Mental Health In-patient Services: Improving Safety

Lord Markham Excerpts

Monday 3rd July 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to have an opportunity to discuss mental health provision, and my comments will very much follow on from those of the noble Baroness, Lady Merron. We are also interested in the Government’s latest thinking about the draft mental health Bill. Now that the workforce plan is out—we will discuss it tomorrow—our new refrain may be, “When will the Government get on with the mental health Bill?”. It is long overdue, and a huge amount of work has gone in that is clearly fundamental to trying to deal with some of the structural issues.

Turning to some of the issues raised in the Statement, I first want to ask about people’s journeys when they are in need of mental health support. The Statement said that 111 will now provide mental health advice, which is very welcome, but can I ask the Minister for his thoughts on what is happening in primary care? My understanding is that at the moment mental health nursing provision is not a requirement of all general practices—some offer it and others do not. Can the Minister, who I know cares about joined-up, seamless services, give us some insights into the Government’s thinking on ensuring that people who present with mental health problems to general practice—which is the first port of call for many of them, before they even get to 111 or 999—see more consistency of support available at that level?

Thinking about the review—a major part of what is in the Statement—a significant proportion of providers of mental health in-patient services are private sector, which has been the case for some time. Can the Minister confirm that they will be included in the review and comment on whether the inspectorate’s powers will be applied equally to the private and public sectors? That is critical to understanding what is happening in all settings.

Will the Minister also talk a little about the input the review may get from related services? Again, we know that the police, local authorities and accident and emergency departments often pick up the pieces where mental health provision has not been made available. Can the Minister assure us that the review will also look at all those other parties to this journey of care that people require? Can he also comment on the data questions? I have seen evidence from freedom of information requests to the Office for National Statistics asking about deaths of people in mental health in-patient settings. My understanding is that the data is not recorded consistently. If we are to have a review and to understand what is happening in the mental health sector, it would be helpful to know what measures the Government will take to improve the consistency of data collection so that, when someone unfortunately suffers a tragic incident, we know where they were at the time and have the data available to build up the national pattern.

The final issue I want to ask for the Minister’s comments on is out-of-area placements. Will he acknowledge that it remains a serious issue that many people with serious mental health conditions are able to get treatment only in places that are far from home and therefore far from their families and support networks? I note from the Statement that the Government are providing three new hospitals. This is of course welcome, but I hope the Minister will also be able to confirm that there is a locality-based strategy, with the Government thinking hard about matching local facilities to local need so that we can end the situation in which people at a time of extreme distress are sent very far away from home, which can only add to the crisis they are facing.

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

I thank noble Lords for their questions and their general welcome for the Statement. On timing, we had hoped that doing it on a non-statutory basis would have been sufficient. The advantage is that you get the results that much quicker; you can often get them within a year, versus three years. We have many examples of where it has worked quite well, such as the Kirkup report. To answer the question of why it is taking so long, in the first place we had hoped that doing it on a statutory basis would not have been necessary. There was a course correction in January, when we were not getting the response we needed and not enough staff were making themselves accessible. There was some improvement at that point, but it was felt by the chair that it was not sufficient, hence the decision now.

We believe that we can build on the work that has been done so far, so we are not starting again from zero. However, there are some lessons. On a number of occasions, trusts and staff have responded well to a non-statutory inquiry, but we have learned from this that sometimes it needs to have the teeth of a statutory inquiry so that it is taken seriously enough. Somehow, there was an impression that, because the inquiry was not statutory, it was not seen as serious enough to trigger that. There is a key lesson to learn from all of that.

How we can seek to restore confidence is absolutely the right question to be asking. We believe that the additional investment of £2.3 billion that we are putting into this space is a key part of that, and the increase of 27,000 staff is another. We are learning from the reviews that we are doing, and we are quickly learning from the rapid review. We are working fast, so I cannot give an exact date for those results. We asked for it to be a rapid review so that we could get on with it and make the most of the findings.

The other key part of this is the Healthcare Safety Investigation Branch. We are asking it to look into a number of questions, one of those being out-of-area in-patients and the impact that has. I think we all agree that it is best if people can have in-patient services locally. That is one of the key parts that it will be asked to review. On the timing of that review, it will start in October and should be able to conclude within a year. We should get results back quite quickly.

On the timing of the mental health Bill, we are working through the parliamentary calendar now. We do not know the timings yet, but the scheduling is being looked at.

The noble Baroness mentioned the prevention agenda. I completely agree that care in the community and the training of staff in GP settings and schools are vital to this. As noble Lords have heard me say at the Dispatch Box before, we are making good progress: about 35% of schools are trained up in mental health support. Last year it was only 24% and next year we think we will be pushing 50%. Those are big increases, but I freely accept that 50% is not 100%. A lot of progress is being made in that area but we accept that a lot more needs to be done.

As for the private sector being included in the review, I have every reason to think that it should be and that there should be equal powers, but I will check that. I am talking off the top of my head now as it seems perfectly sensible, but I will come back properly on that.

I will do likewise with the comments on the recording of and use of data. Again, one of the rapid review findings was that we do not have enough real-time data. That is very much the direction of travel but, again, I will come back with more detail. As ever, noble Lords will know that I like to bring all these things together in a lengthy letter where I hope I am able to cover any points I did not cover here.

There are steps in the right direction, and the investment I talked about is another step in the right direction. I completely agree with the emphasis that it is vital we restore confidence in this area.

--- Later in debate ---

[Baroness Buscombe (Con)]

A question is coming. I was accompanied by a brilliant consultant, Julia Riley. She has not even had a cursory note of thanks from those civil servants. Could the Minister therefore please respond by giving a little more detail on the timing? Could he also let me know whether there has been any progress on developing that particular app? I would also like to know about the implementation of safe places, where people can go when they are in crisis.

[Lord Markham (Con)]

I thank my noble friend for her tireless work in this space. We believe that a number of constructive points were made in the committee report, which I know Maria Caulfield is working on and looking to get a timely response to. Maybe that is something on which we can meet up and discuss later.

[Baroness Uddin (Non-Afl)]

My Lords, I raise the issue of the mental well-being of men from black and Asian backgrounds. I particularly raise the issue of the care they are receiving at the hands of very poorly qualified, untrained, unsympathetic people, who do not adequately understand the complexity not just of mental health and well-being but the way that they should be operating. They are not working in tandem with the families, which is one of the requirements. There have been suggestions from a number of community organisations that black and Asian men are four times more likely to be detained, and sometimes it is more than likely that there has not been any consultation with their families, which is one of the prerequisites. Can the Minister assure this House that any formal forward-thinking and examination of these issues is looking at the disproportionality of the effects and the causes of very poor services, particularly for men from black and Asian minority backgrounds?

[Lord Markham (Con)]

Yes, we are very aware of the points made very well by the noble Baroness, including some of the stats on the community treatment orders and the fact, I believe, that if you are a black male, you are eight times more likely to be detained. I know that that led to some of the recommendations from the pre-legislative scrutiny committee. I can give an undertaking that that will be fundamental to what we are trying to do here.

[Baroness Watkins of Tavistock (CB)]

My Lords, I welcome the Statement, but I will raise two issues. First, it seems that several different bodies will look at what the problem is, yet the ombudsman has just said that it is absolutely imperative that

“The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like”.


Could the Minister comment on how that will be considered in tandem with the proposals outlined in the Statement?

Secondly, will the proposals look at a safe staffing model for all in-patient mental health services? In fact, in-patient services are really looking after only those people who have severe mental health problems; they are almost the equivalent of an intensive care unit in a general hospital. Increasingly, staff do not have time for proper continuity of handover when they leave shifts, and that needs to be examined. It is relatively easy to describe somebody’s blood pressure and blood stats in an intensive care unit as you hand over in a general area, but to describe the complexities you have been working with, for example with somebody who has severe schizophrenia and is deluded and paranoid, takes a good 10 minutes in a handover. I would welcome the Minister’s comments on how we will look at ensuring that that is considered when measuring safe staffing.

