patient receives only the manufacturer’s complete original packs. These must not subsequently be repackaged into plain dispensing packaging.

Further to the consultation responses, an exception is being included: pharmacists will be able to make an exception to whole-pack dispensing of medicines containing valproate on an individual patient basis where a risk assessment is in place that refers to the need for different packaging, such as a monitored dosage system, and where processes are in place to ensure the supply of patient information leaflets. The risk assessment might identify that the patient needs different packaging to support them taking their medication. Otherwise, while dispensing in original packs may support increased access to patient information, there is a danger that it may undermine measures being taken to support individual patients to take their medicine appropriately.

Amendments to the HMRs for OPD will enable pharmacists, or pharmacy staff under their supervision, to dispense 10% more or less of the medicine compared to the quantity prescribed if it means that they can dispense the medicine in the manufacturer’s original packaging. However, judgment by the responsible pharmacist will remain a critical part of the process; for instance, there are some prescriptions, such as a course of steroids or antibiotics, where a decision may need to be made to supply the exact quantity prescribed.

It is important to note that OPD will not apply to controlled drugs, which are medicines that have further legal controls on top of those that apply to all prescription-only medicines. This is because they may cause serious problems, such as dependence and harm, if they are not taken as intended by the prescriber or are diverted for other uses. Furthermore, OPD does not apply where a medicine is in a form that is not practicable to dispense in the exact quantity ordered, where there is an integral means of application, where splitting the packaging could adversely affect the medicine, such as inhalers, or where the packaging is keeping the medicine sterile.

Although the flexibility of 10% will not enable all medicines to be dispensed in manufacturers’ original packs, it will deal with the issue of whether a month’s supply is 28 days or 30 days and multiples. For example, if a prescription is for 28 days but the pack has 30 tablets, the 10% flexibly enables the full pack to be supplied and vice versa.

The amendments for OPD will apply across Great Britain and are enabling, so pharmacists can decide whether they utilise OPD 10% flexibilities. A transitional provision has been included so the flexibility to dispense up to 10% more or less does not automatically apply in NHS pharmaceutical services in England and Wales. This will allow these administrations to decide how they want to apply this in their respective NHS services. In Scotland, the OPD 10% flexibility will apply immediately.

The amendments will directly contribute to the overarching objective of safeguarding public health by improving patient safety. Ensuring that patients receive the necessary information included in and on the manufacturer’s original packaging will support them taking their medicine safely and effectively. More patients will receive their medication with any tamper-evident seal intact, which reduces concerns that someone has somehow interfered with the medicine. This amendment will lead to a reduction in the use of plain dispensing packaging so that patients will stop getting lots of small “snips” from a blister strip, which we know will make it easier for them to manage their supply and supports compliance as it makes it easier for patients to identify whether they have taken their tablet that day.

OPD is a commitment in the community pharmacy contractual framework 2019-2024 to support efficiencies for pharmacies. This will help pharmacists and their staff become more efficient as the number of times that they have to snip blisters, repackage medicines and source extra patient information leaflets are reduced, freeing up their time for other tasks such as providing clinical services to patients.

Both OPD and expanding hub-and-spoke dispensing arrangements are recognised in the primary care recovery plan, published in May 2023. The NHS long-term workforce plan, published in June 2023, highlights hub-and-spoke arrangements alongside the greater use of automation, which would be facilitated by OPD. These plans recognise OPD and hub-and-spoke arrangements as important foundations in the transformation of community pharmacy that, together, aim to facilitate the greater use of automation in order to increase efficiency and free up pharmacists and their staff to be able to provide more clinical interventions.

The benefits of OPD will be synergistic with the benefits of expanding hub-and-spoke arrangements, which we are also progressing and which will need separate further legislative amendments. Hub-and-spoke arrangements are where parts of the dispensing process are undertaken in separate pharmacy premises. Typically, there are many spoke pharmacies to one hub pharmacy. The concept is that the simple, routine aspects of assembling prescriptions can take place on a large scale in a hub that usually makes use of automated processes.

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With that, as this is the last SI—certainly the last health and social care SI—for us to discuss before the summer, I wish the Minister, his officials, the Whip and all noble Lords a very enjoyable and happy Recess.

[Lord Markham (Con)]

As ever, I thank noble Lords for their constructive comments and general welcoming of the proposals.

On the points made by the noble Lord, Lord Dodds, unfortunately, we do not have the power. It is one of those bizarre situations whereby the Windsor agreement enabled us to follow what is happening in the EU but, for other matters such as these, it requires the involvement of the Northern Ireland Executive and Northern Ireland Assembly where we instigate moves from this side. It is a concern; I am concerned. We have all welcomed the benefits here today as an example, but they are benefits that Northern Ireland obviously will not receive.

One of the things that I am responsible for in the department are the rule changes that are happening. It is a general concern in Northern Ireland. We will talk about this in the new year but there are some very exciting medicine developments, for instance point-of-care medicines. We see as one of the benefits that we can get on and move quickly in those areas. It is a concern that we may, again, have to do them as GB-only if there is no functioning Northern Ireland Executive and Assembly. I have met Northern Ireland Office Ministers to express this concern; they are aware of it. From their point of view, they are doing everything they can to try to get the Northern Ireland Executive and Assembly up and running, but I appreciate that these are complex issues. I know that that is not an ideal response but that is the position that we find ourselves in at the moment.

On the other points, I appreciate the welcome given to these regulations and, in particular, the impact assessment. I will directly, for the benefit of Hansard, thank the team for it. It is appreciated. As has been said, there is incredible attention to detail in it. I am impressed by the attention to detail shown by the noble Lord, Lord Allan; I wonder how he is going to occupy himself over the Recess without impact assessments. Seriously, these are a set of well-thought-out, sensible arrangements and, as has been said, are an exemplar of how we should be doing these things.

On the question about savings, my understanding is that they will be seen by pharmacists themselves and people in their stores. They will be getting paid and they will be keeping it in the system, so to speak. This will help their viability, which the noble Lord, Lord Allan, mentioned.

The point on extra training and checks is well made. I know that that is being kept under review. It is a good point that we need to make sure that it is diarised formally so that we can assess it, particularly in terms of risk assessment. How it was explained to me is that we are talking more about where a person has many medications so it is better for them to have a blister pack-type format and they may not be of child-bearing age so making sure that they can take the correct medicine each day outweighs the risk of side effects for an unborn baby. That is one of the examples that have been described to me of where a logical case can be seen.

Noble Lords might be aware that there is also concern about potential fathers taking valproate pre-conception and how that can have an impact. This is primarily a concern for women of child-bearing age but potentially for males as well, hence the suggestion about the packaging.

As ever, I will respond in writing, but I am not aware that this will specifically impact GPs because they will continue to prescribe in the same way. It will be for pharmacists to use their judgment to make sure that they round up or down for the packaging or dispensing, in the case of valproate in its original form. I repeat that I will write in detail but, off the top of my head, I do not think it will have an impact on GPs.

The wider point is that this should help pharmacists in a lot of their processes. The need to sometimes make judgment calls means that they will obviously need to apply a bit more intelligence but, on balance, we believe that those cases will be isolated enough to be outweighed by the benefits of whole packaging. In response to the points made earlier, that is exactly the sort of thing we should consider when we review it all. As the noble Baroness, Lady Merron, mentioned, the whole point is to free up some pharmacy time so that pharmacists can spend it where they want to on patient care.

