Health Promotion Bill [HL]

Lord Markham Excerpts

2nd reading
Friday 2nd December 2022 Lords Chamber

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

Like the noble Lord, Lord Addington, I would like to declare an interest in that I still play rugby. If noble Lords take nothing else from this debate, I hope they will find that they have another willing, if perhaps not that able, rugby player to join the team. I hope that my contribution on the pitch will elicit a bit more than apathy, some sympathy and maybe a bit of empathy from my noble friend Lord Kamall. As a keen sportsman, I thank the noble Lord, Lord Addington, for providing the opportunity to debate this important issue. I hope I can do rather better than his impersonation of what I might say in this debate.

On the rationale for OHID’s creation, I must admit to not knowing the genesis or etymology of the change of name, but I will find out. As we know, it was established in 2021 as part of the Department of Health and Social Care, following the closure of Public Health England. Its core aim is to reduce preventable ill health and health disparities. It works towards this under the professional leadership of the CMO, which we felt was key, and the director-general of OHID within the department.

Many noble Lords, including my noble friend Lord Lansley, asked why it was felt that it would be more effective as part of the department. When reforming the public health system, this was carefully considered. This was before my time, but my understanding is that many stakeholders were engaged in this and the feeling was that having it as an in-house, in-the-tent department was the best way to go. The option of creating an arm’s-length body to sit alongside the UK Health Security Agency was considered, but it was felt that establishing those functions within government outweighed the strengths of an independent ALB. The fear was that the proposal outlined in the Health Promotion Bill would create an office for health promotion with limited advisory functions. This would simply replace or duplicate many activities which are already under way in OHID.

In forming OHID, we were clear about the distinct advantages of convening functions—something I have become very aware of in the short time I have been a Minister—and the ability to access expert advice, analysis and evidence, alongside policy development and implementation. The decision to make OHID a core part of DHSC was taken because influence and proximity to decision-making matters. In addition, advice is offered widely from across the system and there needs to be a mechanism for summarising it for Ministers.

OHID is empowered to work across national government, using evidence to influence policy and ensure greater consideration in cross-government decision-making of the links to and importance of preventing ill health and tackling disparities. We only have to think of policy considering the health impacts of housing, the potential of indoor and outdoor air quality to promote or negatively impact health, and the consequences of ill health, including for high levels of economic inactivity, for current and important examples. OHID is taking action on the major preventable conditions which drive ill health and early death, including cardiovascular disease and some cancers, and the risk factors that cause those conditions, including tobacco, obesity, alcohol and drugs. OHID does this work alongside local government, the NHS, academia and industry.

I would like to highlight some of the achievements that have resulted so far. To answer my noble friend Lord Kamall’s point on the health promotion task force, the real north star for the cross-government action we see now was publication of the levelling-up White Paper and the commitment in it to improve healthy life expectancy by five years by 2035 and narrow the gap by 2030. This provides a clear, ongoing framework and commitment—covering DfE, DCMS, DWP, BEIS, DLUHC and the Department for Transport to name just a few—to work across government and really address the major drivers of ill health.

Last December, we published a cross-government drug strategy, backed by new investment totalling almost £900 million over three years, with more than £500 million for local authorities. They are required to provide 54,500 new drug and alcohol treatment places over the next three years. Going back to last week’s debate on tobacco, my belief is that we are on target for our smoke-free objectives, but again, I will check on this and confirm. Another great example is our effort to tackle health inequalities early on. The investment of over £300 million in family hubs and Start for Life will deliver new and expanded family health networks in 75 local authorities.

We are improving joint local working on population health and reducing health inequalities through integrated care systems. This includes an expectation that local directors of public health will play a vital part in informing the strategy developed by the integrated care partnership and the forward plan of the integrated care boards.

In all of this, as was so wonderfully put, exercise is the “wonder drug”. We really recognise its importance. That came through very strongly in the contributions of many noble Lords. The drivers of physical inactivity are deep-rooted and influenced by the places we live, work and play in. Change will not happen overnight.

