Gender Identity Services: Children and Young People

Lord Markham Excerpts

Wednesday 19th April 2023 Lords Chamber

[Lord Young of Norwood Green]

To ask His Majesty’s Government what steps they are taking to ensure that, during the closure of the Tavistock gender identity clinic, young people who accessed those services receive appropriate counselling, as recommended by the Cass Review of gender identity services for children and young people.

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

NHS England commissions children’s and young people’s gender identification services. All patients at the Tavistock gender clinic receive psychological or psychotherapeutic care. Following the Cass review interim report, NHS England is bringing the GIDS contract to a managed close and transitioning gender services to new providers that will deliver holistic and exploratory counselling. Existing patients will continue under the current care arrangements until they are transferred to new services based in specialist paediatric hospitals.

[Lord Young of Norwood Green (Lab)]

My Lords, I thank the Minister for his reply, but I would like to probe a little more on this. Does he recognise that 80% of the young people who are diagnosed with gender dysphoria, many of whom are girls on the autistic spectrum, realise when they reach the age of 18 that they have gone through a perfectly normal process of puberty? They might end up being gay or lesbian, but they certainly did not need to be prescribed puberty blockers, which are a serious medical risk. Can the Minister assure me that steps will be taken to ensure that those young people receive the appropriate counselling? It could be via CAMHS, but what it cannot be, as he rightly said, is through the discredited Tavistock clinic—and I would like to meet the Minister on this issue.

[Lord Markham (Con)]

Yes. As I have said before, it is one of the privileges of this job that you learn about new areas, and I thank the noble Lord for his Question; this is something I have enjoyed being educated on in the last few days. I am very happy to meet with him. The points he makes are absolutely right: a lot of these people have other issues and going through puberty is a difficult time. So the lessons have been learned and we will make sure that they are implemented.

[Baroness Hunt of Bethnal Green (CB)]

My Lords, I thank the Minister for his thoughtful reply to the Question and his curiosity about this subject area. I think that some issues and data that have just been shared are subject to debate and are not quite as substantial as has been suggested. When might the transition to these new services happen? At the moment, the young people on that waiting list have no knowledge of when they will be transitioning from the Tavistock to another service; there are those who have been waiting for an appointment since 2019, and four years is a very long time when you are a teenager, let alone when you are 43 and a half and a grown-up. We also know that that period is a very confusing time, so could we get some clarity for those young people on when they will be seen, by what service, and how quickly they will be able to get on to the system?

[Lord Markham (Con)]

The points are well made, and they are understood and accepted on this side. My understanding is that the northern and southern hubs, as recommended in the Cass review, have already been set up, so patients are being seen as we speak at the Great Ormond Street and Evelina centres, and a transition programme is being put in place for all those people who are currently there. I will happily pick up with the noble Baroness afterwards to discuss this further.

[Baroness Browning (Con)]

My Lords, the number of autistic children and adolescents at the Tavistock clinic was greater than the number of those in any other group. Would my noble friend just clarify his reply a little? I think this is going to require more than normal counselling, because there is a trait within the autistic mind that often focuses very strongly on a particular issue and, once an autistic person believes something is true, it is quite hard to get them to see it another way. So it is going to need expertise. What is being done to find those experts?

[Lord Markham (Con)]

My noble friend will be aware that I do have some personal knowledge in this area, and I recognise very much the point that neurodiverse people can become fixed on a certain outcome. In terms of the statistics, yes, as many of a third of the people seen at Tavistock do have those sorts of conditions. So, it is something that is understood. Again, I am happy to pick up afterwards. The key point of the Cass review in all this is that these people need to be seen by medical doctors who are considering everything in the round and not just coming at this through a gender identification lens. That is the key thing we need to make sure happens going forward.

[Baroness Burt of Solihull (LD)]

My Lords, whatever one’s views on trans issues, surely the first imperative is to ensure that young people are properly looked after. Would the Minister agree with me that every young person suffering from gender dysmorphia, whether they have attended the Tavistock or not, should receive professional counselling and support? If he does agree, can he ensure that the resources are available in a timely manner, so that these young people do not have to wait years while they try to unravel the complex set of issues they face concerning their gender identity?

[Lord Markham (Con)]

Again, my understanding—and I freely admit that the benefit of having these questions is that you then delve into them, which I very much support in terms of how this process works very well —is that these people who have been through these services need to be looked after and catered for, so that is something we are very much on.

[Lord Winston (Lab)]

My Lords, leaving aside the issue of the serious psychological problems some of these children undoubtedly display, can the Government clarify one issue? Do they regard so-called gender dysphoria, which is a very broad term, as a pathological condition or simply a medical one? Is it a pure choice of the individual? Therefore, the question is: at what stage should the National Health Service be intervening in these cases?

[Lord Markham (Con)]

I feel I am probably outgunned to some degree by the noble Lord. I would like to make sure that I answer that in the proper way and give him a detailed written response. I am happy to follow up, because I want to make sure that I am answering in completely the right way.

[Lord Sandhurst (Con)]

My Lords, the Times of 23 February reported that GIDS patients were still receiving puberty blockers. What arrangements are in place—as recommended by Dr Cass in her report—to monitor patients who receive treatment, both during it and in subsequent years by way of follow-up, to ensure a proper longitudinal study of the effects?

[Lord Markham (Con)]

My noble friend is absolutely correct: one of the main findings from the Cass review was that more research has to be done in the whole space of puberty blockers. The NHS is moving on that as we speak. At the same time, I can assure the House that, from now on, no puberty blockers can be prescribed unless they are part of that research programme, because it is vital that that does not happen as a matter of course until we understand far more about this subject.

[Baroness Wheeler (Lab)]

My Lords, the Cass review interim report underlines that the expansion of gender identity services to regional centres can be successful only if the NHS can attract and engage the workforce within those centres and for crucial network secondary services. This week, however, as we have heard, we have seen just how under pressure these key services are. Over a quarter of a million children in Britain with mental health problems are awaiting NHS referral due to major shortages of psychiatrists and specialist nurses. How are the holistic, person-centred services that young people desperately need going to be provided in the continued absence of a clear government workforce strategy?

[Lord Markham (Con)]

I am glad to say that there is a workforce strategy, which, unfortunately, we have not been able to publish yet. I assure your Lordships that a lot of work is being done, and there is a lot of work in place. I would be happy to meet with the noble Baroness and go through the findings of that, because it needs to cover a lot of these specialisms.

[The Lord Speaker (Lord McFall of Alcluith)]

My Lords, we have a virtual contribution from the noble Baroness, Lady Brinton.

[Baroness Brinton (LD) [V]]

My Lords, in reply to the question from the noble Baroness, Lady Hunt, the Minister referred to the new GID services at the Evelina and GOSH. But the original proposals were for regional clinics in Manchester and London—so when will the Manchester clinic open? Since March of this year, the waiting list and all new referrals are being held by the Arden and Greater East Midlands commissioning support unit. There is real confusion about how this list will be integrated with the existing case load as the new services open. Can the Minister explain what will happen? If he does not have the answer to hand, please will he write to me?

[Lord Markham (Con)]

As ever, I am very happy to write. In terms of the northern hub, I mentioned GOSH and Evelina just as examples. The Royal Manchester and Alder Hey are the northern sites that will be used to provide these services. The idea is that we will have eight regional centres—but I would be happy to provide the detail on both cases and follow up in writing.

Adult Social Care: Challenge Procedures

Lord Markham Excerpts

Wednesday 19th April 2023 Lords Chamber

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

The Government have noted the findings in the report. Encouraging a culture of feedback and learning is vital if we are to improve services and people’s experiences of social care. The CQC’s local authority assessment framework, which went live on 1 April, includes oversight of local authority assessment and eligibility frameworks for adults and unpaid carers accessing social care and support. This includes looking at transparency and accessibility and whether people can appeal decisions effectively.

[Baroness Tyler of Enfield (LD)]

I thank the Minister for his reply. The EHRC report clearly demonstrates the problems facing social care users who have challenged local authority decisions, and it is a pretty bleak picture. But while there is much for local authorities to do to improve their complaints system, there are also important recommendations in the report aimed at government, including making the Local Government and Social Care Ombudsman the statutory complaints authority for social care in England. When and how do the Government intend to respond to these recommendations? Does the Minister agree with me that the shortcomings at local level will be remedied only by long-term sustainable funding of adult social care—not made easier by the Government’s announcement on 4 April, when Parliament was in recess, to hold back £50 million of the money promised to help plug staff shortages?

