Communications Act 2003 (Restrictions on the Advertising of Less Healthy Food) (Effective Date) (Amendment) Regulations 2022

Lord Markham Excerpts

Monday 27th February 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, the Children’s Minister recently admitted that the nation had a problem with childhood obesity that should not be ignored. I am sure that noble Lords who have spoken today, and I am grateful to them, will share that view, not least because children with obesity are five times more likely to become adults with obesity, increasing the risk of developing conditions including type 2 diabetes, cancer and heart and liver disease. This is an extremely serious and pressing matter, as the Minister has been reminded yet again.

Two in five children in England are above healthy weight when they leave primary school and we now see the fastest increase in childhood obesity on record, as my noble friend Lord Brooke highlighted in his remarks. But it gets worse. Children starting school in the most deprived areas are three times as likely to be severely obese as those in the wealthiest, while NHS data shows that almost half of boys in England’s poorest areas are overweight or obese when they leave primary school. Last year, there were 3,400 severely obese children aged four or five in the most deprived parts of the country, as compared with 630 in the richest. So will the Minister give some indication as to what account is being taken of this great disparity between those who have more and those who have less in the Levelling-up and Regeneration Bill currently being considered in your Lordships’ House?

As we have heard today, it is absolutely right that we make informed choices about what we eat and drink, but choice can only really be choice if there is no distortion, and if those who are making the decisions have all the information they need and are able to interpret it. As the noble Baroness, Lady Bull, said, we actually need an integrated health approach to tackle the complexities of achieving a healthy weight. So the question for the Minister that has run throughout this debate is: how will the statutory instrument support this integrated health approach to tackle the complexities we know we have?

In the Government’s original analysis, they suggested a watershed on advertising, saying that introducing restrictions to prevent adverts for products high in salt, fat and sugar being shown before 9 pm could lead to 20,000 fewer obese children. I took it that this was, as others have said in the debate today, about shifting the environment, shifting the power of influences, in order to manage the challenges that we all face in supporting our wish to secure good health. So, will the Minister tell your Lordships’ House what will be the change in opportunity to tackle children’s obesity because of this regulation and the change it brings about? I refer in particular to page 33 of the Secondary Legislation Scrutiny Committee report. The noble Baroness, Lady Walmsley, referred to the figures. The report states:

“Analysis conducted to inform the Government’s Impact Assessment of the advertising restrictions found that under current restrictions children were exposed to 2.9 billion less healthy food and drink TV impacts and 11 billion less healthy food and drink impressions online in 2019”.


The committee observes that the effect of the delays means that, presumably, this level of advertising will continue and asks for an explanation as to why this is acceptable given the harms stated. Perhaps the Minister could refer to an answer on this point. The committee also asks for an explanation as to how the Government anticipate that they will still achieve the target of halving childhood obesity by 2030 if various elements of the strategy are delayed. Again, perhaps the Minister can tell your Lordships’ House his view on this.

Of course, there is a difficult balance to strike when seeking to improve public health and also when working with broadcast and online and the advertising industries. The Government have produced a regulation that has been drawn to the attention of the Secondary Legislation Scrutiny Committee once again, and this clearly does not assist the striking of that balance. It is not acceptable that the Explanatory Memorandum is described as “poor”, and that it fails to evaluate the effects on public health and the NHS from this delay. Nor is it acceptable that it fails to explain the use of a different definition from previous legislation. This refers to the unexplained shift from “high-fat, sugar and salt” to “less healthy foods”. The committee rightly asks whether the Government’s intended scope of products that they want to regulations to cover have been changed. Perhaps the Minister could respond on this point.

The SLSC also says that it

“provides insufficient information to gain a clear understanding about the instrument’s policy objective and intended implementation.”

It also says that, worryingly:

“The views of the NHS are not addressed or explained.”


This, I believe, is quite remarkable and suggests a breath-taking lack of engagement with those who should be engaged with. Once again, poor policy-making and poor administration have come together to leave your Lordships’ House unable to properly scrutinise what the Government are doing and why, even though it is the job of your Lordships’ House to do this. Perhaps the Minister could address these points of concern.

The Minister will recall that I have raised many times before the point about his department’s approach to legislation and the criticism that it has attracted. He kindly gave an undertaking that he would look into this with a view of doing better in future. Can the Minister could update the House of progress in this regard? Finally, I hope that the Government will not be diverted from measures that will have an impact on the health and weight of the nation.

[Lord Markham (Con)]

My Lords, I congratulate the noble Lord, Lord Allan—despite his wish to invite people to kick our balls—and the noble Baroness, Lady Merron, for securing the debate to discuss these regulations. I also thank the Secondary Legislation Scrutiny Committee for its report on this, and I thank all noble Lords for their constructive discussion on how to tackle the pressing challenge on obesity. I thank the noble Baroness, Lady Bull, in particular, for her thoughtful contribution showing the complexities of the subject with regard to the impact on eating disorders, as well as obesity.

I like to think that we are all agreed on the scale and the gravity of the issue at hand. Data from the latest child measurement programme, as mentioned by others, shows that 38% of children leaving primary school were either overweight or living with obesity. One in four were living with obesity. This, as we know, is fuelled by the regular overconsumption of food and drink that is high in calories, sugar and fat—or HFSS food and drink for short. As the noble Baroness, Lady Merron, mentioned, we know that being overweight or living with obesity at a young age increases the risk of being overweight as an adult which, in turn, significantly increases the risk of diabetes, coronary heart disease, musculoskeletal issues and certain cancers. This impacts on both the individual’s well-being and wider society. As we all know, it comes at a very high cost. Not only does it cost the NHS £6.5 billion a year in the latest estimates—there is an economic cost estimated to be as much as £58 billion. For all those reasons, this Government are committed to tackling obesity: it is the morally and fiscally responsible thing to do.

Physiotherapy: Rehabilitation Services

Lord Markham Excerpts

Thursday 23rd February 2023 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government what assessment they have made of the survey by the Chartered Society of Physiotherapy, published on 1 December 2022, which found that there was a shortage of rehabilitation services, that rehabilitation spaces had not been returned to use for physiotherapy care following the COVID-19 pandemic, and that stroke survivors were being “imprisoned at home with a bed and commode” while waiting for care.

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

We welcome the Chartered Society of Physiotherapy survey and the valuable insights it gives us regarding rehabilitation services. Integrated care systems are responsible for commissioning appropriate services for their local populations. Decisions on the use of physical estates are rightly for local organisations. Rehabilitation and physiotherapy are critical to many patients’ care and recovery. For stroke survivors, the NHS aims to deliver personalised, needs-based, goal-oriented rehabilitation to every stroke survivor in their home environment.

[Baroness Wheeler (Lab)]

My Lords, the CSP survey paints a dismal picture of the state of rehabilitation services: overstretched and underresourced prior to the pandemic and still struggling to re-establish physio rehab services that had their staff, space and facilities diverted to deal with the crisis and with chronic staff shortages. The recent stroke audit showed that only 10% of the UK’s stroke survivors were able to access the recommended amount of rehabilitation they need. What actions are the Government taking to address this unmet demand for the vital services that will help prevent patients deteriorating and becoming more frail and vulnerable?

[Lord Markham (Con)]

I thank the noble Baroness for bringing this to our attention; again, I believe that the advantage of these Questions is that they shine the spotlight on particular areas. As the survey pointed out, there are a lot of places which, for very understandable reasons, were swapped over to Covid uses during the pandemic and which now need to be brought back into physio use. That was one of the main recommendations from the society, and we will now write to all the NHS chief executives on the back of that. As the House will be aware, I am doing some work anyway to make more space available as part of the capital programme, so this is very much on my list to make sure that we expand that space and provision.

[Lord Addington (LD)]

My Lords, does the Minister agree that physiotherapists do very little of their work in the actual appointment, and that it is the supervised exercise patterns they give patients afterwards that are probably the most important for all forms of rehabilitative structure? Bearing that in mind, what is the Department of Health doing to make sure that local government has facilities such as swimming pools and gyms that remain open under the financial squeeze?

[Lord Markham (Con)]

I agree with the noble Lord’s point; our estimate is that over half of all physiotherapy takes place outside the hospital environment. Clearly, all sorts of settings, including swimming pools and gyms, are vital for that. The work we have done with the Energy Bill and the caps has been a vital help to those leisure centres, and, thankfully, we are now starting to see bills come done and so these places are on a better financial footing.

[Lord Patel (CB)]

My Lords, I was previously a trustee of the Stroke Association and the chair of Chest Heart & Stroke Scotland. Every five minutes, a person suffers a stroke. Their outcome depends on two crucial factors: first, the so-called golden hour during which they should receive treatment—if they do not, their outcome is poor—and, secondly, the rehabilitation they get over the next three to six months, including training on speech, mobility and dealing with daily life. Sending these patients to care homes or their own homes without that kind of support decreases their outcomes considerably. Currently, 10% of these patients end up in nursing homes for ever; if these services are not available, that number rises to 30% to 40%. So, despite the positive response from the Minister, there is a degree of urgency for integrated care boards to address the issue of rehabilitation for stroke patients.

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[Lord Markham (Con)]

Absolutely. That is why, as part of my research, I was pleased to read up on the national integrated community stroke service, which is designed to give personalised stroke rehabilitation in every person’s home. Its work is vital in achieving this. The House has heard me talk many times about the 13,000 beds that are blocked in our hospitals, and a lot of the way to free them is by having rehabilitation and getting people back into their home environment. I absolutely agree on the importance of this issue, and that is why noble Lords will see it as an important part of the workforce plan.

[Baroness Manzoor (Con)]

My Lords, I welcome the Answer my noble friend the Minister gave, but I will give him a real-life example, and declare my interest in doing so: somebody had two strokes, then had a third while waiting over an hour for an ambulance to arrive, has had no physiotherapy rehabilitation at home, and is still waiting a year on for that. This is a real example of people on the ground. Does the Minister agree that we must connect our policies with very clear outcomes?

[Lord Markham (Con)]

Totally. I am sorry to hear that case, and I think that we would all agree that that is not the sort of service we would want to see. As I said, we have put increases in staff in place—there have been 3,300 extra staff since 2017—but, clearly, we need to do more. That is why I was very pleased to read that this area is an important part of the workforce plan, which noble Lords will be happy to hear we are now seeing drafts of.