During preparation of the national plan for sport and recreation report, which lays the foundations for the Health Promotion Bill, noble Lords provided the Government with plenty to consider. The evidence is clear that physical activity is good for health. Being active offers wide social benefits, brings people together, maintains friendships and through active travel, as was mentioned, can help connect people and places. We remain committed to the former Prime Minister’s commitment on active travel.

As we are all aware, activity levels have declined due to the pandemic—I am probably more aware than most of how hard it is to get 15 out on a rugby field on a Saturday. This is not good for children’s healthy development and is putting adults at greater risk of disease. Furthermore, there is a disparity in physical activity levels, as was identified by many speakers. This affects groups including women, older people, people living with long-term conditions, people from lower-income areas and people from black and Asian ethnic-minority groups. The Government recognise the challenge and the renewed efforts needed to ensure people have the access, opportunities and motivation to be active in their everyday lives. Our commitment to the sport and physical activity agenda will continue.

In quarter 1 of 2023—not quite 2022, I accept—the Government will publish a new sport strategy and a new school sport and activity action plan. We believe there is an opportunity for this refreshed strategy to focus on two areas: strengthening action to address inactivity levels, and making the sector more sustainable for the future. We will continue to proactively engage across government and with the wider sector to effectively inform and shape the strategy. This will allow us to ensure that action is focused on the key issues and the right direction for the future.

As mentioned by the noble Baroness, Lady Bennett, everyone should have access to local, safe and inclusive opportunities to play sport, get active and stay fit to benefit their health.

At the heart of the government policy on physical activity are the UK Chief Medical Officer guidelines, which set out how much and which forms of physical activity are essential across a healthy life course. Through our work on the Everybody Active, Every Day physical activity framework there is consensus that long-term, system-wide action is required; physical activity is everyone’s business.

The Government provide primary schools with £320 million per year for PE premium and school active sport, to support schools to provide high-quality PE and at least 30 minutes of physical activity within the school day. This is at the heart of the school sport activity programme, which enables schools to use a whole-school approach to embedding PE and school sports. I will write to my noble friend Lord Moynihan on the specific points he made on access to those activities.

Our action includes continuing to provide ways for people to access local parks and green spaces through the Department for Transport’s walking and cycling initiatives, and the setting up of Active Travel England to support local councils to help people walk and cycle to work, the shops and to school.

Our world-leading digital and social media campaign Better Health provides digital resources and signposts to opportunities to support people to start to become and stay active. As I have part of the digital agenda, I will look to the use of wearables as another way in which we can increase participation and information. Digital health behaviour change approaches such as Couch to 5K have now had 5 million downloads, and Active 10 provides opportunities for people to build up activity levels.

We recognise that progress has not always been as fast as we would like. Our plans should help to change that. Sport and physical activity are golden threads that run through and align actions of government departments, local government, the NHS, sporting bodies and communities. Understanding the data and evidence on what works and what does not is vital to delivering our ambition to shift the status quo and address inactivity. By doing so, we can create access to more opportunities for everybody, especially people living in underserviced communities, to enjoy leading more active and healthier lives.

I am aware that many questions have been raised in this debate. As a new boy I understand that my response to a Private Member’s Bill is slightly different, but nevertheless I commit as in other debates to follow up in detail and writing on all the points, because I want to make sure that the points raised today have an appropriate response.

It is a privilege to be speaking after such accomplished speakers: some of the sports athletes here today, former Ministers and Secretaries of State for Health, chairs of sporting organisations such as ukactive and others, and top health professionals. They make my Saturday afternoon rugby efforts look rather weak in comparison.

We are all united in wanting to find the best way to promote healthy living through sport, education and active lifestyle. I know we want the same thing, which was probably put best by the noble Lord, Lord Crisp, as health creation, prevention and services. Some strong and passionate views were expressed on that and some excellent points were made.