I will happily follow up in detailed writing on all the questions. I thank noble Lords for their input; as ever, it was a very interesting debate. I echo the wishes for a happy recess; personally, I cannot wait. Although I will be doing a lot of hospital visits, as I mentioned, it will indeed be lovely. On that note, I commend the regulations to the Committee.

Motion agreed.

Emergency Healthcare (Public Services Committee Report)

Lord Markham Excerpts

Thursday 20th July 2023 Grand Committee

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

First, I add my thanks to the noble Baroness, Lady Armstrong, and all the contributors to the report. It was a thoughtful and constructive report, just as today’s debate has been. I thank noble Lords for that.

Probably one of the benefits of debating the report now, a few months later, is that we have had an opportunity to learn some of the lessons from last winter. I will try to reflect those in my reply. We have also had the opportunity to take on board the evidence from the committee’s report and, as the noble Baroness, Lady Merron, mentioned, the NAO—and, I hope, to reflect quite a few examples of best practice, which I will try to take your Lordships through.

As has featured so much in this debate, I completely agree that this is all about flow. I will try to respond by talking through the flow, because we all agree that that is the vital component.

Of course, the first step of the journey in terms of the flow, as a few noble Lords have said, is demand. We know that as many as 50% of the people going into A&E do not need to be seen there. To me, the first step is how we manage demand and make sure that we treat people in the right place. Of course, that comes in two parts, the first of which is making sure we have sufficient primary care in place, because we know people that often turn up in A&E because they feel that they cannot get the necessary GP appointment. The emphasis we are putting on our primary care recovery plan is very much part of that, as is the direction of travel for the long-term workforce plan—investing much more in primary care and prevention, and having that emphasis versus treatment in hospitals, which is the wrong end of the telescope to be always looking through.

Also we want people to use 111. There will be a complete reset of 111, seeing it as a real navigation tool. Again, as noble Lords have heard me mention a number of times, when we relaunch the app in September, that will be a very important feature, so that people can use the 111 app to establish whether they really need to go to A&E, or whether there is a better place for them to be treated. The other side of this is to establish whether it is appropriate for someone to call 999 and whether they need to be conveyed to A&E. It is about having the right treatment in the right places, and it is all about the “falls” ambulance service, which it is now the responsibility of every ICB to supply. We know that sometimes, you can rectify the situation there and then, set someone right and make sure they are okay, and they do not need to be conveyed to hospital.

It is also about making sure that we have experienced mental health handlers in ambulance services and somebody in the control centre trained in mental health who can help. As for steps in the right direction, we are starting to see the numbers being conveyed go down, which is of course what we want. Whereas 58% of people were being conveyed to A&E a couple of years ago, the current figure is 52%. Clearly, there is more that can be done.

The point that the noble Baroness, Lady Morris, and the noble Lord, Lord Allan, made about the risk-averse nature was absolutely spot on. I shall not pretend that we have proper answers to that, but we need to have a grown-up conversation about it, because we all have very good examples to give. The hope is that the 111 navigation I referred to can help to address that issue, but the human attitude to risk is also a factor.

I turn now to the supply side, response and the ambulances themselves. We are putting more resources into 999, and we are investing in 800 new ambulances. A vital part of that is the discharge hubs for ambulances, so that they are not waiting in the car park with their patients and can instead get back out on the road as quickly as possible. As we know, that is all part of the UEC plan.

Crucial in all this and in managing flows—this links to the point made by the noble Lord, Lord Allan, about data and process improvement—are the flight control systems. As I think I have mentioned before, one of the first hospital visits I ever did was to Maidstone, where they had a fantastic flight control system, managing everything in real time. You knew whether the ambulance was there and whether a person was likely to need a bed; the system looked straightaway at finding that bed and managing the person through the system. What impressed me was that it addressed head-on the often risk-averse nature of clinicians. Amanda Pritchard herself explained the situation to me. She said, “If I were a doctor talking to you, Nick, I’d be saying, ‘I’m pretty happy with how you’re doing, but I’m just going to keep you in one more night to be sure.’” However, when that clinician is armed with real-time data and knows that ambulances are coming and there are people with much greater need of a bed than me, they can make the clinical decision that I am 99% probably going to be fine, and another patient needs that ambulance much more. That is an example of real-time data being used by clinicians, and we are rolling that out as we speak to make sure that it is in place for the winter in 16 trusts. I know that 16 is not 120, but it is a good first step towards that, and I hope we will see improvement.

Carrying on in the flow journey and coming to the beds themselves, we are on target to have a real increase of 5,000 beds in place for the key winter period, as per the question from the noble Lord, Lord Allan. In addition, 10,000 virtual ward beds will be available, with the intention of treating about 50,000 patients per month. That will strengthen everything we are trying to do in terms of the back door, the flow and, as mentioned by many noble Lords, the social care element.

We have started to see the impact of all the things we are talking about. The investment that we are putting into social care is starting to have an impact. As for discharge, right now, we are seeing 2,300 fewer beds blocked, for want of a better word. There is still some way to go; as noble Lords will remember, the target is 13,000, but there has been progress towards that. Our action in terms of the extra money is about learning the lesson around getting the discharge fund out early, instead of suddenly getting to January and thinking, “Oh, we’ve got a problem”. A lot of the social care providers have talked about getting it out early so that they can then plan in advance. Those are all things that we are doing towards that aim. Of course, as many noble Lords have mentioned, underpinning all this is the long-term workforce plan, to make sure that we have cover in the appropriate areas.

Best practice more generally was mentioned in the report and by many noble Lords, and I agree that it is often an issue. We do not have a problem with pilots—I am sure that many noble Lords have heard the quip that the NHS has more pilots than British Airways—but the issue is adoption. I have mentioned a couple of examples of that. We now have tiering in place. The performance of hospitals in each area of UEC is looked at and specific plans are put in place with the leadership to address the tiering. There has been some good progress there, but I agree that, of all the things we need to do, that is definitely a work in progress. On that note, the noble Lord, Lord Allan, will be pleased to know that I am spending the summer visiting hospitals. After the last couple of weeks and those coming up, I will have notched up another 15 or 20 on my visit list. I am definitely trying to get out there.

I really appreciated the thoughtful contribution of the noble Baroness, Lady Bennett. She talked about the environmental impact, and I must admit that it made me think about it in a different way. The NHS recognises that it has a role to play in this. I want to give her a proper response because I was struck by what she said and appreciated her sharing that.

The noble Baroness, Lady Armstrong, mentioned the publication of figures on 12-hour waits. We have been publishing them since February 2023, but there is an understanding of the need for complete transparency in this, as mentioned by the noble Lord, Lord Allan. I know that this is something we are trying to achieve.

The right reverend Prelate the Bishop of St Albans mentioned the rural response. We are looking at each ICB to make sure that they are responding with plans that look after all the needs of their area and where they need more help. We know that it is often hard to recruit people to some of those areas, so there is the possibility of these special incentive payments in order to recruit people to them. As ever, if I run out of time and do not manage to answer everything, I will follow up with a detailed letter.

“Frequent flyers” have been mentioned a couple of times. I saw a very good example the other day of one of the best practices we want to roll out. Redhill is taking its top 1% of “frequent flyers” and getting upstream with them by proactively going out to visit, screen and check them. That has resulted in them needing 30% less treatment. What struck me, and as noble Lords have mentioned, is that one of the first experiences I had as NED in DLUHC’s forerunner was the troubled families programme, which I thought was an excellent example of trying to look holistically at the problem. I wonder—I am wondering out loud with your Lordships—whether we need to look at that more holistic approach for some of these cases; that is one of my takeaways.