[Lord Markham (Con)]

First, we will respond in detail to the report the noble Baroness mentions. On funding, as I have mentioned before, the £7.5 billion over the next two years is a 20% increase and is substantial by any measure. I spoke to Minister Whately about this issue this morning, and she was at pains to say that, in terms of funding and overall numbers, everything is in place in this latest programme. Also, £600 million is being held in reserve to follow up in the areas that really need it.

[Baroness Wheeler (Lab)]

My Lords, the report underlines just how difficult the current social care system is to navigate and challenge, as we have just heard, yet it showed that fewer than two-thirds of local authorities commission advocacy services that can be accessed by users and unpaid carers to help them challenge vital decisions on care and support. The postcode lottery, the complexity of local challenge systems and the overall lack of consistency, national standards and effective monitoring prevent vital decisions about care being overturned. How are the Government ensuring that, as per the 2014 Care Act requirement, independent advocates are available across all parts of the country to help users and carers understand and access the system?

[Lord Markham (Con)]

As the noble Baroness says, it is a statutory part of the 2014 Care Act that advocacy be provided where people need such additional support. That is why we were keen to bring in the CQC to oversee local authorities, which it has from 1 April. This is one area where it will be making sure that advocacy is provided.

[Lord Allan of Hallam (LD)]

My Lords, Section 72 of the Care Act 2014 empowers the Secretary of State to regulate for an appeals system through which people can challenge social care decisions. It seems odd that we went to the trouble of legislating for this and yet, nearly a decade later, it still has not been implemented. What more evidence do the Government need to come to a decision about whether the benefits of such an appeal mechanism would outweigh the costs?

[Lord Markham (Con)]

The main point is that we already have two levels of appeal. In the first instance, someone can appeal to a local authority and if they are not satisfied with that, they can appeal to the local ombudsman. Thousands of people do this every year, and compliance in terms of replies to them is very high. I must admit that I am not sure whether an additional, third level of appeal is really necessary in this case.

[Baroness Pitkeathley (Lab)]

My Lords, once again, a Question in your Lordships’ House has pointed out the inadequacy of the social care system, be it funding or personnel. In answer to an earlier Question, the Minister teased the House a little about the workforce strategy. Can he be more specific in answer to this Question?

[Lord Markham (Con)]

First, I take issue with the inadequacy comment. Some 89% of people expressed a high level of satisfaction with the social care provided, which, although not 100%, is pretty good, as I think everyone would agree. As I said, the workplace plan has been drafted. I am afraid I cannot give an exact date of publication—I believe there are local purdah issues now—but I can say that it will be soon.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, one of the things this House has heard about many times is our reliance on unpaid carers and the important role they play in helping people who draw on adult social care to navigate the system. The 2014 Care Act put a duty on local authorities to identify unpaid carers, but that is not happening. What can the Government do to identify unpaid carers, so that we can support them more readily?

[Lord Markham (Con)]

I thank my noble friend for that question. The Government absolutely recognise the role that unpaid carers play—I have fulfilled such a role myself for a number of years—and it something we are working towards. We have introduced the leave provisions and a certain level of payments for them; that may be modest but it is a step in the right direction. Again, the whole idea of getting the CQC in this space is that it can start monitoring local authority provision and ensure that it is identifying unpaid carers, among other things.

[Lord Laming (CB)]

My Lords, last week or perhaps it was the week before—time flies—there was a report on the number of people occupying health service beds who are fit for discharge but are not being discharged, largely due to the absence of social care provision. Are the Government taking seriously reports of that kind?

[Lord Markham (Con)]

Yes, we are taking them very seriously. The House has heard me talk many times about the 13% of beds that are blocked. This is a key issue for the whole flow of the system, which is backed up right the way through. That is why we introduced the discharge fund. Again, Minister Whately is very focused on this issue.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, further to the question asked by the noble Lord, Lord Laming, in response to my noble friend Lady Pitkeathley, the Minister referred to an 89% satisfaction rate among people in receipt of social care. However, as the noble Lord, Lord Laming, has just pointed out, the issue is not the people in receipt of social care but those who are not, of whom there are far too many. That is exactly what is causing some of the problems the noble Lord referred to. Does the Minister agree?

[Lord Markham (Con)]

Again, this goes to the point about the massive increase we have put in place of £7.5 billion. I have not heard of but would be pleased to hear about any plans on the other side of the House to increase that funding, since £7.5 billion is a very large figure—a 20% increase. Clearly, we will continue to review whether more is needed; we have put in increases each year. The importance of ensuring social care provision is completely understood.

[Lord Blunkett (Lab)]

My Lords, can the Minister clarify his last answer? In replying to me on a previous occasion, he conceded that a very substantial part of the money he has just announced is from local authority council tax. Can he confirm that?

[Lord Markham (Con)]

Yes, absolutely; a large part of it is from central government funding and a large part is from local authority funding, given local authorities’ ability to use a precept and increase council tax. Of the 153 local authorities, 151 have taken that opportunity to increase the council tax.

[Lord McColl of Dulwich (Con)]

My Lords, does the Minister agree that in talking about the costs of health and social care, we seem to have forgotten that 40 million people in this country are moving slowly towards suicide by putting too many calories in their mouths, which is costing £27 billion every year?

[Lord Markham (Con)]

I will answer quickly to allow a final question, but yes, our anti-obesity strategy is very much about that.

[Lord Forsyth of Drumlean (Con)]

I am most grateful to my noble friend, who is a glutton for punishment. I wanted to follow up on the point made by the noble Lord, Lord Blunkett. It is all very well saying that the money is coming from local government, but the problem is that the tax base in local authority areas does not reflect the demand in those areas. Therefore, there is unmet need where the need is often greatest, is there not?

[Lord Markham (Con)]

I knew that was coming. As a former local authority deputy chair of finance, I very much understand the problem my noble friend describes. My Treasury colleague has gone, but we all agree that local authorities have a very important part to play in this. The mix between local and central funding is clearly something we need to work on.

Diphtheria

Lord Markham Excerpts

Tuesday 18th April 2023 Lords Chamber

[Lord Roberts of Llandudno]

To ask His Majesty’s Government what plans they have to provide medical support to prevent the spread of diphtheria in the light of reports of a sharp increase in cases linked to Channel migration.

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

In response to an increase in cases of diphtheria in November 2022, the UK Health Security Agency issued guidance recommending that new arrivals into initial accommodation sites be offered a diphtheria-containing vaccine and a course of antibiotics in addition to wider health protection interventions. The UK Health Security Agency is working with the Home Office, NHS England and local NHS teams to ensure that this ongoing intervention is delivered.

[Lord Roberts of Llandudno (LD)]

I thank the Minister for those words. It is amazing that the Home Office has rejected the support and experience offered by the Association of Directors of Public Health, whose president criticised

“the lack of information, co-ordination and engagement from the Home Office”.

This resulted in the situation being

“far worse than it could have been”

and

“put both asylum seekers and … hotel workers at avoidable and preventable risk”.

Why was the assistance offered by the directors of public health “rebuffed”? That is their word. Who in the Home Office took that decision, and why? Will it be immediately reversed?

[Lord Markham (Con)]

All I can say is that the Department of Health co-operates very closely with the Home Office. We have a screening programme for all migrants coming in, as I mentioned, and an 88% vaccination rate for diphtheria among them, compared with 93% of UK children. It is a very high rate indeed; that record speaks for itself.

[Baroness Manzoor (Con)]

My Lords, as the Question implies, the UK has an excellent record on uptake of vaccinations, but my noble friend will know that the level has fallen among children for the MMR vaccine. What action are the Government taking to ensure that the most vulnerable are given this vaccination and that rates go back up to pre-Covid levels?

[Lord Markham (Con)]

We are all aware of the rumours and allegations about the safety of the MMR vaccine, which we are all delighted to know were totally unfounded. As my noble friend says, it has been quite a task to regain confidence in it, but we are doing so and vaccination rates have gone up. I will provide her with the exact details of those new take-up rates.

[Baroness Finlay of Llandaff (CB)]

How are the Government working with those countries through which migrants pass when fleeing for their lives from war zones, given that many of them are held in very poor conditions where they pick up infectious diseases, including such things as scabies—which are parasites—TB and other diseases? They may also be exposed to chemicals because they take on farm work or factory work in a desperate attempt to get some money prior to arriving in this country. By working with other countries, we may decrease the burden on our NHS and prevent people presenting late with conditions such as diphtheria or even cutaneous diphtheria, which is extremely rare in this country but is now being seen in some of these very deprived populations.