I think noble Lords are also aware that I have a very broad background, with many leadership roles in businesses, charities and arm’s-length bodies, and I have been involved in four government departments and now government itself. Honestly, I have seen many different organisational models, both centralised and decentralised, setting up ALBs and having departments inside government. I can say from personal experience that in every one of those, in each instance it took a while for a new organisation to bed down and become effective. It took probably at least a year before you could really see its effects, and I believe that is the same in this instance. Therefore, while I understand and support the reasons expressed today, it is important that we need to give OHID time to take root, to see the publication of the sports strategy by DCMS with our involvement in quarter 1, and judge it on the results. However, I undertake, having listened to this debate today, to come back to the House and speak again on this subject when I believe it has had a proper amount of time to see whether it is working or whether we need to think about some other ways of setting it up.

For these reasons, I maintain my belief that the best way to achieve the objectives set out—which, as I said, were described so well as health creation, prevention and health services—is by OHID as a key and central part of government.

NHS Dental Contract

Lord Markham Excerpts

Thursday 1st December 2022 Lords Chamber

[Lord Young of Cookham]

To ask His Majesty’s Government what plans they have to review the NHS dental contract.

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

In July, the department announced a package of improvements to the NHS dental system, which included reform of the 2006 contract to ensure that dentists are remunerated more fairly and patient access is improved, especially for those with higher oral health needs. Implementation of these changes is under way, and we recently laid legislation in Parliament to deliver them. We continue to work with NHS England and the dental sector on further reform, which we plan to announce in 2023.

[Lord Young of Cookham (Con)]

I am grateful to my noble friend for that reply and for the recent modifications to the contract. But does he agree that much more radical reform is needed to that contract, which was described as “not fit for purpose” by a Select Committee in another place, if we are to address the exodus of NHS dentists, encourage more to join, address the 91% of dental practices that no longer admit new adult patients and help areas of the country with no NHS dentists at all? When will we have the longer-term radical reform referred to the last time I asked this Question, in May?

[Lord Markham (Con)]

I thank my noble friend, and I declare an interest: my wife is a dentist, although she is not practising at the moment. This is one of those rare occasions when it is a case not of announcing new spend but of making sure that the £3 billion we spend is fully utilised. To answer the question directly, it is absolutely right that we need a radical package to make sure that dentists are contracting against their UDAs and finding working in this space worth while and profitable, so that we get the full use of that. I will happily come forward with further proposals, planned for 2023, on what we are going to do in this space.

[Baroness Boycott (CB)]

My Lords, one reason why young children now go into hospital and have anaesthetics is to have all their teeth out, largely as a result of sugary diets. As we see through our Feeding Britain network, a lot of children do not have toothbrushes and definitely do not have toothpaste. Scotland has been trialling some really efficient systems whereby dentists go into school, give out free toothbrushes—which a lot of toothbrush manufacturers will happily supply—and get children into the habit of cleaning their teeth. Given the massive absence of dentistry, which will take a long time to fix, can the Government look at a simple measure such as that, which would greatly improve the nation’s teeth, especially our kids’? It is a nightmare to have all your grown-up teeth taken out at eight years old; you are stuck with lousy teeth for ever, and it is not fair.

[Lord Markham (Con)]

I agree, and I understand the problem. I also agree that we need to look at a broad range of measures. I was delighted that we passed the statutory instruments on water fluoridation recently, and we should look at new ideas. I was also delighted to see oral health advice included in the new family hubs being set up. We are willing to look at measures that work elsewhere as well, such as free toothbrushes in Scotland.

[Baroness Brinton (LD)]

My Lords, the British Dental Association has proposed four simple emergency measures—changes which could be made to the dental contract that would make an enormous difference. The Minister referred to the regulations. Regulations in respect of the workforce will make significant changes too. They were in Forthcoming Business and then removed. When will they be heard in this House? This reform is urgently needed.