[Lord Markham (Con)]

I thank the noble Baroness. The points she rightly makes are exactly what we believe is the remit of the new HSSIB review starting from October. One of the specific points is about developing safe therapeutic staffing models for all mental health in-patient services. I think and hope that the exact points raised by the noble Baroness will be addressed by the review.

[Lord Bradley (Lab)]

My Lords, the Government’s draft mental health Bill proposes—and I and the Joint Committee support this—the banning of prisons as a place of safety and the transfer of patients within 28 days of the mental health assessment to a safe mental health secure unit. Will the Minister ensure that this is included in the national review, so that there are sufficient local safe secure facilities to implement the 28-day recommendation and that these patients are cared for in genuine places of safety?

[Lord Markham (Con)]

I understand the concern brought, quite rightly, by the noble Lord. It would be best for me to write on that, so that I can give the specific position and he can have the detail he requires.

[Baroness Berridge (Con)]

My Lords, I am a member of the Joint Committee. We heard compelling evidence from the Independent Advisory Panel on Deaths in Custody that, although there is always an inquest into an unexplained death, there is the unique situation where if you die detained, in effect, by the state but in a secure mental health institution—as opposed to a prison, police cell or immigration detention centre—there is no independent investigative body to investigate the circumstances around your death. Given that this independent inquiry will look at a series of deaths over 20 years, will it be within its remit to look at whether or not, had there been some kind of independent investigation of those deaths, the themes and problems faced by the trust might have been spotted earlier?

[Lord Markham (Con)]

We see that as being very much in the remit of the Health Services Safety Investigations Body. In fact, the first thing we are asking it to do is to consider how we can learn from those unfortunate deaths, where they have taken place, in terms of their care. The intention is that it will report back. It will start in October and will report back on that within a year, so that we can get some rapid findings.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the Minister return to the contribution from the noble Baroness, Lady Watkins? I note that the HSSIB has been asked to look at and develop a safe staffing model for in-patient services, but I re-emphasise the point made by the noble Baroness: you cannot look at in-patient services only; you have to look at the whole spectrum. Surely, he accepts that. For instance, with young people, the huge waiting times for CAMHS services, which eventually lead to some of them being out-of-area placements, is shocking. Surely, HSSIB should be looking at the whole picture. Can he also say how this will relate to the workforce plan? In other words, will the conclusions of HSSIB’s report go forward into the workforce plan, so that for the future we are developing enough people in the mental health field?

[Lord Markham (Con)]

As I am sure the noble Lord is aware, the second thing that the HSSIB is being asked to look at is exactly the point about how people are cared for as in-patients and how we can improve that approach. On staffing—again, we will debate this more tomorrow night following the Statement repeat—it is vital that there is a feedback loop in terms of the long-term workforce plan. That feedback loop, as I am sure noble Lords are aware, is built into it, so that when new data comes along, as will potentially be the case with the HSSIB, there is a way for that to feed back in again.

[Lord Harris of Haringey (Lab)]

My Lords, I will follow on from the point made by the noble Baroness, Lady Berridge. Until 2015, I chaired the Independent Advisory Panel on Deaths in Custody, which covered the more high-profile areas of deaths in police and prison custody. However, the largest number of deaths under the care of the state was in mental health institutions. The noble Baroness, Lady Berridge, asked about independent investigations and the Minister said that the review will look at what lessons can be drawn. The point is, however, that over the last 20 to 30 years, there have not been independent investigations into the individual deaths, so how will there be an evidence base to decide whether proper lessons were drawn at the time and whether those were acted on?

Secondly, my noble friend Lord Hunt of Kings Heath talked about the difficulties with CAMHS. There is a gulf at age 18 between people being treated under CAMHS and then going into adult mental health services. What are the Government doing to bridge that gap? People who may have received some support from CAMHS then lose it when they go into the adult sector.

Finally—I know I should not ask three questions, but I want to—one of the striking things about the number of deaths that occurred in mental health institutions is that many arose from physical causes. It was not about people committing suicide or their mental health crisis; it was the fact that in a hospital, a place of medical provision, they were not getting adequate physical healthcare. What are the Government doing about that?

[Lord Markham (Con)]

I thank the noble Lord for his commitment in this area over the years. With regard to the first question about past evidence, clearly the HSSIB will be looking at what evidence exists. As the noble Lord said, some investigations go back 30 years, so there will not always be circumstances where it can pick out that evidence, unfortunately. However, where there is that information, we are trying to make sure that we pull it out and learn from it. That is very much the direction of travel. Clearly, if part of the HSSIB’s findings is that we need to make sure that every death in such circumstances is investigated under a certain pathway, then I am sure that will come into its recommendations. In terms of the other questions, I think it is best that I write to the noble Lord, if I may.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Statement includes a number of themes which it is expected the new Health Services Safety Investigations Body will consider. Not included in that list, however, is the growing role of private provision in NHS mental health care services. This is something that patient groups and others are expressing considerable concerns about. Take, for example, the Priory, where the Care Quality Commission reported that the number of deaths at its sites rose nearly 50% from 2017 to 2020. One of those was the tragic death of 23 year-old Matthew Caseby. An inquest jury concluded that his death was contributed to by neglect, and the coroner issued a prevention of future death report because of continuing risks.

The Priory Group earns more than £400 million from the NHS, and much more from social services. It is now owned by a Dutch private equity firm after it was sold by its former owner at a loss and is financed by a sale and leaseback deal of 35 properties with rents subjected to annual inflation-based escalators. Through the mechanisms in this Statement or others, are the Government going to consider the risks presented by private ownership—particularly private equity ownership—of mental health care services?

[Lord Markham (Con)]

As noble Lords are aware from some of my previous answers, I think the key thing is the quality of output rather than the ownership of an institution. Around the House, we have very good examples of where we believe the Government need the help of the independent sector to increase supply and capacity. That always needs to be done with the right quality of regulatory regime, and that is what we have put in place. From my point of view, I am always going to be looking at the quality of the output and not the ownership of a company.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, on the Minister’s last observation, I think there are a number of noble Lords here who would say that the quality of the output has not been that great from some private providers. It is just an observation.

However, the question I want to ask will take us back to the original observations by the noble Baroness, Lady Buscombe—I was also a member of the Joint Committee. The Minister gave a very brief reply to her questions about what has happened to the many recommendations, the vast amount of evidence and a great deal of hard work that went into producing that report. He even mentioned that it was going to be responded to in a “timely” manner. I think the moment for that has passed. Will the Minister have another go at explaining what has happened to the report and when there will be a response to it?

[Lord Markham (Con)]

I am afraid I do not have the timing of a response on that. Minister Caulfield is very engaged in this area. A number of things have been mentioned. I mentioned the community treatment orders, where we are very mindful of the point made earlier by the noble Baroness, Lady Uddin, about black males being eight times more likely to be given one, and the recommendation that they should be abolished altogether. Those recommendations are very much in our thinking and our knowledge base. I know that Maria Caulfield is working on them, but I am afraid I cannot give the noble Baroness an exact time yet.

Lung Cancer: Screening

Lord Markham Excerpts

Monday 26th June 2023 Lords Chamber

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

My Lords, with the leave of the House I shall now repeat a Statement made earlier in the other place by my right honourable friend Steve Barclay, the Secretary of State.

“With permission, I would like to make a Statement on our national lung cancer screening programme for England. Around a quarter of patients who develop lung cancer are non-smokers. We all remember our much-missed friend and colleague, the former Member for Old Bexley and Sidcup, James Brokenshire. He campaigned tirelessly to promote lung cancer screening and was the first MP to raise a debate on this in Parliament. His wife Cathy is continuing the brilliant work that he started in partnership with the Roy Castle Lung Cancer Foundation.

In 2018, after returning to work following his initial diagnosis and treatment, James told this House that the Government should commit to a national screening programme and use the pilot to support its implementation. As I am sure many colleagues in the Chamber will recall, he said:

‘If we want to see a step change in survival rates—to see people living through rather than dying from lung cancer—now is the time to be bold.’—[Official Report, Commons, 26/4/18; col. 1136.]