[Baroness Pitkeathley (Lab)]

My Lords, if stroke survivors are imprisoned at home with a bed and a commode, as my noble friend’s Question suggests, does the Minister agree that their unpaid carers are similarly imprisoned? Is the lack of rehabilitation services part of the reason why the numbers of people giving more than 50 hours a week unpaid care is increasing rapidly, as the latest census figures suggest?

[Lord Markham (Con)]

As I said, physio is key to rehabilitation, whether for strokes, as we have discussed, or for any one of the number of reasons that people are in hospital and trying to come out. As I mentioned, we have seen increases: there are about 7% more people now in training each year, and that figure increases each year. We now have about 50,000 physios in the public and private sectors who are providing those types of services. Clearly, there are examples where we need to do more, but we are also making progress.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest as the president of the Chartered Society of Physiotherapy. Do the Government recognise that almost three-quarters of physiotherapists feel that they cannot do their job properly now, and that, as well as a workforce plan, there needs to be a workplace plan for adequate rehabilitation that goes way beyond cancer and stroke services? All orthopaedic operations, and many other interventions, will not be successful without adequate, immediate physiotherapy in the post-op period, so, by failing to provide physiotherapy, we are stacking up problems for the future with long-term physical dependency and not maximising the benefit of interventions provided early.

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[Lord Markham (Con)]

I start by wishing the noble Baroness a happy birthday. I was pleased to read the three recommendations from the Chartered Society of Physiotherapy: return the rehab space to use; include physios in the long-term workforce plan; and give staff and space to the physio service. As I have said in my earlier responses, we are working on all three: we are working with the NHS trusts to return the rehabilitation space; we are putting physiotherapy in a very important part of the workforce plan; and we are providing the services. So we are making a lot of progress, but I welcome the involvement of the Chartered Society of Physiotherapy in that.

[Lord Allan of Hallam (LD)]

My Lords, it is pleasing to hear that physiotherapists are included in the proposed and long-awaited workforce strategies; there is clearly a shortage in this area. Can the Minister comment on today’s press reports that, while his department is persuaded that there needs to be a dramatic increase in training places across the medical professions, his friends in the Treasury are declining to support that essential expansion?

[Lord Markham (Con)]

As we are all aware, the Chancellor was very keen to kick this off in the first place. We have been participating in this by working very closely with the Treasury, and I am heartened by the work we are seeing on it all. There are some early reports, and, while they do not yet know the full picture, I am looking forward to being able to talk to the whole House about it in the not-too-distant future.

GP Appointments

Lord Markham Excerpts

Thursday 23rd February 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what assessment they have made of (1) the impact that the logistical difficulties of getting a GP appointment has on patient outcomes, and (2) the extent to which the needs and choice of individual patients are being met in making healthcare appointments.

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

We recognise that some people have struggled to access timely care from their general practice. We are taking action to expand general practice times to increase the availability of appointments, upgrade practice telephone systems, and publish data about how practices are performing so that patients can make informed choices when registering and commissioners can help the service to improve. In 2022, nine out 10 patients felt that their needs were met at their last general practice appointment.

[Baroness Merron (Lab)]

My Lords, the latest GP Patient Survey shows that more than one in four of those needing an appointment actually avoid making one because it is just too difficult. So does the Minister accept that practices such as being made to ring at 8 am, long phone queues, waiting hours for a call back and no online booking, all stack up more serious problems for the patient and the National Health Service? What are the Government doing to tackle these very basic practices, so that people can get to their GP in a way that suits them?

[Lord Markham (Con)]

Absolutely. One of the things I am very proud to be leading on the NHS side is our whole digital way of addressing access to the health service. This will be fundamental to how people make their hospital appointments and take control of their own health, so it will be the main thing that will help with the 8 am appointments, alongside the increased telephony services and everything else. Just as every walk of life is coming down to being able, at your fingertips, to make appointments and bookings and get your own records, this will also be the case with GP surgeries and I think it will fundamentally change the way that we address our whole health.

[Baroness Jolly (LD)]

My Lords, part of the problem is where there is no mobile phone signal. People who live or who have homes in Cornwall will identify with that. Does the Minister have any idea what proportion of patients find accessing their GP difficult? What advice has been given to practitioners on resolving the issue? In rural areas such as Cornwall and Northumberland, there are poor bus services, if any. Getting home can mean a really long wait—sometimes half a day if there are only two buses a day. What advice would the Minister give to the GP and to the patient?

[Lord Markham (Con)]

First, my understanding is that the vast majority of homes in Cornwall have broadband, to which your mobile phone will of course connect. That is where people will be making appointments from. They can use digital to do that. Secondly, we are rapidly increasing the number of doctors’ appointments. We made a pledge to increase the number of appointments by 50 million. To date, we have increased them by 36 million—11% up since 2019. So we are making more appointments available. Do we want to do more? Absolutely. Are we going to publish a primary care plan shortly to show how we will address those additional needs? Yes.

[Lord Kakkar (CB)]

My Lords, I draw attention to my registered interests. Deprived communities often have the most acute shortages of general practitioners, yet it is among those populations that there is the greatest burden of chronic comorbidity that requires integrated care, with a particular focus on communities where outcomes are the poorest and the healthy life years are the shortest. What do His Majesty’s Government propose to do about addressing the specific issue of GP shortages in deprived communities?

[Lord Markham (Con)]

As mentioned, we are increasing the number of doctors. We have 2,000 more versus 2019. The House will be pleased to know that that is a key part of the workforce plan for recruiting and retaining more doctors. As to comorbidities and deprived areas, clearly that is the role of the integrated care boards. They are set up very much to understand the needs of their areas and to make sure that they are looked after properly. In a lot of cases that means investing in primary care. We all know that a lot of the reason why we have a lot of people in A&E is that they cannot get GP-type services, so getting upstream of that issue and investing in primary care is the direction in which we need to go.

[Lord Sandhurst (Con)]

My Lords, it is often forgotten that general practitioners, unlike salaried NHS doctors, are self-employed contractors under contract to provide services. What plans, if any, do the Government have to review the existing GP contract to ensure that new terms are imposed to require better delivery of services by general practitioners?

[Lord Markham (Con)]

My understanding is that the new GP contract is part of live conversations with the BMA that we are about to get into—I think it is over the summer that those negotiations will start to take place. Within all of that, we will be looking at all those sorts of things in terms of how we want to see the GP service evolve. At the same time, we will be talking openly to the BMA about what it wants for its doctors, so that we get an outcome that works well for both sides.

[Lord Foulkes of Cumnock (Lab Co-op)]

My Lords, has the Minister seen the report produced today by the Auditor-General for Scotland? It is devastating about every aspect of the NHS in Scotland, including access to GPs. How much of this is because of underfunding by the UK Tory Government and how much because of the devastating administration of the Scottish Government?

[A noble Lord]

Go on.

[Lord Markham (Con)]

Are you going to dare me?

Sorry, I think a diplomatic response is probably wise at this stage. I note that, under the Barnett formula, per person funding for the NHS is Scotland is higher than it is in England. So there is significant funding in place. How well it is administered north of the border is probably a matter for the Scottish Government.

[Lord Bellingham (Con)]

My Lords, is it not the case that many European countries charge patients who fail to turn up for appointments without due cause? Is this something we are going to look at in this country?

[Lord Markham (Con)]

I am clearly aware of that. At the same time, I am very aware that we want to make sure that people are able to see a doctor when they need to and are not deterred from that. So we would have to tread very carefully and it is definitely not in our plans at the moment.

[Baroness Bull (CB)]

My Lords, given that a dual system of online and in-person GP interaction is inevitably the future and that virtual appointments are clinically appropriate in some circumstances, what are the Government doing to increase public confidence in virtual interactions with their GP? How will they ensure that all triage systems do not disadvantage those groups who are less likely to vocalise their preference or to advocate for the urgency of their own needs?

[Lord Markham (Con)]

Absolutely. One of the key benefits of the digital approach is the triage system. We all know that a lot of people who call at 8 am for an appointment could probably be well served by a pharmacy, a physio service or nursing. So proper triage through a digital-type system is a big step forward. It will end up with them being able to make an appointment with the pharmacy, physio—or the GP in this case. It will also free up resources so that those people who are not able to access digital services are able to get through at 8 am and speak to a person. So I really believe there is a win-win for both sides and personally I am very excited to take this through the House later in the year and see all the services that will be launched.

[Lord Allan of Hallam (LD)]

My Lords, following on from the Minister’s previous answer, what steps are the Government taking to develop the profession of care navigator? They are skilled staff who can make sure that people are directed to the right resource, whether a GP, nurse or pharmacist. Some people can use digital, but others need a personal contact for that direction process.

[Lord Markham (Con)]

Absolutely. I know that a lot of the best trusts that I have seen and visited have that right at their front door. It applies to A&E as well. One of the first comments I made when I joined the department was about expanding pharmacy services. That is brilliant and is part of the increase we are seeing but, if we are not telling people when they should go and under what circumstances, how is this going to help? So, yes, there will be both digital and analogue navigation.

[Lord Wigley (PC)]

My Lords, the Minister referred to the generous provision of finance to Scotland through the Barnett formula. In that case, does he accept the underfunding of Wales through that formula? This has been recognised by a committee of this House. Does he therefore recognise that the pressures on the health service in Wales faced by the Government in Cardiff are a direct consequence of this underfunding?

[Lord Markham (Con)]

Again, my understanding is that Wales receives more health funding per person under the Barnett formula than England. I am pretty sure I am right on that—I will confirm if I am wrong, but I am pretty sure I am correct. So both the Welsh and Scottish Governments have more funding than England. Do they get better outcomes? Well, I would rather be living in England, let me put it that way.

Adult Social Care

Lord Markham Excerpts

Monday 20th February 2023 Lords Chamber

[Lord Laming]

To ask His Majesty’s Government what steps they are taking to meet the needs of the 10 million people in England affected by the adult social care system.

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

My Lords, 10 million people in England are affected by the adult social care system, including those drawing on care and support, unpaid carers and the workforce. We have made up to £7.5 billion available over two years to put the sector on a stronger financial footing, improve access to social care and address workforce pressures. We will publish further details this spring, setting out how we intend to make improvements to the system.