[Lord Markham (Con)]

To be honest, I think the most effective method is to have the screening when people enter. Refugees come in from across the world so, to concentrate resources, it is best done on entry. The record speaks for itself; an 88% take-up rate is very high, comparable to that of the general UK population. I think we have got it right.

[Lord Hunt of Kings Heath (Lab)]

My Lords, coming back to the original Question, does the Minister accept that during the Covid pandemic the role that directors of public health played locally was critical to ensuring a co-ordinated and effective response? Does he agree that it is a great pity that the Home Office seems to have refused to engage with the Association of Directors of Public Health on this? Will he assure the House that the Home Office will start to engage with this organisation?

[Lord Markham (Con)]

I am probably best placed to speak about how we engage with the Home Office, which we have been doing pretty successfully. I agree with the noble Lord about the role that those public health directors played during Covid and will play going forward. UKHSA is very much committed to doing that as well. As I said, our record on interactions with the Home Office speaks for itself—it is pretty good.

[Baroness Blackwood of North Oxford (Con)]

My Lords, I am very pleased to see that UKHSA has issued guidance in response to the increased number of cases, but it will be important to know how effective the response and the screening are. What plans are there for pathogenic screening and other forms of surveillance going forward?

--- Later in debate ---

[Lord Markham (Con)]

I thank my noble friend. I was just talking about the first stage; we have a follow-up where we look at not just diphtheria but HIV, hepatitis, TB and other cases, on top of surveillance measures that UKHSA takes into account, such as wastewater surveillance screening. We have a full toolset to make sure that we capture any potential diseases early on.

[The Lord Speaker (Lord McFall of Alcluith)]

My Lords, we have a virtual contribution from the noble Baroness, Lady Brinton.

[Baroness Brinton (LD) [V]]

My Lords, to follow on from the question by the noble Baroness, Lady Blackwood, last week the European Congress of Clinical Microbiology and Infectious Diseases published a report on the rise of diphtheria cases, noting that:

“Linked to an increase in migrant arrivals via small boat in … 2022, the UK experienced a sharp increase in diphtheria cases”.


Its report recommends that border officials and doctors should all have training on screening and identification of symptoms of infectious diseases, such as diphtheria and others outlined by other speakers. Will the Government implement this specific recommendation? Can the Minister say whether, on arrival, all asylum seekers are now offered a full health check and vaccination with doctors?

[Lord Markham (Con)]

As I mentioned, we are doing the screening. We lead Europe on this; my understanding is that no other European country is taking the extensive measures that we are. I can also reassure the House—I was speaking to Susan Hopkins on this just yesterday—that UKHSA has deemed that there is a very low risk to the general population. The uptick in cases that we are talking about is in the migrant population, and the fact that we are vaccinating 88% of them against diphtheria shows that we are on top of the problem.

[Baroness Merron (Lab)]

My Lords, we know only too well from pandemics that diseases do not respect borders, and though, as the Minister says, we ought to be well protected against diphtheria in this country given the vaccination programme, recent increases in vaccine hesitancy have given cause for concern. On the steps that the Minister referred to that should be taken to maximise vaccination rates, can he indicate whether this will reflect regional variations, bearing in mind that the National Audit Office has reported a lower level of vaccine take-up in London?

[Lord Markham (Con)]

Absolutely. As the noble Baroness is aware, vaccination take-up is the responsibility of the ICBs in their areas. Like many other places, London has unique demographics. As I mentioned, our record is pretty good in this area, but it needs to be done nationally on a uniform scale.

[Lord Allan of Hallam (LD)]

My Lords, in response to the questions from my noble friend Lord Roberts and the noble Lord, Lord Hunt, the Minister has twice told us how well his department’s officials are working with the Home Office. But his department’s officials are not present in local communities; directors of public health are. Can the Minister undertake to lobby the Home Office on behalf of the public health officials to make sure that they similarly have a good dialogue with the Home Office, which does not seem to be the case to date?

[Lord Markham (Con)]

Clearly, I am always going to support good dialogue—that is common sense, and we should do that. The proof of the pudding is in the eating, and 88% is a very good result. That notwithstanding, clearly it makes sense that they should work closely with local officials as well.

[Lord Watts (Lab)]

My Lords, 88% is very good, but why is it not 100%?

[Lord Markham (Con)]

As I say, compared with 93% in the UK population—who have many bites of the cherry, for want of a better term, because there are many opportunities for them through schools and everything—88% is very good. Is it perfect? No, but it is very good and definitely better than anywhere else in Europe.

Junior Doctors’ Strikes

Lord Markham Excerpts

Monday 17th April 2023 Lords Chamber

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

“Mr Speaker, the honourable gentleman seems to ignore the fact that we have actually negotiated a deal with the NHS Staff Council, and it is a deal that it has recommended to its members. Indeed, the largest health union has voted in favour of the deal—indeed, it is his own health union—yet he seems to think we should tear it up, even though other trade unions are still voting in response to that offer and their leadership had recommended it.

Secondly, he says that we should sit down and negotiate. We have made an offer of 10.75% for last year, compared with the Labour Government in Wales, who have offered just 7.75%. So the offer, in cash terms, in England is actually higher than the offer that is being put on the table by the Welsh Government, which I presume he supports. He says he does not support the junior doctors in their ask for 35%, and nor does the leadership there. We need to see meaningful movement from the junior doctors, but I recognise that doctors have been under significant pay and workforce pressures, which is why we want to sit down with them.

The bottom line is that the deal on the table is reasonable and fair. It means that just over £5,000 across last year and this year will be paid for a nurse at the top of band 5. The RCN recommended this deal to its members, but it was rejected by just under a third of its overall membership. It is hugely disappointing that the RCN has chosen not to wait for the other trade unions to complete their ballots and not to wait for the NHS Staff Council, of which it is a member, to meet to give its view on the deal. It has chosen to pre-empt that, not only with the strikes that come before that decision of the NHS Staff Council but by removing the derogations—the exemptions—that apply to key care, including emergency care, which is a risk to patient safety.

Trade unions are continuing to vote on this deal. The deal on the table is both fair and reasonable, including just over £5,000 across last year and this year for nurses at the top of band 5. It has been accepted by the largest union in the NHS, including, as I have said, the shadow Health Secretary’s own trade union. It pays more in cash to AfC members than the deal on the table from the Labour Government in Wales. It is a deal that the majority of the NHS Staff Council, including the RCN’s own leadership, recommended to its members. We have always worked in good faith to end the disruption that these strikes have caused and we will continue to do so, but it is right to respect the agreement that we have reached with the NHS Staff Council and to await its decision, which is due in the coming weeks.”

[Baroness Merron (Lab)]

My Lords, last week was the most disruptive in the history of the National Health Service, with some 350,000 patients seeing their operations and appointments cancelled due to industrial action. Does the Minister accept that the public remain supportive of doctors and nurses and also that the public want to see the Government reaching fair, negotiated settlements to bring disruption to an end? If Ministers remain unable to get agreements over the line, what other options are being pursued, including the involvement of ACAS?

[Lord Markham (Con)]

I think we all want fair outcomes and negotiated settlements, and I think we felt that the agreement reached with the Agenda for Change parties was fair and was something, as mentioned in the Statement, that the union leadership recommended to the union members. Of course, we need to wait to see the outcome of the staff council of all the Agenda for Change unions from 2 May to see where we end up on that. Our hope is that, across the majority of those, we will see support. As noted, this is a generous offer; it is higher than the offer made in Wales, for example, and we hope it will be a way forward after 2 May. If that is not the case, we need to sit down and think about next steps.

[Lord Allan of Hallam (LD)]

My Lords, the Secretary of State in the other place rightly referred to the workforce plan as essential to dealing with some of the stress that is contributing to the industrial action. I checked the record, and the Minister first told us that this plan was going to be released “shortly” on 2 February. Yet Valentine’s Day came and went, and there was no plan. Now, Easter has come and gone, and there is no plan. I wonder if the Minister could tell us whether “shortly” is getting shorter or longer? Should we be expecting the plan closer to the Coronation or the 75th anniversary of the NHS in July?

[Lord Markham (Con)]

I am afraid I cannot provide a lot more information to the noble Lord, except that complications now include the purdah for local government elections, so I am trying to find out more details on this very subject as to when a date could be set. I am afraid to say I cannot give much more of an update than to say it will be released shortly. What I will say is that, among all this, we are still seeing increases in staff. I was delighted to see that we now have 5,100 more doctors in place than last year, and we have had an increase over the last few years of 30,000 nurses. So, there are movements in the right direction, but clearly more needs to be done.