[Lord Markham (Con)]

As mentioned, the new package of measures, which is all about encouraging dentists into the NHS space, will be brought forward next year. The workforce plan is now under way. However, central to all this is not the budget but making sure that it is fully utilised. As the noble Baroness said, that will happen by having more NHS dentists. We currently have 3,500 in training, which is working towards that, but, clearly, we need to work further.

[Lord Sherbourne of Didsbury (Con)]

My Lords, does my noble friend the Minister agree that the state of NHS dental care in this country over many years is a national scandal? Following on from the question from the noble Baroness, Lady Boycott, on the importance of making sure that children not only pursue proper dental health but eat the right food and do not have the wrong drinks, is he aware of the charity TasteEd, which is doing a huge job in schools to encourage children to eat the right kind of foods for health of all kinds?

[Lord Markham (Con)]

I thank my noble friend. We need a 360-degree approach. It is not just about dentists on the ground, although we agree that we need more in the NHS; it is also about healthy eating, water fluoridation, and oral health workers in the family hubs, for which a £300 million budget has just been announced. I agree that we need to take all those actions.

[Baroness Merron (Lab)]

My Lords, following much pressure, including in your Lordships’ House, the Government have promised for next year independently verified workforce forecasts for the number of doctors, nurses and other professionals. Can the Minister confirm that the space to which he has repeatedly referred in this Question will include dentists? If so, can he commit to an assessment within this of the impact of the NHS dental contract on recruitment and retention?

[Lord Markham (Con)]

My understanding is that the staff plan will include dentists, but I will confirm that in writing. I absolutely accept that the contract changes must attract people into the profession. For the dental deserts, we need to encourage, for example, a dentist who has been in practice for eight years to set up a new practice. They are used to being a dentist, but they are not used to raising the money to set up a new clinic in a new area, which is what they need to do. Clearly, that is the sort of support we need if are to tackle the dental desert issue. I am under no illusions as to what needs to be done, and we are working on it.

[Lord Scriven (LD)]

My Lords, I declare my interest as a vice-president of the Local Government Association. Does the Minister agree, despite the new package that has just come forward, with the Conservative chairman of the Local Government Association Community Wellbeing Board, who has said that the Government should urgently commit to a comprehensive dental workforce strategy and increase councils’ funding of the public health grant in real terms to help deal with the dental desert in many parts of the country?

[Lord Markham (Con)]

I thank the noble Lord. As I mentioned, dental deserts are very much a part of the package we are looking at. To give noble Lords an idea of the sense of direction, another approach to the workforce issue is a modular escalator system, and we are talking to the BDA about training. For instance, on the way to becoming a fully qualified dentist, might a dentist become part-qualified, allowing them to do some dental nurse treatments, thereby adding to that capacity in the meantime? These are all measures we are looking at to increase the workforce.

[Lord McColl of Dulwich (Con)]

Can the Minister tell us what proportion of the population is actually receiving fluoride in their drinking water?

--- Later in debate ---

[Lord Markham (Con)]

I will need to write to give the exact number. From memory, it is not a big number at the moment—less than 10%—but I will confirm that. That is why I was pleased that we agreed the measures the other day, so that we can expand that. Evidence shows that in areas where water is fluoridated—again, I am speaking from memory and I will confirm it in writing—tooth decay declines by as much as 20%, so it does work.

[Baroness Jolly (LD)]

What advice does the Minister give to people in Cornwall for whom the nearest NHS dentist is 50 miles away but there is no public transport from the local town to the practice?

[Lord Markham (Con)]

I am aware of some of the dental deserts. Some 700 urgent care centres have been set up to try to cater for such cases, and they have seen 4 million people. In total, there were about 26 million treatments last year. About 75% of patients who wanted to get an appointment were able to. Clearly, that leaves 25% who were not. We need to work further on that, including in Cornwall.

