Mental Health Services: Huntington’s Disease

Lord Markham Excerpts

Monday 12th June 2023 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

In begging leave to ask the Question standing in my name on the Order Paper, I apologise to the House as I should have declared my GMC board interest in the previous oral intervention.

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

NHS England has not made an assessment, as this is not data that is routinely collected or would be captured. Minister Whately has asked NHS England to look into reports that people with Huntington’s disease are being denied access to mental health services. NHS England is also in the process of developing a neuropsychiatry service specification, which will outline the approach to caring for patients with neurological conditions who require mental health support.

[Lord Hunt of Kings Heath (Lab)]

I am grateful to the Minister for that positive Answer. He may be aware that the Huntington’s Disease Association has research which shows, first, that many people with that disease suffer from severe mental health issues and, secondly, that in many parts of the country NHS mental health services refuse to give mental health treatment to those people. In addition to the work that his fellow Minister is requiring from NHS England, will the department look at the training of mental health staff so that they have the capability to support people with Huntingdon’s disease who have mental health issues?

[Lord Markham (Con)]

Yes. The noble Lord has heard me say many times that I have really come to appreciate the Questions format for looking into areas that might otherwise not be seen. I thank the noble Lord and the Huntington’s Disease Association for bringing this to our attention. We have the steps in place but that is a good point about the training.

[Lord Kirkhope of Harrogate (Con)]

I declare an interest as a former Mental Health Act commissioner. Mental health seems to be very much the poor relative when it comes to resources and definitions in our health service. Does my noble friend not feel that we perhaps need to readdress matters such as guidelines for determining mental health? Many issues which arise are about pressures on people in their lives but do not necessarily come within the category of mental health. Would we not be better off having some clearer approach to this in future?

[Lord Markham (Con)]

Our commitment is very much that mental health should be treated just as seriously as physical health conditions. I was delighted to announce today that on the NHS app we are launching mental health digital therapeutics, which are available for everyone to use. I recommend everyone tries them. The idea behind it all is that it is accessible to everyone at any time in their life.

[Lord Patel (CB)]

My Lords, part of the problem of patients with Huntington’s chorea not being given proper treatment is that it is regarded as a neurodegenerative organic disease rather than what it is: it presents first with mental health symptoms. Guidelines are required, maybe from NICE, that clearly outline the patient journey of care for people with Huntington’s disease.

[Lord Markham (Con)]

I have learned in the process of researching this that it is absolutely vital that commissioners understand what the patient pathway needs to be in each area. That is why we have tasked the NHS with a neuroscience transformation programme to set out those care pathways.

[Baroness Wheeler (Lab)]

My Lords, we know that people living with Huntington’s disease, and their families, are faced with significant challenges throughout their lives. Many young people grow up in the shadow of the disease, are caring for their relative while worrying that they will get the disease themselves, and often face daunting choices around starting a family and genetic testing. All this underlines the need for mental health care and support for all the family. What steps are the Government taking to ensure that NHS mental health trusts take a whole-family approach to this vital issue?

[Lord Markham (Con)]

The noble Baroness makes a very good point; it is a whole-family problem. The investment we are talking about, in allowing us to access 2 million extra mental health patients, is about making sure we have got the numbers. The digital therapeutics are another way we are making sure there is access. The specific point the noble Baroness makes about looking at the families of people with Huntington’s disease is a good point that I will take back.

[Lord Weir of Ballyholme (DUP)]

My Lords, there is also a great deal of evidence that Huntington’s disease can be one of the conditions which can lead to dementia. It is a concern both in Huntington’s disease and dementia that there is a level of underreferral for mental health services. What specific action is being taken to tackle this issue, given that figures suggest the number of referrals for those suffering from Huntington’s disease and dementia to mental health services is minuscule compared with the level of demand?

[Lord Markham (Con)]

The research from the Huntington’s Disease Association, albeit with a small sample size of only 100, suggests there is an issue here. That is why I spoke to Minister Whately about this just this morning. She is being very firm in terms of tasking the NHS to come back with a plan to make sure we get that diagnosis. We will not know until we see the situation across a larger sample size, but clearly it is something we need to work more on.

[Lord Allan of Hallam (LD)]

My Lords, the Huntington’s Disease Association is pressing the Government for a number of actions in its campaign “Mindful of Huntington’s”. Could I press the Minister on one of these: that there should be a care co-ordinator in each area to help manage the various professionals? Do the Government agree in principle with this approach? What specifically are they doing to work with integrated care boards for situations such as this, in which you need primary, secondary, mental health and social care to all work together?

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[Lord Markham (Con)]

The plan with the neuroscience transformation programme is to give that pathway to every ICS, which it should follow and commission to, to make sure that specific treatment is in place. It is a complex area, as we all know. Again, as I understand it, there are more than 7,000 rare conditions. I want to be open about the ability to put in place a specific individual care co-ordinator for every one of those, but we need to make sure that ICSs have enough skills in their locker—for want of a better word—so that they can recognise the situations and make sure they are commissioning to the plan.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, I declare my interests as chair of the Scottish Government’s neurological advisory committee and a trustee of the Neurological Alliance of Scotland. This is an issue not just for people with Huntington’s disease but for people with other neurodegenerative conditions, such as Parkinson’s. NICE standards for people with Parkinson’s recommend the prescription of Clozapine for hallucinations or delusions, but only psychiatrists are enabled to prescribe it; therefore, people with Parkinson’s do not have access to this treatment because neurologists cannot prescribe it. Will the Minister look at this? Maybe this is one way to ensure that people get the treatment they need.

[Lord Markham (Con)]

Yes, I think is probably the best answer I can give in the circumstances. I will absolutely do that and will write to my noble friend.

[Baroness Finlay of Llandaff (CB)]

My Lords, the draft major conditions strategy refers to mental health conditions and dementias so that should include diseases such as Huntington’s. The problem is—and I declare my interest in palliative care—that as these patients become terminally ill, they have complex physical and mental health needs, yet we know there are serious inequities in provision. Despite the Government’s own amendment to the Health and Care Act 2022, the draft strategy does not have a distinct section on palliative and end-of-life care. Why have the Government not made this a core, integrated part of the strategy for these major conditions when patients, such as the ones with Huntington’s, have really complex needs—and their families have complex needs too—particularly around the time of their death?

[Lord Markham (Con)]

The noble Baroness is correct that they have complex needs and I know from personal experience, with both my mother and my father, the importance of end-of-life palliative care. I thank the noble Baroness for the warning of the question and have been assured that the integrated whole person care approach that the major conditions strategy sets out will include palliative care measures.

[Lord Laming (CB)]

My Lords, the Minister will know that many of the people who suffer from this disease depend very heavily on the support of unpaid carers. I note that his fellow Minister is going to hold a cross-government round table on the needs of carers. Might that lead to the development of a national carers’ strategy?

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[Lord Markham (Con)]

I think and hope we have done quite a bit in this space already. Obviously, we have put in place measures to get carers’ some leave and some pay for what they do. I accept that they are a huge army of helpers and there is probably more that we need to be doing. I know that Minister Whately is right on the case.

Medical Devices (Amendment) (Great Britain) Regulations 2023

Lord Markham Excerpts

Thursday 8th June 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 27 April be approved.

Relevant document: 38th Report from the Secondary Legislation Scrutiny Committee (special attention drawn to the instrument). Considered in Grand Committee on 5 June.

Motion agreed.

NHS GP Surgeries: Purchase by US Companies

Lord Markham Excerpts

Monday 5th June 2023 Lords Chamber

[Lord Warner]

To ask His Majesty’s Government, in the three years up to 31 March, how many GP surgeries providing NHS services have been purchased by private companies of which one of the controlling shareholders was a United States company; and whether they intend to take action with regard to such purchases.

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

This information is not held centrally because local commissioners arrange appropriate services for their populations by contracting with providers. Commissioners do not normally request details of corporate structure. Our focus is on high-quality services and patient experiences, regardless of practice ownership. All GP contract holders and providers of NHS core primary medical services are subject to the same requirements, regulations and standards. We expect commissioners and regulators to take action if services are not meeting the reasonable needs of patients.

[Lord Warner (CB)]

My Lords, I am a little surprised by that particular Answer. I would have thought that, given the problems of shortages of GPs in the NHS, there might be a little more interest in the Department for Health and Social Care in finding out about this. Is the Minister aware of the scale of acquisition of GP practices that has been achieved with very little public transparency? Let me give him the example of Operose Health, which is a UK subsidiary of Centene Corporation, a major US health insurer, which now owns nearly 70 GP practices serving nearly 600,000 patients. I would have thought that the centre might want to take a little more interest in this, because what is very clear is that the APMS system is an offering that many corporate individuals can exploit to get a hold of very large numbers of GP practices—and, just for afters, Centene is in deep trouble in the United States.

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[Lord Markham (Con)]

What the centre is most interested in is quality of the service; that is exactly what we do. As for Operose, which the noble Lord mentioned, 97% of its surgeries are rated by CQC as good or excellent. In the case of the one where there was a concern, CQC did a deep dive of the surgery and looked at the staff mixing, and that practice is now considered good. The key thing, I think all noble Lords will agree, is the quality of service, not ownership.

[Baroness Manzoor (Con)]

My Lords, as my noble friend said about ensuring the quality of services for users, since the inception of the NHS, GPs have been private practitioners and have invested money from their own pockets to improve their surgeries. What are the Government doing to ensure that there is equity and accessibility of good GP services to those who live in inner-city and deprived areas, and in rural areas?

[Lord Markham (Con)]

My noble friend is correct, of course. GPs have always been independent businesses, and that is the backbone of the service. We have managed to increase the number of GPs by 2000 since 2019, but we all accept that more needs to be done to attract them, especially to the key areas that my noble friend mentions. We have a £20,000 bonus in place to recruit GPs to those difficult areas and, most importantly, we have a record 4,000 GPs in training.

[Lord Watts (Lab)]

My Lords, is it not a national scandal that someone can purchase a building for £1 million, they can locate health services in there, they can get the NHS to pay the mortgage on that building and at the end of that period, that person owns that building? In other words, we have transferred £1 million from the taxpayer to an individual.

[Lord Markham (Con)]

I think it was the noble Lord opposite who introduced patient choice. That looked to the independent sector to increase supply, which is what we care most about. I do not believe that anyone should be fundamentally against who owns a business. What they should care most about is the supply of good-quality services.