[Baroness Falkner of Margravine (CB)]

My Lords, we still call it the National Health Service, but the Minister will be aware of the alarming figures for people who have no choice but to move to private provision of care. The numbers registering even for GP services privately must give cause for alarm, because we have got to be in this together to retain the national character of the National Health Service. I appreciate the Government’s concern about higher inflation due to very large settlements, but perhaps the answer is to sit down through ACAS, as the noble Baroness said, and think about slightly more generous one-off payments, because that will not bake in the inflation or increase costs in the longer term.

[Lord Markham (Con)]

I thank the noble Baroness. As I mentioned, we felt we had put a fair offer on the table—something that was recommended by the trade union leaders themselves. I think we need to see the overall verdict come out across the board on all this. I note that less than a third of the membership of the RCN actually turned it down in the end, so we have to see what the overall outcome is. There is an absolute commitment on our side to continue meeting constructively with the RCN and to use all means possible to get to a solution.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, those who have awarded degrees to doctors and heard them take the Hippocratic oath that they shall do no harm can scarcely be impressed by action being taken in which the public—patients—are suffering and in which enormous pressure is put on other colleagues in the health service. I, for one, think this is a very miserable occasion, and I hope to goodness that all those in the health service involved in action will think again.

I would like my noble friend to remind us about the importance of the pay review bodies, which were fought for long and hard. If we jeopardise or undermine them, that will be a long-term legacy that not only this Government but a Government of any other persuasion may pay the price for. Can he also say a little more about junior doctors and the steps being taken to increase their remuneration and deal with their working patterns?

All will agree that the health service today is extraordinarily complex. When I was Secretary of State, we spent 5% of GDP on health. That figure is now 12%, and there is not an infinite pit. I hope that reason will prevail.

[Lord Markham (Con)]

I thank my noble friend for her questions and the wise points borne out by her own experience. The impact this is having on patients is a regret to us all. On derogations, the history has been that the unions have sat down and made sure that life is protected. It is a regret that the BMA junior doctors have not done that in this instance, and that the RCN is saying right now that it is not considering derogations in its new strike. I hope that this position will change. I do not think anyone in this Chamber would want to see life threatened in this way. I know that we are doing everything we can on our end—as I say, offering more than devolved Governments—to solve this situation. I ask for good will on all sides so that we can protect patients first.

[Baroness Bennett of Manor Castle (GP)]

My Lords, in following on from the last question, I point out that the rising percentage of GDP spending reflects a fast-ageing population and the fact that we have terrible levels of public health, terrible housing and terrible diets. All sorts of other issues that are putting huge pressures on our NHS are at historically high levels.

I want to focus on the junior doctor situation in particular. There are currently 9,000 NHS doctor vacancies. The rate of departure of doctors from the NHS is twice what it was a decade ago. Does the Minister acknowledge that the situation of doctors in particular—and, in fact, that of all medical professionals—is rather different from other professions in the sense that we have a huge global shortage of medical professionals? We are seeing many doctors voting with their feet over their current terms and conditions and leaving the NHS, and the Government are not in what you might call a normal industrial situation of saying, “Well, we’ll just have to play tough and negotiate”. There is a huge risk that we are going to lose a whole generation—or generations—of doctors from the NHS who are irreplaceable. The Government have to look at this in a co-operative way to find a way forward, rather than setting out a confrontational approach to the strike action.

--- Later in debate ---

[Lord Markham (Con)]

I thank the noble Baroness. Yes, we do live in a global market. We absolutely have to be mindful of the fact that if our working conditions are not attractive, people will vote with their feet. At the same time, I am glad to say that we have 5,100 more doctors than we did last year, as I mentioned earlier. Clearly we want to do more work on that, but the proof of the pudding is in the eating, so to speak. That is not to say that we do not want to retain as many doctors and nurses in all their professions. Of course, that is what the workforce plan will be all about as well.

House adjourned at 7.30 pm.

Social Care

Lord Markham Excerpts

Thursday 30th March 2023 Lords Chamber

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

My Lords, it is my pleasure to respond to the excellent debate today, to follow so many distinguished speakers and, probably most of all, to hear, in my noble friend Lord Polak’s words, the politics being taken out of care. Today has been an excellent example of that, and I hope I can follow in that vein.

I regret that our social care report has not been published today. As noble Lords will be aware, we were hoping it would be published yesterday, and we were going to offer an embargoed copy of the report so that everyone could contribute. That is the reason for the delay in responding to both committee reports. I undertake that we will respond to both reports after we publish our social care report, and I personally offer a round table to everyone who is interested, where I will seek to bring the relevant officials along as well. I hope we can have a productive conversation in a similar vein to this one, where we all get around the table as people who care about this issue and, as mentioned, take the politics out of care.

I thank the noble Baroness, Lady Andrews, for securing today’s debate, all noble Lords across the Chamber for their thoughtful and considered contributions, and all those who have sat on the committees that have been mentioned. I feel that they have really added impetus to this whole debate. I hope the report that we offer will answer many of these points, build on the progress made so far in this space and bring a vision into reality.

Before I go into detail and respond to the reports, starting with the Lords Select Committee report, I would like to say how fitting the words “gloriously ordinary life” are. I was struck by the whole sense that, if I caught the phrase right, we can live in a place we call home, with the people we love and the things we care about. That is something that we can all agree with and commit to as our North Star and vision for what we hope to do.

Not only is it vital that we allow people to live in the way that they want but it is a vital part of our health service, as mentioned by my noble friend Lady Shephard and the noble Lord, Lord Turnberg, who had many brave words to say today. We all know it is vital to unblock the system. Some 13% of our beds are blocked at the moment, to answer my noble friend Lady Shephard’s point. As the noble Lord, Lord Turnberg, said, it is often as difficult to get out of hospital as it is to get into it. We have put in funding to help with this issue: £700 million of funding this year alone to help with discharge and £1.6 billion over the next two years. This whole debate shows that it is vital not just to the well-being of our people that we have a good system of social care but to our health service in improving the whole flow of the system.

On that, I reassure noble Lords that the Government recognise the importance of responding to the Lords Select Committee report. As mentioned, we will release a response shortly after the social care report is published—I hope, as I say, next week. I assure the committee that the Government agree with the vision in the report. We particularly welcome the committee’s view that social care does not have the voice and the visibility that it deserves. That often means that people are not supported to meet their ambitions. By rethinking attitudes to care and support, we can ensure that people access the care and support that meet their needs.

Equally, I thank the most reverend Primate the Archbishop of Canterbury, the right reverend Prelate the Bishop of Carlisle and the Commission on Reimagining Care for its recent report, Care and Support Reimagined: a National Care Covenant for England. I was struck by the words, “care based on faith and values”, where we recognise that we all have a mutual responsibility in delivering that. That struck a chord with me, along with the idea of the need to develop a national care covenant, where we all look to do our part in delivering the system. I look forward to developing those thoughts more at the round table.

It is important that we recognise the important contribution that communities and faith organisations make to adult social care. We echo the commission’s vision for care and support that is inclusive, universal and fair, and recognises our mutual responsibilities as citizens. The Government are keen to work collaboratively to make change a reality, and, having spoken to Minister Helen Whately, I know how much she enjoyed the meeting she had with the commission and how keen she is to drive forward the report.

I turn to the Government’s vision for adult social care. Again, I apologise; I feel that my hands are slightly tied behind my back, having to make this speech prior to the publication of our report. As we all know, back in December 2021 the Government published People at the Heart of Care. This set out a 10-year vision that put people at the centre of social care to make sure that everyone who draws on care and support feels empowered to have the choice, control and support they need to live independent and fulfilling lives. This is a vision that aims to make social care fair, accessible and of high quality, and to lead to better outcomes for people who draw on, work in and provide care and support. This Government remain committed to that vision.

I am pleased to report that the Government’s upcoming plan will outline how we will make progress towards this vision. It will also provide the clarity asked for by this House on key policy areas, including outlining how we plan to allocate the funding set aside for reform. Ahead of that publication, I would like to share some of the progress that the Government have made so far.

I start with the workforce, the importance of which the noble Lords, Lord Lipsey and Lord Prentis, and the noble Baronesses, Lady O’Grady and Lady Tyler, to name just a few, focused on. This was a point reiterated by our Prime Minister the other day. We all know that the social care workforce is one of our biggest assets, but we recognise the challenge we have right now to recruit a workforce of the right size, with the right skills, that feels appropriately motivated and rewarded. The Government have taken action to boost workforce capacity with recruitment opportunities both at home and abroad, with over 55,000 visas granted for care workers and senior care workers last year. This is complemented by our national recruitment campaign, Made with Care.