Despite being a non-smoker, James knew that the biggest cause of lung cancer was smoking and that the most deprived communities had the highest number of smokers. That is why I am delighted that today the Prime Minister and I have announced targeted lung cancer screening programmes at a national level, building on our pilot, which will be targeted at those who smoke or have smoked in the past.

Lung cancer takes almost 35,000 lives across the UK every year—more than any other cancer. Often, patients do not have any discernible symptoms of lung cancer until it is well advanced; in fact, 40% of cases present at A&E. Since its launch in 2019, and even with the pandemic making screening more difficult, our pilot programme has already given 2,000 lung cancer patients in deprived English areas an earlier diagnosis. That matters because when cancer is caught at an early stage, NHS England states that patients are nearly 20 times more likely to get at least five years more of life to spend with their families.

We all know that smoking is the leading cause of lung cancer. It is responsible for almost three quarters of cases, and in deprived areas people are four times more likely to have smoked. We have deployed mobile lung trucks equipped with scanners to busy car parks in 43 deprived areas across England. Before the pandemic, patients from those areas had poor early diagnosis rates, with only a third of cases caught at stage one or two. To put that in context, while a majority of patients diagnosed at stage one and two get to spend at least five more years with their children and grandchildren, less than one in 20 of those diagnosed at stage four are as fortunate. Thanks to our targeted programme, three quarters of lung cancer cases in those communities are now caught at stage one and two.

Targeted lung cancer checks work. They provide a lifeline for thousands of families. We need to build on that progress, which is why we will expand the programme so that anyone in England between the ages of 55 and 74 who is at high risk of developing lung cancer will be eligible for free screening, following the UK National Screening Committee’s recommendation that it will save lives. It will be the UK’s first and Europe’s second national lung cancer screening programme. If results match our existing screening—there is no reason to think that they will not—when fully implemented the programme will catch 8,000 to 9,000 people’s lung cancer at an earlier stage each year. That means that each and every year around 16 people in every English constituency will be alive five years after their diagnosis who would not have been without the steps we are taking today. That means more Christmases or religious festivals with the whole family sitting around the table.

Alongside screening to detect conditions earlier, we are investing in technology to speed up diagnosis. We are investing £123 million in AI tools such as Veye Chest, which allows radiologists to review lung X-rays 40% faster. That means that suspicious X-rays are followed up sooner and patients begin treatment more quickly.

How will our lung cancer screening programme work? It will use GP records to identify current or ex-smokers between the ages of 55 and 74 who are at a high risk of developing lung cancer, assessed through telephone interviews. Anyone deemed high risk will be referred for a scan and will be invited for further scans every two years until they are 75.

Even if they are not deemed at high risk of lung cancer, every smoker who is assessed will be directed towards support for quitting because, despite smoking in England being at its lowest rate on record, tobacco remains the single largest cause of preventable death. By 2030, we want fewer than 5% of the population to smoke. That is why in April we announced a robust set of measures to help people ditch smoking for good, with one million smokers being encouraged to swap cigarettes for vapes in a world-first national scheme. All pregnant women will be offered financial incentives to stop smoking, and HMRC is cracking down on criminals who profit from selling counterfeit cigarettes on the black market.

The lung cancer screening programme has been a game changer for many patients: delivering earlier diagnoses, tackling health inequalities and saving lives. We are taking a similar approach to tackle obesity, the second biggest cause of cancer across the UK. The pilot we announced earlier this month will ensure that patients in England are at the front of the queue for innovative treatments by delivering them away from hospital in community settings. Together, this shows our direction of travel on prevention, which is focused on early detection of conditions through screening and better use of technology to speed up diagnosis and then treatment, because identifying and treating conditions early is best for patient outcomes and for ensuring a more sustainable NHS for the next 75 years. I commend this Statement to the House.”

--- Later in debate ---

[Lord Allan of Hallam (LD)]

My Lords, I would like to follow the noble Baroness, Lady Merron, in welcoming the Government’s acceptance of the National Screening Committee’s recommendation to introduce a targeted lung cancer screening programme, and echo her tribute to the late James Brokenshire, whom I dealt with in a previous capacity when he was a Minister advocating for child safety online. I found him to be very effective; a firm Minister who was also very pleasant to deal with—the most effective model for all of us.

The new programme is especially welcome as a step towards addressing the glaring health inequalities we face in the United Kingdom. I hope the Minister will reassure us that sufficient data will be collected in order to understand whether it is having the kind of impact the Government intend, as he outlined in the Statement.

I hope the Minister can also provide more information about how it can be delivered, given that we already have dire shortages in capacity to deliver diagnostic tests. This shortfall is reflected in today’s report from the King’s Fund, which shows a serious gap in CT and MRI scanner capacity between the UK and comparable countries. When can we expect to see investment from the Government in additional scanners, to bring us up to something more like the international mean? As well as the lack of machines, we do not have sufficient people to operate them or to assess the test results. I invite the Minister to refresh his formula for when we may see the long-awaited NHS workforce plan, including the element that relates to radiologists, perhaps updating it from “shortly” to “in the next week”, as it surely has to come before the 75th<sup>anniversary of the NHS on 5 July.

The concern we continually have with announcements of new services by the NHS in the current context is that they will come at the expense of existing services; the noble Baroness, Lady Merron, also referred to this. I believe this is a rational and reasonable concern to have, given the evidence of missed targets and unacceptable wait times that is all around us. I hope the Minister can give us further assurances that, as the Government will the end of catching more cancers earlier, they will also be willing to will the means to deliver on this promise.

Anyone with eyes in their head can see that vaping is being cynically promoted to young teenagers; it is all around us in high street shops and in the evidence from the litter around schools. The Statement refers to the role of vaping as a tool to help existing smokers give up their harmful habit, but there is increasing evidence that vaping is creating new nicotine addicts, with associated risks. The Australian Government have found that young people who vape are three times as likely to take up smoking, and they have plans to bring in a range of measures to suppress vaping among young non-smokers. Can the Minister explain what assessment the UK Government have made of the Australian evidence of vaping leading to higher smoking prevalence among young people, and are the UK Government considering similar measures to reduce vaping use here? It took us five years to follow Australia in introducing plain packaging for cigarettes. I hope we can follow faster here, on vaping.

The new screening programme is welcome, but it must be properly resourced with both machines and people. I hope the Minister can give us some insights into how that will happen, and at the same time explain what action the Government intend to take to reduce vaping among non-smokers, so that we do not end up creating a new wave of people who are at risk of lung cancer.</sup>

[Lord Markham (Con)]

I will start with a small correction to the Statement. It should have said:

“We are investing £123 million in AI tools such as Veye Chest, which allows radiologists to review lung”


scans, not X-rays. I do not whether the etiquette is that I should have said that during the Statement. I repeated the Statement verbatim because I was told I should, but the correct word is “scans”.

I thank both the noble Baroness and the noble Lord for their comments and support. I too had the pleasure of working with James Brokenshire, and I realise what an effective and kind person he was. Like others, I am delighted that we are making these positive steps today and welcome the constructive and supportive comments.

Regarding trying to show that we are matching the will with the means on MRI scanners, that is exactly what the 100-plus CDCs are all about. It is a recognition that we do not have the same diagnostic capability, as highlighted by the King’s Fund report. That is what the investment in those centres is all about. My understanding is that about four million tests have already been done, so we are looking to match that. We will need 184 radiographers and 75 radiologists to do this work, but the other big support will be the use of AI. We are seeing some promising technology, which will help to a large degree. I am glad to say that a lot of this will be set out in the long-term workforce plan in the coming days—a new formulation. In other words, pretty soon.

In terms of the comments about screening being targeted at those most in need, that is where I have been most pleased by the pilots. Use of the mobile trucks really made a difference in those areas most in need. It really made a difference in the most deprived areas, which, as the noble Baroness, Lady Merron, mentioned, have higher levels of smoking. I am glad that it is targeting those areas.

Can we work to hasten the timetable? I think we would all like to but what we are trying to do here is to put down plans that we are confident we can hit. To answer the money question, it is £1 billion of extra investment during that time and that increases over time so that by the end it is about £270 million extra per annum.