As for the NAO report on the NHP, I am still very confident about the 40 new hospitals. The NAO report talked about the original list of 40 but ignored the fact that we have brought in the RAC hospitals. It says that of the original list of 40, we are committing to only 32 by 2030. That is absolutely correct, because we have brought in the RAC hospitals on top of that which were not previously on the list. It is 40—but it is not the same 40 hospitals. That is what the NHP was pointing out, but I think all of us here today would agree that the RAC hospitals were clearly the priority which should have been brought into the list.

The £150 million is new and is a separate part of the budget which I look after as part of the whole capital programme. It will be subject to bids from the hospitals, which need to make sure that they have the revenue to do it.

To conclude on the question on the assessment: yes, I do think there will be improvements next year. Is it going to be challenging? In all honesty, I think it will. I am not going to pretend that there will be one leap and we will be there, but we have a number of measures in place through which we will see step-by-step improvement next year, and, I hope, reflect a lot of the points made in today’s debate on the report.

MMR Vaccine

Lord Markham Excerpts

Thursday 20th July 2023 Lords Chamber

[Baroness Twycross]

To ask His Majesty’s Government what further steps they will take to work with schools to encourage greater take up of the MMR vaccine among pupils.

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

The UK Health Security Agency is closely engaging with the Department for Education to boost uptake of the MMR vaccine, especially in areas with lower uptake. Earlier this month a messaging campaign to the education sector encouraged uptake among pupils, and an NHS England national MMR call/recall campaign between September 2022 and February 2023 reached approximately 940,000 parents and guardians and resulted in the delivery of over 160,000 vaccinations.

[Baroness Twycross (Lab)]

My Lords, I declare an interest as chair of the London Resilience Forum and as someone who contracted viral encephalitis as a child, albeit from mumps, not measles. Measles in children can cause death or serious disability. The increase in measles breakouts comes as research finds that the number of nurses in schools has dropped by 35%, with some local authorities scrapping the role altogether. Does the Minister believe that the decline in school nurses has contributed to falling MMR take-up in schools? Have the Department for Education and the Department of Health and Social Care set a joint target to achieve an uplift in the take-up of MMR, and what is it?

[Lord Markham (Con)]

I do not necessarily believe that that is the reason for the reduction. What we saw during Covid, as with so many things, was a couple of years when people were not attending school so much and were not attending GP surgeries for their vaccinations. That is why we have had a series of catch-up campaigns, which are working. We are getting there, but clearly there is a long way to go.

[Baroness Blackwood of North Oxford (Con)]

My Lords, we learned from Covid that high-uptake vaccine programmes can be effectively delivered only with a firm foundation of high-quality data and surveillance. The UK measles and rubella elimination strategy set out by UKHSA commits to a target of rigorous case investigation and the testing of over 80% of suspected cases with an oral fluid test. Can the Minister update the House on our performance on surveillance so that we can get on top of falling vaccination rates?

[Lord Markham (Con)]

I thank my noble friend. I was speaking to the senior epidemiologist at UKHSA just this morning about this. My noble friend is right to point out the concerns in this area. On exactly where we are on oral fluid testing, I will need to write to her.

[The Lord Speaker (Lord McFall of Alcluith)]

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

--- Later in debate ---

[Baroness Brinton (LD) [V]]

My Lords, the NHS says that susceptibility is not just among the under-twos; it is particularly high among 19 to 25 year-olds whose parents were affected by the unfounded Wakefield stories two decades ago, and many may still not be vaccinated. What is the NHS doing to reach this cohort, including at further education colleges and universities, to ensure that they are fully vaccinated before they start their own families? Catching measles when pregnant can cause miscarriage, stillbirth, premature birth and low birth weight.

[Lord Markham (Con)]

The noble Baroness is correct. The unfortunate Wakefield effect had quite an impact on that cohort of people, so the campaigns have been targeted particularly at specific communities in particular areas. Outreach campaigns are being done as part of that, looking at every area where it can be done. Sometimes that involves looking at colleges and sometimes it involves going specifically to community centres themselves.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, the Minister referred to outreach campaigns in relation to the take-up of MMR. Will that extend to children who are disabled and who are forced to be off school for certain periods of time to ensure that they are able to access their MMR vaccines?

[Lord Markham (Con)]

Yes. This whole campaign is looking particularly at hard-to-reach communities. The concern is particularly in London. Whereas we have about 85% take-up across England as a whole, in London it is around 75%, so that is where the particular outreach is. That also involves looking at children who are not able to go to school or who are home-schooled.

[Baroness Manzoor (Con)]

My Lords, I welcome the catch-up campaigns that the Government are running. They are very welcome. I particularly note the campaign in London. As the Minister will know, there is variation across the country. The WHO stipulates that 95% is the target reach, yet we are at 89%. So how are those hard-to-reach communities, particularly the ethnic-minority communities, being targeted? The uptake is slightly lower in those particular areas.

[Lord Markham (Con)]

There are two main approaches. If a child is under 11, we would prefer to have a parent present, for obvious reasons—because it involves a vaccination—so that is normally done through the primary care system, through nurses. Post 11, because you do not need the parent there, that is where schools really come into effect. In particular, there is a school-age assisted immunisation providers programme that goes into every school in a particular area, targets it and speaks to every child to see whether they have had their vaccination—and they can give it on the spot if they have not.

[Lord Allan of Hallam (LD)]

My Lords, does the Minister agree that the experience of both the MMR and Covid vaccination programmes shows that vaccine hesitancy is actually a very complex problem with multiple factors? Given the importance of high vaccination rates for public health, are the Government commissioning any research from academic experts in misinformation and disinformation so that we can understand what kinds of government campaigns will work and which ones will not and will only reinforce vaccine hesitancy?

[Lord Markham (Con)]

The noble Lord is correct about trying to make sure that we learn the lessons from all these areas. The approach that they have been responding to so far is very much “horses for courses”. In the last six months alone, they have had four different types of campaign. We do not have the results from those campaigns yet, but the point is a very good one and I will make sure that we get those results from the research and share them.

[Lord Kirkhope of Harrogate (Con)]

My Lords, as my noble friend has referred to, it is very important that young people, children, get vaccinations when they are due, but the current government campaign to encourage adults to have a shingles jab, and indeed other areas, seems to point out—I have heard this from GPs—that the fact that adults are not now taking boosters for things such as tetanus, and other areas where vaccination is so important, means that there is a gap. Does my noble friend not think that we ought to do more to encourage adults to take up vaccinations, renewals and boosters where appropriate to safeguard their health?

[Lord Markham (Con)]

Yes. That is where we really see UKHSA coming into its own in terms of taking an intelligence-led approach. The concern came from its modelling: its epidemiologists brought this up as a concern, which led to the alert going out on 14 July. Likewise, it is looking into other categories and, where there are those concerns, it will come out and suggest such outreach programmes.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I refer to the question asked earlier by the noble Lord, Lord Young, about the high level of absence of children from school at the moment; I believe the present figure is in the order of 24%. What special steps are being taken there, where the appeal to the school will not make any difference yet we have to try to get to the homes of the individual parents?

[Lord Markham (Con)]

As mentioned, there are outreach programmes, particularly for home-schooled children or children who are not there. There are also programmes in community centres, with the idea of trying to pick them up in as many places as possible. Obviously, there is concern about certain communities that are harder to reach than others. That is particularly the case in London, as I mentioned earlier. That is where we are trying to specifically target those community centres with outreach work.