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

My Lords, the Minister’s replies have been exceptionally helpful. I wonder whether he and the Government could consider what might be done to get non-practising dentists back into practice.

[Lord Markham (Con)]

It is a good question. I will take the noble Lord’s compliment of being exceptionally helpful; I hope I can give another helpful answer. We need to look at everything we can do to attract dentists. The contract is fundamental to that, because, unless it is attractive for them financially, it will not help.

[Lord Bird (CB)]

Is it possible also to look at some of the innovations that are done socially, especially for homelessness? We have brought back travelling dentists, and maybe they can go to Cornwall and other places. We have invested in a business in Plymouth that goes around hostels, and it has been remarkably successful.

[Lord Markham (Con)]

As mentioned before, we are open to all ideas to try to tackle this problem. As we all know, it has been going on for a long time—probably decades. A 360-degree solution is needed; we are open to looking at everything.

Care Homes: Severely Disabled People

Lord Markham Excerpts

Wednesday 30th November 2022 Lords Chamber

[Baroness Pitkeathley]

To ask His Majesty’s Government what assessment they have made of reports that some care charities have been forced to evict severely disabled people from their care homes because of disputes with local authorities about fees.

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

The disruption of care where it negatively impacts vulnerable service users is unacceptable. Under the Care Act, local authorities have a duty to shape their markets and provide services to those with eligible needs. The Government are providing up to £7.5 billion over the next two years to support adult social care and discharge. This historic funding boost will help local authorities to start addressing waiting lists, low fee rates and work- force pressures in the sector.

[Baroness Pitkeathley (Lab)]

I thank the Minister for that Answer, but I cannot say that any of it was a surprise to me. Will he acknowledge that this is just the latest manifestation of a long-standing problem? For years, the social care system for adults with complex disabilities has been held together by charities and not-for-profits that have poured literally millions from their reserves into subsidising the services they provide for the NHS and local authorities. Now these organisations are in financial trouble and can no longer afford to do so. Those who are suffering are those in greatest need. Does the Minister agree that the whole system of funding for social care is broken and that the only solution is complete root-and-branch reform, not the piecemeal solutions offered by the Government?

[Lord Markham (Con)]

I thank the noble Baroness and echo the sentiment of thanks to the charitable sector for the work it is doing in this vital space. We have shown that we have listened in this area through the £7.5 billion—a 22% increase over two years, which I think everyone would agree is substantial. At the same time, we are in touch with these bodies; we reached out to the charity Leonard Cheshire, which is involved in this, to try to understand the issues. If there are ways in which we can directly help, we will do so.

[Lord Laming (CB)]

My Lords, does the Minister agree that there was a time when, if the local authority asked to see the parents, they assumed that this was for a review of what progress had been made by their offspring in residential care? More recently, parents are saying that they fear any approach by a local authority, because it may say that it will have to move their child to a different arrangement because it cannot afford to pay the fees now being set.

[Lord Markham (Con)]

As I say, we are working on this. The CQC has a vital role to play and we had a discussion recently with the Association of Directors of Adult Social Services, which welcomed the relief the Autumn Statement brings in this area. I can only reiterate that we have listened and acted.

[Lord Wigley (PC)]

My Lords, I draw attention to my registered interests. Do not these cases underline the need to ensure that the additional costs of severe disability, whether incurred in charitable establishments, commercially run accommodation or at home with families, should be met consistently from central sources rather than falling on local authorities, which may have neither the expertise in the degree of disability nor the resources to meet them?

[Lord Markham (Con)]

As ever in these areas, there is a debate to be had on centralism versus localism. I happen to believe that local authorities and healthcare systems are best placed to understand the needs of the people in their area, and I will continue to support that. Clearly, where help is needed, we are there. I reiterate that we have funds to support them from the centre, including a £2.3 billion increase for mental health, to give one example. Generally, I would keep to the principle that it is best that local people and authorities identify and meet local needs.