[Lord Laming (CB)]

My Lords, I am grateful to the Minister. He will know that, at any time, any one of us could suddenly become responsible for the care of another person who has experienced a life-changing condition—indeed, any one of us might need to be cared for in those circumstances. The evidence to the Adult Social Care Committee was extremely compelling, indicating that unpaid carers feel that they carry a huge burden but are largely unappreciated and ignored. One wrote only last week, saying that, “after years and years of nursing experience, I now feel completely worn out and very lonely”. Could the Minister assure the House that the Government will take note of the recommendations of the report?

[Lord Markham (Con)]

I thank the noble Lord for his Question and for the work he has done around this report. As an unpaid carer for a number of years myself, I am familiar with the circumstances and the fact that unpaid carers are the backbone of the social care sector. I like to think that we are making moves in the right direction. The weekly allowance, the ability to have a one-week break and the ability to go to your local authority for extra support where needed are all steps in the right direction. But there is definitely more we will be announcing that we are doing in this space.

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[Lord Forsyth of Drumlean (Con)]

Answer.

[Lord Markham (Con)]

It is lovely to have noble friends.

Given the conversations I am sure we will come to shortly about improving hospital flow and the 13% of beds that are blocked, we felt that the focus needed to be very much on providing beds for short-term care. That is where we wanted to put the £7.5 billion of extra funding. We thought that was the immediate priority because we knew the flow issues were impacting A&E, ambulance wait times and everything else. That is not to say that we do not intend to implement all the Dilnot reforms, but the priorities were very much around improving flow and discharge.

[Baroness Barker (LD)]

My Lords, when Sajid Javid was Minister for Health and Social Care, he stated publicly what some of us had long suspected: namely, that we have a health and social care system that is predicated on the assumption that people will be looked after primarily by their families. One million people are ageing without children; they do not have close family to look after them. When will his department acknowledge the existence of this group of people, and when will it be a requirement for planners of health and social care to take them into consideration?

[Lord Markham (Con)]

Again, I would like to say that the big increases in funding—the 20% increase that we are talking about in two years’ time—are very much an acknowledgement that there is a demographic issue here, where more and more people are going to be coming into this situation. That is why we are putting those plans in place and working on the workforce; we are already seeing thousands of people being recruited every month to assist with capacity in the system. So we are putting in place the plans to address that.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, one of the issues identified in the report of the Adult Social Care Committee, on which I had the privilege to serve with the noble Lord, Lord Laming, was the invisibility of unpaid carers. What are the Government doing to support services to identify unpaid carers, and what more targeted support can we give this vital population—more than just one week of carer’s leave?

[Lord Markham (Con)]

Again, as I said before, they are the backbone of the system; some of my personal experience attests to that. So I hope that what we were talking about will be seen as the start, rather than the end, of what we are trying to do. But we recognise that it is a decent start, because this issue has been out there for many years and we are starting to address it. Obviously, forums such as these make sure that it is something that more people are aware of. I accept at the same time that a week a year is a start in terms of a break; it is not the end of the situation.

[Baroness Meacher (CB)]

My Lords, I recognise that the Government are understandably very concerned about public expenditure, but I wonder whether they have recently undertaken a cost-benefit analysis of spending on social care. For £1 million of additional spending on social care, what would be the savings to the health budget? I have a feeling that it could be at least £1 million, and possibly rather more.

[Lord Markham (Con)]

Absolutely, and that is the whole intention behind the ICSs: the ability in their areas to know local needs and invest in the right places—that is, in social care rather than having people in beds in hospitals, because it is a much more effective use of resources, and also in primary care. We all know that a lot of people go to A&E because they have not got primary care services, so the whole point of the ICSs is that they start to invest where demand is in the area, rather than using hospitals as the place of last resort to go to.

[Lord Bradley (Lab)]

My Lords—

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[Lord Bradley (Lab)]

My Lords, I too was a member of the Select Committee. One of the other key recommendations of our report was the establishment of a commissioner for care and support, to act as a champion for older adults, disabled people and, crucially, for unpaid carers, and that we should prioritise to ensure a review, update and implementation of the Care Act. Do the Government support these proposals?

[Lord Markham (Con)]

Again, we welcome the report and many aspects of it. What I and my ministerial colleagues care most about is having the results and the impact. I think—and hope that noble Lords will agree when they see the work that she is doing in this space—that Minister Whately is gripping it and providing results. Let us see how that progresses first, because I think that that will have the impact that we need.

[Lord Forsyth of Drumlean (Con)]

My Lords, given that the Government promised that they would fix social care, and given that in the Answer to this Question the Minister said that there were 10 million people affected, is it wise to go into a general election without having done so?

[Lord Markham (Con)]

As ever, I thank my noble friend for his friendly questions. No; we know that this is an area that needs to be addressed, and I think that it is an area that we are addressing. I have been up here for about five months now, and in the time that I have been here, we have announced a £7.5 billion increase in spending over two years, a £700 million discharge fund over this year, and the recruitment of thousands of people every month from overseas. Yes, there is a lot more to be done, but there have been some very solid results in the meantime.

[Baroness Wheeler (Lab)]

My Lords, on that theme, the Minister makes much of the Government’s historic £7.5 billion social care funding settlement, but he knows that it has been and remains seriously underfunded—the Health Foundation’s estimate is a £12 billion a year shortfall. As the excellent Lords committee underlines, it is no good attempting to resolve the social care crisis by providing short-term funding for more care packages while still depending on local authority council tax flexibility to raise the extra funds. Is the Minister concerned that three-quarters of the largest councils in England with responsibility for social care have been left with no choice but to raise their council tax by the full 4.99% increase, just to keep current inadequate levels of service going?

[Lord Markham (Con)]

I am aware of some of the challenges raised by funding through the local authority system—and I say that as a former deputy leader of a local authority, so I am very familiar with the situations at play there. At the same time, we have put a lot of the central funding in place to make sure the security is there. As I said, we will see more measures as Minister Whately announces them in the spring, not far from here; there will be further progress in this area.

[Baroness Butler-Sloss (CB)]

My Lords, one group of carers is made up of children. What are the Government doing to help local authorities to identify and to give extra help to children?

[Lord Markham (Con)]

I am aware of the many circumstances where it suddenly falls to children, who obviously have their own demanding situation with education and are suddenly expected to provide a lot of care. We have tried putting steps in place with the local authorities so they can provide further support to children. We know that childhood is a critical part of their own development, so expecting them to look after a parent is not the right way around, if I can put it that way. So we have done work there, but there is more to be done.

Maternity Services

Lord Markham Excerpts

Thursday 9th February 2023 Lords Chamber

[Lord Patel]

To ask His Majesty’s Government what steps they intend to take in response to the Care Quality Commission’s Maternity Survey 2022, published on 11 January.

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

My Lords, we are committed to continuing our work to ensure that all maternity services provide safe and compassionate care. We will continue to closely monitor progress in improving the standard of maternity care across the country. We have made significant investment into maternity and neonatal services, with £127 million announced in 2022 to go into the maternity system to help to increase the NHS maternity workforce and improve neonatal care.

[Lord Patel (CB)]

My Lords, I thank the Minister for his Answer. The Ockenden report on Shrewsbury and Telford, the Kirkup reports on East Kent and Morecambe Bay, the current report of the CQC, the fact that the CQC fined a Nottingham hospital the maximum amount—£800,000—for a baby death, and the fact that we are now paying out in maternity litigation costs over £1 billion per year all point to one thing: a question of safety in our maternity units. Mothers and babies should not die in our maternity units without care and compassion, but that is what is happening. I am glad that the Minister, the honourable Maria Caulfield, met Dr Kirkup last week, which is a great improvement and progress. I hope the Government will now take seriously the need for zero tolerance of mothers dying in our maternity units and zero tolerance of normally formed babies dying or being damaged in childbirth. I shall keep pursuing this until we get that.

[Lord Markham (Con)]

I welcome the noble Lord’s pursuit because that is absolutely the right thing to do. I think we all agree with that, and we would all say that what happened in East Kent and the other examples from the Ockenden report are clearly not something that we are happy with or that we should put up with. The Kirkup and Ockenden reports gave us a north star, a way forward. I am pleased to see that we are making progress on that, but I expect the noble Lord to hold us fully to account because I am holding the department to account on this.

[Baroness Manzoor (Con)]

My Lords, building on what the noble Lord, Lord Patel, has said, my noble friend will know that continuity of care is really important and has been recommended by the Better Births maternity review. That builds up with better medical understanding of the woman, the pregnancy and the issues related to it. However, only 37% of women are afforded this, and that drops down to 27% in antenatal care. What are the Government doing to take steps to address this so that the terrible examples that we have seen recently are averted?

[Lord Markham (Con)]

I agree with the work by my noble friends, including the noble Baroness, Lady Cumberlege, to put the importance of midwifery continuity of care at the centre of everything. The survey to which my noble friend’s question refers shows that that is coming through in terms of a consistent message that having that confidence in the person in treating them is vital to all of this. That remains important. Key to this is the workforce, so this is one of the things that is being built into the workforce plan. That is starting with ensuring that we have new people coming in. The 1,200 graduates that we now have going into training each year are a vital part of making sure that we can deliver.

[Baroness Barker (LD)]

My Lords, report after report shows that the current system of treating maternity and reproductive health services on an episodic basis is costly and inefficient. Will the Government undertake to review that so that we can begin to go back to the system where staff were trained in both maternity and general nursing? We could therefore treat women on the basis of the whole of their lifestyle and get back to doing the most important jobs, such as making postpartum contraception available, which in the end would not only enable women to be treated more safely but save the NHS money.

[Lord Markham (Con)]

That question probably deserves a more detailed reply then I can give here in 30 seconds. In terms of the direction of travel, continuity of care, not just in the maternity service but in understanding that person and their needs, has to be the right thing to do to make sure that we have cradle-to-grave treatment with people who know your case. So I agree with that direction of travel and I will follow up with a more detailed response.

[Baroness McIntosh of Pickering (Con)]

My Lords, will my noble friend update the House on the number of midwives available? I understand that there is concern among expectant mothers about the availability of midwives.

[Lord Markham (Con)]

The figure for the number of midwives has been roughly constant over the last few years at about 23,000. We want to increase that, which is why we have made a commitment to increase the number of graduate places to more than 1,000 each year. This year, as I say, we have 1,200 places, so we are making good progress.

[Baroness Merron (Lab)]

My Lords, there is an almost twofold difference in maternity mortality rates between women from Asian ethnic groups and white women, while black women are now 40% more likely to experience a miscarriage than white women. When will there be a report from the Maternity Disparities Taskforce? Could the Minister confirm that Parliament will have a full opportunity to examine its findings and review the progress that has been made?