[Lord Allan of Hallam (LD)]

My Lords, further to the Minister’s answers around quality, does he agree that there is a significant public interest in understanding how well different general practice ownership models perform for patients? In this context, can he confirm whether his department is carrying out any research into patient satisfaction and outcomes by ownership type, using sources such as the general practice patient survey and the OpenSAFELY trusted research environment for GP data?

[Lord Markham (Con)]

I am not aware of any correlation between the type of ownership and the quality of the services from it. If there is one, then we can look at that, but we are focusing resources on the areas where they make most difference, and the focus is: what is the performance of that clinic? That is what we should all care about. How are the doctors there performing in terms of appointment times and everything else? I will not put a false target on who owns it and the structure of it, because that is not relevant. What is relevant is the quality.

[Baroness Bottomley of Nettlestone (Con)]

Is it not the case that the former chief executive of the NHS brought some extremely valuable experience back from America, from UnitedHealth? I remember long ago in the distant past, when the Labour Party was last in power, that Kaiser Permanente was constantly being consulted. Surely it is an arrogance to have a xenophobic approach to where we take advice and where we learn from other people’s experiences?

[Lord Markham (Con)]

I totally agree with my noble friend. I like to think that we will take advice from whoever is best placed to give it, whether they are public sector, private sector, UK or international.

[Lord Reid of Cardowan (Lab)]

My Lords, I thank the Minister for referring to me in the context of patient choice. I am proud of that and would like to see more of it. The problem as regards GPs is that it is not just the right to choose but the ability to exercise that right that is prevented if every GP’s list of patients is so large that you cannot jump from one GP to another. The key to exercising the quality and the choice that the Minister quite correctly mentioned is to create more GPs. As long as we have a shortage of GPs, we will negate the choice of the patients.

[Lord Markham (Con)]

The noble Lord is absolutely correct that it is all about supply and the quality of that supply. That is why, again, I am pleased to say that we have a record number of GPs in training. We can learn from innovative measures. I have been looking at an advanced draft of the workforce plan. The number of doctors in the most advanced medical systems in the world—those of Japan and the US—is lower per head of population than here, but the number of nurses is higher. They have altered their staff mix to get the optimum performance, and we should be open to these innovative approaches to get the best output.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord referred to the workforce plan. Can he assure me that, when published, it will be fully funded?

[Lord Markham (Con)]

This is absolutely the work that the Treasury is doing at the moment. Noble Lords have asked, many a time, when it is coming out. I think people will understand that part of the delay is making sure that, when the plan does come out, it really does work.

[Lord Patel (CB)]

My Lords, what does the Minister think is the main reason that general practitioners might be leaving the NHS to work in the private sector?

[Lord Markham (Con)]

My understanding is that it is a range of issues, clearly including workload, pay and conditions. We are trying to address those; I think the change in the pensions rule has been generally welcomed in terms of encouraging more doctors to stay on in place. But it is a range of those measures—again, all things we are hopefully addressing through the new training and skills programmes, and the long-term workforce plan.

[Lord Forsyth of Drumlean (Con)]

My Lords, could my noble friend take the Question from the noble Lord, Lord Warner, a little more seriously? If we look at what has happened to vets, for example, private equity has bought up veterinary practices and prices have gone through the roof in order to pay for the funding costs. If this were to happen with general practice, I think that would be a very retrograde step.

[Lord Markham (Con)]

My understanding on this is that actually it is not a massively profitable area at the moment. The biggest provider in this area, Babylon Health, as we all know, did not manage to make it work. So, while I think we all understand my noble friend’s concerns, I do not believe that this is the case with the GP funding model.

[Baroness Merron (Lab)]

My Lords, research has shown that GP surgeries owned by some private limited companies have been offering a lower level of care, with unqualified staff seeing patients. So, in view of the Minister’s comments on quality, how much of a concern is this for the Government? On top of this, with some 4,700 GPs being cut over the last decade, cuts to training places and the many years that it takes to train a GP, what response will the Minister make to the latest GP patient survey, which reports that patients are now ever less likely to be able to see a GP?

[Lord Markham (Con)]

Clearly, we have our targets in terms of making sure that people can see a GP. I am glad to say that 70% of appointments are now face to face, and we are on target to hit our 50 million increase in appointments. So it is good to see that we are getting that done. Do we need to do more? Clearly, there is ever-increasing demand from the demographics of the situation, so we need to increase supply through additional training places, as I said.

Sodium Valproate

Lord Markham Excerpts

Monday 5th June 2023 Lords Chamber

[Baroness Cumberlege]

To ask His Majesty’s Government what further steps they are taking to protect patients and families from the harmful effects of sodium valproate taken during pregnancy, and what is their timetable for doing so.

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

Our aim is to reduce and finally eliminate the harms of valproate in pregnancy. In December, we announced additional measures to protect women and families through a requirement for two prescribers, further warnings in the valproate product information, and improved educational materials. No woman of childbearing potential should receive valproate unless no other treatment is effective or tolerated. Implementation plans are now being finalised, with engagement with healthcare and patient organisations.

[Baroness Cumberlege (Con)]

My Lords, I thank my noble friend for that Answer. It goes some way, I think, to reassure many of us who have been very concerned about sodium valproate being given to pregnant women, and the result that that has had. I am seeking to ensure that, with the plain boxes which contain sodium valproate, those tablets are not actually opened without a clear warning, so that people know exactly what is contained in those boxes and the harmful effects it could have on their babies. Can the Minister tell me what is actually happening to those plain boxes, because sodium valproate should not be prescribed without a really clear warning about what it could do to babies and women?

[Lord Markham (Con)]

First, I thank my noble friend for all the vital work that she has done in this space. She is absolutely correct. The key thing is that there are circumstances where sodium valproate is the only effective treatment for bipolar and epilepsy-type disease problems. However, we have to ensure that if people are taking it, they are going into it with their eyes completely open, so that they fully understand the risks. That is absolutely to do with the packaging. It is also about making sure that if that packaging is split up there are leaflets in every part, and that everyone signs a consent form at least once a year, fully acknowledging the risks. Thereby, if people take the treatment, they are doing so with their eyes fully open.

[Baroness Stuart of Edgbaston (CB)]

My Lords, last year the Scottish Government set up an advisory group on the use of valproates. To what extent does the Minister work with the devolved Administrations to make sure that there are clear guidelines on this subject across the four nations?

[Lord Markham (Con)]

The regulatory authorities absolutely work closely here. It is my understanding that it is the intent of all the devolved Administrations to make sure that while there are circumstances in which this drug might be the correct treatment, as I mentioned, it is used only when everything else has been tried—and, in our case, in England—that two independent specialists will be required to prescribe it.

[Baroness Wheeler (Lab)]

My Lords, ensuring that patients’ decisions are based on informed consent and shared decision-making with their doctors and pharmacists is vital, especially in relation to the exception to ensuring that valproate is always dispensed in its original packaging. What steps are the Government taking to raise awareness among the health professionals involved and ensure that there is a properly joined-up approach to the advice and treatment given to the patient? How is data collection on this issue being improved, so that the effects of the safety measures and issues can be fully identified and addressed?

[Lord Markham (Con)]

The noble Baroness is correct. In terms of data, it is vital: first, that we have a register of all the people who are taking valproate so that we can be sure that the information is there; secondly, that we then keep a record of where patients have signed the annual acceptance; and, thirdly, that we are gaining data on testing. The latest suggestion is that we should also be looking at males taking valproate because there is evidence that it can, through their sperm, cause difficulties in pregnancies. On all those factors, data is central and we should make sure we collect it.

[Lord Patel (CB)]

My Lords, we have known for decades that sodium valproate, particularly when given in early pregnancy, causes 1% of babies to be born with deformity and as many as 10% to be born with learning disabilities. Despite the guidance issued two years ago, last year 250 babies were born to mothers taking high doses of sodium valproate. Does the Minister agree that we need to make the guidance much stricter, particularly about the appropriate contraception to use, and that when advising women who might be planning a pregnancy, sodium valproate should stop being prescribed for them?

[Lord Markham (Con)]

The noble Lord is absolutely correct. Everyone taking sodium valproate who is of childbearing age should be on a pregnancy prevention programme to make sure that those sorts of incidents do not happen. It is vital, when it is necessary for people to take it, that they really understand the risks and do everything to avoid pregnancy.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, mention has been made of the reduction in the prescription of sodium valproate but can my noble friend clarify that with a few more figures? In the report by my distinguished noble friend, which has done so much, mention was made of a redress scheme. In December the Select Committee tasked Dr Henrietta Hughes, the Patient Safety Commissioner, to bring forward proposals of what that might look like. Can he inform the House of progress there?

[Lord Markham (Con)]

I thank my noble friend. Yes, the number of cases of people of childbearing age—this is a key criterion—taking sodium valproate has reduced by 33% over the past five years. The number of pregnancies has reduced by 73% but clearly that is not zero so more work needs to be done. I was speaking to Minister Caulfield this morning about the Patient Safety Commissioner. We are expecting her report shortly and from there we hope and believe that there will be a lot more we can do on regulation.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I refer to the work of Dr Hughes, the Patient Safety Commissioner, and the initial Question from the noble Baroness, Lady Cumberlege, which referred to where sodium valproate is prescribed in different numbers of pills from the number that come in a packet, so the excess pills are taken by the pharmacist and put into plain paper packaging. The Patient Safety Commissioner has identified this as a real issue because sodium valproate must not be dispensed without the appropriate safety labels, but that is clearly happening. What are the Government doing to stop it?

[Lord Markham (Con)]

The noble Baroness is correct. First, the MHRA is working on guidelines which say that you must always dispense in the original packaging, come what may. In the meantime, secondly, all pharmacists should absolutely be putting leaflets in, whatever the packaging. Thirdly, everyone should have to sign an acceptance form so that they are going into this with their eyes open and understand the risks. Every year they are supposed to renew that acceptance form to make sure that, while it may be necessary in some cases, everyone goes into it with their eyes open to the risks.

[Baroness Brinton (LD)]

My Lords, in 2020 after the publication of the report by the noble Baroness, Lady Cumberlege, we had many debates in your Lordships’ House about the role of and the support for the Patient Safety Commissioner. She had not heard what her budget for the current financial year was at the beginning of May and said that, even leaving that aside, she would not be able to do her job properly. To follow the course of how patients with sodium valproate are supported and treated, she will need that resource. Will the Government review the resource needed for her to do this and many other tasks in her important role?