[Baroness Bennett of Manor Castle (GP)]

My Lords, in April the UK Health Security Agency’s director of public health told the Health and Social Care Committee in the other place that the workload for delivering vaccines now falls disproportionately on general practices—particularly after the 2012 NHS reforms—and that this is one of the weaknesses we are trying to put back together.

In that context, the Minister may be aware of the issue around the quality and outcomes framework payment to GPs. GP practices in deprived areas are missing out on payments for delivering vaccines that could help them deliver more vaccines because it is extremely difficult for them to register the patients whom they have tried to contact multiple times when those patients do not respond. So, the GPs are missing out on payments they need to be able to reach those difficult-to-reach patients.

[Lord Markham (Con)]

I am sorry, I am not quite sure what the question was there. Clearly, we need to make sure that the system is working in terms of making sure that the payments are there so the doctors can follow up. If the noble Baroness would like to follow up with me, so that I can fully understand it, I will get her a response.

Food: Two-For-One Offers

Lord Markham Excerpts

Wednesday 19th July 2023 Lords Chamber

[Baroness Walmsley]

To ask His Majesty’s Government on the basis of what health evidence, if any, they have postponed the planned ban on two-for-one offers for foods high in fat, salt and sugar.

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

The volume price promotion restrictions have been delayed for two years while we prioritise the implementation of the location restrictions. This is the most impactful policy for reducing children’s calorie consumption, and accounts for 96% of the expected health benefits of the promotions policy. Kantar data suggests that it is working. The evidence suggests that this will have the biggest impact on tackling obesity.

[Baroness Walmsley (LD)]

I thank the Minister for his reply, but according to the Food Foundation’s most recent Broken Plate report, the most deprived 20% of families would have to spend half of their disposable income on food to comply with the Government’s healthy diet advice. Bearing that in mind, why are the Government continuing to allow retailers to sell HFSS foods, which can make people ill, at a discount? Do the government really want to encourage people to buy cheap food that could, in the end, kill them?

[Lord Markham (Con)]

First, I thank the noble Baroness for her tireless work in this space. I think we have shown that our restrictions are absolutely placed to inform and educate people so that they can have a healthy diet. I mentioned what we have done on location—the so-called pester power avoidance. It is estimated that these measures will reduce calorific intake by 96%. That is the prize that we are looking at here.

[Lord Rooker (Lab)]

My Lords, can the Minister confirm that the Secretary of State for Health actually believes in public health policy, because his recent speech at the Centre for Policy Studies—I watched all of it—indicates he does not?

[Lord Markham (Con)]

He definitely does. He was very much behind these measures. Just look at what we are doing in the smoking space, through the swapping out of cigarettes for vapes—another example of where we are taking action. As I mentioned, the evidence from Kantar suggests that it is working.

[Lord Naseby (Con)]

My Lords, if a product is marketed legally in the United Kingdom, why should His Majesty’s Government feel they have to interfere at all with the marketing of that product? I understand the point about education and totally accept it, but is it not wrong for His Majesty’s Government to restrict what is a legally marketed product?

[Lord Markham (Con)]

We are trying to educate, inform and nudge. The best example of all is encouraging the industry to reformulate its foods to be healthier. At this point, I am glad to say that, since we introduced these restrictions, Mars, Galaxy, Bounty and Snickers have reformulated, and even Mr Kipling’s Deliciously Good cakes are compliant.

[Lord Allan of Hallam (LD)]

My Lords, next week it will be three years since the Government committed to legislate to end the promotion of high-fat, salt and sugar foods by volume. Would a reasonable person think that this commitment has been met when the legislation has been passed but not implemented, and will not be for another couple of years?

[Lord Markham (Con)]

As I mentioned, the key is giving industry time to adjust so that it can reformulate. We would all agree that, if you can get the same taste but it is a lot healthier, with less fat, salt and sugar, that must be a good outcome. The examples that I just gave show that, and it is working.

[Baroness Boycott (CB)]

The NHS Food Scanner is promoting to children a number of ultra-processed food items. Do the Government not think that this is quite perverse given the new knowledge about what exactly ultra-processed food means? It is not just about the sugars, salts and fat but about the chemical destruction and reformulation of foodstuffs into something else.

[Lord Markham (Con)]

As I mentioned in answer to a Question on ultra-processed food yesterday, as a definition that is not particularly helpful because wholemeal bread, baked beans and cereals are all examples of ultra-processed food. The real point is the content of the food, and that is what our regulations should look to.

[Baroness Merron (Lab)]

My Lords, when the anti-obesity strategy was published, this ban was said to be supporting food affordability, citing evidence that multi-buy offers such as “buy one, get one free” increase the amount that people spend on foods by around 20% but often on foods high in fat, sugar and salt. With the Government now making the opposite argument to support this postponement, do they no longer stand by the evidence? Would a ban on these deals make it easier or harder for those who are struggling to get by?

[Lord Markham (Con)]

As we have mentioned before, our general direction of travel is to educate, reformulate and give people the best chances through having choices, and a good start in life through the fresh fruit and vegetables that we have in schools. Those are the things that will really make the difference.

[Lord Lansley (Con)]

Does my noble friend the Minister recall, on that exact point about access to fresh fruit and vegetables, the very successful scheme that we pioneered about 12 years ago with the Association of Convenience Stores so that corner shops would carry fresh fruit and vegetables close to the till and make them accessible, with us carrying the risk of wastage? That led to a significant increase in corner shops selling fresh fruit and vegetables.

[Lord Markham (Con)]

To me, that is a great example of how working in co-operation to allow people to make the right choices is the best way. For instance, 78% of shoppers have said that they are in favour of not having unhealthy items at the till because they know that they give in to pester power. That is why this has been focus of what we have done.

[Baroness Bull (CB)]

My Lords, notwithstanding the interesting “legal but harmful” point made by the noble Lord, Lord Naseby, I think that most of the House would agree that reducing high-fat, sugar and salt content is a good idea. However, the Minister has at least twice mentioned reduction of calories. Does he acknowledge and recognise that while one way to address obesity is calorie reduction, it is not an appropriate message for everybody and it certainly is not the sole cause of obesity across this country?

[Lord Markham (Con)]

The noble Baroness is correct; this is a complicated area, and a number of measures need to be taken. The best thing is the promotion of healthy foods, and the fresh fruit and veg initiatives that we have talked about today are perfect examples of that.

[Lord Dubs (Lab)]

My Lords, some years ago, the British-Irish Parliamentary Assembly looked at obesity in children, during the course of which we went to Amsterdam to look at what was going on there. Two of the things that were very enlightening were educating children in schools and educating pregnant mothers. What about that?

[Lord Markham (Con)]

I am aware of the Amsterdam initiative. Off the back of that, the OECD said that there were four main strands to what countries should be doing: first, information and education, such as the good examples I spoke about; secondly, increasing healthy choices through the reformulation of foods, which again is something we are doing; thirdly, the modifying of costs—the sugar tax, which has reduced sugar consumption by as much as 40%, is a perfect example of that; and, fourthly, restrictions on where product placement should take place. I am absolutely familiar with the initiative in Amsterdam, and am pleased to see that we have taken action on a lot of those things.

[Lord Brooke of Alverthorpe (Lab)]

Is the Minister not ashamed about what has happened to children’s health while the Conservatives have been in power since 2010? We have more obese children than ever before, and a plethora of policies which would work if implemented, yet so many are delayed. Will the Minister give a commitment to go back and look at the regulations governing children’s school meals? They were changed in 2014, with permission granted to give children more sugar. The Government were reviewing this in 2019 and 2020, but that stopped because of Covid. Will the Minister give a commitment again to start a review? Even if they cannot implement it, the next Government could.