[Lord Markham (Con)]

The noble Baroness is quite right to point out those figures, and they are something that none of us is happy with. That is exactly what the Maternity Disparities Taskforce was set up to deal with, so I am happy to make a commitment to talk through with the noble Baroness the progress of that.

[Baroness Finlay of Llandaff (CB)]

My Lords, running through the reports that my noble friend Lord Patel referred to are two strands: one is workforce, which relates to numbers and qualifications, but the other is dysfunctional teams and a failure of teamwork across the different disciplines, both within maternity services and relating to general medical services, for providing support to women, particularly those with multiple comorbidities who are then going through pregnancy and delivery. I wonder whether the Government are commissioning a specific piece of work to look at ways in which these teams can alter their behaviours internally and be supported to improve on this dysfunctional behaviour within them, which is having an adverse knock-on effect on the experience of mothers and on the clinical outcomes which, as has been said, are sometimes fatal.

[Lord Markham (Con)]

Yes, one of the Kirkup recommendations—recommendation 3, I believe—was about an improvement in teamwork, and that is what will be done under the guidance of national and regional maternity safety champions. I should say that while there is much improvement that we want to do, the overall context is a 19% decrease in stillbirth since 2010 and a 36% decrease in neonatal mortality over 24 weeks since 2010. So it is an improving picture, but it is something that we want to improve further.

[Lord Allan of Hallam (LD)]

My Lords, another day, another area of the NHS that is suffering from serious staff shortages, and these shortages are having a real impact on the willingness of midwives to stay in the profession, more than half of whom are considering leaving the NHS, according to surveys by the Royal College of Midwives. What is the Minister’s view on the proposals that have come from various groups that there should be nationally agreed minimum staffing levels for maternity and neonatal staff?

[Lord Markham (Con)]

Again, I think there are certain things that we are saying we want to see in place. Continuity of care is part of that, and the workforce plan is how we put teams around to do that. It will always be a feature that we then expect the local health trusts and ICBs to work out how best to do that in their own situations. I also say in this context that we are increasing our numbers but this is not like other demographics where we have an ageing population. The birth rate, as we all know, is actually constant/declining, so it is not like those other areas where we are talking about that. Notwithstanding that, as I mentioned before, we are increasing the number of graduate places.

Hospitals: Maintenance

Lord Markham Excerpts

Thursday 9th February 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what assessment they have made of the NHS’s Estate Returns Information Collection data, which show that the cost of maintenance work on hospitals in England exceeded £1 billion in 2021–22.

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

Patient and staff safety is our top priority: that is why the Government are providing £12 billion in operational capital to the NHS over the next three years for trusts to maintain and improve the estate. We support the increasing levels of investment by trusts to ensure that facilities are safe and maintained to a high standard.

[Baroness Merron (Lab)]

My Lords, while the cost of replacing crumbling wards and operating theatres soars, only 10 of the 40 proposed hospital construction projects have full planning permission and the National Audit Office is investigating the programme. Can the Minister confirm how many of the 40 promised new hospitals will actually have been built by 2030? Can he also confirm that they really will be hospitals and not extensions or refurbishments?

[Lord Markham (Con)]

Twenty-one outline or full planning permissions have been given, which is totally on track with the target. Clearly, if some of those hospitals are not being built until, say, 2027, there would be no detailed planning permission yet. So those statistics are not representative of the situation, which shows that the programme of planning applications is on track. I am committed, as are my colleagues, to ensuring that we deliver the 40 by 2030.

[Lord Scriven (LD)]

My Lords, what are the Government going to do to end the ludicrous situation whereby even if NHS trusts have cash in the bank or access to the proceeds of asset disposals, they can be barred from improving major equipment on their estate because of arbitrary departmental capital expenditure limits imposed by the Treasury?

[Lord Markham (Con)]

Clearly, we want to give each trust the freedom to spend where it needs to. Obviously, there are overall Treasury rules but the main thing is the increased allocation we have made available in this space. We have spent £1.4 billion in the past year, which is a 57% increase, recognising that it is a good thing to put preventive maintenance in place to get on top of the backlog.

[Lord Davies of Brixton (Lab)]

My Lords, I may not be doing the Minister much justice but I admire his ability to give straight answers. I also admire his ability to maintain the fiction of 40 new hospitals. Does he accept that the Nuffield Trust puts the number of hospitals that any person in the street would recognise as new at three?

[Lord Markham (Con)]

I know that it is a lot more than that. The number of cohort 1 and cohort 2 hospitals being built at the moment is substantially more. This is a real programme; in fact, I invite all my colleagues here to a parliamentary open day, which I think will happen in the next month or so, when we plan to exhibit exactly what we are doing. We will have virtual reality glasses so that noble Lords can see the hospital of the future. Please come along and see for yourselves how real this programme is.

[Baroness Wheatcroft (CB)]

My Lords, the old joke about how many men it takes to change a light bulb tends not to go down well in PFI hospitals, where the answer can be “Several—and a lot of money”. In November, the Minister said to me that he was re-examining all these ruinous PFI contracts. Can he tell the House what progress he has made?

[Lord Markham (Con)]

We are actually making a lot of progress on them. A number of them, dare I say it, were introduced by Governments of a different colour and we are now working through and correcting those. At the same time, private capital can do a lot of good things. Many in the House will have heard me say just yesterday that if we put LED lightbulbs in every hospital, it would cost £400 million and save £100 million a year. That is the sort of thing private capital will fund every day of the week, probably at a 5% yield, giving us £95 million of savings a year. That is a good use of private capital, and the sort of thing I am looking at.

[Lord Allan of Hallam (LD)]

My Lords, I am surprised that more noble Lords have not dived into this report. It is fascinating, especially sheet 7 of the spreadsheet, which tells us that NHS England is spending £234 million a year on storing medical records. So while some parts of the NHS are working towards all-singing, all-dancing federated data platforms, in other places the height of modern technology is a new shopping trolley to move mouldering files in and out of a dingy basement. Will the Minister share with the House the Government’s plans to digitise or securely dispose of those paper records so that in future editions of this ERIC report, we will see that that £234 million has fallen close to zero?

[Lord Markham (Con)]

The noble Lord makes an excellent point. As he knows, we are investing heavily in a federated data platform, which is precisely about stopping storing paper and making such savings. Even more importantly, it is about improving patient care so that we can ensure that records are transferred instantaneously and really build on the knowledge that will bring.

[Lord Harris of Haringey (Lab)]

My Lords, I am not sure that the Minister really addressed the question my noble friend raised about the number of hospitals. He said that it was substantially more than three, then tailed off without giving us a number. He promised us a virtual reality opportunity to look at “the hospital of the future”, but I do not know whether that exhibition will show exactly which hospitals the 40 in question are, what is going to happen and how many of them a normal person in the street would regard as new. While he is on his feet, can he tell us what feedback Ministers have had from NHS staff working in hospitals about the physical state of those buildings and the extent to which that impedes their daily activities supporting patients?

[Lord Markham (Con)]

We have eight cohort 1 hospitals, which all have full planning permission and are in various stages of construction. We have 10 cohort 2 hospitals, of which two have full planning permission, seven have outline planning permission and one is awaiting approval of outline permission. All have had the preparation works done. So that is 17 where massive progress is being made. We then have cohort 3 schemes: the new hospital 2.0 projects, which are introducing modern methods of construction to standardise production and get cheaper and more efficient hospitals at a quicker rate of output. That is what I invite noble Lords to come and see for themselves over the coming weeks. This programme is very real and I will happily take people through whatever detail they want because, believe me, it is all there.

[Lord Foulkes of Cumnock (Lab Co-op)]

Is the Minister aware that, from time to time I have asked his predecessors to discuss with Scottish Ministers how they can help each other? However, in this area I am not going to do that because in Scotland, the children’s hospital in Edinburgh was delayed by a year and the Queen Elizabeth University Hospital in Glasgow has had enormous problems. Is there a competition between the English Tories and the SNP to see who can bring the NHS to its knees first?

[Lord Markham (Con)]

I can speak clearly on the subject of the new hospital programme, which I think the noble Lord will find is world-class. I will happily demonstrate that to him; indeed, people will see how ground-breaking this project actually is. We will see standardised designs with improved clinical standards, and more efficient productivity and costs as a result. It will be world-class, and we will export it around the world.

[Baroness Finlay of Llandaff (CB)]

My Lords, if the Government are saying that these are to be world-class hospitals, what is the comparison? Is it hospitals such as those in the Netherlands, which are extremely well designed and function very well, versus the many hospitals here which do not function well and have appalling design features? As soon as the staff move into them, they deteriorate rapidly.

--- Later in debate ---

[Lord Markham (Con)]

We are assessing best practice around the world in order to design them. That is exactly the point: we are taking on board things from the Netherlands and all round the world to make them state of the art and world class.

[Baroness Foster of Oxton (Con)]

I do not know how many hospitals have been completed, and I accept that there is a huge programme. But what I do know is that, since we came into power, in Liverpool we have had the brand new, state-of-the-art Liverpool University Hospital, a multi-billion pound hospital that has opened recently; Alder Hey Children’s Hospital, a first-class, world-renowned children’s hospital which has been opened in the last few years; and a huge cancer research centre—all within three miles of each other. I am sure there must be many others around the country. Does my noble friend the Minister agree with me on this?

[Lord Markham (Con)]

Yes. Now I am no longer holding anyone up in terms of time, I welcome noble Lords to visit places like Liverpool hospital and Chase Farm Hospital, where they will see brilliant examples of state-of-the-art hospitals. There will be many more—in fact, 40—going forward.

NHS Staff: Food Banks

Lord Markham Excerpts

Tuesday 7th February 2023 Lords Chamber

[Lord Hain]

To ask His Majesty’s Government how many NHS trusts are (1) providing, or (2) planning to provide, food banks for nurses and other NHS staff.

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

I reassure the noble Lord, Lord Hain, that we are working to support the welfare of NHS staff. We continue to support all NHS staff during these challenging times; individual employers across the NHS are best placed to prioritise support for their staff. Information on food banks set up by NHS trusts is not held centrally, but from March 2023 the Family Resources Survey will track food bank usage.