[Lord Markham (Con)]

My understanding from speaking to Minister Caulfield on exactly this subject this morning is that she has recently spoken to the Patient Safety Commissioner, who is happy that she has the resource that she now requires to do this part of the study.

[Baroness Hollins (CB)]

My Lords, I note that the damage caused by sodium valproate happens during the first trimester, when many women do not realise they are pregnant for a while, and, despite attempts to plan pregnancy, many pregnancies are unplanned. It is one thing to say that it is the woman’s knowledge, understanding and consent, but what about the long-term care of children who are born with damage caused by sodium valproate? What measures are being taken to attend particularly to the needs of this group?

[Lord Markham (Con)]

The noble Baroness is correct that unfortunately there will always be some cases. Dr Charlie Fairhurst has been advising the Government on how best to create the care pathways so we can make sure that we are catering for the children in this scenario. How it manifests itself, as I am sure the noble Baroness understands, is in things such as increased autism or cystic fibrosis, for which we have existing patient pathways for treatment. We must make sure that these children can get quick and easy access to those treatment pathways.

Cancer Referral Targets

Lord Markham Excerpts

Monday 5th June 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what steps they are taking to ensure that NHS trusts in England meet their target for cancer patients to be treated within two months of an urgent GP referral.

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

My Lords, NHS England continues to actively support those trusts requiring the greatest help to cut cancer waiting lists. This work is backed by funding of more than £8 billion from 2022-23 to 2024-25 to help drive up and protect elective activity, including for cancer. To increase capacity, we are investing in up to 160 community diagnostic centres—CDCs. Within CDCs, we are prioritising cancer pathways to help reduce the time from patient presentation to diagnosis and treatment.

[Baroness Merron (Lab)]

My Lords, nearly 90% of cancer patients in 2010 received their first treatment within two months of urgent referral, which exceeded the operational standard, something the Government have not achieved since 2014, while last year fewer than 65% of cancer patients were treated within this standard. With earlier intervention being key to saving lives, what is the Government’s estimate of how many lives are lost each year due to failure to meet this agreed standard? What is the impact on survival rates of continued delays to a workforce plan promised long before the pandemic and still being reported as not having been signed off by the Treasury?

[Lord Markham (Con)]

The noble Baroness is correct about early diagnosis. That is why we have invested in 160 CDCs, which will be primarily focused on cancer, and why there are 11,000 more staff than in 2010, a 50% increase, as well as 3,000 more consultants, a 63% increase. We are seeing more supply than ever but at the same time, given Covid and the pent-up demand caused by that, we are also seeing more than demand than ever. The major expansion of supply is focused on making sure that we quickly detect those people.

[Lord Kamall (Con)]

My noble friend the Minister mentioned Covid. One thing we learned from Covid was the importance of testing at home and rolling out home testing. A few weeks ago, I received a letter from the NHS asking me to provide a sample to test for a certain cancer—a test given to people my age. I thought that that was very interesting. How much more rollout of home testing are the Government intending to do, so that we can catch these cancers early—not just colon cancer but a whole range of cancers?

[Lord Markham (Con)]

I am not exactly familiar with the test that my noble friend might have taken but many of us will have heard about the early promise shown by the GRAIL programme. It is a simple blood test and, right now, has a two-thirds success rate for early detection. Those are early indicators, but early diagnosis and innovative approaches such as the GRAIL blood test are important.

[Lord Allan of Hallam (LD)]

My Lords—

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[Lord Markham (Con)]

The noble Lord is absolutely correct that we always need to keep these things in balance. What I was trying to express was that we have an opportunity to innovate in this space. We have another innovation in our targeted lung cancer programme, which has now been rolled out to 43 sites. In 2019, 50% of such cancers were not detected until stage 4. Now, through mobile delivery of services to these sites, we are detecting 60% of such cancers at stage 1. Those are the sort of innovations for which we have very solid data, and they do show promise for the future.

[Lord Allan of Hallam (LD)]

My Lords, national waiting times for cancer treatment have fallen way off target, as the noble Baroness, Lady Merron, set out in her Question, but these national numbers mask significant regional variations. In March, they ranged from 45% of referrals within the target time in Birmingham and Solihull to 80% within target in Kent and Medway. How does the Minister account for such significant variations and what are the Government doing to level up those integrated care board areas that are falling furthest below the targets?

[Lord Markham (Con)]

That is exactly the example I was giving when I mentioned lung cancer targets, where mobile devices are being used. Interestingly, the most deprived areas have been targeted because they are often areas of high smoking, and these are the areas where they have managed to get screening times down the most. We have the opportunity to put CDCs in the areas of most need. We all agree that there is unprecedented demand and that we have to expand supply; there is no other way to meet that demand but to expand supply.

[Lord Rooker (Lab)]

Having gone through treatment myself in the last few years—successfully so far—I want to ask the Minister whether anybody is measuring the growth of mental illness among people who know that they need treatment but where it is constantly delayed. The pressure on those people and their families is enormous. Is there any measure of extra mental illness caused by this delay?

[Lord Markham (Con)]

The noble Lord is correct. I have a friend who is in that situation. We all understand the stress of waiting and what it can cause. I will come back to the noble Lord on the research into the impact on mental health. I absolutely accept that a lot more needs to be done, but one of the main things is the target of diagnosis within 28 days, which we are now hitting 75% of the time. That gives people peace of mind quickly, particularly as 94% of those people end up being negative—only 6% are positive. Peace of mind is crucial here.

[Lord Warner (CB)]

My Lords, is the Minister aware that in 2017 this House, under the distinguished leadership of the noble Lord, Lord Patel, produced a report which said that the sustainability of the NHS was in doubt unless there was a workforce plan? Would he like to remind his friend the Chancellor, who was the Health Secretary at the time, of that report?

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[Lord Markham (Con)]

I know that the Chancellor is very aware of it, and of course it was the Chancellor who in the autumn kicked off that this workforce plan should be done. The Chancellor is quite rightly very involved in making sure we get the right answer now.

[Lord Hannan of Kingsclere (Con)]

My Lords, during the first lockdown we had some 40,000 fewer cancer diagnoses than we would have expected during a normal period. Cancer develops slowly and we cannot yet calculate the lethality, but will my noble friend the Minister consider, before we ever contemplate another policy of mass house arrest, the long-term consequences for health of people being confined to home? It may be, as we see the excess mortality figures coming in from around the world, that lockdowns ended up killing more people than they saved.

[Lord Markham (Con)]

My noble friend is correct that there were knock-on implications of lockdown, cancer detection rates being one of them. Noble Lords have heard me speak of Chris Whitty’s concern about heart disease because those check-ups were missed, and mental health is another area. Clearly, these are some of the things we are hoping to learn from the Covid inquiry, so that we know the impact of lockdowns, not just on restricting Covid but more widely, on the population as a whole.

[Lord Winston (Lab)]

My Lords, have the Government made an assessment of the cost of false positive tests in this kind of screening and the cost to patients?

[Lord Markham (Con)]

When the noble Lord says this kind of screening, I am not quite sure which type of screening he is referring to.

[Lord Winston (Lab)]

For cancer.

[Lord Markham (Con)]

I did not know whether the noble Lord was referring to GRAIL and the comment from the noble Lord, Lord Patel, about false positives. This question probably deserves a detailed reply but, as with any test, it is not about just specificity but sensitivity, which is key, so that the number of false positives is minimised. I will provide a detailed reply.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the noble Lord has referred at several points in this discussion to early diagnosis. He will be aware that cancer very often develops later in life and that the older you are the greater the risk is. Yet older people are excluded from routine screening tests past a certain age. Can he explain the thinking behind that?

[Lord Markham (Con)]

It is about trying to make sure that we are screening those of highest risk, given the impact on quality of life, and catching it early. I know that is very specifically the thinking around it. Beyond this, while we know the challenge around waiting lists, we have increased the supply through a 15% increase in activity. We are supplying more than ever, but we know that a lot more needs to be done to meet the demand.

National Health Service (Dental Charges) (Amendment) Regulations 2023

Lord Markham Excerpts

Monday 5th June 2023 Lords Chamber

So I hope that the Minister will be able to comment on all the salient points that were raised. But, in the end, how will this hike in charges assist the provision of NHS dental treatment to those who need it, and in particular to those who need it most? I hope that the Minister can answer those points.

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

My Lords, I am pleased to respond to this debate on these regulations and to address the concerns about their impact on patients and access to dental treatment. I thank the noble Lord, Lord Hunt of Kings Heath, for securing this debate on this important matter, and I thank noble Lords on all sides of the House for their contributions to the constructive debate.

Dentistry is an important part of the NHS and we acknowledge the gravity of the challenges that some people have faced in accessing these services—and the real impact on the health service and A&E, and on young children, that the noble Baroness, Lady Merron, mentioned. So, to answer clearly the point of the noble Lord, Lord Hunt, about this not being about decreasing access, I say that access challenges are at the top of our minds. Hopefully, this speech will show that we have an aspiration to increase access to dentistry, as the noble Baroness, Lady Merron, said.

In July 2022, we announced a package of dental system improvements, having fully engaged, via the NHS, with the dental profession and patient representatives. These initial changes were aimed at improving information for patients, improving incentives in the contract to deliver more complex care and enabling the NHS to better work with the sector to ensure that dental care is delivered.

Most importantly of all, I will address the underspend head on. I appreciate the noble Lord’s maths, but I will be absolutely clear that we do not want the underspend; it is caused by dental surgeries that are not delivering on their contract. In many cases, they declare a number of UDAs to underpin their business and then try to sell in the private sector, ending up with an underdelivery at the end of the year. The changes that we introduced on 18 May were all about being able to adjust those contracts so that, where dentists underperform, we can remove those UDAs from them and redistribute them to those who are performing. So, effectively, I can say categorically that we are not trying to bank that £400 million—which is not the final number, I should say—or to bank an underspend; rather, we are trying to find ways to prevent that happening, because we absolutely accept that we want access to increase in all of this.