[Lord Markham (Con)]

The noble Lord is correct: good school meals are fundamental to all of this. My understanding is that the review is something that the Government are looking to do, but I will happily provide more details on what the plan is.

[Lord Morse (CB)]

My Lords, can I just test with the Minister whether there is still a commitment to the policy of banning two-for-one promotions? If there is, is there an effective deal going on with the food producers that they will change certain processes if this ban continues to be pushed backwards and effectively talked out of effect?

[Lord Markham (Con)]

There is absolutely the commitment for October 2025. The tactic behind that is to give industry the time to make its food healthier. That is exactly what it is doing in the examples I mentioned, including the Deliciously Good cakes. It is good to see industry respond in that way.

Ultra-processed Food

Lord Markham Excerpts

Tuesday 18th July 2023 Lords Chamber

[Baroness Boycott]

To ask His Majesty’s Government what assessment they have made of the latest research into the effects of ultra-processed food on the mental and physical health of children and adults; and whether they plan to introduce any further restrictions on these foodstuffs.

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

The Scientific Advisory Committee on Nutrition did not find evidence for a causal link between ultra-processed food and mental and physical health. It is unclear whether ultra-processed foods are inherently unhealthy, or whether it is more that those foods are typically high in calories, saturated fat, salt, and sugar. Therefore, the Government’s priority is continued action to reduce the consumption of foods high in calories, salt, sugar and saturated fat.

[Baroness Boycott (CB)]

I thank the noble Lord for his Answer, but I beg to disagree. The latest scientific evidence indeed shows that ultra-processed food, which is, in essence, not really food given that ordinary foodstuffs have been put through industrial processes that render them chemically different from what they were when they began, has had a massive impact on the nation’s health, especially in the past 30 years. Some 66% of our diet is ultra-processed food, and 16% of everything we eat every day goes to our brain. It seems to be no coincidence that instances of heart disease, cancer, obesity and many other illnesses, as well as mental illnesses, might have something to do with the food that we are eating, the fuel that we are putting in our cars. No noble Lord in this House would put Coca-Cola in his Rolls-Royce and expect it to do its best. I beg the Government to come back and have another look. I would be very happy to set up a meeting for the Minister with the newest experts in neuroscientific research to see whether we can take this forward.

[Lord Markham (Con)]

First, I thank the noble Baroness for the work she does and has done in this space for a number of years. The problem is the definition of “ultra-processed food”. It includes things such as wholemeal bread, baked beans and cereal. It is not a helpful definition. There are certain ultra-processed foods which are high in fat, salt and sugar. We completely agree that those things are bad for us and that we should do everything we can to discourage people from eating them. The label “ultra-processed food” is not helpful.

[Baroness Manzoor (Con)]

My noble friend will know that one-third of baby and infant foods contain ultra-processed food which, in effect, is leading to obesity, and he will know that obesity can lead to cardiac problems and hypertension in later life, which costs the NHS significant sums of money. There is evidence in recent research that firms’ marketing is providing misleading information. What are the Government doing to ensure that this aspect, particularly with baby and infant food, is better regulated?

[Lord Markham (Con)]

I thank my noble friend. We are focused on the sugar, salt and saturated fat content. It is not the fact that food is called ultra-processed, per se. We would not discourage people from eating whole- meal bread, but wholemeal bread is considered to be a processed food. The action we are taking is for a reduction in sugar, salt and saturated fat.

[Lord Brooke of Alverthorpe (Lab)]

The Minister is focusing on reducing fats, salt and sugar in meals. When are the Government going to reduce those elements in school meals for children?

[Lord Markham (Con)]

Absolutely. That is why we are at the highest level of free school meals for children ever. More than a third of children are now receiving free school meals, including all infant schoolchildren. The noble Lord is correct that a healthy start to life is vital, and if we can make sure that children are getting a good, nutritionally balanced school meal, that is a good start to life.

[Lord Allan of Hallam (LD)]

My Lords, as the Online Safety Bill works its way through this House, we see how interventionist the Government can be in the interests of public health and well-being when they put their mind to it. Learning from that effort, does the Minister agree that the phrase “legal but harmful” is quite an accurate description of some of the kinds of ultra-processed food that are sold and marketed in the UK?

[Lord Markham (Con)]

Absolutely. Some of the foods are not healthy at all, and we totally want to discourage them. We have taken a lot of steps in that space. The whole product positioning strategy, whereby you cannot now put such foods in places where there will be so called pester-power influences, is beginning to have an effect. We are already seeing healthier foods outgrowing non-healthy foods from that. Those sorts of actions were modelled to show that they were effective for 96% of the things that we are trying to target to reduce in terms of calories.

[Lord Krebs (CB)]

My Lords, I declare my interests as listed in the register and I hate to disagree with my noble friend Lady Boycott but, on this occasion, I do. Does the Minister agree with the conclusions of the nutritional advisory committee of the five Nordic countries, published on 20 June 2023? It says:

“The … committee’s view is that the current categorization of foods as ultra-processed foods does not add to the already existing food classifications and recommendations”.


Does he also agree with the Brazilian scientists who coined the notion of ultra-processed food when they say that their classification is a good way to understand the food system, but not individual foods?

[Lord Markham (Con)]

Yes, the noble Lord is absolutely correct and makes the point that I have been trying to make but far more eloquently; I thank him. That is precisely the point. Some ultra-processed foods are very unhealthy and we should be doing everything we can to discourage them. Others, such as wholemeal bread or baked beans, are totally fine.

[Lord Hannan of Kingsclere (Con)]

My Lords, I am very grateful for my noble friend’s reply to the noble Lord, Lord Krebs. The definition of ultra-processed foods to which I think noble Lords on all sides are referring comes from the recent book, Ultra-Processed People. It is food that is

“wrapped in plastic and has …one ingredient that you wouldn’t find in your kitchen”.

I suspect that is true of the contents of almost all of our cupboards, including, as my noble friend the Ministers says, sliced wholemeal bread. Is it not time that we stood up against moral panic, focused on the actual empirical data and followed the science?

--- Later in debate ---

[Lord Markham (Con)]

I thank my noble friend; that was excellently put. Again, it is the content of the food that matters and not what it is called.

[Baroness Merron (Lab)]

My Lords, to follow on from the Minister’s comments about the definition of ultra-processed foods, can he confirm what work is taking place to nail down a definition and, upon this definition, will the Government carry out the research that scientists believe to be necessary?

[Lord Markham (Con)]

As I have said, the fact that something is processed is not a helpful definition. I would recommend that we focus all our activity on the contents of the foods—whether they are high in saturated fat, sugar or salt—and not on whether they are processed.

[Baroness Jenkin of Kennington (Con)]

My Lords, will my noble friend the Minister let us know what assessment the Government have made of food industry links with the Scientific Advisory Committee on Nutrition and whether this might have influenced the evidence and recommendations of the review?

[Lord Markham (Con)]

On any advisory body you clearly want to get experts in the field. Necessarily, they will often be experts from companies as well. It is vital that they abide by the principles of conduct in public life and make sure they declare any conflicts. As such, we are content that we have a proper expert panel.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, may I take the Minister back to the question from my noble friend Lord Brooke, who asked about the content of school meals? The Minister replied that school meals are a good thing and more people should have them, with which I do not suppose anybody would want to disagree. However, I did not hear him say in what way the Government are ensuring that the content of those school meals is appropriate and free from salt, sugar and fat in the way that my noble friend Lord Brooke was asking for.