[Lord Hain (Lab)]

My Lords, I thank the Minister for that Answer, but it was not really an answer. An NHS Providers survey last autumn found that 27% of trusts had food banks for staff and 19% were planning to have them. That is nearly half the trusts in England. At least one trust was providing food vouchers as staff were going without meals, and the cost of living has severely worsened since then. Are the Government not utterly ashamed? Why do Ministers not start paying nurses, ambulance workers and other staff properly, instead of forcing them to go on strike for better wages to feed themselves properly?

[Lord Markham (Con)]

I thank the noble Lord. The lowest paid, who are obviously most at risk in this category, we have sought to protect the most. They received a 9.3% pay increase. In all these circumstances, we have been looking to follow the guidance from the independent bodies, which we will continue to do.

[Lord Allan of Hallam (LD)]

My Lords, the Minister will be aware that food price inflation is now running at over 16%. This disproportionately affects lower-paid workers, including many health and social care staff, yet the Government’s approach seems to be, “Crisis? What crisis?” Does the Minister accept that nurses are seeing real-terms pay cuts at present? Is he worried about the effect of these cuts on his long-awaited workforce strategy?

[Lord Markham (Con)]

As has been mentioned many times, the workforce strategy is key; being able to recruit and retain staff, and pay, are vital elements of it, so I accept the challenges in this space. At the same time, I am mindful that we have sought to protect the lowest paid through these increases, as I mentioned. I am confident that the new pay review body, which is coming up, will seek to take the inflationary pressures into account to make sure that there is a fair settlement for everyone.

[Lord Watts (Lab)]

My Lords, why are the Government hiding behind the pay review body? When it looked at wages for the health service, inflation was running at 4% or 5%. We have just heard that food inflation is now running at 16%. Will the Government think about this again and ask the pay review body to look at the facts now?

[Lord Markham (Con)]

Again, April is very close; the pay review body will be looking at the facts then. The noble Lord is quite correct that the real change is inflation, and that is why the priority for all of us has to be to reduce inflation. It is pernicious in its impact on every single one of our pockets, and most of all on those people with the least money. That has to be the priority, but we will continue to support these people.

[Baroness Boycott (CB)]

My Lords, back in 2008, there were only 26,000 people visiting food banks—they were brought in, really, as a response to the crash—but that figure is now 2.56 million people. Back in those days, Ministers were somewhat ashamed that we had them; now they seem to be handy photo opportunities for Prime Ministers. Where do food banks figure in how the Government look at the economics of this country? It seems to me that they count on them a great deal more than they should.

[Lord Markham (Con)]

Clearly, food banks should be a last resort for people; that is definitely my hope. I am glad to say that there are some good examples of where hospitals have thought that this is the appropriate thing to do and have set them up to help people in that circumstance. However, the biggest increase has been in energy bills, which we have sought to protect people from. I am glad to see that prices are forecast to reduce in future. Actually, gas futures prices are down 71% for next year, so things are starting to get better. Is it challenging right now? Yes.

[Lord Lexden (Con)]

My Lords, are the means of improving the conditions and welfare of all aspects of our much-valued NHS workforce forming a central part of the discussions that are continuing in an effort to reach an agreement in this current tragic dispute?

[Lord Markham (Con)]

They are a central part of the discussions, but at the same time, we have to work out how we can best spend the budget. There are difficult choices here. Clearly, we want to make sure that we are protecting elective recovery and front-line services in A&E, so there are a lot of competing demands in this space. We are seeking to balance those in the best way possible, with the help of the independent pay review bodies, to make sure that we protect and pay what is appropriate in the circumstances.

[Baroness Merron (Lab)]

My Lords, a survey by the Cavell Nurses’ Trust found that 14% of nurses and health workers are using food banks to feed themselves and their families, and nearly 70% are either unprepared or very unprepared for a financial emergency. What assessment have the Government made of the effect this is having on the health and well-being of staff? Does the Minister feel that this ought to provide a greater incentive to the Government to resolve the long- running pay dispute?

[Lord Markham (Con)]

That is a concern; we want to resolve the pay dispute. I know personally how much time and energy are being put into this from our side as well. Clearly, more needs to be done. We are not there yet, but I am hopeful that we will get there. At the same time, we did try to protect those on the lowest incomes, as I mentioned earlier. Everyone received a minimum of £1,400, which is 9.3%. Clearly, we will need to do more for the next year, but we are trying to protect those in the most difficult circumstances.

[Baroness Tyler of Enfield (LD)]

My Lords, can the Minister tell the House what percentage of NHS hospitals have subsidised canteens that staff can use at the end of long shifts, and how many of these are open in the evening and during the night, when access to reasonably priced hot food is hard to find? If the Minister does not have those figures, could he please write to me with them?

[Lord Markham (Con)]

I do not have those figures so I will happily write to supply them to the noble Baroness. However, I have some examples, such as Newcastle upon Tyne, where they have good free meal cards that they can give out to help people buy their meals discreetly themselves, or the Birmingham Women’s and Children’s Hospital, which has subsidised £2 hot meals that are available at any time. So there are some good examples of what trusts are doing to help people in the space, but I will write to the noble Baroness about the other cases.

[Lord Sikka (Lab)]

My Lords, on a recent visit to a food bank at my local hospital I met a nurse, a single parent with two children, who has a gross pay of about £30,000 and income tax and national insurance of £5,600. Her rent has gone up from £1,000 to £1,500—that is £18,000 a year—and she has energy bills of £3,000. That leaves her about £10 a week for food. Yet the Minister seems to be implying that these people are awash with cash. Is he not ashamed that he is not giving these people decent wages so that they do not have to use food banks?

[Lord Markham (Con)]

I do not think I have implied today that people are awash with cash—that has not been my tone for one moment. My tone has been one of complete understanding that we are in a difficult situation, with difficult choices to be made. We are trying to navigate our way through while bearing down on inflation, which is the priority, and making sure that our scarce resources are focused on the areas of most need. The noble Lord talks about taxes but clearly tax is one area where we want to make sure that it is as fair as possible as well. There are a number of measures and the solutions are not easy, but we are definitely mindful of the issue.

[Lord Trefgarne (Con)]

My Lords, most of the publicity we hear about the present dispute refers to percentage increases, not absolute salaries. What is the approximate salary of a junior health service employee?

[Lord Markham (Con)]

Clearly, there is a wide range with regard to that. If I was to take an average overall, we would probably be talking about the mid-£30,000s as a very broad average, but I will quite happily provide my noble friend a breakdown of those detailed figures. However, as I say, we have made sure that as a minimum everyone received at least £1,400, accepting that the lowest paid need the most protection.

Bread and Flour Regulations 1988

Lord Markham Excerpts

Tuesday 7th February 2023 Lords Chamber

[Lord Rooker]

To ask His Majesty’s Government when they expect to announce a decision following the consultation on the Bread and Flour Regulations 1988 which closed on 23 November 2022.

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

The Government will publish an interim response within 12 weeks of the consultation closing, on 14 February, with a fuller government response later this summer. We received 369 responses, and UK officials are currently reviewing them in detail with a review to finalising policy decisions. Following that, the Government expect to lay new legislation early in 2024 subject to clearing parliamentary process. Discussions with industry on the practicalities of folic acid fortification of flour are also ongoing.

[Lord Rooker (Lab)]

I have to say that is the first time the Minister has answered one of my Questions on this, and I am very grateful to him. He gave some positive dates, which we can hold him accountable to, and it looks as though there is some progress. I will make just one point. It is already three months since the end of the consultation. That is another 250 neural tube defect pregnancies, 80% of which will be terminated, and close to 50 live births of children who will have lifelong disabilities. It really needs to speed up. I fully accept what the Minister said, and I am very grateful for that—it would be churlish to be otherwise. However, the fact is that time is of the essence on this. We have a cure for 80% of the issue, but we are not using it at the present time.

[Lord Markham (Con)]

I thank the noble Lord, who has been a tireless campaigner on this issue. Again, a benefit of this position is getting to learn new subjects, and this is one of them. I can see why he campaigns so hard on it. I am delighted to say that we are getting there, albeit that it could be argued that maybe it could be quicker. At the same time, industry is seeing that, and the good news is that it is already adjusting. The majority of breakfast cereals are now fortified and a lot of the rest of the industry is responding. We are making a difference, and I thank the noble Lord again for his campaigning.

[Baroness Walmsley (LD)]

My Lords, does the Minister consider that too low a dose would leave people believing that fortification does not work? Is he aware that the Royal College of Obstetricians and Gynaecologists believes that the proposed level of folic acid fortification will prevent only about 20% of neural tube defects? It recommends that fortification be set at a level that is sufficient to prevent four out of five neural tube defects, which is 1 milligram per 100 grams. Will the Minister consider that?

[Lord Markham (Con)]

I am very aware of the range of scientific advice on this. I am also aware that the official results of the consultation, which will come out, are not clear cut. A sizeable number of people, 40%, are anti-fortification. As ever, it is about trying to get that balance right. We completely agree on the direction of travel. There is some scientific advice that at too high a level there is a potential masking of pernicious anaemia in the elderly. This is the first step. Let us get all the evidence. The critical thing is getting that first step right.

[Lord McColl of Dulwich (Con)]

My Lords, can my noble friend the Minister find out exactly how many people are involved in the decision-making on this subject? How often do they meet?

[Lord Markham (Con)]

I do not know the precise number; I know there are many stakeholders in this. The devolved Administrations have been involved in all of this. Part of the delay is because, once we go ahead, we have to notify the EU, because of the Northern Ireland elements of it, and that is a six-month notification. We also have to notify the World Trade Organization. All these aspects mean that this is not as quick as we would want, and then we need to let the industry have time to adjust. It is a process involving many people, but we are getting there.

[Baroness Wheeler (Lab)]

My Lords, despite their seriously delayed decision-making, the Government promised nearly two years ago that major efforts would be made to step up awareness raising of the importance of taking folic acid supplements, particularly among at-risk groups such as Afro-Caribbean women and women under 20 years old. Can the Minister tell us what actions have been taken, and what measurable impact awareness raising has had among these risk groups and on ensuring that women whose pregnancies were unplanned are not missing out on these vital nutrients in the early stages of their pregnancies?

[Lord Markham (Con)]

The noble Baroness is correct. Key to all these things is awareness that the best advice is to take folic acid supplements, as suggested. I am happy to provide precise figures of how that has moved in recent years. I completely agree that, as ever, education and awareness are key to this.