The dental patient price increase—I will not say “charges uplift”—is very much about generating money which will be used around the system. This is not a case of saying, “Oh, we’re going to try to bank the underspend and generate some more for us”; this is about trying to get to where people can afford to pay. Let us remember that 50% of people, including those in the most need, receive their dentistry completely free, so this is for the 50% or so of people who are in a position to afford it. Of course, since dental charges were last increased, we have had an increase in inflation of 17.9%, so what we are doing here is increasing those prices by only half that amount. This is about making sure that the money is there to fund an expansion of dentistry.

We consider that the 8.5% is a proportionate increase; it is about £2 on the cost of an NHS check-up. I reiterate that it is being paid only by those people who are in the best position to be able to afford it; we are making sure that those who cannot afford it continue to receive it free at the point of care. We know how important it is to provide the courses of treatment. We provided 8 million courses, 5.6 million of which were to children. The noble Lord, Lord Hunt, will be pleased to know that 54% of those are for fluoride treatments. We understand that it is vital that we provide those preventive measures to children.

To answer the noble Lord, Lord Allan, we know that we need to go further; the creative thinking has continued, and there will be further, wider-reaching changes to improve access to NHS dental care that we hope to announce shortly. I can say, hand on heart, that we are actively looking at ways to fund these increases. This is not about trying to bank underspend; this is about trying to make sure that those underspends are delivered. If those we are contracted with are not delivering it, we will find others who will do it. That is also where some of the creative ideas will come in.

[Lord Allan of Hallam (LD)]

I am curious about the point the Minister made about the underspend resulting, in a sense, from accounting practices—or, as I understood it, that people are seeking additional contracted amounts to boost the financial health of their dental practices. It is first time I have heard that. I wonder whether he thinks that that is a temporary phenomenon that will somehow come out of the system, or whether it is something that is inherent in the way the system has been established so that private dentists are contracting for blocks of NHS work.

[Lord Markham (Con)]

I will try to unpack that point a bit more. A dentist can say, “Okay, I can provide so many UDAs over the course of the year”, and they will be contracted to do that. But there is then the situation whereby some of them—I am not saying all of them—having that banked in and knowing that they have the money to afford it, might go out to try to sell private healthcare, underpinned by that money. At the end of the year, if they have not delivered all the UDAs, then, in effect, the only reason that they have not delivered it is because they substituted that for private care work, resulting in that underspend, which we do not want.

That is what the changes we talked about in May were about: removing the UDAs from those persistent underdeliverers, for want of a better word, and having the capacity to give them to those who are persistent deliverers, so that we can increase their amounts by 110%. This is very much about taking away from those who are not delivering and giving to those who can, and also having money in the bank for some of the more creative ideas that Minister O’Brien is very focused on, and that we look forward to delivering. I can say, hand on heart, that is not about banking underspend; this is about making sure that we can redistribute it. These price increases—which, again, are half the rate of inflation—are for funding a dentistry plan through which we want to improve access; that is fundamental to all of this.

I hope that noble Lords understand a bit more where we are coming from and understand that it is an 8.5% increase versus 17% inflation. We are looking to recycle that increase and put it into more access for those who are not receiving it at the moment. I hope that noble Lords will see this in a better light and that it is all about increasing access.

In conclusion, as the noble Lord, Lord Hunt, mentions, it is important that patients can access NHS dental care and that it is affordable. No price increase is easy but we hope it is seen that this is a proportionate increase at less than half the rate of inflation and only for those 50% of people who are in a better position to pay. Most of all, this is part of a package of measures, of which more will be announced shortly, about expanding access to NHS dentistry—because I completely agree with the noble Baroness, Lady Merron, that it is vital to the health of our children, particularly, but to all the people in England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister and for him attempting to explain the mystery of the dental contract, which has defeated many Ministers over many years. Explaining it in the way he did lends support to those who think we need a fundamental rethink about the way we remunerate dentists. I took part in some of the discussions with the profession which led up to the last contract and before that there was the contract in the 1990s. Essentially, it seems to me, each time there is a revenue envelope agreed with the Treasury on how much can be afforded for a new contract. The profession will always exceed performance in general because it is always based on a payment for a procedure, although efforts have been made to bring in incentives to treat the oral health of a person as a whole, more like the way in which GPs are remunerated. But at the end of the day, we still await a change in contractual arrangements which will provide the right incentives.

I am grateful to my noble friend for her support. She is right to say that at the heart of this is needing to know the Government’s aspiration for NHS dentistry. The Minister said that dentistry is an important part of the NHS, that he recognises the access challenges faced by the public and that we can await further announcements. I welcome that and hope that we can reset NHS dentistry on a much more positive route for the future.

In relation to charges, the contrast between the difficulty so many patients are having in getting access on the one hand and the 8.5% increase on the other is very difficult to understand and to support. Many of the people who rely on the NHS but do not get benefit support from the state are really caught by high inflation in general and dentistry charges is one more burden they have to face. That ultimately is what makes the proposal before us really rather worrying.

I hope this is an opportunity to reset our whole concept of NHS dentistry. I am very grateful to noble Lords who have supported the debate tonight and beg leave to withdraw my Motion.

Medical Devices (Amendment) (Great Britain) Regulations 2023

Lord Markham Excerpts

Monday 5th June 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Medical Devices (Amendment) (Great Britain) Regulations 2023.

Relevant document: 38th Report from the Secondary Legislation Scrutiny Committee (special attention drawn to the instrument)

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

My Lords, I am grateful to be here to debate these important regulations. Plasters for a scraped knee, blood tests that detect cancer, pacemakers, pregnancy tests and software that calculates insulin doses for people with diabetes—medical devices are used by millions every day.

The MHRA regulates medical devices in the UK, helping to ensure that these products are safe and perform as intended. Today, almost 2 million different medical products are registered with the MHRA for use in the UK, of which an estimated 500,000 different product types are regularly used in the NHS. The past few years have been a time of great change for medical devices. The Covid-19 pandemic saw big advances in the life sciences and diagnostics sectors.

This instrument is intended to give the medtech sector additional time to transition to our post-EU exit regime for medical devices. It extends the time during which manufacturers and importers can place CE-marked medical devices on the Great British market.

Since January 2021, manufacturers wishing to place a medical device on the GB market have been able to follow either the post-Brexit UK route and use a UKCA mark or the EU legislation and use a CE mark. Without this SI, this flexibility would cease on 30 June this year, with only the UKCA route available. This will impact an estimated 11,000 businesses that have registered medical devices with the MHRA with a CE mark only. These regulations will allow industry the flexibility to use either mark on medical devices for longer.

Continuity of supply is key and we recognise that the industry needs more time to prepare to transition. Without it, manufacturers of medical devices without a UKCA mark would have to stop supplying their products in GB from this July. This could mean some patients losing access to the devices that they need. I make it clear that this instrument has no impact on medical devices already on the market with a UKCA mark.

I will now take a moment to summarise the key changes. First, the instrument provides that medical devices compliant with the EU medical devices directive or EU active implantable medical devices directive with a valid declaration of conformity and CE mark can be placed on the GB market up until the expiry of the device certificate or 30 June 2028, whichever is sooner. Secondly, in vitro diagnostic medical devices, or IVDs, that are compliant with the EU IVD directive can be placed on the GB market up until the expiry of the device certificate or 30 June 2030, whichever is sooner. Thirdly, medical devices and IVDs, including custom-made devices, that are compliant with the EU medical devices regulation or the EU IVD regulation can be placed on the GB market up until 30 June 2030. This is in keeping with the Government’s response to the consultation on the future regulation of medical devices, which ran from September to November 2021.

I thank the SLSC for its thorough review of this instrument. The committee raised with the MHRA the important practical concern of whether firms will be incentivised to seek UKCA certification at an additional cost if CE certification is still accepted. Since January 2021, it has been possible to use a UKCA mark on medical devices. In the year ending March 2023, an estimated 9% of new medical products—around 71,000—were registered with the MHRA with UKCA marking, despite CE marking being an option.

Manufacturers will be prompted to consider shifting to using the UKCA mark through the transition period, including as their CE certificates expire. To transition to the UKCA mark, many manufacturers will need to use a conformity assessment body approved by the MHRA. The capacity of these approved bodies is currently limited. The MHRA is working proactively to build approved body capacity to allow a smooth transition to the UKCA mark. The agency engages regularly with the medtech sector and will continue to do so as it develops a future regime.

By supporting these regulations, we can help ensure that patients and the wider public benefit from continued access to quality, safe medical devices; that the UK remains an attractive market for manufacturers of medical devices; and that the wider medtech industry has adequate time to prepare for the transition to the future regulatory framework for medical devices. I commend these regulations to the Committee.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for his explanation of the statutory instrument. I do not oppose it at all, although the fact that the Government are doing it seems to reflect the serious lack of preparation and planning for the post-Brexit world in which we now exist.

I have two points to put to the Minister. The first is in relation to the 30 June 2030 cut-off date for the sole use of UK conformity assessments for medical devices placed on the market in Great Britain. My understanding is that the transition timelines to 2030 are causing significant confusion for companies, especially SMEs in the health tech and medical devices sector. I refer noble Lords to paragraphs 7.6 and 7.7 of the Explanatory Memorandum in particular, which begin to explore some of the complexities. I say this to the Minister: a clear timeline would be very helpful in giving clarity and certainty to companies.

My second point picks up the point that the Minister made right at the end of his opening speech about the MHRA’s capacity and its plans to reform the current regulatory system. I pay tribute to the MHRA’s work and am sure that it will rise to the challenge but the plan includes proposals

“to reclassify products, to increase information gathered at the point of devices’ registration, to strengthen post-market surveillance requirements to ensure better incident monitoring reporting and vigilance, and to introduce alternative routes to market”.

I can see the reasons for this, of course, but additional regulatory burdens for industry to supply the UK may mean that manufacturers will not bother and will focus on the EU and other larger, certainly more valuable, markets. The number of products made just for the NHS is very small indeed.

The Minister will be aware that the Chancellor talked in the Budget about the rapid, almost automatic approval of devices approved in markets such as the US. Is the MHRA signed up to this? It seems essential to build on current product recognition routes from the EU and rapidly explore building a UK product regulation equivalence route for the approval of medical devices to include other trusted jurisdictions, such as the US, for a greater proportion of products. I would be grateful if the Minister could comment on this.