[Baroness Brinton (LD)]

My Lords, the Minister just referred to mental health funding and referred earlier to the increased funding to cover delayed discharges and get more people coming out of hospital into social care. Neither of those affects severely disabled adults; funding for them from central government to local government has not been increased. I repeat the question of the noble Baroness, Lady Pitkeathley: does the Minister think that the provision and arrangements for this particular group of people are broken?

[Lord Markham (Con)]

No—it is for local authorities to decide how best to use the funding we have put in place, as I said. That means looking at the needs of local people and how best they will put this in place. The 22% increase in funding can be channelled to exactly these types of places and people if a local authority believes that that is in the best interest.

[Baroness Browning (Con)]

Does my noble friend accept that many disabled people in residential and nursing care are of an age such that there are no parents or close relatives left and there is no one with a lasting power of attorney? How can that vulnerability be coped with by the state in a way we would all approve of?

[Lord Markham (Con)]

My noble friend identifies an ageing demographic, the challenges that brings to all of us and the pressure on adult social care and the centres. As I have said, this is a challenge, but there are high levels of satisfaction in the sector: 89% of people are satisfied and 64% are very satisfied. So, although we have not got this right in every case, we are broadly on the right track and getting good results.

[Baroness Wheatcroft (CB)]

My Lords, eight out of 10 of the largest providers of care for the disabled and children are at least in part private equity owned and, in many cases, wholly so. Their interest rates are already their major concern, and these are going up. Is the Minister concerned that these private equity-owned homes will be forced either to cut what they do and serve their customers less well, or close? If he is concerned, what is he doing about it?

[Lord Markham (Con)]

The financial health of this sector is an area of interest; we all of course recall some of the problems and failures about 10 years ago. I had a meeting on this subject just this week, identifying the health of the providers to see if that is of concern. The margins made in this space are fairly typical of other industries, so they are not indicative of an area under particular stress. But I have my mind on this issue and will keep an eye on it.

[Baroness Wheeler (Lab)]

My Lords, ADASS reports that in the past four months,

“64% of councils … reported that providers in their area had closed, ceased trading or handed back council contracts”

either through an inability to recruit staff or escalating care home running costs. We all know that the extra funding to councils, which the Minister repeats in almost every response, just about props up existing services and does not provide the sustainable and long-term funding that was promised to commence with the again delayed social care cap. When will the Government fulfil their pledge to fix social care?

[Lord Markham (Con)]

My Lords, the 200,000 extra care places that this funding provides is a solid example of an expansion of supply, and I hope all noble Lords agree that that is a substantial number. I hope they also agree with the work we are doing to recruit from overseas to increase the workforce in this sector, which is indeed increasing. Areas such as these show that we are committed to expanding the supply, and we are seeing that rewarded in the increase in the last few months.

[Lord Forsyth of Drumlean (Con)]

My Lords, has my noble friend yet had an opportunity to read the Economic Affairs Committee report on social care, a “national scandal”, which points out that in care homes in both the private and the charity sectors, people who pay their own costs subsidise others to the tune of 40%? The local authority rates are simply unsustainable, and this issue is therefore urgent and needs to be addressed. Simply talking about inputs all of the time is no good; we need to see what is happening to the outputs, which is a tragedy.

[Lord Markham (Con)]

Funnily enough, the meeting on the sector’s financial health that I mentioned was precisely in response to the Question last week, so that I can make sure that proper work is being done in this space. I will not pretend to have the answers to that yet because, as my noble friend mentioned, a long-term review needs to be done. But rest assured that I am working on this.