[Lord Jackson of Peterborough (Con)]

My Lords, I welcome my noble friend the Minister’s very positive tone. I first campaigned on this issue as a constituency MP 18 years ago, but it is 32 years since the Medical Research Council established the causal link between the ingestion of folic acid and the reduction of neural tube defects such as spina bifida and hydrocephalus. Scores of countries have pursued this policy and it has had a significant impact on reducing the tragedy of lifetime disability that has affected many families. Can the Minister ensure that the review is concluded expeditiously so that we can erode these terrible medical conditions as soon as possible?

[Lord Markham (Con)]

Yes, I am very happy to do so. It has been quite a process, as my noble friend says, but we are getting there. As I said, the good news is that the industry is seeing the direction of travel and is responding as well. That is always better when done voluntarily. We are seeing more foods with levels of fortification. We will get there in terms of it being mandated as well.

[Lord Patel (CB)]

My Lords, there has to be some progress. I think the noble Lord, Lord Markham, is the seventh or eighth Minister to answer this Question, the first being the noble Earl, Lord Howe. To get the scientific facts right, the advice given by the Royal College of Obstetricians and Gynaecologists of 1 milligram is based on the surmise that higher doses do not cause any harm. It is wrong science, for which there is no proof, to say that doses as high as 1 milligram mask B12 deficiency. It is completely false and we must not use that. The chief scientific officer of the Department of Health confirmed that at our last meeting, which the noble Lord, Lord Rooker, may well remember.

[Lord Markham (Con)]

To be clear, I was referring to scientific advice I received today about the potential risk of masking, as I said. It is a concern but, as ever, one of the wonders of this House is the expertise available on tap. I will go back to consult on that and write to the noble Lord.

[Lord Cunningham of Felling (Lab)]

My Lords, between 80 and 90 countries now add folic acid to flour, with no known side-effects. What are the Government waiting for? All the evidence is there, all the science is there and this is all well known. I do not know, speaking for myself, what the delay is about.

[Lord Markham (Con)]

As I say, there is a process involving co-ordination with the devolved Administrations. We have to consult the EU, as mentioned, because of Northern Ireland is part of it all, and then allow the industry to get on board. Again, we are all in favour, without a doubt, but 40% of the respondents were anti. So we need to be careful to do this in the right way. I hope and believe this to be the first step but, as ever, the first step is often the hardest. We are getting there and this will make a difference.

[Lord Dodds of Duncairn (DUP)]

My Lords, I join the noble Lord, Lord Rooker, in welcoming the Government’s firm announcement on dates. The delay has been as frustrating as it has been inexplicable for many people. Can I seek an assurance that, when this measure is finally adopted legislatively, it will apply across the entire United Kingdom equally and at the same time?

[Lord Markham (Con)]

Yes, that is my understanding. One of the aspects that has taken time is getting the devolved Administrations on board and the complications of the Northern Ireland situation with the EU.

[Baroness Jolly (LD)]

My Lords, many countries put folic acid into bread to prevent neural tube defects. When it was added to flours in Australia, the number of these defects reduced by 14%. More folic acid in more bread products could save 800 babies a year in the UK from developing birth defects such as spina bifida. The Minister gave your Lordships positive news, but when can we expect it to bear fruit?

[Lord Markham (Con)]

As mentioned, there is a process that we are going through. As I said in my first Answer, we will be laying the legislation early in 2024, but it is happening. More importantly, in the meantime a lot of the industry are voluntarily adopting it.

Urgent and Emergency Care Recovery Plan

Lord Markham Excerpts

Thursday 2nd February 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, as is usual for this kind of Statement, it is peppered with promises of more of everything. I hope the Minister will help us to dig into the numbers we have been given to see how much lies behind them. First, on the new hospital beds, this seems to come from a process of making winter surge beds permanent. For a real long-term increase in capacity, we need the promised 40 new hospitals. How many of these will be on stream by next winter?

The Statement also tells us that there will be 800 new ambulances, which I think most people would interpret as fully staffed, blue-light vehicles. Can the Minister offer a more detailed breakdown of the different types and capabilities of what is being offered here? The Statement itself said that, for example, 100 of these will be mental health emergency vehicles rather than classic blue-light ambulances.

Of course, staffing these beds and ambulances and the other measures in the Statement will depend on good workforce planning. Here, I echo the comments made by the noble Baroness, Lady Merron, and by these Benches over many months. The Statement tells us that the plan will come this year; can the Minister offer any more precision on when this year we might expect it?

The Statement also talks about data and transparency. We are told that integrated care boards will now have to focus much more on data about patient flow. Can the Minister commit to making more of those statistics public, as well as the ambulance wait time statistics?

Finally, the promised new care hubs can add value only if care services are actually there. This brings us back to workforce limitations. I end with three questions for the Minister: where is the staffing for the beds, where is the staffing for the ambulances, and where is the staffing for the care services?

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

First, I thank the noble Lords for their questions. To put the UEC recovery plan in the context of the three plans we will be announcing, there was last month’s elective recovery plan, which we spoke about, followed by this UEC recovery plan, and then, within the next month or so, we will also talk through the primary care recovery plan. That plan will seek to address exactly some of the points the noble Baroness, Lady Merron, rightly made about getting care in the right places, such as primary care.

I hope noble Lords agree that what we see today is a sensible and pragmatic plan. It has been welcomed by NHS Providers and described by the Royal College of Emergency Medicine as a

“significant step on the road to recovery”,

seeking to increase capacity in urgent and emergency care. The 5,000 beds that the noble Lord, Lord Allan, mentioned are a recognition that more capacity is needed in that space.

As has been mentioned many times, and as was raised by the noble Lords today, growing the workforce is crucial. This includes student places and getting to the bottom of whether there is a cap on those numbers, on which a written reply will be given soon. Again, the workforce plan is in draft and will be shown shortly—as I say, in weeks. I cannot give a date, but it will be soon. It is designed to tackle the whole question of how we are going to staff all of this and the points that have quite rightly been made. We need the staff: the nurses, the ambulance staff and all the others. There are 30,000 more nurses than three years ago, so we are on target to hit the 50,000 increase. There are 5,000 more doctors than a year ago, but that is not to say that we do not need more. That is what the workforce capacity plan should be all about.

This plan is looking to show those milestones and what we are trying to do to increase capacity, with the 5,000 new beds, growing the workforce, speeding up discharge, expanding and having better joined-up community services and making it easier to access the right care in the right places, such as primary care. I would say this, probably, because I am biased, but I feel that this is a useful and pragmatic plan because it is trying to build on the evidence of the things that we have seen work, which noble Lords have heard me talk about over the last few weeks. They include the Maidstone “mission control”, which really is making a difference there and we are now looking to roll out to all trusts and ICBs; the Watford virtual wards, which we are looking to roll out to 50,000 places; and, in all instances, using data-driven analysis to make sure we are making the right decisions.

The plan is backed up by funds and is part of a long-term plan. We are using the £1 billion of support for this year and the £500 million for social care capacity, but this is in the context of an increase of £14 billion over the next two years. It is part of a sizeable plan, but it is realistic action. I would love to be able to stand here today and give targets, but we are trying to be realistic about where we are coming from—for example, in setting the 30-minute category 2 ambulance wait time. Likewise, the target of 76% of patients being seen within four hours is not the limit of our ambition. That is the minimum, and from there we would look to increase it beyond that target. I would much rather come to your Lordships’ House with targets we think are realistic, with achievable plans behind them, as a statement of intent from which we can grow, rather than setting unrealistic expectations.

Of course, I say all of this in the context of what the House knows is an unprecedented challenge. It is not just England facing these challenges; I have spoken to colleagues across Europe, the US and Canada, and within the UK, in Wales and Scotland. Every health system is facing these problems off the back of Covid, and there are also the demands coming from flu coinciding with that this winter in particular.

I believe that this is a realistic plan. It is centred on the workforce; I agree on that. Prevention is also a key element of this. The five-year life expectancy improvement target is still key. We are looking at what we realistically need to do to make a difference on that—so, what are the causes of death, and what are the things we need to tackle? Again, the House has heard me speak many times about Chris Whitty’s concern about cardiovascular disease, and that it could be the next cohort of potential excess deaths among 50 to 65 year-olds, because they missed out on their blood pressure monitoring over the last couple of years. We all agree that rectifying those sorts of prevention actions is key.

When this plan is seen in the context of the primary care plan, which will also come out shortly, I hope it is understood that this is about treating people in the right place, which is not A&E. We all know that far too many people go to A&E who do not need to be there, and that is because we need more primary care spaces. We are on target to achieve the 50 million more primary care spaces, but, again, we need to do more. We really need to look to expand capacity in pharmacies, as I have mentioned before. We need to look at what some of our colleagues in Scotland are doing and the ability of pharmacists, for instance, to prescribe a lot more. Longer term, the new hospitals are a key part of this. Just this morning, I was going through the plans and some very good virtual reality examples, which we are going to bring to Westminster Hall for one day in the next few weeks. I look forward to showing colleagues exactly what is happening and how that will be the future.

I hope that noble Lords will see this plan in the context in which it is meant. I will, as ever, write in detail on the points I have not managed to cover in this quick reply. I hope noble Lords will see this as a down payment for the future, within the context of the elective care recovery plan and the primary care plan that we will see later, building on solid things that we know work and making sure that we are expanding those rapidly, so that we have learned the lessons from this winter and have them in place in time for next winter.

[Baroness McIntosh of Pickering (Con)]

My Lords, my noble friend will be aware that this problem is not unique to this country. I am ashamed to say that Denmark, my mother’s original country, is building new hospitals all over the place but people cannot be treated because there are not enough doctors to treat them. Is my noble friend aware of the report from the Health and Social Care Committee in the other place, which noted that there are almost 500 fewer full-time equivalent GPs in a three-year period and that the committee realised that that accounts for the fact that there is an increased challenge in accessing GPs and also a lack of continuing healthcare? Will my noble friend take this opportunity to explain to the House what proposals the Government have to retain GPs so that recently qualified GPs are not working as locums in preference to being salaried or partners in a practice? I declare my interest as an adviser to the Dispensing Doctors’ Association.