I now come to the very serious capacity and capability constraints. Clearly, the MHRA has suffered from the reduction in its funding, especially on the devices front. I hope that the Minister will be able to say what is being done to improve it. Also, what philosophy will the MHRA adopt in future? Will it continue to oversee the regulatory process in relation to devices or will it take a more expansive, more centralised and certainly more expensive FDA-style approach, with the attendant recruitment challenges that that brings? It has been announced that one of the MHRA’s senior executives, Dr Laura Squire, will focus on devices and that there is a recognition of skill shortages but I cannot begin to overestimate the problem for UK companies if, in meeting the target that the SI now sets, they find that one of the major problems is a lack of capacity in the MHRA to provide the necessary speedy regulatory assurance that is required.

This comment can generally be made about the post-Brexit arrangements as a whole. If, by “taking back control”, the Government mean that they are serious about developing a new regulatory regime that serves the public interest and is effective in attracting industry to this country, they really must ensure that the regulatory system is both fast and effective. This is the major issue that must lie behind this SI.

--- Later in debate ---

I look forward to the Minister’s response to the key questions asked by noble Lords, especially on the expected timing of the new MMD regulations. I also look forward to his response on mutual recognition, which the noble Lord, Lord Lansley, spoke about.

[Lord Markham (Con)]

I thank noble Lords for their valuable interventions; I will try to answer a lot of their points as far as is possible.

First, I completely agree that clarity is vital in this market. As ever, as well as trying as best as I can to reply now, I will follow up in writing so that there is absolute clarity there. A lot of this depends on the timing. I say this up front in answer to the question from the noble Lord, Lord Allan, on whether things will change for new products from 2025: no. In effect, we are saying that the deadline is the deadline and, as long as a product is approved during that period, it will run to 2028 or 2030. In fact, new products will now be largely under the new EU regulations so will generally run to 2030. Effectively, that 2025 deadline will apply to any new products even if they are approved and get their CE registration after 2025—say, in 2026. Generally, they will run up to the 2030 deadline.

I hope that what I have said clears up that point but, again, I will set all this out in writing; I am sure that I will be thumped by the team behind me if I misspoke. I think I proved the point very well in my explanation just now: this is non-trivial. As a businessperson by background, I know that, if you want people to invest in this market, they absolutely need to understand the rules.

Two major themes came through in all the points and questions. First, we want to maximise the supply of products. That has to be a good thing for us in making sure that we benefit as much as possible, and it goes to us recognising other quality—for want of a better word—regulators. You could say that approving the ceiling now up to 2028 and 2030 is a step along that way.

Similarly, we want to maximise capacity for our regulators. If you start to approve other quality regulators’ approvals, you are in effect pooling capacity and using their regulatory capacity as well. We know that that is an issue. In the last Budget, the MHRA was given a £10 million funding increase to make sure that it can recruit, but we recognise that it having that capacity is vital to all this.

On the point about mutual recognition, we can of course do it in only one way but, as in most free trade arguments, there is an understanding that it is generally to our benefit to recognise other quality regimes. That is to our benefit in terms of having a high supply of quality items here. Clearly, you want them to do the same in reverse. As ever in these things, there is a bit of trade-off in the negotiation: “Do I want to hold back so that I can maximise my leverage and get them to agree with it all?” Generally, as mentioned by the Chancellor, we are at the moment on the page of it being in our interests to recognise quality regulations from other countries because that can maximise our supply. We hope that they will recognise ours in a similar way, obviously, but that is in their power rather than ours.

I will try to answer some specific questions. There was a question from the noble Lord, Lord Allan, about class 1, low-risk products. Generally, the answer is yes, but this again goes to some of the confusion so I will definitely set this out in writing as well. It is not a blanket “yes”, which I appreciate does not help. Class 1, low-risk devices will benefit from the transitional periods in this instrument only where they are within the EU’s own transitional arrangements. I hope that that make sense.

[Lord Lansley (Con)]

My noble friend was talking about capacity. One aspect of it is the capacity of the regulators here and in the EU but, in some ways, I am equally concerned about the capacity in the approved bodies, or notified bodies as the EU has them. That is what has been delaying the EU’s regulations and its ability to implement them. It could equally be a problem here. We would both have less of a problem if the approved bodies in the European Union and the United Kingdom were all able to work on both sets of certificates.

[Lord Markham (Con)]

Yes; that is what I mean by pooling capacity, for want of a better phrase. My noble friend is saying that we can effectively use the EU’s capacity if we are willing to accept that it is doing proper scrutiny and measurement of products. By and large, we would all agree that that is a sensible approach, just as, similarly, there are situations in a lot of clinical research where, even if the regulators want a final sign-off, accepting each other’s data has to be sensible in terms of pooling capacity.

As ever with these things, it takes two to tango. We need to prove willingness on our side. I hope that the recent Windsor Framework agreement is a way to put things on a co-operative basis. Building trust on both sides takes a series of steps but we are trying to put our best foot forward and we hope that that is met in response.

This goes to the point about the EU-wide shortage of approved body capacity, which impacts us all. If, as we all agree, we want the best supply of products here, it must clearly be a concern if they cannot get through that way. If a company is finding that, through a lack of capacity, they cannot get through the EU route because there is no capacity there, it now has the opportunity to take the UKCA route if our capacity is in place, with the increases to the MHRA to which I referred.

[Baroness Wheeler (Lab)]

When the Minister writes—I understand that this is very complex; I would certainly appreciate having it in writing—could he refer to three things? The first is small businesses; the SI says that it will not have an impact on them but it is clear that it will. When? The second is the timetable for the new MHRA framework being in place, whether there will be consultation around it and whether that process is separate or uses the consultation that took place last year. The final issue is that of the timetable for the new MMD regulations—that is, the timescale by which we will see them coming along. It will help us make sense of the totality of this if we know when all this work is coming forward.

[Lord Markham (Con)]

It is probably best if I write on those points. In terms of timing, the MHRA is planning a further consultation on its future regime from October, but I will come back on those other points.

[Lord Allan of Hallam (LD)]

On the labelling question, I wonder if I could helpfully suggest to the Minister something like an infographic, which shows what labels are needed in Great Britain and Northern Ireland and which labels would be helpful on which dates. Somebody who is making devices could just look at that and go, “I’ll need that kind of labelling at this stage of the transition process”. That would help.

[Lord Markham (Con)]

I absolutely agree. To clarify—I may have used the terms interchangeably—I am talking here about the Great Britain market. It is a great British market as well but we are talking particularly about Great Britain because we know that, under the Windsor Framework, Northern Ireland has separate CE arrangements.

I think I have answered as much as I can at this point. I will clarify further in writing. I thank noble Lords because this debate has been incredibly valuable in making sure that we are getting this right; it is non-trivial, to say the least. With that, I commend this instrument to the Committee.

Motion agreed.

NHS National Health Inequalities Improvement Programme

Lord Markham Excerpts

Thursday 25th May 2023 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask His Majesty’s Government whether the NHS National Health Inequalities Improvement Programme plans to review and improve the nutrition of free school meals.

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

The focus of the NHS healthcare inequalities improvement programme is the delivery of healthcare services. Free school meals are outside its remit. The Department for Education continues to keep school food standards under review. The current standards provide a robust yet flexible framework to ensure that pupils in England continue to receive high-quality and nutritious food. Developing healthy habits early in life can influence health in childhood and reduce the risk of diet-related diseases in later life.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful to the Minister for his reply. Who actually is responsible if one tries to change the formulation of school meals for children? In previous debates on obesity, he has stressed the importance of reducing calories. The Government have estimated the number of calories that need to go down to get child obesity down. As we are giving children so much sugar in school meals and such highly processed food, why do they not run a trial with less sugar and healthier food than we are doing at the moment to try to deliver on the calorie objective, which he has talked about previously?

--- Later in debate ---

[Lord Markham (Con)]

First, I thank the noble Lord for the work that he does in this space; I know it is something very close to his heart. It is the school foods standards that set and define the formulation in the food and drinks provided by schools. That is all through the school day: breakfast, lunch and afterwards. They were due to be reviewed around the time of Covid in 2019; clearly, that did not happen then, so we are looking again at whether we should be reviewing those. Precisely in that, we shall be looking at levels of calorific intake.

[Baroness Manzoor (Con)]

My Lords, as my noble friend will know, in the short term a poor diet can lead to stress, inability to concentrate and tiredness. In the longer term it can lead to obesity, diabetes, high blood pressure and indeed heart disease. Of course, my noble friend will be aware that there are great inequalities within ethnic minorities. Can he say what the Government are doing to reduce the inequalities and ensure that micronutrients play an important part in the promotion of the food strategy?

[Lord Markham (Con)]

First, I wish my noble friend a happy birthday. I totally support her question. The most important thing with regard to inequalities—funnily enough, this was the answer to an earlier question—is the use of free school meals. I think we can all welcome the fact that 37.5% of children now receive free school meals and therefore a nutritious start to life. Clearly, that is the best way to make sure that children, particularly those with potential inequalities, are getting a healthy start in life, as well as the under-fours clubs to make sure that they get healthy food.

[Baroness Walmsley (LD)]

My Lords, according to Henry Dimbleby, the Government’s public food procurement system is dominated by a few very large corporations, creating little incentive for innovation or improvement. Can the Minister give us an update on the trials in south-west England, in which small, local, high-quality food suppliers can get into public procurement—for example, to schools and hospitals? I understand that early evidence reports better quality and choice at no increased cost.

[Lord Kamall (Con)]

My Lords—

[Lord Markham (Con)]

Absolutely. Again, there are also very good grounds for locally sourcing in that way in terms of the environment and reducing the carbon footprint. I must admit to not being very familiar with some of the pilots mentioned, so I will find out and get back to the noble Baroness.

[Baroness Finlay of Llandaff (CB)]

My Lords, the latest data from the National Child Measurement Programme showed that among 10 to 11 year-olds at school, almost 38% were overweight, of whom nearly two-thirds were obese. Do the Government recognise that this represents severe malnutrition in that cohort and that public health should be involved in the planning and inspection of school meals to try to improve that figure? These children will become health problems for the whole of the nation going forward unless their malnutrition is corrected.

--- Later in debate ---

[Lord Markham (Con)]

I agree with the noble Baroness. It was said in answer to a Question not so long ago that the hypothesis about much of the reduction in increases in life expectancy in the G7 nations, apart from Japan, is that it is very much linked to obesity, and that starts early on in life. Education is a key part of that, but the things we are starting to do as regards the placement of foods in supermarkets are already having an impact, and the reaction of the industry to that has been the reformulation of some foods which has already taken out 14% of sugar and 20% of salt—but clearly there is a lot more to be done.