To respond to the points made by the noble Lord, Lord Turnberg, and the noble Baroness, Lady Wheeler, our upcoming plan for adult social care will include proposals for a new adult social care workforce pathway, building on our commitments in the People at the Heart of Care White Paper to give a career structure for people in this vital sector. Our chief nurse champions and raises the profile and visibility of nursing in social care, working alongside the Chief Social Worker for Adults to increase the recognition and appreciation of all our care workers.

On funding in this space—this is a point noble Lords have heard me make many times before but it is worth reflecting on—the £7.5 billion increase over the next two years will flow through to workers. The vital point is that it will largely flow through into the workforce.

Many noble Lords talked about technology. We all know that to increase workforce capacity we have to significantly increase the use of digital tools. Last year, we made £35 million available to the integrated care systems to support sector digitisation, including the adoption of digital social care records. As a result, approximately 52% of providers now have a digital social care record, up from 40% in December 2021, and we have plans to extend this much further. These records can provide up to 20 minutes per care worker per shift, and allow more time to provide care and support. Good data is fundamental to the delivery of high-quality care and, as the noble Baroness, Lady Barker, mentioned, sharing that data is vital as well. Our use and understanding of adult social care data is better than it has ever been, but we know there is a lot more to do.

From next month, our flagship client-level data project will become mandatory for local authorities in England. This will transform our understanding of people’s experiences and outcomes. For the first time, we will be able to track an individual’s journey through the health and care system to aid with navigating its difficulties—again, as mentioned by the most reverend Primate the Archbishop of Canterbury and my noble friend Lord Polak. Also as of Monday, the Care Quality Commission will begin to assess local authorities’ delivery of their Care Act duties, including those for unpaid carers. This will make good practice, positive outcomes and outstanding quality easier to spot locally and share nationally, while identifying where improvement and additional support is needed. But as much as data and technology could help, I totally agree with the point made by the noble Baroness, Lady Bennett: there is no substitution for the loving care of a human.

To ensure that care and support is personalised to people’s needs, our White Paper rightly sets out our ambition to support high-quality, safe and suitable homes, recognising that they can help people of all ages stay independent and healthy for longer. That is why, alongside the Department for Levelling Up, Housing and Communities, we will shortly launch the older peoples’ housing taskforce. It will bring together experts from across the sector to make recommendations on how people can access the housing they need.

I turn to the area of unpaid carers, which we all agree is the backbone. As noble Lords are aware, it is something that I have personal experience of. The point was brought out very well by my noble friend Lady Fraser, among others, because it is important that we recognise the vital role that unpaid carers play in our communities. We all owe them a debt of gratitude. Under the Care Act 2014, local authorities are required to undertake a carer’s assessment for any unpaid carer who appears to have a need for support, and to meet their eligible needs on request from that carer. This year, we have earmarked over £290 million for unpaid carers through the better care fund, including to provide short breaks and respite services. It is a step in the right direction; I use those words advisedly because carers are a vital area, as many noble Lords, particularly the noble Baroness, Lady Pitkeathley, have recognised, and there is a lot more that we need to do.

I hope that I have addressed many of the questions as I have gone through. I will try to pick up a few others and, as ever, follow up in writing in detail. It will be after the reports are published next week—and, to answer the noble Baroness, Lady Andrews, yes, we are planning to publish more on people at the heart of social care next week.

In answer to the noble Lord, Lord Bradley, yes, the ICBs will be at the forefront of this system for the planning and provision of social care. However, I will need to come back in writing on his question around the role of the DWP in analysing and reporting in this space.

In answer to the noble Baroness, Lady Campbell, we definitely embrace the principles of co-production. I hope that will come out in the report itself, as we work with 200 stakeholders in the provision of it all. We really hope to see the ICBs at the forefront of this and the better care fund being a key part of co-production.

I was struck by the point made by the noble Baroness, Lady Jolly, about 90 year-olds caring for 70 year-olds. I await my next Oral Question after the Recess.

The noble Baroness, Lady Donaghy, asked about help for providers on energy funding. Again, I hope noble Lords would agree that we have provided significant help. I am glad to see that, the last time I looked, gas prices were lower than last summer, when the action was prompted. They are moving in the right direction, but it is probably an example of needing to watch this space, while being mindful of the issue at stake there.

I hope that I have answered many of the questions raised. In conclusion, over the past year, the Government have invested significantly and have secured another £7.5 billion of funding for over the next two years—but this is only the start of the journey.

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

Before the Minister sits down, can he provide an answer to the question about the media reports on cuts to the £500 million workforce budget?

[Lord Markham (Con)]

This is one of the areas covered in the report that will be published next week. At this stage, I can say only that the need for the training and development of our social care staff is understood and recognised in that report. I hope that it will give a response to the noble Baroness’s question, and that she understands why I cannot say more at this point.

Taking the words of the Select Committee’s report, I hope that these actions show that we are moving in the right direction

“to live in the place we call home, with the people … we love”,

based on faith, value and our own mutual responsibility in delivering that aim. Once again, I thank the noble Baroness, Lady Andrews, for securing the debate and this valuable opportunity to discuss the future of adult social care. I reiterate the hope that we can all gather at a round table to discuss this once the report has been announced and we have responded to the various other reports. Finally, I extend my thanks to everyone who works in the social care sector and to the unpaid carers for everything they do to support others.

Junior Doctors’ Strikes

Lord Markham Excerpts

Thursday 30th March 2023 Lords Chamber

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

My Lords, I shall now repeat in the form of a Statement an Answer to an Urgent Question given in another place. The Statement is as follows:

“I am grateful to the honourable Member for his Question. I know that colleagues and constituents are concerned about the planned 96-hour walkout organised by unions representing junior doctors.

The honourable Gentleman asks about its impact. We know that during the previous walkout by junior doctors earlier this month, 181,049 appointments had to be rescheduled. With this four-day walkout, the disruption and the risks will be far greater not only because it lasts longer but because it coincides with extended public holidays and Ramadan, with knock-on effects before and after the strike action itself and because a significant proportion of junior doctors will already be on planned absence due to the holiday period.

NHS England has stated that it will prioritise a number of areas, including emergency treatment, critical care, maternity care, neonatal care and trauma, but has been clear that it cannot fully mitigate the risk of patient harm at this time. That is concerning and disappointing. Patients should not have to face such disruption, and I have invited the BMA and the HCSA to enter formal talks on pay, with the condition that they cancel strike action.

The BMA’s junior doctors committee’s refusal to engage in conversations unless we commit to delivering a 35% pay increase is unacceptable at a time of considerable economic pressure and suggests the leadership adopting a militant position, rather than working constructively with the Government in the interests of patients. None the less, we remain determined to find a settlement that not only prevents further strikes but, equally, recognises the important work of junior doctors within the NHS, just as we have done with the Agenda for Change trade unions in their disputes. We will continue to work in good faith, in the interest of everyone who uses the NHS.”

[Baroness Merron (Lab)]

My Lords, junior doctors are being asked to do the work of many. The NHS is short of more than 150,000 staff, yet the long-promised NHS work plan remains just that—long promised. We are still waiting for the general practice plan, the review of integrated care services and the social care update. Do the Government intend to get those plans out over the Recess when Parliament is unable to scrutinise them? With a quarter of a million appointments and operations potentially facing postponement because of the forthcoming strikes, when will the Health Secretary get back around the table with the BMA, this time to take talks seriously to stop the damage to patient care?

[Lord Markham (Con)]

We have taken the talks incredibly seriously. We have proven in other areas with the Agenda for Change unions that, with good will on all sides, we have managed to reach an agreement. I think most people would agree it is not a reasonable position to go in saying that, unless they get a 35% pay increase, they are not willing to have any further talks. That is not something that I believe many of us could support. We are always open to reasonable negotiation, as we have proved in the other cases, and we remain open to having that reasonable negotiation now.

[Baroness Thornhill (LD)]

My Lords, many hospital trusts are having to bring in more senior doctors in this period to cover the strikes, at what must be considerable expense. Given that quite a few trusts are already going into deficit due to inflationary pressures, will the Government be making provision to cover these additional and unexpected costs? We know that working as a junior doctor is physically intensive, but it is also a mentally exhausting line of work. The decision to strike will have put serious mental stress on junior doctors; they did not train for years to go on strike and cause this. So who is looking after the mental health and well-being of our junior doctors?