[Lord Markham (Con)]

I thank my noble friend and agree that the GP service is the backbone. As per the earlier comments, a lot of the issues and challenges we have with A&E are because people are not getting their appointments in the GP space, and fundamental to that is having enough doctors. I did not quite recognise the figures. I am aware of an increase of over 2,000 GPs since 2019. That is not to say that that is enough, and so, again, the workforce plan will be key to making sure that we are building for that long-term future. However, we are also looking to retain them. We had a very good debate in the House about pensions and what we need to do in that space, and we will make sure that everything we do—including, I hope, the primary care plan—will show that primary care is key to the solution.

[Baroness Armstrong of Hill Top (Lab)]

My Lords, I am sure the Minister has taken note of the House of Lords Public Services Committee report on emergency access to healthcare, which came out two weeks ago. Many of its recommendations have been taken up by the Government. I thank the Minister in particular for the one on the 12-hour waiting list. We found out to our shock that that was not honest, as the witness said to us when they came to talk about it. I am pleased that the Government have done something about it. Our previous report was on workforce, and I urge him to read that too. Any report or plan is worth the paper it is written on only if it will and can be delivered. We were promised the outline of the workforce plan last September—we have had nothing yet.

Can the Minister help me on what I see as a major problem this week? As he has said today, a major part of the plan is increasing capacity. As others have said, you need the staff to do that. However, the Government, having said on Monday this week that increased capacity was really important as part of the emergency plan, wrote on Wednesday to Lincolnshire ICT to say, “You have a deficit. In order to deal with that deficit, you must cut beds”. What are people there to think when on one day the Government say, “We will sort emergency access by increasing capacity and beds” for one thing, and then two days later say, “Oh, you have a deficit—cut the beds”?

[Lord Markham (Con)]

I thank the noble Baroness for her question and her recognition of the 12 hours. In all these spaces, data is always the way that you give a backdrop to better services, and 12 hours is part of that. As regards capacity, I totally agree that we need more of it. I was surprised by what she said—I will find out some more about it. However, the absolute direction is a recognition that, with Covid and flu, what might have been the right number of beds a couple of years ago is not today. That is why we are committed to the 5,000 extra beds and, just as importantly—potentially more so—the 50,000 in virtual wards, because that is using technology to look at how we can expand supply, and absolutely critical to that is having the workforce.

[Lord Forsyth of Drumlean (Con)]

My Lords, my noble friend quite rightly pointed out that there are more doctors than ever in the NHS, but many of them are in training. As my noble friend Lady McIntosh pointed out, we are losing very senior and experienced doctors because of the rules that apply on pensions. My noble friend said that this was being addressed. I remember raising this several years ago—it is a continuing problem. What is worse is that doctors leave the NHS because of the tax implications for their pensions and then come back and cost it even more money. My noble friend says that this is being addressed, but in the autumn I heard the Chancellor say that he was going to freeze the level of the maximum amount that counts towards the pension before you pay tax for the next three years—so how is that addressing the problem? Is it not an urgent problem? We may be putting more people into the service who are in training, but we are losing people out the bottom at a greater rate.

[Lord Markham (Con)]

I thank my noble friend. As I mentioned just now, retaining doctors is critical, and pensions are a key issue. We had an excellent debate on this a couple of weeks ago. Again, we are working on all of that with the Treasury. However, as I said then, the simplest thing is that, while I understand the Treasury’s concern about making special rules for special groups and the potential knock-on from that, we can very quickly make sure that, if people are hitting that pension ceiling, they can get the equivalent pay in their pay package very quickly. As a health department we have the ability to do that, to make sure that no one is financially losing out from that. If it does not make sense for them to get it through their pension, they can get it through their salary instead. I am not saying that that is perfect, and more work needs to be done across the Treasury, but we can do that quickly.

[Baroness Blower (Lab)]

My Lords, the Minister has attempted to give a full response on this. However, there is clearly an absolute urgency about the workforce plan, and noble Lords would have been very pleased to have heard something rather more specific about the date on which it would come before us. If it is in draft, perhaps he could go back and say, “Can we speed up the final drafting of it?” The Minister also used the word “realistic” on a couple of occasions. Can he say whether he understands that the workforce plan will not be realistic unless we can pay staff in an appropriate way to make sure that we can hold on to their services, without which any attempts to remedy the difficulties we are facing are, frankly, a forlorn hope? Finally, on virtual wards, can we make sure that there are not people in the digital divide having difficulty engaging with the virtual ward if they have broadband problems and other problems?

[Lord Markham (Con)]

I thank the noble Baroness. Taking those questions in reverse order, yes, it is understood that virtual wards do not work for everyone. At the same time, I am constantly surprised by the data: for instance, the average age of an NHS app user is in the mid-60s—so it is not a particularly young demographic who use this. Obviously, the examples I have seen, particularly on COPD at Watford, show that an older population is using that. However, we absolutely need to make sure that there is not a digital divide from that.

On the noble Baroness’s points on the workforce, she is quite right. We live in a competitive market, and one of the benefits of full employment is that, again, most people who want to work have a job, but one of the downsides is that there is competition for jobs. We have to face up to those realities and be realistic in terms of workforce, in that if you are going to attract and retain the good people, which you need to have as the bedrock of your services, you need to make sure you have an attractive and rewarding place to work. Clearly, that has to be a feature.

[Lord Bellingham (Con)]

My Lords, the Minister mentioned new hospitals. Is he aware that the biggest obstacle to major health improvements in west Norfolk is the chronic state of King’s Lynn’s Queen Elizabeth Hospital, which I gather is the most internally propped-up hospital in the UK? He will be aware of an all-party campaign to secure the building of a new hospital. Can he tell the House where are we with that process?

[Lord Markham (Con)]

I am very familiar with the problems with the so-called RACC—reinforced, autoclaved aerated concrete—hospitals. King’s Lynn is one of those, and there are a handful of others. There is a recognition that everything we do in the new hospital programme has to ensure that those hospitals are rebuilt in time, because they have a useful life that is fast reaching its end. Our priority number one is making sure that they are replaced.

[Baroness Masham of Ilton (CB)]

My Lords, what are the government plans for long-term rehabilitation? We need more physiotherapists and occupational therapists. There is an idea of getting people out of hospital quickly, but some of them need confidence and ongoing care.

[Lord Markham (Con)]

That is absolutely right. The figure that struck me on one of my many hospital visits was that apparently people lose 10% of their muscle mass each week they are in hospital, making it harder for them to look after themselves. The noble Baroness, Lady Merron, mentioned that we need to make sure the resources and investment are in the right places. All too often, hospitals become the place of last resort, when we all know that it is much better to put resources into the primary care at the front end or the social care and domestic help for physios who can visit homes at the back end. Central to the plans of my colleague, Minister Whately, is recognition that we will solve this in the long term, as all noble Lords want, only if we invest those resources in the right places.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I welcome the plan and hope that the Government can keep to the targets they have set. I had experience of being in a major London hospital recently, spending five hours in A&E. It was the first time I had been in A&E for a long time. I was surprised at the number of young people there. When eventually I was seen by a nurse, I asked why so many young people were there. She said, “We’re surprised; there was a good football match on tonight, and we thought there wouldn’t be so many”.

It is odd when people are in A&E. Should they be with a GP? We wait with interest to see the report on GPs. I suspect that we have far more people now getting involved in health, for a whole variety of reasons, than need be in the system. This takes us back to prevention. I still do not believe we are addressing prevention as we should—trying to reduce the number of people in ill health. The programmes we have on obesity and in a whole range of areas where we are trying to get people to change their lifestyle are not having any impact. Until we seriously address those and put money and personnel into them to get ourselves reasonably healthy by comparison with the rest of Europe, we will just see the health service getting into even more difficulty, no matter who is in power.

I am sorry for going on at length. I hope the Minister will say something about a proper plan on prevention.

[Lord Markham (Con)]

I agree with the noble Lord. We have a manifesto pledge about five years of healthier living. I am keen to do exactly that, to say, “Okay, let’s unpack this—how can we make that realistic?”. We have all talked about being realistic. What are the causes of death or ill health that we need to get on top of? I mentioned cardiovascular disease earlier. We need to quickly address that because there is a cohort of people of my age who have missed out. Obesity is a clear thing. It is not just the treatments but everything we talk about in terms of supermarkets. I know that there is some discussion in the House on whether we have gone far enough on some of those things, but the action we have taken is hitting the big numbers. It is hitting about 95% of the planned reduction in calorific intake; we are seeing that have an impact already. There is also anti-smoking; I am keen to make that into a coherent plan. We all know that we can spend more and more money on hospitals and the health service, but we will have healthier lifestyles only if we can get up stream on the problem and talk about protection.

[Lord Porter of Spalding (Con)]

My Lords, I declare my interest as a non-executive director of a care company and lead Peer for the Local Government Association.

It is great that politicians are trying to sort out problems with the health service, because those problems have largely been created by politicians—national politicians from both sides of the other Chamber. Clearly, the last Labour Government’s disastrous changes to GP contracts exacerbated the situation we are living in now. The even worse contracts for construction companies to build new hospitals at exorbitant prices were bizarre and are currently impacting the health service.

The coalition Government and this Government are responsible for the chronic underfunding of social care services. We have all contributed to people not being able to see the right GP or whatever at the start of the process, and we are now contributing to people not being able to get out of hospital.

That is not really what I wanted to say, even though I have just said it. I live in Lincolnshire. If a member of staff somewhere in the Lincolnshire health network has suggested, contrary to the Government’s position of increasing hospital beds, that they have to reduce their hospital beds, one way they could save some money is by deleting the post of the person who suggested that. That is probably a good place to start, because a lot of people want to use acute services but cannot because some of the budget is being diverted away to people dressed like me rather than to somebody dressed in those suits they wear in hospitals.

I am quite simple and do not understand why I saw a picture on the news the other day of 40 ambulances queueing up outside a hospital with 80 members of staff and only 40 patients inside the ambulances. Why can we not put up a big inflatable building of some description, offload the 40 people from the ambulances with 40 of the staff, and let the other 40 staff drive 20 ambulances back out again? Nobody seems to be controlling the resources that are being used, even though we all admit that they are scarce.

[Lord Markham (Con)]

I will take it in reverse order. We do have the ability to stand up that capacity quickly so that the ambulances can discharge. I have already ordered a number of those, and some are ready to go, to provide exactly that capacity. Others are coming on stream in the coming weeks, so we are rapidly responding to the exact point that my noble friend raises.