[Lord Kamall (Con)]

My Lords, I apologise to my noble friend the Minister and reassure him that I was not trying to answer the previous question. However, in answer to a previous question, my noble friend the Minister mentioned that the responsibility of school meals and nutrition lies with the Department for Education. Is he aware of any conversations and interaction between the Department for Education, the Office for Health Improvement and Disparities, and the Department of Health and Social Care?

[Lord Markham (Con)]

Absolutely. We work very closely together. The Healthy Start programme gives seven fruits a day to kids up to the age of seven to make sure that they get fruit and vegetables, and that is very much a joint initiative. Clearly, we need to be joined at the hip on some things, but as regards school meals, the DfE takes the lead.

[Baroness Merron (Lab)]

My Lords, the levelling up White Paper promised to design and test a new approach to ensure compliance with school food standards. Although pilot schemes were meant to start last September, a recent Written Answer from the Schools Minister stated that

“standards are being kept under review”,

with no sign of the pilot scheme. Have the Government given up on their promise and does the Minister consider the existing standards for school meals and the means of compliance sufficient to tackle nutritional inequalities across the country?

[Lord Markham (Con)]

As mentioned previously, the review did not happen because of Covid, and it is very much within the plans that it is time to look at school standards again. Clearly, that is key to making sure that there is a healthy diet in schools, and of course that goes across the board.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain whether the Department of Health is working with other departments to consider funding families entitled to free school meals with additional allowances during the summer vacation in the light of the current cost of food and the need, as he has acknowledged, to provide adequate nutrition to promote health in young people?

[Lord Markham (Con)]

Yes. It is worth reiterating that the 37.5% free school meal level is an achievement, as is the fact that all infant schoolchildren receive free school meals—higher than ever before. However, the noble Baroness is correct in terms of what happens during holidays. That is why we have the holiday activity fund, which in the summer holidays, for instance, provides meals for four of the weeks, as well as for another week in winter. Clearly, we need to keep that under review to make sure that that is sufficient.

[Lord Mann (Non-Afl)]

My Lords, currently some Jewish children are having to survive due to the funding formula on a bagel every dinnertime. Is that acceptable and, if not, which Minister will sort it out?

[Lord Markham (Con)]

I hope that every child would have something more nutritious and healthier than just a bagel. I will happily discuss that with the noble Lord; I am not familiar with that particular case but it is something I will happily take up.

[The Earl of Devon (CB)]

My Lords, in response to the noble Baroness’s question on the South West Food Hub, I was on the advisory board until last week. That project has now folded, purely through lack of engagement from the Cabinet Office and the procurement services. Can the Minister speak to his colleagues at the Cabinet Office to see whether they can re-engage in these dynamic procurement activities for local farmers?

[Lord Markham (Con)]

I would be happy to. I need to find out more first, and I would be delighted if there was some information or if we could meet on this, but I would be happy to take it up.

[Baroness McIntosh of Hudnall (Lab)]

The Minister has twice cited the figure of 37.5% of children now receiving free school meals, which, as he rightly says, is an achievement of a sort. However, if the standard of food those children are receiving is insufficiently good—and there appears to be some evidence of that from the information that has been going around the House this morning—adding to the number on the list of those receiving free school meals, although admirable in terms of the numbers, may be contributing to the problem. Does the Minister agree?

[Lord Markham (Con)]

I do not think anyone would say that the current school food standards are insufficient. I think the feeling is that it has been a while since they were changed because of Covid, and it is time to ask whether improvements can be made, because this is an ever-evolving situation. So I would not agree with that categorisation, but we should indeed always be looking to see whether we can make better choices.

Branded Health Service Medicines (Costs) (Amendment) Regulations 2023

Lord Markham Excerpts

Thursday 25th May 2023 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I thank my noble friend for his usual expert and comprehensive explanation of his regret Motion on this SI, which is so important for the future of the NHS and the UK’s pharmaceutical industry and life sciences sector.

While the Government’s argument for maintaining equivalence between the two schemes makes sense, we certainly do not want companies to choose to leave the voluntary scheme for better rates. We on these Benches fully recognise the strong concerns about the impact and potential damage that the 27.5% clawback rate will cause to the manufacturer of branded medicines, to the availability of those medicines to the NHS and its patients and to future investment in the research and development of new drugs.

I point out that this is the first opportunity, on such an important subject, that we have had to discuss in depth the key issues my noble friend and other speakers across the House have raised, since the short Grand Committee debate last October on pharmaceutical research and development spending. The Minister will recall that it was his first debate as Health Minister and that he surprised us all by bursting into maiden speech mode when he summed up the debate. He expressed his confidence that the Government

“through Life Sciences Vision … will develop the end-to-end improvements required to attract an ever-growing proportion of pharmaceutical investment to the UK”.—[Official Report, 13/20/22; col. 135GC.]

He also made the acknowledgement that growing the UK’s proportion of global pharmaceutical investment meant improving

“every aspect of the life science ecosystem”.—[Official Report, 13/20/22; col. 133GC.]

As my noble friend and other expert speakers have shown today, this is just not happening.

The continuing dramatic decline in the UK’s share of global pharmaceutical investment is clear evidence of this, causing the loss of billions of pounds to the industry over the past 10 years. We have heard the stark figures. The NHS faces huge challenges and obstacles to becoming an effective innovation partner in supporting the access to and uptake of new and innovative drugs, which are so critical to developing better outcomes for patients and creating a thriving life sciences ecosystem. If the NHS continues to be slow on the uptake of innovative medicines and treatments, the UK could lose its position as a world leader in life sciences, particularly with the rapid advancements in biotechnology and AI.

For the UK to become a destination of choice for cutting-edge research, urgent action has to be taken to reverse the sharp decline in industry clinical research trials within the NHS and to address the standstill we have reached in developing the comprehensive strategy on patient data and research that is vitally needed. We need to balance the safeguards for patients and public engagement with the ability of accredited researchers to access the data they need to develop the valuable research at the heart of innovative medicines and treatments. What consideration are the Government giving to further embedding research within the NHS, both to underline the importance of patient participation and to allow a more direct link between health and science? During Covid we saw how, with the right drive and attitude, this can be done successfully for vaccine development, with life-saving results.

That is why the background and context of the proposals in this SI are so important. Despite the “remote” risk optimism of the impact assessment, and all the flaws that noble Lords outlined, the SI’s proposals for a substantial clawback, in 2023, of net sales income for UK biopharmaceutical companies greatly increases the risk of them reducing their current level of R&D investment. I look forward to the Minister’s explanation of how other countries that have similar clawback schemes—Ireland, Germany and Spain—managed to keep their clawback rates considerably lower than half what is proposed in the UK. This was mentioned by a couple of speakers. What assessment have the Government made of the impact these lower rates would have on investment in the UK? Why do they think that AbbVie and Lilly chose to leave the voluntary scheme?

In 2023, manufacturers of branded drugs in the voluntary scheme will be required to return almost £3.3 billion—or 26.5% of sales—to the Government, up from around £0.6 billion in 2021 and £1.8 billion in 2022. ABPI says that this means that the money spent on branded drugs has declined by 14% in real terms over the past decade, despite rising demand. The noble Lord, Lord Warner, pointed out that, overall, the savings to be made are minor when compared with the likely damage.

On the consultation exercise, I look forward to the Minister’s explanation of how 39 days of consultation over the Christmas period was sufficient to provide this. This is made even starker by the fact that 32 out of 33 respondents opposed the proposals. One thing we know businesses need in order to invest their money is certainty, but they are not getting it.

Finally, today’s discussions have made a convincing case for taking a long, hard look at the current scheme and how it is working. Negotiations are under way for the new voluntary scheme for pricing, access and growth, and we will watch them carefully. The priority must be to find a solution that allows patient access to the best-quality treatments, with good value for the NHS and taxpayer, while ensuring a fair return for the industry. We need to secure arrangements that will build confidence and provide mutual benefit for the NHS and industry. Can the Minister provide an update on the early talks or negotiations that have taken place? I noted the comments of the noble Lord, Lord Warner, about how this SI’s approach could be paused in the light of any significant developments that are likely to take place.

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

I thank noble Lords for the debate, and I particularly thank the noble Lord, Lord Hunt, for bringing forward this important subject. It was clear from the contributions of noble Lords that we all want the same thing here, and this is a discussion about how best to achieve it. We all want the UK to be a

“science and technology superpower by 2030”,

as quoted by the Prime Minister. We all want a thriving life science sector, we want access to the best medicines for the NHS and we all want to ensure that the NHS is achieving value, in terms of money for the front line—I think we are united on those things. I also commend the fact that this debate was very much a discussion, so I will respond in that vein, rather than reading out a speech. I will try to discuss this from the Government’s point of view. I apologise if that means that I might not come across as quite as polished, but I would rather respond directly to the points raised.

We would all accept that we are striking a delicate balance here: between having value for the NHS—through, for example, the funding of £2.5 billion this year—and having value and making savings for frontline services, which we all want to see. While we are focusing on those, we also want to make sure that we do not go too far and damage what is, and what we want to be, a thriving sector.

The noble Lord, Lord Hunt, asked whether the Government are being complacent about this. The words of the Prime Minister, saying that he wants a negotiated outcome with the ABPI, are probably the strongest sentiment in terms of wanting a sensible, negotiated outcome. At this point, I say to the noble Lord, Lord Warner, that I am responding on behalf of the Government.

As the noble Lord, Lord Warner, pointed out, just today, the Chancellor is having a round table with the life sciences industry. That, too, is very much about getting a solution that works all the way round. Having said that, please remember that some of the comments I am making in this debate are about a balance. We are all aware that we are entering into a negotiation and obviously, in any negotiation, sides make points—sometimes at the negotiating table and sometimes publicly. Please take my comments in that vein; we want to make sure that a balance is brought to the debate.

[Lord Warner (CB)]

I am sorry to interrupt the Minister’s flow. He said that we are having the fruitful discussions that the Prime Minister wants with the industry and that they are starting to progress. However, the industry itself is starting with a figure in the single figures, nowhere near 27%. I am curious as to why we are having this discussion about progressing these regulations, as they seem to be going in totally the opposite direction from the aspirations the Prime Minister has.