[Lord Markham (Con)]

My understanding is that those guidelines are there; it is absolutely the right question. The Department for Education, working with the Department of Health, makes sure that a nutritionally balanced diet is there. There is also a joint DfE/DHSE programme in respect of nursery milk and fresh fruit and vegetables for young children, to give them a good start in life.

[Lord Forsyth of Drumlean (Con)]

My Lords, is it not the solution to this problem not to ban things but to improve education so that people understand what they are eating and make rational and clear choices? Is it not the case that many of these processed foods are bought by people because they are cheaper? If we could encourage people in schools to learn what used to be called domestic science—cooking skills and so on—so they can use fresh ingredients, then we would advance this case far more effectively than by banning things.

--- Later in debate ---

[Lord Markham (Con)]

I absolutely agree with my noble friend about education and teaching people how to cook a decent meal. The other crucial thing is the industry reformulating foods to take out sugar and fat content. That is where some of the restrictions are working. Advertising and product placement really do work, so if you make it harder, the industry is incentivised to take sugar and fat out of those meals to make them healthier so that they can still be marketed.

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

Lord Markham Excerpts

Thursday 13th July 2023 Lords Chamber

I am sure that the Minister has got the message that while there is no issue with the actual changes, there are many issues with the way in which the regulations have been dealt with. There are great concerns that they may not deliver the impact that the Government seek and, indeed, we all seek—that is, improvement to access to dental care.

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

I thank noble Lords for their contributions and the noble Lord, Lord Hunt, for bringing this topic before us today. As noble Lords know, I have an interest in this case in that my wife is an overseas dentist, which means I can trump the website search by the noble Lord, Lord Allan, and say that I have filled in these forms myself.

Overall, I am glad that there seem to be shared goals in that we all want to increase the supply base of doctors, dentists and opticians—in this case, the focus is particularly on dentists. Clearly, we all want to maintain high standards and remove unnecessary red tape. That is what we are trying to do here.

I do not think anyone is going to pretend that this alone will be a massive thing. I liken it to Team GB cycling—noble Lords have probably heard me use that example before—where you are looking at 1% and 2% changes and sensible things at the margin that will accumulate over time. The noble Baroness, Lady Merron, asked about some of the July 2022 changes. The noble Lord, Lord Hunt, mentioned the changes to the UDAs and those earlier changes. Each of those on its own will not make a massive change, but the accumulation of all those things will begin to have an impact. That is why it is so difficult to do an impact analysis on any one individual measure, because we are trying to combine all those things to make it into the right space for people to want to do this.

I think we all agree that it seems strange not to trust that the Scottish, Welsh or Northern Ireland NHS has gone through a process good enough that we would automatically use it. It is sensible that we trust them and their standards but have a case to verify afterwards if we need to. I do not know whether it will be reciprocal. I argue that we should do it regardless, because it has to be to our benefit that we are as inviting as possible. I would not be surprised if they follow suit. Funnily enough, if they do not, it might be to our advantage through a narrow NHS England lens and making sure that we have the easiest approach to work and practice.

The other main point is where I really have a personal interest. I hope it will add some colour to the thinking behind this, albeit with a sample size of one. Please take this as an anecdotal experience rather than as a massive data analysis. I have seen that you go through a very thorough GDC process. That is something that I filled out in the context of my wife when we did all this. She had practised and had her own practice in Madrid for about 15 years and was very experienced. She went through a very thorough GDC process to make sure that she was eligible to practise here. She then practised in Manchester and Liverpool at some very high-end private clinics.

We then decided to move to Surrey. She saw that there were a number of jobs on offer that wanted people with private registration, but that it would be helpful if they had NHS as well, because a number of clinics have a hybrid model whereby they will offer both NHS and private treatment. She went down that process and I was involved in it. Eventually, she came to the conclusion that she was doing a hell of a lot of hard work. There was a two-year process and all sorts of courses she needed to take—it was very much a checklist of things to do—so she thought, “Do I really need to do this? I have plenty of private practice anyway”. In the end, she concluded that there was no point. I grant that this is a sample size of one, but I think we can all see that, if someone has been practising for many years to a very high level and can continue doing that, but suddenly there is a load of red tape in the way of becoming an NHS dentist, eventually they would say that it is not worth it. That is what this approach is all about.

It is also about accepting that you need judgment; you cannot put down any hard and fast rules, as was questioned, because every case is going to be different. Part of the problem now is that it is almost a tick-box exercise when looking at their experience. That is what this is designed to do. If a dentist has worked in the private sector or overseas for 10 to 15 years and can show evidence of the different types of treatment they have done, you can be pretty confident—by all means, meet them and talk to them—that they can do that at the NHS level. Those are the judgment calls that they make, and that is where we are coming from.

Healthcare (International Arrangements) (EU Exit) Regulations 2023

Lord Markham Excerpts

Wednesday 12th July 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 5 June be approved. Considered in Grand Committee on 5 July.

Motion agreed.

Community Health Services: Waiting Lists

Lord Markham Excerpts

Wednesday 12th July 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what recent assessment they have made of current levels of waiting lists and times for community health services for (1) children and young people, and (2) adults.

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

We regularly monitor community health services’ waiting lists and recognise the variability between the number of people waiting and the time on waiting lists across services in local areas. We are committed to reducing waiting lists; that is why the NHS Long Term Workforce Plan sets commitments to grow the community workforce, with increases in training places for district nurses and allied health professionals and a renewed focus on retaining our existing staff.

[Baroness Merron (Lab)]

My Lords, long waits have a more severe effect on children because delays in assessment and treatment have a knock-on effect on their communication skills, social and educational development and mental well-being. With over 37% of children and young people on waiting lists for community health services for more than 18 weeks, compared to under 16% of adults, when will the Government address this ever-widening gap and what steps are they taking to prevent a disproportionate impact on vulnerable families both now and in the long term?

[Lord Markham (Con)]

The noble Baroness is correct about the urgency for young people; I have personal experience of this as well. We are taking steps by piloting nine early language and support services for all children focused on exactly what the noble Baroness mentioned. There is £70 million behind that pilot, with the intention being that we learn lessons from that and roll it out quickly.

[Baroness Manzoor (Con)]

My Lords, my noble friend will know that a number of surveys have identified that over half a million adults are waiting for adult care assessments. The normal waiting time is 28 days, but for some it is, sadly, significantly longer, which has a disproportionate effect on some of the most vulnerable. What action are the Government taking to reduce it?

[Lord Markham (Con)]

We are starting to see a blue- print which is beginning to work. The highest waiting list for adults is related to musculoskeletal issues. Since we put an improvement framework in place, 91% of people are now being seen within 12 weeks—a big improvement. We are moving to self-referral also, and digital therapeutics beyond that. There is a road map in place that we need to apply across other areas.

[Lord Allan of Hallam (LD)]

My Lords, within the published data for wait times in community health services, we see that some people face very long waits for home oxygen assessments, including some waiting for over a year. Given that home oxygen is key for many with respiratory conditions staying out of hospital, will the Minister prioritise looking into why we are seeing these delays, and ensure those who need home oxygen do not face unnecessary waits?

[Lord Markham (Con)]

As noble Lords probably know, we published this data for the first time in March, so it is only now we are getting the data that we can truly work on it. It sets out 35 different areas where we understand those waiting lists for the first time, so we know which ones to prioritise—home oxygen being clearly one of those.