What does that mean in terms of the Dr Khan responses? As I mentioned, we are committed to the smoking cessation results. As part of that we are considering all the points in the Khan review. I think we all accept that vaping is much better than smoking. We are very much trying to encourage vaping over smoking. But you have to be careful of the side-effects of that. As we have seen, vaping can be used in a somewhat cynical way—to borrow the phrase—with young people. More work undoubtedly needs to be done in that space but it is recognised that there needs to be a balance. I think I will need to come back in writing on air quality and cystic fibrosis.

I have tried to cover the points at this stage and look forward to further questions.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I have two questions. My first question is about the timeframe and the role of GPs. The Statement says that, using GP records, current and ex-smokers aged 55 to 74 will be assessed by telephone interviews. Will that require resources from GPs? We all know that there are many different computer systems so where are the resources going to come from? Specifically on GPs, I can well imagine at many GP surgeries tomorrow morning at that terrible time of 8.30 am as everyone frantically tries to hit the dial button that a lot of people will be asking for a scan. Have GPs been equipped to handle that? Do they know what to say and how to manage that kind of scenario?

My other question follows on from the questions about the Khan review. That said that we are grossly underfunding things. Mass media campaigns in particular are funded at 90% under what is needed, while other services are about 50% underfunded. Surely we have to stop these cases happening. Can we see a commitment from the Government within some sort of timeframe to say that we are going to put more money into this?

[Lord Markham (Con)]

I thank the noble Baroness. In terms of identifying the smokers, the telephone is just one way of doing it. The hope is that using the digital data and the app means that more of these things will be on people’s records and identified with them. As ever with these things, electronic means will be the best way to do that, albeit those telephone resources in terms of supporting the GPs are very much part of the plan. It is understood that GPs have a large burden at the moment.

There is not a lot more to add about the Khan review. The ambition is still there to be smoke-free by 2035 and investment has gone behind that. The best example of that, as has been mentioned, is people swapping cigarettes for vapes as one means to do it. Undoubtedly, a lot more needs to be done in that direction as well.

[Lord Kennedy of Southwark (Lab Co-op)]

My Lords, I join noble Lords in paying tribute to James Brokenshire. I met him a few times, and it was a tragedy when he lost his life after a brave fight. I also pay tribute to the work his wife continues to do in his name.

This progress is to be welcomed, but can I say—if nobody else is going to come in—that cancer takes many forms? One area of cancer where we need to make much more progress is that of brain tumours and glioblastomas. We all remember our dear friend Tessa Jowell, who died on 12 May 2018 of a brain tumour. My brother John was a cab driver. Many people would not know my brother; he was just a cheeky, funny London cab driver who had a view on everything and who was loved by his family. He died on 26 March this year at 57, having fought a brain tumour for nearly three years. Our dear friend Baroness McDonagh was mentioned in the other place today. She died on 24 June at 61. She was my friend for 42 years; I met her when I was 18.

It is devastating. There has been no progress in this area of cancer treatment. There are quite clear inequalities, partly because only about 3,500 people a year get glioblastomas, so there are not huge numbers. There is no research, no trials and no hope—it is a death sentence. That cannot continue. We are no further than we were 30 years ago in this area. What happened today is brilliant, and I think there is now an 85% survival rate for breast cancer and that the rate for bowel cancer is 55%. However, brain tumours are virtually a death sentence. We have to improve that. It is an outrage that people can die so young from them and that there is no hope.

I do not expect an answer from the Minister today; I just want to put down a marker that I and other colleagues here and in the other place will keep mentioning this. I refer all colleagues here to the wonderful speech made by my honourable friend Siobhain McDonagh MP—my friend Margaret’s sister—when she talked about her sister and the treatment she had to undergo. I saw Margaret about three or four days before she died; it is a real tragedy, as is my brother’s case. I hope we can all work together and with the cancer charities, and that we can get some research done, put some money in and improve the situation. It cannot carry on.

[Lord Markham (Con)]

I thank the noble Lord, Lord Kennedy, and I am sorry for the loss of his brother. I agree with his sentiment that while this is good news today and is welcomed by all, it shows that this is a journey and that we need to do more in lots more areas. I take on that point and say, from our point of view, that we agree that we must work together to make further progress.

[Baroness Merron (Lab)]

Could I give the Minister another opportunity to pick up on the key point I raised? We very much welcome the improved diagnosis rates—and my noble friend Lord Kennedy makes a very pertinent point that, of course, we are talking not just about one cancer. I thank him for sharing his views and feelings with your Lordships’ House. That takes me to my reminder to the Minister: I asked about matching improvements in diagnosis with improved access to treatment; otherwise, we are leaving people diagnosed but not matching it by giving them the treatment they need in a timely manner. Could the Minister assist with that point?

[Lord Markham (Con)]

I am sorry; I was answering in a generic format in terms of the new CDCs. The noble Baroness is quite right that diagnosis is one thing—and we all know that the early stages are key—but you then have to follow that up with treatment. Of course, the good news is that if you can detect cancer in people at the earlier stages, they need less treatment. The resources I mentioned, in terms of what is being spent on the programme, take into account the treatment required as well.

Of the people being identified at this stage, only 1.4% from the pilot were then positive and needed treatment, thankfully. Obviously, those resources are in place. There is a second interesting category of people—about 17% or so—who are fine but we want to make sure that what has been noticed is in an okay state.

I am going to grab my notes to make sure I am referring exactly to the right term at this stage. I apologise; about 1.7% have nodules, which is not a problem per se, but it is a problem if those are growing. The idea is that we will be getting those people back in for frequent scans on a three- to six-monthly basis and using AI technology to see whether or not the nodules are growing. If they are not growing, it is not a problem, but we then keep up the frequency of scans. Obviously, if they are growing, that would be a concern at the early stages, and that would then move them into the treatment category.

The other 80% or so of people fortunately will not have any concerns from the scan at all. At that stage, they will be put into this continual programme, where they will be reviewed every couple of years to make sure that we keep on top of it. I hope that this shows that this is a well thought-out, entwined service, with the idea being that for the 1.4% who are identified as needing cancer treatment, the treatment is there to back them up.

NHS Procurement: Palantir Contract

Lord Markham Excerpts

Thursday 22nd June 2023 Lords Chamber

[Baroness Brinton]

To ask His Majesty’s Government, in light of the contract awarded to Palantir, what plans it has to ensure that NHS contracts are procured through a public and transparent tender system as outlined in the Procurement Bill.

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

All NHS contracts are procured using correct procedures. This is a new transition contract with Palantir, with new and improved contract terms, including robust exit and transition schedules to support transition from Palantir to the new federated data platform supplier. This contract includes additional terms, such as termination for convenience and a six-month break clause. The contract was procured by a compliant and transparent direct award tender process, using a Crown Commercial Service framework agreement.

[Baroness Brinton (LD)]

My Lords, it is not the first closed contract used that way, particularly for Palantir, since 2020. Ministers deliberately excluded the NHS from the new rules in the Procurement Bill, giving the Secretary of State for Health the powers to create regulations, resulting in untransparent closed contracts such as the £24 million Palantir contract just granted. Unlike every other public body and government department, senior NHS leaders are excluded from any restrictions when they move to providers, as happened last year when two senior staff moved to Palantir. These NHS practices are the exact opposite of what the Government hope to achieve in the Procurement Bill. Will Ministers please reconsider bringing the NHS under the Procurement Bill?

[Lord Markham (Con)]

This was a very sensible move to ensure that the tender process we are going through at the moment allows us to transition to whoever wins the federated data platform. That is a sensible way to do it. It was done according to the Crown Office pre-tendering framework agreement, which is very transparent and well set out. It is normal in these situations that, when you need transition arrangements, you do not want hospitals left in the lurch. You need a transition so that, whoever wins the new bid, hospitals are safe in the meantime.

[Lord Berkeley (Lab)]

My Lords, it is quite easy to invent rules to get away from competitive tender and do direct awards. It goes back to the Horizon Post Office scandal, which is still there 30 years on. Why is this contract exempt from competitive tendering? What is the benefit? Given that the Procurement Bill requires it, why are the Government not doing it?