[Lord Markham (Con)]

The mechanics behind this debate—I was planning to say that my noble friend Lord Lansley made this point—are about the alignment of the voluntary and statutory schemes. I think that we would all agree that it is sensible that the two are roughly aligned. We can argue over how high or low that figure should be, but we would agree, I think, that it is quite sensible that the two are aligned. If you had large disparities between the two, you would disadvantage, for instance, the members who have joined the VPAS system.

[Lord Warner (CB)]

I am sorry to interrupt the Minister again. We are talking about signals given to the outside world, in these discussions that are now taking place about the voluntary scheme. As the noble Lord, Lord Lansley, asked, rather elegantly, why do we have two schemes in the first place? There is something very odd about levelling up to a voluntary scheme’s level with a big increase and, at the same time, sitting down with the industry and saying how much we love it and that we want a new, agreed programme, when the industry is talking about figures which are nowhere near the figures in these two schemes. It seems almost politically inept.

[Lord Markham (Con)]

As I said, this is about the scheme and the pricing for this year. The negotiations happening now are about future years, while, technically, this debate is about making sure that the alignment is there for this year and its pricing. Given that the discount has been decided on for this year for the voluntary scheme, having alignment will ensure fairness, so that members in the voluntary scheme are not suddenly disadvantaged against the statutory scheme—which would happen if we were not putting in a similar price. It does not in any way predicate what a negotiated outcome might be for future years.

In terms of a future negotiation, if there was a VPAS-type scheme—again, everything is on the table—you would have the argument about alignment. Most people would accept, as my noble friend Lord Lansley was saying, that having an alignment between the two is a sensible mechanism. The real debate today is about what level that discount should be. Regarding the balance—and I am not making any value judgment about what the right level is—when this was first forecast in 2018, a forecast was put out about what the discount would be over a five-year period, and in year 5 it showed a discount in 2023 of 31.1%. Those were the projections made, at that time—in 2018—the ABPI welcomed the scheme as an innovative one. In fact, today, the discount is less than that, at 26.5%. This was all known and projected as part of the scheme at the time. That is not to say that, in these negotiations, it should not be reset or that we should not make sure that there is a sensible conversation, but I am trying to do this while making sure that there is a balance in the negotiation.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister. I think he has responded in a positive way, which is gratifying and, I hope, sets the foundation for a proper negotiation with the industry to get a jointly owned voluntary scheme which will incentivise global pharma to invest in the UK.

For me, two or three themes come from this. First, the noble Lord, Lord Lansley, talked about the curiosity of a fixed drugs budget, and I found it curious when the Minister said we need value for money on medicines in order to have resources for front-line services. But medicines are a front-line service. Why is it a good thing to increase the number of doctors and nurses and buy more medical equipment, but it is suddenly shock-horror to spend more on medicines? What would we do without medicines? It is curious. I have never understood why the Department of Health has such a downer on the medicines budget, when it has just said—and I declare an interest as a member of the GMC—that it wants to see a massive expansion in medical school places. Why is the medicines budget regarded as such a negative factor? It defies all understanding; of all the great advances we have made in healthcare, how many have been made through new medicines? And I have to say that new medicines are rather easier to get than extra staff.

[Lord Markham (Con)]

May I just clarify? I completely agree that medicines are of course valuable. My comments were not about not spending money on medicines but about getting value for what we spend on medicines—not the quantity, not the quality, but the price that we are paying. I think that all noble Lords would agree that we want to make sure that we are getting the best value on pricing.

[Lord Hunt of Kings Heath (Lab)]

I fully accept that, but the sentiment that comes through is something that is shared throughout the National Health Service: that drugs expenditure, per se, is something to be held down. That is why, even though we have NICE, and bilateral negotiations—as the noble Lord, Lord Lansley, said—between NHS England and pharma companies in relation to specific drugs, at local level you have formularies and all sorts of mechanisms designed to ration medicines to patients. It is a curiosity about our whole approach. I agree with the Minister that one needs to start with a health budget. If we have—and I hope we do—new medicines coming on in relation to, say, Alzheimer’s, we will need to spend extra money in order to invest in them.

My second point—also made by the noble Lords, Lord Warner and Lord Allan, and my noble friend Lady Wheeler—is that it is very important that this is seen as a cross-government approach. If this is seen simply an issue for the Department of Health and NHS England in terms of the NHS budget, we will never get the kind of agreement that we need. If the Prime Minister is true to his word in terms of trying to reset the relationship—as the Minister implied—that is very welcome indeed.

This has been a very useful debate and I am very grateful to the Minister and other noble Lords. I beg leave to withdraw my Motion.

New Hospitals

Lord Markham Excerpts

Thursday 25th May 2023 Lords Chamber

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

My Lords, I will repeat a Statement made today in another place on the new hospital programme. The Statement is as follows:

“As we celebrate 75 years of the NHS this summer, we must continue to set up its success for the 75 years to come. At the heart of this is our new hospital programme, the biggest hospital building programme in a generation, which will help us deliver on our manifesto commitment to build 40 new hospitals by 2030. Today, I can reconfirm to the House our commitment for 40 new hospitals to be built by 2030.

We made our manifesto commitment in 2019, and in 2020 we listed 40 schemes as part of the new hospital programme. Since we formally launched the schemes, we have learned more about the use of reinforced autoclaved aerated concrete, more commonly known as RAAC. RAAC is a lightweight form of concrete that, between the mid-1950s and the mid-1980s, was commonly used in the construction of a number of public buildings, including hospitals—often on roofs and occasionally in walls and floors.

We now know that RAAC has a limited lifespan, with difficult and dangerous consequences for the people who rely on or work in those hospitals. I know that this has caused considerable concern to colleagues in this House, to NHS staff in those hospitals and to constituents who are treated in them.

We remain committed to eradicating RAAC from the wider NHS estate. As part of the spending review allocation up to 2024-25, we allocated the affected trusts £685 million in immediate support, but in some cases we must go further. Seven hospitals in England were constructed, either wholly or in major part, with RAAC, and an independent assessment shows they are not safe to operate beyond 2030. Two of the hospitals are already part of the new hospitals programme, namely the West Suffolk Hospital and the James Paget University Hospital. The five remaining hospitals have submitted expressions of interest to join the programme but are not yet part of it. Those are Airedale General Hospital in Keighley, Queen Elizabeth Hospital in King’s Lynn, Hinchingbrooke Hospital near Huntingdon, Mid Cheshire’s Leighton Hospital, and Frimley Park Hospital in Surrey.

We accept in full the independent assessment that these hospitals are not safe to operate beyond 2030. Today, I can confirm to the House that we will expand our new hospitals programme to include those five hospitals built with significant amounts of RAAC. Taken together with the two hospitals already in the programme, the seven RAAC hospitals will be rebuilt completely using a standardised design known as hospital 2.0, with the aim of completing all seven by 2030. I can confirm to the House today that these new hospitals will be fully funded.

I want to take a moment to thank all those who have campaigned so tirelessly for new hospitals to be built to replace the existing RAAC hospitals, including the Members for Keighley and for Shipley, who have championed Airedale vociferously; the right honourable Member for Surrey Heath, who campaigned so strongly for Frimley; the honourable Member for Huntingdon, who lobbied hard for Hinchingbrooke; the honourable and learned Member for Eddisbury and the honourable Member for Crewe and Nantwich, who led the campaign on Leighton Hospital; and the honourable Member for North West Norfolk, the honourable Member for North Norfolk, who is my PPS, and the right honourable Member for South West Norfolk, who all campaigned so assiduously for the hospital in King’s Lynn.

Taken together, the new hospitals programme represents a huge commitment to strengthening the NHS. Since 2020, we have committed to invest £3.7 billion by the financial year 2024-25, and we expect the total investment to now be more than £20 billion for the programme as a whole. Resolving the uncertainty over the RAAC hospitals, which today’s announcement achieves, in turn allows much-needed clarity for the rest of the new hospitals programme. The programme has already been divided into cohorts 1 to 4, with construction in cohort 1 already started. Cohort 1 contains eight schemes. Two hospitals are already open to patients, with the new Louisa Martindale Building at the Royal Sussex County Hospital in Brighton due to open later this year. Work at Moorfields Eye Hospital is due to start imminently, having cleared its final business case.

Cohort 2 comprises 10 schemes. The following schemes will now be ready to proceed, in line with plans set out by the respective trusts: the National Rehabilitation Centre; Derriford emergency care hospital in Plymouth; Cambridge Cancer Research Hospital; Dorset County Hospital in Dorchester; and St Ann’s Hospital, Christchurch Hospital, the Royal Bournemouth Hospital and Poole Hospital, all of which are in Dorset. A further two schemes within cohort 2, Shotley Bridge Community Hospital and the women and children’s hospital in Cornwall, will also be approved to proceed, but in line with the standardised design elements we are promoting through hospital 2.0, on which I will set out further details in a moment. As such, with the uncertainty that surrounded the RAAC hospitals now addressed, all the cohort 2 schemes can proceed, and they will be fully funded.

The cohort 3 schemes include major hospital new builds at Sutton, Whipps Cross, Hillingdon, Watford, Harlow, Leeds and Leicester. Today’s announcement confirms that those schemes will now proceed and be fully funded. They will be constructed using the hospital 2.0 standardised approach. It is worth reminding the House of the merits of using that methodology. First, although longer will be taken on the initial design, rather than each scheme beginning to construct to its own bespoke design, the current approach has meant that the average time from design to completion of a major hospital has been around 11 and a half years. By embracing modern methods of construction, we will massively speed up the construction phase and, in addition, accelerate Treasury and other government assurance processes. There has been much debate to date on when hospitals start, but the more important issue is when schemes are completed. A standardised modular scheme has been shown to work in other sectors—for example, when building schools and prisons—and is widespread across the private sector.

Today’s announcement confirms that all cohort 3 schemes can now proceed. In turn, enabling works that had been held up due to the uncertainty about the RAAC hospitals can now progress. I pay tribute to the right honourable and honourable Members who have campaigned so strongly for the cohort 3 hospitals to proceed. They include the right honourable Member for Uxbridge and South Ruislip, the right honourable Member for Chingford and Woodford Green, the right honourable Member for Harlow, the right honourable Member for Epping Forest and the honourable Member for Hertford and Stortford. I know that not all of them can raise points during this Statement, but the latter three have championed Harlow and its case. The Member for Carshalton and Wallington, to name just one, has raised these issues.