[Lord Markham (Con)]

I think we all agree that the mental health and well-being of everyone in society is paramount. At the same time, I would hope that junior doctors did not feel the need to take this action. As I say, in other areas relating to Agenda for Change we have reached a good outcome. We sat down with the BMA junior doctors committee hoping to have the same constructive conversations around settlements that we had already reached, but unfortunately that was not forthcoming. So my main response to concerns in that space is this: please do not strike. Please sit down with us again and engage constructively.

[The Lord Bishop of Carlisle]

My Lords, we know that a major cause of the strikes that we have recently seen in the health service relates to staff who are overstretched. That is the result of chronic shortages, which suggests a lack of adequate workforce planning. We have just heard that there are currently over 124,000 reported vacancies, according to the NHS Confederation. I repeat a question that was asked earlier, or shall at least reinforce it: when will the workforce plan be published? Without it, healthcare staff will continue to struggle to provide the level of care that they would like.

[Lord Markham (Con)]

As I have mentioned many a time and am happy to mention again, the workforce plan will be announced shortly—soon. I wish I could give an exact date, but it is there. However, I am sorry to say that I do not believe that can be used as an excuse for the strike action that we are talking about now, which puts patients at risk. I know that, in other areas, the Agenda for Change unions have worked constructively with NHS trusts on derogations to protect patients, but I regret to inform the House that that is not the case now. There is lots that we need to do in the workforce space, and there is lots that we want to do around recruitment, motivation and making it a good place to work, but I would like to think that none of that means that the delay of a report is a reason to take this sort of action and put patients’ lives in danger. I do not think any of us would agree that that is a suitable reason.

[Baroness Merron (Lab)]

My Lords, perhaps I could invite the Minister to respond to my first question, building on the points made by the right reverend Prelate. In addition to the NHS workforce plan, which we await, I remind the Minister that we are also waiting for the general practice plan, the review of integrated care services and the social care update. Could the Minister take this repeated opportunity to say whether the Government will be publishing these over the Recess? If this is so, it is obviously of concern that Parliament will not have the chance to scrutinise the plans.

[Lord Markham (Con)]

Like all noble Lords, I absolutely agree that Parliament has to have every opportunity to fully assess, discuss, debate and scrutinise the plans. As noble Lords know, I cannot say when the report will be released, so I cannot say with all honesty whether it will be over the Recess or afterwards. I can only repeat the words “soon” and “shortly”, and say that there is not a definite plan to announce it over the Recess. What we fundamentally agree on is that these plans are being produced with stakeholders and a lot of consultation, and they will absolutely be subject to a lot of scrutiny, as we would expect. I expect to answer on the plans in this House, as I expect my ministerial colleagues in the other place to have to do as well.

[Baroness Thornhill (LD)]

My Lords, I rather cheekily snuck two questions in, and the Minister did not give me an answer to the first one, which in many ways is very important. Will the Government look at and support those trusts that risk going into deficit because of inflationary pressures?

[Lord Markham (Con)]

I thank the noble Baroness for reminding me of that. I will need to confirm it but my guess is that, although trust are having to pay more for consultants to cover positions, unfortunately a lot of junior doctors will not turn up and so there will not be the same level of pay because there are far fewer consultants than there are positions to cover. I wish there was not that problem, candidly. I think we all wish there were enough consultants to cover the exact number of junior doctors. My hunch is that, because of that, the wage will end up being a bit less. I will check if I am wrong, though, and correct it.

Stroke Rehabilitation and Community Services

Lord Markham Excerpts

Wednesday 22nd March 2023 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government what steps they are taking to address staffing and facilities shortages in stroke rehabilitation and community services, and to ensure the national integrated community stroke service is fully resourced to deliver personalised, needs-based, goal-orientated rehabilitation to every stroke patient.

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

We are increasing the number of qualified staff and ensuring a widened pool of trained staff who can work across pathways. This will help ensure that the national integrated community stroke service is fully resourced and address the workforce challenges in rehabilitation and community services. I have raised the issue of access to appropriate facilities with the CEO of NHS England, who will engage with NHS trusts to ensure access to appropriate facilities as the pressure on NHS space abates so that physiotherapists can continue their vital rehabilitation work.

[Baroness Wheeler (Lab)]

My Lords, following my previous Question on this issue, I thank the Minister for writing to ICB CEOs on the urgent need for pre-Covid hospital and community rehab facilities to be returned to their former use. Can he tell me what timescales have been set and how this will be monitored to ensure that it actually happens? Strokes cost the NHS £3.4 billion a year and social care £2.3 billion in year 1, with another £2 billion on top of that for every subsequent year. What specific plans are there to expand the national integrated community stroke service, to ensure specialist rehab within five days of a stroke and to tackle the 68% of stroke sufferers who currently do not get an assessment, let alone rehab treatment, after hospital discharge?

[Lord Markham (Con)]

I thank the noble Baroness for her question and for her tireless work in this space. I have fortnightly meetings with the NHS chief executive. One of the matters that I regularly raise with her is the timing of the return of physio space for this. As for ensuring that we are properly rolling out the services, the national integrated stroke service guarantees people individualised programmes of work and stroke rehabilitation services, in their homes if need be.

[Lord Allan of Hallam (LD)]

My Lords, the Minister told the House yesterday that the long-awaited NHS workforce plan is due “shortly”, which we are reliably informed is sooner than “soon”. We now wait with bated breath. I know that the Minister cannot speak to the specifics of the plan until it is released but I hope he can comment on its structure. Will it have the kind of detail that we need to see how staff shortages in specialist areas such as stroke rehabilitation will be remedied, or will it be so high level that further subplans will need to be developed so that specialist functional needs are not lost in the mix?

[Lord Markham (Con)]

I can confirm that it is a detailed plan. Services such as physio are an important part of that and will be planned accordingly.

[Lord Shinkwin (Con)]

My Lords, as somebody who benefitted from life-saving neurosurgery almost 30 years ago, I can attest to the body’s amazing capacity to repair itself, provided that there is timely intervention. Can my noble friend confirm that timely intervention is crucial, that the resources will be made available, and that not doing so would be a false economy?

[Lord Markham (Con)]

I thank my noble friend and agree. When I was looking at the waiting lists of those in need of physiotherapy, I was delighted to see that 80% of people were waiting less than 18 weeks. A plan is being put in place for musculoskeletal priority patients, so that they do not have to wait any more than two weeks. The urgency of putting these things in place quickly is recognised.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister talked about the national integrated service. He will be aware that rehabilitation services are very patchy and that, over the last four or five years, the amount of time that professionals have spent with individuals has got less. Will this new integrated care service bring us up to higher standards and see consistent standards throughout the country?

[Lord Markham (Con)]

During the pandemic this was one of the areas that probably did not get enough time, for all the good reasons that we understand. Therefore, I am pleased to see that these pathways are being set out so that we can get back to the standards that we need. I believe this is something that we will see happening now.

[Baroness Bull (CB)]

My Lords, the Minister will know that stroke survivors, once in the community, face challenges with long-term rehabilitation and higher levels of depression, anxiety and loneliness than the rest of the community. What assessment have the Government made of arts-based therapies—I declare an interest as I am an adviser currently with King’s College Hospital—to address the whole patient as they recover from a stroke?

[Lord Markham (Con)]

We are very much believers in the importance of social prescribing. I was at a reception just yesterday given by the Alliance of Sport, talking about the importance of active lifestyles for people’s mental health and recovery, and in the criminal justice system. It is something that we agree on the importance of. I will come back in more detail on the arts.

[Lord Addington (LD)]

My Lords, can the Minister expand upon the encouragement that the Government are giving to people in secondary services, to encourage people to fulfil the exercise programmes that are given to them by the experts? Without that encouragement from GPs and practice nurses, such programmes may seem very difficult and may not happen.

[Lord Markham (Con)]

My Lords, that is a very important point. Two things have really struck me. When people are in hospital, they lose 10% of their muscle mass per week, which is clearly key in their ability to have an active lifestyle and look after themselves outside. At the same time, they need constant support and reminders to keep up that active lifestyle. It is very much at the front of our mind.

[Lord Patel (CB)]

My Lords, we know that rehabilitation at the appropriate level is key to the best outcome for stroke patients: some 10% will not have any residual disability, 25% will have a minor disability and 40% will have a moderate disability, but without rehabilitation, 80% will have a major disability. Would it be a good idea to carry out a country-wide audit of what services for the rehabilitation of stroke patients are currently like?