[Lord Markham (Con)]

As I said, there is a very clear benefit. We are going through the process of a very large £500 million contract for a data platform that will be key to the NHS. Everyone agrees on the importance of data in health work, but we want to make sure that we have an open process so that suppliers have a chance to win the contract. In any circumstance, you need to make sure that transition arrangements are in place; otherwise, the current supplier is the one most likely to win—if there is a concern about ongoing procedures. By having a transition arrangement in place—clearly, transition can work only with the current supplier—you are making sure that there is an open process for new bidders to come in.

[Lord Fox (LD)]

My Lords, the reason the Minster is able to call this contract “sensible” is that it follows on from a contract given to Palantir that was already granted without tender. This is compounding one after another. To return to my noble friend’s original point, can the Minister tell your Lordships’ House why all other public services will be subject to a Procurement Bill that hopes to deliver transparency, fairness and ethical purchasing, yet his department is exempting itself from the Bill?

[Lord Markham (Con)]

This went through the long-term plan in 2019, and the idea behind it all—it was debated a lot as the Health and Care Act went through—was to provide an approach which allows the flexibility in place here. What we are doing here is very good: I do not think anyone would want to see hospitals left in the lurch and the impact that would have on waiting lists. This makes sure that we have a robust situation in place so that we have an open tender, which we are going through the process of right now to get the best solution for the NHS—something which I think we all want.

[Lord Lansley (Con)]

My Lords, my noble friend will recall that the review led by the noble Lord, Lord Carter of Coles, and followed up by Professor Briggs with the Getting it Right First Time programme, has made significant improvements in how the NHS procures its services. During the debates on the Procurement Bill—I hope my noble friend will say that this will indeed be taken up in the NHS—we talked about the promotion of innovation through public procurement. I wonder whether the Getting it Right First Time programme could be a mechanism for that, by bringing evidence-based innovation to the attention of procurement managers across the NHS.

[Lord Markham (Con)]

I thank my noble friend. This is absolutely about enabling innovation: the data platform is there so that providers can use it to innovate. We all hear about AI, and AI depends on data. This puts in place a data platform that AI can use. It can also be used for scheduling appointments—currently done in 32 hospitals—and for the dynamic discharge of waiting lists. All those applications can work in place only if we have an open tender process, which is exactly what we are doing here, while making sure that transitions are in place so that no hospital is left in the lurch in the meantime.

[Lord Alton of Liverpool (CB)]

My Lords, one of the issues raised during the passage of the Procurement Bill and, certainly, in the context of transparency, efficiency and getting value for money, was the keeping of some 118 million items of PPE in storage in the People’s Republic of China, at a cost of millions of pounds to British taxpayers. I have also raised this directly with the Minister. Can he give us an update as to what has happened to those items? Will they stay in storage? Are we continuing to pay and, if so, at what cost, or are we going to dispose of them? What lessons have we learned from that?

[Lord Markham (Con)]

As I said in a previous Answer, we are in the process of disposing of those contracts. On many occasions, it is easy to look with hindsight. Noble Lords may remember that, at the time, there was a massive rush and countries were gazumping each other to get hold of PPE. It was very much the feeling of this House, and all the people in the UK, that we had to desperately contract suppliers to do it. Did we make mistakes? Yes. Were we right on more than 90% of occasions? Absolutely. To keep the front line going, we needed to order more than 9 billion essential items, and we did so using the very system that we are talking about here in respect of Palantir. There are circumstances—Covid is a prime example—where it is appropriate to do those sorts of direct awards. That notwithstanding, I think we all fundamentally agree that an open, transparent and competitive tendering process will always be preferable.

[Baroness Hayman of Ullock (Lab)]

My Lords, the £25 million contract awarded this week is a drop in the ocean compared with the £480 million that is on its way. The scope of the federated data platform is vague, but there is no doubt that the data it stores will be both vast and sensitive, so it is vital that any procurement process is fair and transparent and enables the public to engage with it so that the system works as intended. However, 48% of adults, when asked, said that they were likely to opt out if it was introduced and run by a private company. This would have a catastrophic impact on the quality of NHS data, which is an extremely valuable resource. Do the Government recognise this as a risk? How will they ensure that we have public faith in the process?

[Lord Markham (Con)]

The noble Baroness is correct: public confidence is vital, particularly in the case of data, where we are concerned about privacy. We are arranging a briefing of noble Lords so that everyone can have the opportunity to understand what we are talking about here, which is almost like the plumbing of the system. The NHS maintains primacy of use—it is the only organisation allowed to use it—and privacy will be maintained at all times. It is much better to think of whoever wins this contract—we do not know who they are—as just the technology provider, like Microsoft, for instance. We use private sector companies for technology all the time. The key thing is that the provider is protected. That is the NHS, and no one else can get access.

[Lord Clement-Jones (LD)]

My Lords, the Minister talked about the plumbing, but is it not the case that, with this further contract, which has had no tendering, Palantir’s Foundry system is further embedded in the federated data platform of the NHS, and what we are effectively seeing is what the Doctors’ Association UK calls a “monopoly lock-in” that is therefore a shoe-in for the award of the next contract?

--- Later in debate ---

[Lord Markham (Con)]

Actually, it is the opposite. It absolutely lets bidders know that, when we are assessing who the best bidder is, we are looking only at who is the best provider. We do not need to have any concerns at all about continuity or risks because we are giving them plenty of time to get their new contract and systems in place. We do not need to worry about any services being lost in the meantime.

[Baroness Boycott (CB)]

My Lords, Palantir is a data analytical company. It wants our data. In cases where it has been in business with other people, it has used that data and sold it under the surveillance capital model. Is the Minister absolutely confident that we are safe in entrusting all of the NHS’s data to an American company? It seems to me that that is not in the best interests of a not-for-profit organisation such as the NHS.

[Lord Markham (Con)]

Yes. I really appreciate having this opportunity to state categorically that the NHS will remain the data user here. The data controller will remain in place for each individual institution; sometimes it is the GP and sometimes it is the hospital. Fundamentally, everyone’s data will be allowed to be used only by the NHS in these circumstances. There are no circumstances in which Palantir—or any other supplier should it win—will have access to see individuals’ data.

[Lord Davies of Brixton (Lab)]

My Lords, health service data is incredibly valuable. The Minister should, and probably does, understand the sensitivity of Palantir in this context. The Minister said that the quality of the contract was the only criterion. Where does price come into it? How can we build in protections against predatory pricing by the sitting tenants of contracts, who create an effective monopoly?

[Lord Markham (Con)]

I think I said that we wanted the best supplier to win; I will check and correct the record if I mentioned quality only. Quality is very important because the contract has to be good, of course, but the price has to be right as well. There are a number of criteria. Again, we will hold a session so will be able to take noble Lords through the whole process. I am confident that, at the end of that process, people will feel confident that we have reached a decision on the best supplier across all the criteria.

[Lord Wallace of Saltaire (LD)]

My Lords, press coverage of this contract has indicated that an alternative British consortium was prepared for this contract. Can the Government confirm whether they examined alternative bidders, in particular British ones, given that the issue of trust in the use of data is an important one? As the noble Baroness remarked, trust in Palantir as a supplier is absent from substantial chunks of the NHS.

[Lord Markham (Con)]

Again, it is important to say that the whole point of this transition arrangement was to allow us to have an open bidding process across loads of suppliers, knowing that, when they were able to put their solution in place, their transition arrangements were in place. That opened up the field to British suppliers and suppliers from around the world. We have had an open process, which has been going on for a number of months now and continues. We expect a contract award around autumn time and I can assure the noble Lord that we have looked at a whole range of suppliers to make sure that we get the best outcome.

[Lord Allan of Hallam (LD)]

My Lords, can the Minister confirm something that he said in a previous answer: namely, that whoever wins the federated data platform contract will not have the right to use any NHS data outside the terms of that contract? Secondly, assuming that the current provider, Palantir, does not get the contract, will the NHS put in place by the end of this transition period procedures to ensure that all the data and access that Palantir had is removed safely so that there is no ongoing situation?