Turning to the hospitals in cohort 4, two of the schemes—West Suffolk Hospital and James Paget University Hospital—are RAAC hospitals. As I touched on a moment ago, they have been confirmed as part of the seven RAAC hospitals. They will therefore be funded for completion by 2030. Four hospitals in cohort 4 remain on track for completion by 2030: Milton Keynes University Hospital, Kettering General Hospital, Musgrove Park Hospital in Taunton and Torbay Hospital. Again, I pay tribute to the Members for those constituencies, including the Members for Milton Keynes South, Milton Keynes North, Kettering, Taunton Deane and Torbay.

The remaining seven hospitals within that cohort will also proceed as part of the new hospitals programme. The work will start on those schemes over the next two years, but they will be part of a rolling programme where not all work will be completed by 2030. That is a reflection of the disruption that two years of the Covid pandemic caused, as well as the pressure from construction inflation.

Some work within cohort 4 will start next year. That includes a new surgical hub at Eastbourne, alongside the discharge lounge already under construction. We will discuss key worker accommodation on the site with the trust, as part of engagement with the local housing association. At Charing Cross Hospital in Hammersmith, work will begin on temporary ward capacity to enable the floor-by-floor refurbishment to proceed. In Nottingham, work will begin on a new surgical hub and three new operating theatres will begin as part of the wider redesign, taking forward the Ockenden report recommendations. In Lancashire, a new surgical hub will be opened at the Royal Preston Hospital, which is due to be completed this year. We will reconfigure services across two trusts. I am sure that one of those sites will be of interest to Mr Speaker, as it is expected to be near Chorley. We are in active discussion with the Royal Berkshire Hospital, given the problems with the existing site, which had already made a 2030 completion date very stretching. In addition, we are building three new mental health hospitals in Surrey and Borders, Derbyshire, and Merseyside.

Turning to Devon, I pay tribute to my honourable friend the Member for North Devon and my right honourable and learned friend the Member for Torridge and West Devon, who have secured new community diagnostics centres at North Devon. The new discharge hub is near completion, and we will take forward discussions with the trust and the local housing association on key worker accommodation over the next two years, as the first part of the North Devon new hospital build. We will discuss the original refurbishment proposal alongside the new build hospital 2.0 option.

In summary, the cohort schemes will all proceed, but the commitment to completion by 2030 applies to the 40 schemes set out today, which meets our manifesto commitment to build 40 hospitals by 2030.

Finally, let me set out the merits of the hospital 2.0 approach. Building new hospitals this way has clear advantages. Construction experts estimate that, with modular design, the efficiency saving will be in the region of 25% per square foot. That is essential in addressing the pressures of construction inflation and unlocking the additional schemes that are being observed as a result of the RAAC announcement.

There is one key risk to today’s announcement: the plan announced by the party opposite. As we speed things up, it is determined to grind them to a halt. The plan it set out on Monday said,

‘as a first step, before we commit to any more money, we’d make an assessment of all NHS capital projects to make sure money is getting allocated efficiently’.

So the risk to these schemes is from those on the Benches opposite.

Today’s announcement confirms over £20 billion of investment for the NHS estate. It confirms that all seven RAAC hospitals, which NHS leaders have called on the Government to prioritise, will be prioritised, with complete rebuilds using modern methods of construction. It will allow all cohort 2 schemes to proceed once business cases have been agreed, and modular build will be used for two of the schemes. It gives trusts the certainty to begin enabling works on major schemes in cohort 3 and a package of early work for schemes in cohort 4, two of which will be accelerated as part of the RAAC programme.

In 2019 we committed to the biggest hospital building programme in a generation, and today we confirm the funding to build 40 hospitals by 2030. I commend this Statement to the House.”

--- Later in debate ---

[Lord Allan of Hallam (LD)]

My Lords, when I worked in business we had a maxim that we should always try to undercommit and overdeliver as a way of pleasing clients. It feels like the opposite is applying here, with the Government scrambling to show that they are not underdelivering on their overcommitment. Of course, 40 hospitals was a classic election promise, oversimplifying a much more complex need, with the reinforced autoclaved aerated concrete hospitals being one of those such complications that emerged once they had turned over the aerated concrete block.

I do not expect the Minister to comment on the election promise, but I hope he can comment further on three aspects of the Government’s programme that he has set out. The first is the modular hospital design approach, which certainly seems a very smart way to proceed if it can provide more and better-quality hospital capacity at lower cost. Of course, any negative impact of failures in design will be multiplied if you are using a similar, consistent design. We should remember that RAAC was the future once, and public buildings were built according to that specification because it was seen to be cheaper and better back in the 1950s and 1960s. What assurances can Ministers give us that they will get it right this time and that the modular approach being used everywhere is the right one? By the way, on branding, 2.0 is now very 1.0, and it might be more appropriate to call it “the metahospital” or “Hospital.AI” these days.

The second is the planning process, which the noble Baroness, Lady Wheeler, raised. It does not matter if the modular design allows much quicker construction if everything is held up in seeking the relevant permissions to build the hospital in the first place. I would be interested to hear how many of the schemes have been given planning permission already and the extent to which the Government see planning as potentially a disruptor to their plans.

Finally, on the risks, if there are delays or cost overruns, which we hope there will not be—but inevitably one sees those with schemes of this kind—I look for assurances from the Minister that the contracts are written in such a way that any additional bills will not fall back on the taxpayer and, crucially, that if some schemes overrun or get into difficulties and incur extra costs, it will not mean that other schemes in the programme have to be cancelled as the overall budget runs short.

[Lord Markham (Con)]

I thank noble Lords for their comments. On a personal front, this is a project I have been working on directly. It is very close to my heart and is something that I am delighted to be able to put forward. I would like to mention a couple of hospitals that probably did not get quite the prominence they deserved in the earlier Statement, which happen to be quite close to my heart as well: the North Manchester General Hospital, which is one of the Cohort 3 hospitals. I have worked closely with Manchester City Council in the past on the redevelopments around Manchester Mayfield, and that is very much part of the plans. Also, being an ex-deputy leader of Westminster Council, I am excited by the plans around St Mary’s, where we are looking at a couple of alternative sites. That will be in conjunction with the plans for the refurbishments of Charing Cross and Hammersmith so we have got three hospitals in one. Just to clarify an earlier statement: the surgical hub is planned for Chorley and South Ribble Hospital rather than the Royal Preston Hospital.

I am not quite sure on the point from the noble Baroness, Lady Wheeler, about the target being abandoned. What we were saying before was not that at all. We were saying we are positive about how it is progressing. To the point from the noble Lord, Lord Allan, about overpromising and underdelivering, I am sorry for the branding of the hospital 2.0 approach, and I take the blame for that. In terms of MMC, I was at one of the plants the other day, and it really is amazing the way its builds them and the speed with which they will go up. Many buildings have built like that for a long time. When I was up there, I saw them constructing the new Everton stadium, which is just one example. I believe that they will give the necessary speed we need for them all.

In terms of the funding, the estimate, as mentioned, is more than £20 billion. Each hospital has an indicative allocation. They are fully funded. We are not publishing them for obvious reasons: when you go out to tender, you do not want to tell the marketplace what you are expecting to pay. I hope noble Lords understand the reason for that. I am confident that the funding is in place. The hope in all of these things, as we have seen in the prison space and the schools space, is that if the first hospital costs £100 to build, the next one costs £95, the next one £90, the next one £85 as you get the economies of scale. So, you should be seeing 20% to 25% reductions, as you do a large production line. The benefit of all this is that there is such a mass volume of them all that you get the economies of scale. I genuinely hope that this will become the way we build hospitals for generations to come. It is very much cross-party, something that we all believe is a good way forward.

Some hospitals, as mentioned—as part of the timing and to try to make sure it all works in terms of the funding envelope—have been pushed into the 2030-35 bracket. They were mentioned in the Statement, and we have been speaking to them about that. They include Eastbourne, the Royal Berkshire, all the ones around St Mary’s with the complications there, Lancashire and Charing Cross to name just a few. In all those cases, they understand the reasons, and I think most people understand the need to prioritise the RAAC hospitals as a matter of absolute urgency.

On the questions about the planning process, we are on target. Obviously, you do not want to get planning permission too early, given the time it takes. In all the programmes I have seen, we do not yet have planning permission because we do not yet need it. I am confident that we are on track. We know that there are always X factors in these types of projects but, when you have so many, you want the flexibility to move some forward and some back, in a portfolio-type approach. That is well known when you are running as many projects as this.

At this stage, in all honesty I can say that we are as confident as we can be that we are on target to build them. Undoubtedly, there will be bumps in the road, and we are grown up enough to know that there are challenges, but I can say with a high degree of confidence that this really is the best approach. We will have world-class hospitals that will be state of the art, not only in their design but in their use of digital technology. A hospital today that is fully digitised costs 10% less per patient. With these hospitals, we should be looking at savings of 20% or more. That will really make a material difference to how we treat patients, increase productivity and be seen as the real way forward. I am very hopeful that the economics will become so compelling that this programme will not stop at 40 hospitals—in fact, 45, because of the extra ones we have brought in—and will become a rolling programme across the whole estate.

I am sure that we will have many more questions on this. As I say, it is my pet subject, as the priority lead, so I would be happy to talk about it in greater detail at a suitable juncture.

[Baroness Wheeler (Lab)]

Can the Minister say something about NHS maintenance costs, which I did ask about? I do not have the actual question in front of me, as my speech has just been taken away, but if he would like to write to me on that, it would be helpful.

[Lord Markham (Con)]

Yes, I will happily write. We are spending a record amount in capital. The current capital budget is about £12 billion, which is a 50% increase on 2019. Speaking of underpromising and overdelivering, believe it or not, we have been hiding our light under a bushel regarding the hospital upgrades. Just this morning I visited Frimley, one of the RAAC hospitals, and they said, “Oh, we’ve just had a new hospital at Ascot”. We have not called that a new hospital but they refer to it as such, and when you see it, it is a new building. It is not massive, but by most definitions it is a hospital.

I will happily provide that extra detail and information. We know that there is a lot to be done on maintenance, but we are putting more resources into it.