Just as important—I am glad to have the opportunity to talk a bit more about this—is that a lot of the time ambulances do not need to bring the person to A&E. The mental health ambulances we are introducing, or the falls service ambulances that every ICB now has to introduce and have running every day, are critical. They can go there, right the person who has fallen and set them back up again. That needs only one person, not a big ambulance. That sort of care in the community—solving those problems and the right access—is critical in this situation.

On Lincolnshire, I will find out. The key thing here is making sure that we are expanding capacity in terms of beds.

[Lord Hogan-Howe (CB)]

My Lords, I sat with the noble Baroness, Lady Armstrong, on the Public Services Committee for that report. Two things were left with me; they follow up on the point from the noble Lord, Lord Porter, about ambulances attending the scene. We heard numerous cases, the worst I heard being that of a 95 year-old man who lay on the floor for 24 hours with a broken collarbone and hip. His family put a tent around him and no one in the health service—I do not mean just the ambulance service—went to help.

I just cannot understand that. There are over a million people in the health service; the Minister just mentioned that he is trying to get action around this, but why did the bosses not get out and drive an ambulance? Why did a GP not attend? Why did someone in society not think that that guy should not be lying there for 24 hours on the floor with a tent around?

Those examples really shame us. I do not say “the Government” or anybody else; they shame us. A piece of evidence which stuck with me was that one of the paramedics pointed out that one of the good things that has changed in strategy to improve outcomes for patients is that they spend longer on the scene, so they improve the initial treatment and improve the outcome. Of course, I asked what the overall impact of that was; he reckoned that they were able to attend about half the incidents that they did before, so were halving the effectiveness of the number of ambulances that we have. It does not look like the number of ambulances and staff will shift as a result of that change, or that there will be a different model of delivery—perhaps that one person might go or whatever. But those good outcomes for the heart-attack patient, perhaps, were not replicated for everybody: if they never got the ambulance, that did not help them. It just struck me that the change of delivery had not changed as much as the change of the model—spending longer at the scene—had improved the outcomes where ambulances attended.

[Lord Markham (Con)]

Yes, what the noble Lord talks about is critical. To my mind, this is where the data—I know data and analysis sound dry—is needed to arm the local decision-makers. This is the whole idea behind the ICSs: that they can invest in the right services in the right places. We have often got too much into thinking that the one-size-fits-all model of the ambulance with the two paramedics is the solution, whereas we know that the full service can do things far more effectively and keep the person in the home. To my mind, that is the whole sense of direction of the ICBs, which need to understand and own their areas. I saw a fantastic example in Spain: Ribera Salud, with which many people here are familiar, I think. It ran the local hospitals and local primary care. There was investment in primary care, and A&E entrances plummeted. That is what I want ICBs to look at, and what I want the workforce plan to do: to make sure that we give the right care in the right places, and have flexible delivery of different types of ambulances and types of staff, who will go and problem-solve. Sometimes that is problem-solving as per the example that we gave, but mainly it is trying to give the local ICBs the analytical tools, powers—for want of a better word—and resources, so that they can properly shape things. Some of them will do very well, and others will probably take longer. But that is the critical thing about letting people run their own areas: making sure that they adopt best practice, but that they have flexibility in that approach so that they can solve the problems on the doorstep.

Mental Health Act Reform

Lord Markham Excerpts

Thursday 26th January 2023 Lords Chamber

[Baroness Buscombe]

To ask His Majesty’s Government what reforms they are proposing to the Mental Health Act 1983.

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

The Government published their draft mental health Bill on 27 June 2022, which contains our intended reforms to the Mental Health Act 1983. I am grateful to the joint pre-legislative scrutiny committee on the Bill for its report, which was published last week, on 19 January. The Government will now review the committee’s recommendations. We will respond in the coming months and introduce a revised Bill when parliamentary time allows.

[Baroness Buscombe (Con)]

I thank my noble friend the Minister for his comments on the Joint Committee’s report. I had the privilege of chairing its inquiry and I am grateful for the contributions of Members of both Houses. The Government must of course spend time considering with care our recommendations, but as a committee we feel strongly that a Bill should be introduced to Parliament as soon as is practicable to bring about the really important reforms to the mental health system that people so dearly deserve. Will my noble friend give an assurance that the Government will introduce a formal Bill to Parliament in the current Session?

[Lord Markham (Con)]

First, I thank my noble friend and all noble Lords who took part in the pre-legislative scrutiny committee. I think all noble Lords agree that what we are trying to do with the mental health Bill is a very good thing. We would like to bring it forward as soon as we can. From my side, I know that we are ready to go, but we are working with the parliamentary authorities to make sure that we can get the legislative time. We want to do it as soon as possible.

[Lord Touhig (Lab)]

My Lords, due to the current mental health legislation, autistic people are being detained in hospitals not because they have a separate mental health issue but because they are autistic. Autism is not a mental health condition, but more than 2,000 autistic people are currently locked up. This is a stain on Britain’s reputation for defending human rights and a challenge for us to define the liberty and freedom of some of our most vulnerable citizens. So will the Minister ask his noble friend sitting on the Bench with him, the Government Chief Whip, for a debate in government time on this matter, so that the voices of some of these people, some of whom have been locked up for decades, can at last be heard?

[Lord Markham (Con)]

I have some personal experience in this space, so I understand exactly what the noble Lord is saying. I think we all agree on its importance. We have a commitment to decrease the number of in-patients with learning disabilities and autism by 50%. It is something that every ICB must have a lead on, so that they can really tackle it, and I personally would be happy to meet the people the noble Lord mentioned to understand further.

[Baroness Berridge (Con)]

My Lords, this process began four years ago, with the then Prime Minister announcing the initial reason for the review, which was the disproportionate way that the Mental Health Act is applied to many black and minority ethnic communities. Beyond the review and the White Paper, the Joint Committee recommends the abolition of community treatment orders, which are disproportionately applied: if you are black you are 11 times more likely to be under a community treatment order. Most of the recommendations of the Wessely review were to be enacted by changes within NHS England. Can my noble friend the Minister assure us that he will hold its feet to the fire to change the culture, practices and training of many of our mental health professionals, because those communities are being disproportionately affected by the way the Act operates?

[Lord Markham (Con)]

Yes, I too saw the statistics on the number of black people who are detained. Clearly that is not right and is something that we need to get on top of. I know that the NHS has set up a patient and carer race equality framework to try to tackle this, but clearly we need to act on it. Again, it is the responsibility of every ICB to ensure to tackle this as well.

[Baroness Barker (LD)]

My Lords, a key reason why people with learning disabilities and autism are wrongly detained under the Mental Health Act is that mental health professionals are not trained to recognise autism and learning disabilities. Without waiting for legal reform, will the Government work with the professional bodies now to train and retrain psychiatrists and psychologists in learning disabilities and autism so that we can stop the scandal of these people being locked away wrongly for years and years?

[Lord Markham (Con)]

Yes, and understanding starts in schools. Again, I am very aware of that, and of the fact that training in schools is vital. We have increased the proportion of schools with trained mental health assessors from 25% last year; it will shortly be about 35%. The target is 50% next year. It is not 100%—we need to do more—but it is rapid progress.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, like other noble Lords who have spoken, I was a member of the scrutiny Joint Committee. I should say in parentheses that I entirely support the legislation being brought forward, but one of the things that came through very strongly from all the evidence we took was quite serious anxiety about resourcing for the kinds of reforms that are required. That is about not just money but, to go to the point made by the noble Baroness, Lady Barker, the recruitment of appropriate people to deliver the services that are needed, and the retention and training of those people. Can the Minister tell the House whether the Government will review the resource allocation for the proposed changes to the Mental Health Act, to ensure that these workforce issues are addressed?

--- Later in debate ---

[Lord Markham (Con)]

The noble Baroness is correct; these things do need resources. We have committed to £2.3 billion of extra spending next year and an increase of 27,000 in the number of mental health nurses; I am glad to say we are well on the way, with a 7,000 increase over the last year. This all comes back to workforce planning—I am sure I will be asked that question later. And, yes, we will publish our plan soon.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister comment on why it is 50 years since we have had a revision, and say whether in fact the Government are delaying this legislation because of the resources that will be required, as has just been referred to?

[Lord Markham (Con)]

No, I hope that all noble Lords will see that there is no sense of delay on this side—and we are not waiting for the legislation to introduce a lot of these measures. It is very important, and we are ready to push on as soon as parliamentary time allows.

[Lord Bradley (Lab)]

My Lords, declaring my interests in the register, particularly as a trustee of the Centre for Mental Health and a member of the Joint Committee, perhaps I might press the Minister on one of our key recommendations: to establish a statutory mental health commissioner to oversee the implementation of the draft Bill, which we fully support, and to have a laser focus to ensure consistency across the country in the services required, underpinned by investment in community services. Unless those are forthcoming in a timely way, the Bill’s intentions will be undermined. Will the Minister confirm today that he will accept the recommendation for a mental health commissioner?

[Lord Markham (Con)]

I hope noble Lords accept that the report came out only last week and we need a little time to consider it. What I can say is that we are all focused laser-like on making sure that change is happening in this space. If the best way to do that is by appointing a mental health commissioner, that will have my support. At the same time, I am very aware that ICBs are responsible for this, and I want to give them the space to make sure they can properly manage mental health and other health services in their area.

[Lord Selkirk of Douglas (Con)]

Some years ago I visited a health centre with a lot of autistic patients who were quite young. One of them came up to me and said, “What is your favourite film?” I replied immediately, “Chariots of Fire”—whereupon he took me through every detail of “Chariots of Fire”, which revealed that in one respect he had a problem but in other respects he had great ability. Does the Minister accept that there is much to be hoped for in young people who have this difficulty?

[Lord Markham (Con)]

I agree 100%. As I say, I have some personal experience. In many ways, these children or young people have incredible skills and are gifted in many directions, and the economy we live in, with IT and everything, gives more and more opportunity for these people to thrive.

[Baroness Merron (Lab)]

I congratulate the Joint Committee on its excellent work and refer to a report in the Times yesterday that the Government have written to universities to ask them to limit the number of medical school places they offer or risk fines. Can the Minister shed any light on what I regard as a baffling move? Can he explain to the House how the Government will address the concerns of the Joint Committee about getting the right workforce in place if they are planning to reduce the number of doctors in training?

[Lord Markham (Con)]

Again, I agree that workforce is key to this. I am not aware of the report; I will look it up. I am somewhat surprised, because I know that we all accept that we need to invest in this space to recruit doctors, nurses and mental health professionals.