[Baroness Finlay of Llandaff (CB)]

My Lords, with a staff absence rate of 5.6% overall for NHS community staff, which is equivalent to 75,000 staff, what are the Government doing to address this high level of sickness, including mental health sickness? Without the staff, the services cannot be provided. Can the Minister also explain what is being done to target those who have particular training in looking after children, given that in some areas the waiting lists for children are incredibly high, particularly for mental health services for children in the community?

[Lord Markham (Con)]

The noble Baroness is correct: absenteeism is often an example, in the same way as poor retention is, of problems in the wider workplace and the pressures that people have to face now. That is why the long-term workforce plan, which I think was welcomed by all noble Lords, looks to tackle every aspect: recruiting more staff so the pressures on individuals are reduced; making sure we have training and retention plans in place; and the necessary skills training in each area, including that of young people.

[The Lord Bishop of Southwell and Nottingham]

My Lords, in a recent survey of the Association of Directors of Adult Social Services, over 90% agreed that unpaid carers are now coming forward with an increased level of need, with directors ranking burnout as the number one reason for the increasing carer breakdown over the past year. Unpaid carers are clearly bearing the brunt of shortages in health and social care support, so can the Minister say what the Government can do to help more with unpaid carers?

[Lord Markham (Con)]

We all agree that unpaid carers are the backbone and hidden army behind a lot of what we see. We have made some good moves in that direction. We have the set-up for leave, so that they can have time away and a reduction in stress. We are setting up payment for them, albeit we all accept that there is such a hidden army we need to do more.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, recent research has found that almost three in five disabled children seeking physical and talking therapies are waiting more than 12 months for appointments, which is totally unacceptable? How do the Government plan to address such a large backlog and improve opportunities for disabled children? Perhaps the Minister can elucidate on that particular area.

[Lord Markham (Con)]

Unfortunately, as we know, we have a backlog in quite a few areas, often as a consequence of the pandemic and the period when we could not see as many people as we would have liked to. I wish I could say there was a quick solution; we all recognise the long-term solution is the long-term workforce plan, where we need to address the vacancies and have more staff to increase the output and supply. We are putting in a record investment of £2.4 billion behind this, but I freely admit it is not an overnight solution.

[Baroness Browning (Con)]

My Lords, I draw attention to my interest in the register and my association with the Alzheimer’s Society. My noble friend will know that, when asked, most people will say that when they die, they would like to die at home in their own bed. There is one group of people for whom there seems to be no structured plan to make that possible, and that is for people with dementia and Alzheimer’s. They are cared for at home until the end of their life, but the end of their life very often ends up in a hospital ward—the most inappropriate place for somebody with dementia, unless there is a genuine medical need to be there. Could my noble friend look to see if we can put together a structured plan that would be of help to families in planning the end of life of close relatives? I particularly do not mean something that follows the way the Liverpool care pathway was put together.

[Lord Markham (Con)]

I thank my noble friend. This was actually a conversation of a big task force summit that we had just last week. We commented that a lot of people have pregnancy plans, for instance, which might say that they want to have birth planned at home; a lot of people will have “Do not resuscitate” plans; what we do not have enough of are frailty plans, which say, “I don’t want to go into hospital. I’d rather be cared for at home. I know it might mean that I don’t live for quite as long, but that’s my preference”. I think there is a whole debate that we need to have to start to move towards that, and to make sure we have that support in the community to do it as well.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, is the Minister aware of the spare capacity of therapists in the private sector, some of them specialising in the mental health of children? As we have such long waiting lists for children and mental health, why is that not being used?

[Lord Markham (Con)]

The noble Lord is correct, and my understanding is that we are looking to use the independent sector more and more. I will check and verify this, as it was from the briefing probably about three or four months ago, but my belief is that about 51% of the physiotherapy that we use is from the private sector. I absolutely agree with the noble Lord that we need to use the independent sector more and more in these situations—something pioneered by the noble Lord, Lord Reid, over there.

[Lord Patel (CB)]

My Lords, every day, about seven children will develop cancer; eight out of 10 will survive more than five years with modern care, but these children who survive require long-term community care, both for their families and themselves. Would the Minister agree that the integrated care pathways developed by integrated care systems should improve community care for cancer-surviving children?

[Lord Markham (Con)]

Yes; our whole direction of travel, as noble Lords are aware, is putting more and more power in the hands of the local integrated care boards. Going into the detail of it, the whole workforce plan moves a lot of the emphasis away from treatment in hospitals into care in the community—primary and prevention. This is a direction of travel that I think we all agree on, which is why we are putting more resources behind it, albeit that these things take time.

Healthcare (International Arrangements) (EU Exit) Regulations 2023

Lord Markham Excerpts

Wednesday 5th July 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Healthcare (International Arrangements) (EU Exit) Regulations 2023.

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

My Lords, reciprocal healthcare arrangements enable UK residents to access healthcare when they live, study, work or travel abroad. They not only provide an added safeguard for our residents when they travel but support those with long-term pre-existing conditions to avoid them facing expensive insurance premia or funding private treatment. This is why the UK Government are proud to have concluded healthcare arrangements that provide our residents with greater access to healthcare in countries across the world, such as with the European Union, Switzerland and our overseas territories.

Last year, we amended our primary legislation that enabled the implementation of comprehensive reciprocal healthcare arrangements in the European Economic Area and Switzerland. Thanks to the Health and Care Act, which noble Lords played a crucial role in scrutinising, the UK can now implement comprehensive healthcare arrangements with countries around the world—not just in Europe—where it will be to the benefit of the UK. This means that we can implement arrangements that include the reimbursement of costs and exchange of data, such as the one we have with the European Union, across a wider geographical area where it is in the interest of the UK to do so. Overall, extending arrangements offers potential benefit for all UK residents, providing them with greater reassurance when travelling and deepening diplomatic ties with our international partners.

Following the amendments to our primary legislation, secondary legislation is now necessary to continue implementing our existing reciprocal healthcare arrangements, as well as future ones. I am pleased to introduce the regulations to the Committee. They will replace implementation regulations made under our former primary legislation, the geographical scope of which was limited to the European Economic Area and Switzerland.

While these regulations remain substantively similar to the regulations they replace, they also provide the necessary legal framework to implement any future arrangements with countries around the world. They work by conferring functions on the NHS Business Services Authority and local health boards across the UK to give effect to our existing healthcare arrangements. For example, they enable the NHS Business Services Authority to make payments, process applications and provide information to the public, including issuing the global health insurance card.

The regulations also confer functions on Welsh and Scottish local health boards so that they can deliver planned treatment provisions within our arrangements, which is an area of devolved competence. Until a Northern Ireland Executive are in place, we will save our existing implementation regulations to ensure that planned treatment can be delivered across the UK according to our obligations under the reciprocal healthcare arrangements that we have with the EU, EEA states and Switzerland. We have worked closely with the devolved Administrations in the drafting of the regulations and they have confirmed, through a formal consultation, that they are content.

We have included a Schedule to these regulations, which consolidates all the healthcare arrangements that the UK currently has with countries and territories around the world. It includes not only our arrangements with the European Union, which contain reimbursement provisions, but our existing international arrangements, where no money is exchanged and where the cost of treatment is waived, with countries such as Australia and New Zealand. To add a new country or territory to the Schedule, it must be amended by affirmative statutory instrument, providing noble Lords with the opportunity to scrutinise the implementation of any new arrangements.