[Lord Markham (Con)]

I thank the noble Lord. I believe that this is what the national integrated community stroke service is all about. It is the responsibility of each ICS to make sure that there is sufficient capacity in their area. At the same time, it is always good to make sure that that is happening, so I will follow up with the NHS to see what plans are in place to make sure that we really are getting that uniformity of service.

[Lord Kamall (Con)]

My Lords, the noble Baroness, Lady Bull, mentioned the importance of arts therapy for rehabilitation and for other issues. I add to her question by asking about the importance of musical therapy, not only for rehabilitation but to help people address mental health concerns. Could my noble friend the Minister add to his answer specifically with respect to musical therapy?

[Lord Markham (Con)]

As I say, I see social prescribing as taking in a whole range of arts, music and sport. Given that that is a particular interest of my noble friend, I am happy to follow up on both arts and music.

[Lord Kakkar (CB)]

My Lords, I draw attention to my declared interests. One of the most effective ways to reduce the burden of disease associated with stroke is to intervene earlier in trying to prevent stroke. What approach do His Majesty’s Government take to screening in the community and in populations for risk factors such as heart rhythm disorders, which, once identified, might be managed appropriately and reduce the ultimate burden of stroke?

[Lord Markham (Con)]

The noble Lord makes a very good point. The House has heard me mention before that Sir Chris Whitty’s major concern right now around excess deaths is the cohort aged 50 to 65, as they missed out on three years of blood pressure and cardiovascular tests during the pandemic. With that in mind, we are looking at how we can roll out those sorts of services to the community so that they are accessible. You might not necessarily need a GP appointment, but could be tested in shopping malls and places like that, so that those things are picked up.

Social Care: Workforce Strategy

Lord Markham Excerpts

Wednesday 22nd March 2023 Lords Chamber

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

The Department of Health and Social Care will shortly publish a two-year plan for how it will reform the adult social care system. That publication will confirm the Government’s commitment to the 10-year vision set out in the People at the Heart of Care White Paper. It will provide specific detail on how we will implement workforce proposals, including funding activity and milestones.

[Baroness Pitkeathley (Lab)]

I thank the Minister for that Answer, but note that he has not assured me about the proposed or rumoured cuts to the current investment in the social care workforce. As he knows, these rumours have caused great distress to those trying to provide decent care to some of the most vulnerable in our society, against the background of a 13% vacancy rate—so one in eight posts is vacant—with subsequent difficulties in recruitment and retention. The money that has been promised seems very slow in reaching the front line, according to local authorities and carer organisations.

I am very glad to know that we are going to see the plan for the social care workforce; we have waited for it a long time. When we finally see it, which I hope will be before the House rises for the Easter Recess, will it ensure that those who work in social care are properly recognised, rewarded and trained so that, at last, their status is comparable with those who work in the NHS?

[Lord Markham (Con)]

I apologise because, in some ways, the timing is slightly unfortunate with the report coming out before the Recess, as is my understanding. I am not allowed to steal much of Minister Whateley’s thunder on that, but I will answer as best as I can. I hope that noble Lords will be pleased that questions around training, recognition of the importance of the service and career structure are all addressed in the report.

[Lord Weir of Ballyholme (DUP)]

My Lords, in my experience, many families in need of social care for members of their families find themselves in a form of postcode lottery, where the quality and quantity of social care that they receive is very much dependent on the local availability of social care workers. What further steps are the Government taking to try to ensure consistency of social care provision for people throughout the country?

[Lord Markham (Con)]

The noble Lord is correct, in that this is pivotal to the whole health service and to health and well-being. It is very much the duty of the integrated care boards, and our Ministers are personally holding them to account on this. I have frequent meetings on seven integrated care boards, and this is very much on the agenda. The other six Ministers have 42 in total, seven each, so that we can make sure we hold them to account.

[Lord Allan of Hallam (LD)]

My Lords, the Minister has repeatedly agreed on the need for increased social care funding when replying to questions in debates. His party set out an ambitious plan for making such an investment in the Government’s Build Back Better strategy of September 2021. How have social care needs changed since then, such that the Government now seem comfortable to cut hundreds of millions from the commitments that they made less than 18 months ago? Does he think that we no longer need more supported housing or better digital services, two of the areas that the reports tell us are facing cuts?

[Lord Markham (Con)]

I do not recognise “cuts” in this context. Noble Lords are aware that we have committed to a £7.5 billion increase over the next two years, which amounts to about a 20% increase. We will see record investment and provision in this area.

[The Archbishop of York]

My Lords, the report by the Archbishops’ Commission on Reimagining Care was published in January. I am sure that the Minister is aware of this: in fact, I know that he is having a meeting later today with the right reverend Prelate the Bishop of Carlisle, who co-chaired that commission. We argue for a very bold approach to social care, which puts at its heart the concept of a care covenant, with clear expectations on each of us of what we should give and expect in return, recognising that each of us is a carer and that most of us will need care one day.

I speak as someone representing a region. In the cities of Hull and Middlesbrough, which I serve, I see many people in need of care and not receiving it; I discover that recruitment and retention are appalling; and I find care workers having to use food banks so that they can feed their families. It gives me no pleasure to say that we are in a very distressing situation.

I realise that the Minister is not in a position where he can say much but, surely, at the heart of this, as the noble Baroness said, it is about valuing the care worker in the same way that we value others. Can he give us an assurance that this will be at the heart of what is proposed?

[Lord Markham (Con)]

Absolutely. I speak as an ex-carer myself. Caring is part of everyone’s role, as has been quite rightly written about. Part of this is about the people we are employing. I am glad to say that we are managing to increase recruitment, which is not easy in the age of full employment. It is about the parts that you and I—all of us—can play in care in the community, and organising domiciliary care so that we can have a full wraparound service.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, on seeking to increase the size of the workforce, could the Minister give an indication of whether there will be more overseas workers? They have made such an important contribution in the past but have run down in numbers latterly, yet people want to see more coming from overseas.

[Lord Markham (Con)]

Yes, and I am delighted to say that it is working. We will have granted 57,000 visas towards that in the last year, which is a big increase on previous years. It is fundamental, and a fine tradition of our health and social care services, that we can use overseas workers.

[Lord Hodgson of Astley Abbotts (Con)]

My Lords, when you have very rapid turnover of staff and a high level of resignations, it is not always the staff who need training but the managers. As we make people more valued among the staff, will we ensure that managers learn how to do that and that training goes to all levels of the care-working profession?

[Lord Markham (Con)]

My noble friend makes a very good point. I am aware that some homes have half the turnover rate of staff than others, clearly demonstrating much better levels of management and skills. I agree, and that will be part of the training.

[Lord Kamall (Con)]

Following the question from the noble Lord opposite about recruitment from overseas, I thank the Government for acknowledging that we will need immigration to fill some of the skills gaps. An issue that has been raised a number of times in this House is visas for social care personal assistants. Can my noble friend the Minister update us on whether visas are being issued for this category of workers?

[Lord Markham (Con)]

We recognise the contribution that overseas workers can make here, as demonstrated by the 57,000 visas. I will need to come back to my noble friend in writing with details on his precise point on personal assistants.

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

My Lords, on recruitment and retention, the Minister will be aware that the majority of care workers earn less than £10 an hour. Can he tell us when the majority of care workers will earn a real living wage?

[Lord Markham (Con)]

My understanding—I am doing this partially from memory so I will correct it if need be—is that the national living wage will come in shortly, in April. Care workers are paid that. I believe it is over £10, but I will confirm that.

[Lord Walney (CB)]

Further to a number of questions, I point out that the Minister talks about the recognition of the need for overseas workers to plug the gap at the moment, but where is the government strategy to focus on the growing number of British people who are trapped outside the labour market and need further support? This care profession, with appropriate levels of remuneration and support, could be a way to get more people off inactive benefits and into the workforce.

[Lord Markham (Con)]

I was very pleased, as I hope other noble Lords were, that the centrepiece of the Budget just last week was the need to get more people into the workforce. The health department clearly plays a key part in that with mid-life health MoTs to help and support people getting back into work, including things such as physiotherapy, which we mentioned just now, to give them the strength and confidence to go back to work.

Medical Devices and Blood Safety and Quality (Fees Amendment) Regulations 2023

Lord Markham Excerpts

Wednesday 22nd March 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 6 February be approved.

Considered in Grand Committee on 20 March.