[Lord Markham (Con)]

I thank the noble Lord for giving me an opportunity to clarify that absolutely. The answer is yes on both counts. If Palantir is not successful in winning the contract, no data will remain on its systems; it will be transferred over completely and, as the noble Lord says, whoever ends up winning the contract will be allowed to use that data only in an NHS context—that is, in no other context at all.

[Lord Fox (LD)]

My Lords, can the Minister clarify when he expects the large contract of nearly £500 million to be awarded?

[Lord Markham (Con)]

Round about autumn time. Currently, we think that the contract will be awarded in September and then finalised. The new database should in place by April. Having this transition arrangement until June gives us a safety net to make sure that everything is in place.

[Lord Davies of Brixton (Lab)]

My Lords, I welcome the opportunity of a meeting to discuss data security. Can the Minister say whether it is anticipated that that security will go beyond what is currently being established in legislation going through Parliament? If it will be stronger, why are the other protections not stronger?

[Lord Markham (Con)]

I am sorry; I am not sure that I completely followed the question. It is fundamental here that everyone’s data is strongly protected in the best possible terms. As I say, we will arrange in the next few weeks a meeting where we can answer all the questions that noble Lords have and have the experts in the room as well.

Dementia Palliative Care Teams

Lord Markham Excerpts

Thursday 15th June 2023 Lords Chamber

[Lord Crisp (CB)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare a personal interest, as I have a relative who is cared for by the Derbyshire palliative care team which is as described in the Question.

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

The Derbyshire model is recognised as an example of best practice. The Derbyshire palliative care service toolkit has been widely shared by NHS England, which encourages regions to adopt good practice. Resources from the toolkit have also been published on the FutureNHS platform. It is a superb example of how better integration of the excellent services already available, not always requiring more funding, can have a positive impact on communities.

[Lord Crisp (CB)]

My Lords, I am grateful to the Minister for that very positive reply, with which I absolutely concur from my own experience. It is good to have the chance to say something positive about people working in the NHS at a time when it is under such great pressure.

As all noble Lords know, dementia is a dreadful and deeply distressing disease, or set of diseases. One in three of us will experience it and almost all of us will be affected, as family or as carers. It is a very complicated process that people have to go through. One of the issues I want to ask the Minister about is co-ordination of care and the help that is available to people. People looking after people with dementia need help with medication, with incontinence, with devices and aids, with falls, with hospital clinics and with a whole range of different issues, coming from primary care, social services and hospital care. The dementia palliative care team in Derbyshire provide the co-ordination. What needs to happen in cases where there is no such team? How can that care be co-ordinated or does it all land on the principal carers and the spouses and partners of the people concerned?

My second question is—

[Lord Crisp (CB)]

Sorry. I note the Minister’s point about the excellence of this particular team and the intention to spread the idea. How far do the Government think it will spread and be adopted in other parts of the country over the coming two or three years?

[Lord Markham (Con)]

I thank the noble Lord. I have an auntie with dementia in care in Derbyshire. The noble Lord is correct that it is a perfect example of a wraparound service that takes in all the facilities that people need. The intention is that we want to spread that everywhere. It is the responsibility of each ICB to set the right commissions in their local area, but we are spreading knowledge of the dementia model as far as we can. A big example is that we promoted it at the recent national clinical excellence celebration day in the Midlands.

[Baroness Pitkeathley (Lab)]

My Lords, I am not sure the Minister actually answered the question about where co-ordination happens, which is the essential part of this. He will know that much care and palliative care for dementia patients and their families is provided in the voluntary sector and by charities. What support can we give to charities, which often are acting in a co-ordinating role? Can the Minister update us on newspaper reports that his department intends to recruit an army of volunteers to help solve the social care crisis?

[Lord Markham (Con)]

The voluntary sector is a key element of this. On behalf of the department, I thank it for all the work it does. The direction of travel is very much to engage the sector and enlist its support as much as possible. The ICBs do the commissioning, and Derbyshire is a fantastic example of commissioning all the different strands, including the voluntary sector, hospices and palliative care to deal with clinical need. It is an excellent example of how to do it well and one that we need to spread everywhere.

[Lord Scriven (LD)]

My Lords, this service is patchwork, yet the demand is across the country. What can NHS England do to ensure that the unmet need for palliative and end-of-life care for people with dementia is met?

[Lord Markham (Con)]

First, we were very upfront about it; part of the Health and Care Act 2022 is that the ICBs commission palliative care. Secondly, it is part of the six major conditions strategy. It is a major cause of death; about 11.4% of all deaths are caused by dementia. It is fundamentally the responsibility of the ICBs but we at the centre are making sure that the ICBs are commissioning in the way they need to.

[Baroness Manzoor (Con)]

My Lords, I very much welcome the work that is being done in Derbyshire and, quite rightly, we want to see it commissioned elsewhere across the country. My question follows on from that of the noble Lord regarding the NHS board. What is it doing to evaluate where these kinds of proposals are being developed elsewhere? Unless it does this, and can demonstrate that it is doing this and providing guidance, we will not get the excellent service that residents in Derbyshire are receiving in more deprived areas, such as places in West Yorkshire and so forth.

[Lord Markham (Con)]

We have developed the dementia palliative care toolkit, which we are spreading around all the ICBs. Health Education England has developed an end-of-life care training programme, which is being taken up. Derbyshire has been a key part of the efforts as well, with its own programmes. It is very much our responsibility to make sure that the ICBs, which by law have to provide these services, are providing them to a high standard.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest in palliative care and as vice-president of Marie Curie. When are the Government going to produce a strategy for these ICBs to commission against, and against which the provision of palliative care can be measured across the country? The evidence at present is that it is extremely variable. While toolkits have been rolled out in some areas, that has not happened everywhere, and some ICBs seem to have remarkably little commissioning on the table working with the voluntary sector, in particular, and local authorities. I was appalled to see the draft major conditions strategy, in which palliative care for people with dementia is only one short phrase rather than a distinct paragraph.

[Lord Markham (Con)]

Dementia is an important part of the major conditions strategy and obviously there will be more coming out of that going forward. As I said, the Health and Care Act made the ICBs firmly responsible. Some are excellent examples, such as Derbyshire; for the others that are not, it is very much our responsibility in the centre, and I include Ministers in that. I have mentioned before that each of us has six ICBs that we look after, and part of our job is making sure that they are commissioning to the standards they need to.

[Baroness Wheeler (Lab)]

My Lords, the ONS figures showing that dementia and Alzheimer’s were the leading cause of death last year make it even more urgent to get dementia palliative care right. Given average life expectancy in care homes, what steps are the Government taking to ensure the Care Quality Commission has sufficient oversight of end-of-life care for people living with dementia?

[Lord Markham (Con)]

It is absolutely one of the things that it has to do. We are at the forefront of this. We are backing the Dame Barbara Windsor Dementia Mission, and have doubled the funding to £160 million to make sure we are doing more research in this space. There is a lot more to do but there are a lot of good examples of work as well.

[The Lord Bishop of Durham]

My Lords, to go back to the voluntary sector, many churches are working on becoming dementia-friendly churches as part of dementia-friendly communities. How might this spread out in developing dementia-friendly communities as a whole as part of this support?

[Lord Markham (Con)]

As I have tried to say, it is a full community response, which I know the Church is very much part of, and I am grateful for the work it does within that. That is why I keep going back to the Derbyshire model. It is an excellent example which has managed to pull all these strands together. Our job is to make sure that that good practice is disseminated everywhere.

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw noble Lords’ attention to the recent research report from King’s College London about better palliative care and end-of-life care for those affected by dementia. It shows clearly the cost-effectiveness that can be achieved and the reduction in the use of in-patient hospital beds. I declare that I am on the NHS Executive and am pushing for this. What can the Government do to ensure that ICBs actually take this forward?

[Lord Markham (Con)]

As I said, we think that the ICBs are the right place to manage this at a local level, but it is our responsibility from the centre to make sure they are delivering on that. I personally have seen good examples: my father was cared for at home, with palliative end-of-life care, and I know how happy he was to be able to do that, so I totally agree.