The regulations enable the Secretary of State to make payments outside of an arrangement only when there are exceptional circumstances to justify the payment and only in countries or territories where a reciprocal healthcare arrangement with the UK is in place. Having this power means that we can support UK residents when they face difficulties and extraordinary situations when accessing healthcare abroad is critical. This will be accompanied by a policy framework, which we have developed and consulted on publicly. The framework will guide exceptional payment decisions while providing adequate flexibility for the Secretary of State to assess cases individually.

Finally, I take this opportunity to reassure your Lordships on concerns which were raised previously in the House about the interaction of reciprocal healthcare and trade. I reiterate that these regulations are not about trade deals or privatising the NHS; they are about implementing reciprocal healthcare arrangements and supporting UK residents to access healthcare abroad.

I am happy to bring forward this legislation today. These regulations are crucial to honour our current commitments and obligations under our existing healthcare arrangements, and to continue supporting the people who depend on these arrangements to access the healthcare they need while abroad. I beg to move.

--- Later in debate ---

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his introduction to the SI and the other noble Lords who have spoken to it. For the record, we wanted to look very closely at it, given the discussions, commitments and reassurances made last year by the Government and the then Health Minister, the noble Baroness, Lady Penn, about the Government’s policy intentions on reciprocal health agreements during the passage of what is now the Health and Care Act.

We had strong concerns that any provisions under the Act which reflected post-Brexit arrangements should be confined to the implementation of reciprocal healthcare arrangements, not to the negotiation of international health agreements which could be used for wider and different purposes, such as the privatisation of parts of healthcare. The Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 included explicit constraints to make such agreements on the powers of Secretary of State in this regard. We also had concerns that the new arrangements should not change the definition of future reciprocal healthcare agreements.

Reassurance from the Government that the purpose of the 2019 Act was not to implement trade deals and that reciprocal healthcare agreements do not relate to the commissioning and provision of services for the NHS were very welcome. We are therefore content that the SI properly reflects this; I thank the Minister for his reassurances in his opening remarks. We are also pleased that the affirmative procedure ensures that Parliament is able to be kept up to date with developments and that these issues are properly debated.

The Explanatory Memorandum is very helpful. I look forward to the Minister’s response to the issues raised by the noble Lord, Lord Allan, about scope, because they are important.

We recognise that the regulations are vital to implement international healthcare agreements following our exit from the EU. Reciprocal healthcare agreements support people to access healthcare in the listed countries. Those faced with the stress and worry of a healthcare emergency abroad will rightly expect suitable arrangements to be in place where possible. That is particularly true of people with a disability, those who are older or who live with a pre-existing or chronic health condition.

The amendments to the Act allow the Government to implement more complex agreements with the ability to make financial reimbursement at cost, as the UK currently does with many EEA countries, and confer further powers on the Secretary of State. Can the Minister outline further details about the Government’s plans for other international healthcare co-operation outside the EEA and Switzerland and what these plans might look like?

From our understanding of the SI, we think that payments can be made only if both the following conditions are met: the healthcare treatment is in a country with which we have an international healthcare agreement, and the Secretary of State considers that exceptional circumstances justify the payment. Can the Minister explain the Government’s thinking on what would constitute exceptional circumstances and how the policy framework might work? What guidance is being issued by the NHS Business Services Authority, which has certain administrative functions conferred on it through the SI?

The public consultation on the policy has just closed but we understand that the results and an analysis of it will be published this month. An early indication of the timetable and results would be welcome.

On the role of the NHS BSA, can the Minister provide more detail on the work currently undertaken to establish and maintain the public information and advice service on healthcare provision under relevant healthcare agreements, as set out in the SI? Again, the noble Lord, Lord Allan, mentioned this important function. The importance of transparency has been underlined. It will be crucial in the future to help people understand how reciprocal healthcare agreements work and can be accessed, to ensure they are doing all the right things to be properly covered, and to make claims, as the noble Baroness, Lady McIntosh, said.

I look forward to hearing answers to the questions about the issue of EHIC and GHIC. Specifically, can the Minister update the House on how the transfer from EHIC to GHIC has worked and whether any complications have been experienced—for example, the impact of the non-application to the UK of the EU cross-border healthcare directive, which enabled UK patients to pay for qualifying private healthcare in Europe and to receive reimbursement up to the amount that the treatment would cost the NHS? UK travellers can now no longer seek reimbursement, and I wondered if there had been any instances where the lack of awareness of that has caused problems—for example, for patients needing kidney dialysis where reimbursement for private treatment has not been allowed.

I appreciate that the Minister might need to come back to me on that. I think we are about to have a vote, but I look forward to his response.

[Lord Markham (Con)]

I will try my best, potential votes notwithstanding. I thank noble Lords for their contributions to today’s debate and for the generally received welcome. To try to answer them in turn, on the point made by the noble Baroness, Lady McIntosh of Pickering, I believe the arrangements made with the EFTA countries were signed on 30 June 2023. The expectation is that they will become operational by the middle of 2024—saved by the bell.

--- Later in debate ---

[The Deputy Chairman of Committees (Lord Duncan of Springbank) (Con)]

My Lords, I understand that another vote is coming, so I do not think there is any point in having another few minutes of the Minister—fun though that may be. Shall we twiddle our thumbs until the next vote?

[Lord Markham (Con)]

Unless I can finish before then.

[The Deputy Chairman of Committees (Lord Duncan of Springbank) (Con)]

Unless the Minister can finish in the next two minutes.

[Lord Markham (Con)]

Perhaps.

[The Deputy Chairman of Committees (Lord Duncan of Springbank) (Con)]

I will leave it in the Minister’s hands.

[Lord Markham (Con)]

I am happy to try. We will see. I will write a detailed letter after all this, so noble Lords can decide, when the bell rings, whether they want me back for more. That was a nice break in terms of being able to get some—

--- Later in debate ---

[Lord Markham (Con)]

I guess it is probably easier if I recap. On the question asked by the noble Baroness, Lady McIntosh, on the EFTA countries, the situation was that they were indeed under EHIC, but under the Brexit arrangements they effectively fell out. These arrangements mean that they have signed, so they are back in again and will be covered there.

As regards how it works, first, as I believe the noble Baroness got salmonella at a Conservative event, I apologise on behalf of the ex-CEO of the Conservative Party. The way the system should work in most cases is that you can show your GHIC—or your EHIC, which is still valid—and, in most cases, state-to-state paperwork and payment should be made on that basis rather than you having to pay personally. Unfortunately, there are examples where you have to do that. That might be just because a hospital is not fully aware of it at the time. However, there is also an NHS Business Services Authority hotline that you can ring, which can help you through all of it.

On the questions from the noble Lord, Lord Naseby, there is no reciprocal arrangement with the Cayman Islands and the Pitcairn Islands at the moment. There is a quota system, whereby the Cayman Islands and the Pitcairn Islands—he did not mention the latter but it is another example of the same situation—are allowed to send a number of their residents to us each year and they pay on a fully costed basis. However, there is no reciprocal arrangement; it is just on a pay-as-you-go basis. However, I clearly understand the issue, given the desirability of the Cayman Islands; I personally volunteer for a ministerial mission to negotiate there—with help from all sides, clearly.

On the question from the noble Lord, Lord Allan, about the GHIC rather than the EHIC, it is indeed clearly an aspirational ambition. However, there are additional countries—I think I already mentioned Australia, New Zealand and Montenegro—so it is an E-plus; maybe it does not quite deserve a “G” at the front of it yet, but clearly that is the direction of travel.