Motion agreed.

Health Education England (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Lord Markham Excerpts

Tuesday 21st March 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 20 February be approved.

Relevant document: 32nd Report from the Secondary Legislation Scrutiny Committee

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

My Lords, the noble Baroness, Lady Merron, has tabled a Motion to Regret, and I will first address her concerns in turn.

First, the noble Baroness noted that the regulations do not offer sufficient evidence to support the change, and that the information on the potential costs of and savings from this reorganisation are unspecified and vague. In response, I note that an amended version of the Explanatory Memorandum for these regulations has been laid, with additional information on the costs and benefits of, and evidence for, the transfer of functions from Health Education England to NHS England.

As the Explanatory Memorandum sets out, there are some smaller costs and savings relating to the transfer of Health Education England’s functions to NHS England, and more significant costs and savings related to the wider transformation programme that NHS England is currently undergoing, which would include the transferred Health Education England functions. As I will set out in more detail later, overall, the merger of HEE and NHS England will bring significant benefits to the delivery of workforce planning for the NHS.

Transition costs include the creation of the HEE transition programme office and short-term consultancy to deliver the overarching design and the new workforce function. Ongoing savings and efficiencies from the wider NHSE transformation programme are expected to include a reduction in the total size of the new NHSE, including Health Education England and NHS Digital, of up to 40%; savings from not having a Health Education Board; and removing the need for a range of duplicate processes currently in place.

These amendments to the Explanatory Memorandum are also intended to address comments on the regulations by the Secondary Legislation Scrutiny Committee in its 32nd report of Session 2022–23.

The noble Baroness’s second point was that the regulations have not been published alongside the Government’s NHS workforce plan. I will say more about the longer-term plan later, but I can confirm that the Government have committed to publishing the plan this spring and will include independently verified projections for the number of doctors, nurses and other professionals who will be needed in five, 10 and 15 years’ time, taking full account of improvements in retention and productivity.

The noble Baroness’s final point was that the regulations do not guarantee that NHS England will give long-term workforce issues sufficient priority. I can confirm that the Government are putting in place a range of measures to ensure that NHSE places sufficient priority on these vital issues. This includes setting objectives on workforce within the NHS England mandate, continuing to monitor and track expenditure on education and training, and establishing a ministerially chaired board to provide oversight and governance of workforce in the NHS.

--- Later in debate ---

[Lord Markham (Con)]

I thank noble Lords for their contributions to today’s debate. As ever, I will attempt to answer the questions as best I can, and I will come back in writing with the details.

First, on when the workforce plan will be published, forgive me for this answer but I cannot resist it. I looked on the HEE website and it will be delivered “at the right time and in the right place”. I could not resist that one. I think the term I am allowed to use is “shortly”, which is different from “soon”, but I will let noble Lords decide. Seriously, however, there is a very detailed plan. While I acknowledge that there are concerns about delays and this being “Treasury-fied”, at the same time, serious questions have been raised, as we would expect. This is leading to a lot more thinking, which is the right thing to happen, provided we come out with the right answer. I hope noble Lords understand that work is going on to ensure deliverability.

I will try to answer the many questions asked, particularly on what the measures of success will be, as raised by the noble Lord, Lord Scriven. From my point of view—it may be personal—we are publishing the workforce plan and the measure of success will be how well this body performs against that. It will not be down to that body alone; it is part of the newly merged entity. As the noble Lord, Lord Scriven, said, it is about recruitment, training and retention.

A key issue, as I know from being tangentially involved in some of the conversations with unions in the last few weeks, is a real recognition on our part that pay is a core issue, but so are things such as hot meals, rest areas for staff and parking. Some of those issues are important “health factors”, if you will excuse the pun, and we are very alive to them.

Turning to the questions raised by the noble Baroness, Lady Merron, and the noble Lords, Lord Allan and Lord Scriven, as I say, it is about looking at savings across the piece. As noble Lords will know, we are talking about quite a considerable structure. The average trust is run by 300 or 400 admin staff; an ICB has 700 staff; a region has 650 to 700 staff; the NHS itself, at the centre, has 4,000 staff; and the Department of Health and Social Care accounts for another 3,500 to 4,000 staff. I think we would all agree that layer upon layer of management is not good, from not only a cost and efficiency point of view but a management point of view. We all talk about our various backgrounds, and speaking from mine, the fewer layers you have between the so-called management and the front line, the better. That is the wider picture of what we are trying to do here.

[Lord Scriven (LD)]

I totally agree. I think Tesco, for example, has four levels of management between the customer and the chief executive. But I hope the Minister understands that, regardless of layers—this may not make me popular outside this place—the NHS is one of the most effective health services in western healthcare in terms of management costs. I hope the Minister does not take the populist view that having a go at the managers suddenly makes savings. We have to get the balance right. On comparators, the NHS is significantly well placed in the western world in terms of its cost ratio of managers to patient care. I hope the Minister will accept that.

[Lord Markham (Con)]

The noble Lord is right: it is about the effectiveness of the layers. I come at this from the view, “How do we make this most effective?” That is the major gain to be won from all this.

The noble Baroness is right to bring up the issue concerning the Secondary Legislation Scrutiny Committee. I have spoken to all the staff in the DHSC about it, and I have given assurances to the House on the importance we attach to it. I am meeting the Leaders of both Houses tomorrow to discuss how we are working to make improvements in this space. Hopefully, we are making progress.

I thank the noble Baroness, Lady Watkins, for her contribution. It is fantastic to have her on the board, given her experience. Several noble Lords asked about the social care element. As we know, the situation is slightly different because most people in the social care space are employed by third-party organisations. There will not be a direct read across, but the Minister will be announcing shortly the next version of People at the Heart of Care, which aims to address a number of issues. It is probably best to wait for that, and we can take it from there.

I have tried to cover as many of the issues raised as possible, and I am quite happy to follow up in writing any I have missed. Reassurance was sought regarding current training budgets, pointing out that, while we want to make savings where possible, we need to know they are being made in the right place. A separate board structure is being set up within the organisation to make sure that such matters are separately scrutinised and not lost within the overall picture, because it is understood how vital that is. These are all elements I will try to cover more completely in a written response.

[Lord Scriven (LD)]

That is a helpful answer. To be clear, you can have a separate board, but if the budget is not ring-fenced, all that they are scrutinising is a smaller budget. I think the question that was asked—although maybe not specifically—was, will the training budgets be ring-fenced and will the board therefore be looking after a ring-fenced budget?

[Lord Markham (Con)]

I think that is probably one element I need to come back to the noble Lord on in writing.

As I said, I will try to follow up the questions in detail. I welcome the contributions of various noble Lords and their understanding of what we are trying to do here. I understand the arguments, as an ex-management consultant, regarding centralisation versus decentralisation and how they go in and out of fashion. This is a slightly different case because it is about bringing a core function in house. To me, that is the key change and the key thing we will be seeking to measure. As well as setting out clinical needs, the key role of the NHS at its centre is making sure that it is recruiting, training and retaining talent to meet the workforce plan needs. On that note, I thank noble Lords for their contributions and hope that my follow-up answers any questions that I missed.

[Baroness Merron (Lab)]

My Lords, I am grateful to the Minister for his response, and to the noble Lords who have spoken in this debate: the noble Lords, Lord Scriven and Lord Allan, and the noble Baroness, Lady Watkins. I did smile when the noble Baroness gave us an update on the workforce plan, which I am sure was helpful to the Minister, and I also wish her well in her new role.

As the Minister and your Lordships’ House will have equally understood, this is not about the actual steps that are being taken. We have had a useful debate to pull out some aspects, but the regret Motion is about the workforce and, in particular, the failure to have produced a workforce plan. This is not something recent from the last year or so. We have to remind ourselves that this Government have been in government for 13 years, and still we wait. For every day we wait, we lose an opportunity—as noble Lords have said—to plan for the future, as well as to deal with the immediate, and that is what motivated me to put forward this amendment.

We are all in agreement today that a workforce plan has to be for health and social care, which are inextricably linked, and has to not sit on the fence—well, it may; we will see. The plan has to not sit on a shelf but be fully resourced and do the job it is intended to do. We will look forward to holding the Minister to account on that point, as I know he expects.

Regrettably, I do not believe that in this debate the Minister has addressed the shortcomings of the regulations before us. Those shortcomings are somewhat unnecessary, which is a great shame because overall the statutory instrument is one that will be beneficial. It is a shame that we have had to debate it in this fashion. With that, I beg leave to withdraw the amendment.