NHS: Performance and Innovation

Lord Markham Excerpts

Thursday 15th June 2023 Lords Chamber

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

I thank the noble Lord, Lord Scriven, and all noble Lords for what I found to be a very thoughtful debate. I hope to answer in the spirit engendered by all noble Lords but particularly the noble Lord, Lord Scriven. I will not be defensive, so I will not try to answer point by point but will try to lean in.

I will try to summarise the approaches, and I think there are a number. The first, as pointed out by the noble Lord, Lord Addington, is getting upstream of the problem. It is about prevention and how we can use primary care, be it through the example of Salford, mentioned by the noble Lord, Lord Turnberg, or Westminster, mentioned by the noble Lord, Lord Crisp, or Redhill, where, as I saw the other day, they are trying to identify those who need the most help and care in order to get ahead of the problem. Real prevention is better than cure.

Secondly, there is innovation. Yes, it is about technology, but it is also about people and culture and what we can learn. By the way, I think that is the hardest one. Thirdly, there is approaching this issue from the perspective of outcomes. When looked at from that end of the telescope, you often come up with a different approach; in that respect, I love the drone example. Fourthly, again as the noble Lord, Lord Addington, said, there is taking a holistic, society-wide approach to health. The saying that strikes me most in that regard is that health is one of the things we all take for granted, until we lose it. This leads on to my fifth point: what can we do to help people take control of their own health? It is so important to our whole welfare. What can we do to enable people to take control?

In my speech, I hope to talk through some of the thoughts, ideas and approaches that we are trying to adopt as a Government. I hope to offer some of those glimmers of light that the noble Lord, Lord Allan, mentioned. I will not pretend that it is a panacea that will solve everything, and I accept the challenges that the noble Baroness, Lady Merron, brought up. She will probably be pleased to know that I will not try to give a point-by-point defensive rebuttal, because she probably hears enough of that from me in Questions every day.

In the spirit of what we are trying to do, first, I completely agree with a number of speakers, particularly the noble Lord, Lord Allan, about contextualising the issue. We are already spending 12% of our GDP on healthcare. With an ageing population, where a 70 year-old patient will need five times the amount of treatment of a 20 year-old, and the fact that that population has grown by 33% in the last five years as a proportion, and with the problems of obesity and comorbidities, we know that that 12% will just go up and up unless we can really get ahead of the issue. As the noble Lord, Lord Allan, mentioned, we have to run fast to stand still. I fundamentally believe that, if we cannot transform and innovate, we are really going to struggle to see the NHS model being sustainable right the way through the 21st century; it really is that fundamental.

The good news is that we do have some early glimmers of light, so to speak. We have done a really good digital maturity assessment to see the state of different hospitals: to aid the rolling-out, we need to know what our start point is. We see that the most mature digital hospitals actually have 10% more output and are more cost efficient, and that is just things today; I will come on to talk about the new hospital programme later and how that can improve things further.

As for what we are trying to do as a Government, I want to talk through six things that we are trying to do to set down platforms to enable. The first thing is to support small companies to develop and deploy the new medical technology. I have seen many examples of the AI that the noble Baroness, Lady Merron, mentioned, and she is absolutely right. We know the scale of what it can do: we see a whole category of cancer-reading MRI AI-type devices that we are putting through their paces at the moment, for want of a better word. I will come later to how we will try to scale those up.

We are doing a number of things to support these small medtech companies. As I say, we have put £123 million through the AI Lab on 86 projects. Through the small business research initiative for healthcare, we have funded 324 projects for £129 million, and there is some early promise there. We are trying to back them early on, as I will come on to, but the problem is often not the original innovation or idea but its widespread adoption. I am sure we have all heard the joke that the health service has more pilots than British Airways, but how do we seek to roll things out?

First, we are backing small companies. Secondly, dare I say it, I am going to mention the app, in that we have a £32 million platform, as the noble Baroness, Lady Merron, mentioned, that offers an opportunity for companies and different solutions to reach the population. I announced just this week what we are doing in the space of digital therapeutics, with mental health apps and musculoskeletal apps that will be available to everyone, but what is also vital in this space, I firmly believe, going back to one of my early themes, is that the app allows people—excuse the saying—to take back control of their health. For me, that is a fundamental thing that we need to enable people to do. It is not just about booking appointments; it is absolutely about getting patient records.

To be honest, we need help there, because we do have opposition from some of the medical profession to giving access to patient records on the app. We have 25% of our GPs who are currently doing it, so you see certain areas where they are definitely benefiting from it all, but we see others where we still need to win them over. Let me put it politely that way. I firmly believe that what we are doing with the app—and we will see a series of new features being launched over the coming months—will give more and more functionality and power into the fingertips of the individual to really take control of their health in a way that people do with some of the financial apps. That is a fantastic opportunity that should really make a difference.

Thirdly, as the noble Lord, Lord Scriven, mentioned, I want to talk about the new hospital platform that we are building. It is not just about buildings; it is actually about the whole processes and technology. We are planning a parliamentary day on 18 July, where we will be inviting everyone to see the plans for what we are trying to adopt for the whole systems and processes. We call that Hospital 2.0. I know that the noble Lord, Lord Allan, thinks we could have been more creative with that title, so we are open to new ideas. As I mentioned before, the digitally mature hospitals are 10% more efficient. We believe that these hospitals will be at least 20% more efficient. That is not just 20% more productive, but probably most important is the reduction in length of stay that they can make as well. One of the statistics that struck me the most is the fact that older people lose 10% of their body mass each week that they are in hospital. In respect of some of the comments made about the importance of social care by the noble Lord, Lord Turnberg, of course the best solution is having people in hospital for as little time as possible so they can go straight back to their home environment. Around that, some of the innovations on the same-day emergency care, where as many as 85% of people treated that way, show a very good example of that.

With the new hospital plan, where we are looking for productivity gains of 20%-plus, my sincere hope from all of that is that, rather than us asking the Treasury for more money to build these hospitals, it will see those sorts of productivity gains and will be encouraging us—“How quickly can you build them? How many more can we have?”—because they really will have that transformational approach.

Fourthly, again, as mentioned by a number of noble Lords, including the noble Lord, Lord Allan, the 50 million patients we have are providing a data platform. Regarding a secure data environment, the plan is that the data will always be held securely in its place, but people doing clinical research will have access to that environment, so they will not be able to take it away but they will be able to do it in that environment where they can conduct the clinical research and start to see the results. Again, I see our job very much in terms of innovation, with us providing that secure data platform for others to be able to do their research on.

The fifth area—and I think this is particularly relevant to the AI field—is the regulatory environment and support. Again, we all know that AI has fantastic opportunities for innovation, but we also know that, without it being done in a safe and ethical manner, there are challenges there as well. We also know that it is a complex field, with the MHRA, NICE, CQC, HRA—we have an alphabet soup of regulators—to navigate your way through. We have tried to launch a one-stop shop web service so people can really understand how to navigate their way through and have all the information in one place.

I now come to the sixth, and probably the hardest, part in all this: how we get innovation adopted and scaled up across the system. There are many advantages to having 120 different hospital trusts, 42 ICBs and thousands of GPs, and that freedom can often bring innovation, but there are also many disadvantages in the scaling up and rolling out. We have seen many examples where you have a promising new technology with a small start-up company, and you say, “Well done, it’s great. Here’s the telephone directory—good luck”. A small company especially just does not have the resources and time to get out and scale up.

For certain technologies, we are trying to bring them to a central buying point and process. There are examples of where we are doing that already. Noble Lords will often have heard me mention the Maidstone flight control system, which arms the clinicians with information about what is happening across the hospital, what the 999 calls coming in are, where they are likely to need beds and what they need to free up, so that they can make on-the-spot decisions. We are scaling that up and rolling it out across multiple hospitals. We are looking to do that in a number of areas, where we think we can do things better from the centre. I do not pretend for one moment that we have all the answers, because rolling out and scaling up are some of the most challenging areas. One of the first things I learned on taking up this role is that the word “national” in National Health Service is probably not apt.

The rollout of the buying points is a key thing that we hope to do. We are also seeing the rollout of virtual wards, as mentioned by the noble Lord, Lord Crisp. On new technologies, I have seen things where you can monitor the electrical usage in the homes of people who need more support. This is particularly relevant for dementia patients. If you normally see a spike in their electricity usage at 8 am because they turn on the kettle to make a cup of tea, when that suddenly does not happen you have an early warning. Have they suffered a fall? Is there something we need to investigate? That technology lends itself to mass scaling, and those are the sorts of things we see promised in those early technologies that we look to roll out across the system. That is one of the biggest challenges.

I hope noble Lords can see in my response that I am not pretending we have all the answers but, taking on the spirit of the debate, we are trying to adopt and innovate. I thank all noble Lords for their contributions.

General Practitioners: Recruitment and Retention

Lord Markham Excerpts

Monday 12th June 2023 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

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

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

We acknowledge that there are challenges in growing GP numbers. We are working with NHS England and the profession to explore measures to boost recruitment, address the reasons why doctors leave the profession and encourage them to return to practice. As of March 2023, there were 1,903 more full-time equivalent doctors working in general practice compared with March 2019, and we have a record 4,000 doctors in GP training.

[Baroness McIntosh of Pickering (Con)]

I have slightly different figures, although I thank my noble friend for his Answer. Since 2015, there has been an 18% increase in the number of patients per GP but a 7% reduction in GPs, with potentially 39% of the GP workforce considering leaving the profession in the next five years. Does my noble friend share my concern about the recruitment and retention of GPs? What urgent action is he going to take to address the workforce strategy for GPs to double the number of medical training places and to ensure that general practice once again becomes an attractive place for doctors to work?

--- Later in debate ---

[Lord Markham (Con)]

I agree with my noble friend that recruitment and retention are key. To clear up the figures, the numbers I gave referred to all doctors working in GP surgeries, including people who have been qualified for five years and are just finishing off the GP element. Within that we absolutely need to increase training numbers. We already have 4,000 doctors in training, which is a record number, but we are looking to grow that. We are introducing specific actions on retention, such as the new changes to pensions.

[Lord Hunt of Kings Heath (Lab)]

My Lords, plugging the gap in relation to GPs will take many years. The noble Lord will know that in hospitals, specialist and associate specialist doctors have increased in number. Many would like to work in primary care but are prevented by bureaucratic barriers. Do the Government not think that one way to get an immediate injection of doctors into primary care is to get SAS doctors there and to lift the current barriers?

[Lord Markham (Con)]

I completely agree that we need to look creatively and flexibly. We are on target to deliver 50 million more appointments, which is 10% more each day. That is through recruiting more staff. We have about 29,000 more staff in the GP work space, and that is using them flexibly and creatively.

[Lord Stirrup (CB)]

My Lords, part of the pressure being experienced by secondary care specialists is as a consequence of inadequate time for appropriate diagnosis by primary care specialists—the GPs. Numbers are, of course, a part of this, but what are the Government going to do about setting targets for consultations with GPs that reduce the pressure on hospitals and see more patients dealt with in primary care?

[Lord Markham (Con)]

I totally agree; it is all about getting upstream of the problem. I visited an excellent surgery—Greystone House in Redhill—where they are doing exactly that. They are taking their most critical 1% of patients in respect of need and trying to get appointments in ahead of time so that they can move into preventive measures; I absolutely agree.

[Baroness Hodgson of Abinger (Con)]

My Lords, I understand that often locums are paid more than GPs in practice. How can we reverse this so that we can encourage young doctors to go into GP surgeries, become general practitioners and actually get to know their patients?

[Lord Markham (Con)]

First, I would agree—I think we all agree—that continuity of care is very important. We absolutely want a career structure that attracts and retains exactly those types of people, so that they feel it is more rewarding, both financially and as a job, to work in such a practice environment.

[Lord Allan of Hallam (LD)]

My Lords, I expected this Question to be the cue for our weekly reassurance from the Minister about the workforce plan, which will be coming “shortly”, “imminently”, “in the blink of an eye”, or whatever the latest formulation will be. In spite of all the reassurances that he has given about numbers, the stark reality remains that many people up and down the country find it extremely hard to see a GP when they need to, and that has knock-on effects for everyone else, including accident and emergency services. Does the Minister have anything new to offer that might give us some confidence that we will turn the corner in the near future?

[Lord Markham (Con)]

The primary care plan was a very good example of something new, substantial and backed by £1.2 billion of investment to beat the 8 am morning rush and use technology—which I know the noble Lord is very interested in—to allow people to self-help in a lot of these situations.

[Baroness Wheeler (Lab)]

The Minister will know that the Health Foundation independent think tank summed up the Government’s recent primary care recovery plan as falling

“well short of addressing the fundamental issues affecting general practice”.

Staff shortages and the sheer number on NHS waiting lists are a key reason for such high demand on GP services. Do the Government accept that, unless they urgently get a grip on waiting lists, the crisis in general practice will only deepen?

[Lord Markham (Con)]

What we totally accept and believe is that primary care is where a stitch in time saves nine, to take that saying. That is why I believe that the primary care plan is a big step forward. As I said, the fact that we are doing 10% more appointments per day is significant, as is the Pharmacy First initiative that we have announced, which will bring on stream another 10 million appointments a year, allowing people to navigate whether a pharmacy is the best place for them to get treatment, in which case they can go there first. These are all practical plans that are in place and are making a difference.

[Lord Singh of Wimbledon (CB)]

My Lords, I declare an interest as someone who has children and grandchildren in the medical profession. Would the Minister agree that there is something terribly wrong in the recruitment and retention of doctors when newly qualified doctors from Nigeria are paid more than those in this country when doctors find it easier and more profitable to do locums than stay in a fixed career path; and, finally, when doctors are being inundated with attractive requests from Australia and New Zealand to emigrate to those countries, leaving a dearth in this country?

[Lord Markham (Con)]

All the things that the noble Lord points towards are covered in our plan for recruitment and retention. The things that we have announced, particularly on pensions—a key reason why people were leaving—were welcomed by the sector and the fact that we have record numbers in training is also a step in the right direction. But, as we freely admit—this is what the primary care plan is all about—a lot more work needs to be done and is being done.

[Lord Naseby (Con)]

As my noble friend knows, we have an Armed Forces scheme for young doctors to train and they have to commit to five years in the Armed Forces. Is he also aware, as I am sure he is, that Singapore’s health service has a scheme whereby young medics who qualify have to work in the Singapore national health service? At a time when we see an increasing number of our qualifying young doctors going abroad, is it not time that we looked at both these schemes and modified them to the UK situation?

[Lord Markham (Con)]

My noble friend makes a good point: if we are investing eight years in training, in the case of a GP, to ensure that they are at the top of their profession, so to speak, it is reasonable to expect them to work for a number of years in the UK so as to make good on that investment.

[Lord Turnberg (Lab)]

My Lords, one way of encouraging retention would be to relieve GPs of the burden of having to manage their service by making them salaried employees. How far have we got with that proposal?

[Lord Markham (Con)]

I actually think the partner model works very well for a lot of people and has been the bedrock of our GP service, as we know, since the beginning of the NHS. However, what is critically important is reducing the admin so that GPs can get more face-to-face time. Again, at Greystone House surgery in Redhill on Friday, I saw excellent examples of where those admin duties are being taken away so that doctors can do what they want—and are best trained—to do, which is face-to-face treatment of patients.

[Baroness Hussein-Ece (LD)]

My Lords, is the Minister aware of how many GP practices are still insisting on online applications to get an appointment? Many people, such as those with learning disabilities or dementia, or older people, are not well versed in using online applications. Is anything being done to encourage GP practices to make sure that those people who are disadvantaged can access GP services, without being constantly referred back to doing everything online?

[Lord Markham (Con)]

Absolutely; I am a firm believer that you need to have lots of channels of distribution, for want of a better word. Online is a very important one, but being able to phone up is important. The primary care plan was all about making sure that we had enough capacity to beat the 8 am rush, and to let anyone who rings know that we are going to contact them if they cannot get through at that moment, at a time of their convenience, so that they can be certain that they will get the right treatment.

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?

--- Later in debate ---

[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?

--- Later in debate ---

[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.

--- Later in debate ---

[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.