Covid-19: PPE Procurement

Lord Markham Excerpts

Wednesday 30th November 2022 Lords Chamber

[Baroness Smith of Basildon (Lab)]

My Lords, I have raised the issue of fraud in PPE contracts previously. Apparently, PPE Medpro was awarded contracts via the VIP lane amounting to £200 million, despite it not even existing when Ministers were first contacted. Then, just over a year ago, the noble Lord, Lord Bethell, then the Health Minister, admitted that the department was engaged in ongoing

“discussions (potentially leading to litigation) in respect to 40 PPE contracts with a combined value of £1.2 billion covering 1.7 billion items of PPE.”

The following January, the noble Lord, Lord Agnew, resigned, criticising the Government’s track record in countering fraud across government. In relation to the PPE contracts of £1.2 billion, will the Minister update the House on how much of that money has now been returned to the taxpayer? Can he say what amount is outstanding, either where negotiations continue or where legal action is now being taken or is pending? If he does not have that information immediately to hand, will he commit to write to me and place his letter in the Library?

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

I thank the noble Baroness, and I commit to write with the precise figures. To put it into context, we should remember that this was at a time when unprecedented action was required. Of the 38 billion PPE items ordered, 98% were delivered and just 3% were unfit for purpose. Within that, clearly there is action that needs to be worked on and action is being taken to pursue those damages. I will put those in writing, so that the noble Baroness can understand them all. As I say, it is good if noble Lords recall that the priority at the time was clearly getting equipment to help protect and save lives, and that was what was done. Were mistakes made? Of course. Are we seeking to address those now by going back to take action against those people? Yes, of course we are, but we need to keep it in the context that the undoubted priority was to buy PPE and protect lives.

[Baroness Brinton (LD)]

My Lords, from these Benches we echo the questions that the noble Baroness the Leader of the Opposition has asked. We note that at least 71 PPE deals were awarded to firms, of which at least 46 were put into the VIP lanes by Conservative Ministers and officials during the Covid pandemic, as well as by some MPs and Peers, before a formal eight- stage due diligence and checking process was put in place. There were also deals made not for PPE during that period, including for testing and some non-health ones.

I think we all agree that the wastage and profiteering should never happen again, but we warned from these Benches, as did other Members across the House, in the early stages of the pandemic that all the right contracting arrangements, protocols and scrutiny needed to continue. The Minister has said that the pandemic posed problems, so will he push for a separate, independent-led inquiry able to examine the whole procurement process, including the VIP lanes, and analyse forensically the bids, profits, wastage and catalogue of links to Ministers, MPs, Peers and others who had influence on them?

[Lord Markham (Con)]

I thank the noble Baroness. My understanding is that there have already been three NAO reports and three PAC reports on this, so it has been covered in depth. I think people have accepted that mistakes were made and that the high-priority lane, so to speak, should not have been on the basis of referrals but more burden of proof should have been put on the applicants, so we could get more information and sift it that way. Again, to put it all into context, there were 19,000 applicants at the time. This was led by officials, and they put the high-priority lane in place to try to sift those. Also, of the 430 that went into the high-priority lane, only 13% actually ended up in contracts. Are there lessons to learn from this? Of course, but the NAO and PAC reports have outlined those lessons.

[Lord Browne of Ladyton (Lab)]

My Lords, experience tells us that the best deterrence against fraud and corruption are the twins of transparency and accountability; in the absence of such transparency and accountability, the reporting of the saga of PPE Medpro risks tainting others by association. So, for transparency if nothing else, will the Minister agree that relevant correspondence between PPE Medpro or its representatives, and Ministers or their officials, should be published and placed in the House of Lords Library, perhaps soon after the current investigations are concluded? Also for transparency, surely the public are entitled to understand what due diligence was conducted on this company and other similar ventures that emerged, apparently from nowhere, during the initial stages of the pandemic?

[Lord Markham (Con)]

I thank the noble Lord. As I am sure we are all aware, this is subject to a criminal investigation at the moment, so in terms of paperwork we need to let that take its due course. What I can talk about is what we are doing as a department on that, particularly in terms of the contracts for gowns which were defective, and it is in that area that we are in dispute with them. We have made a claim and put in place a process so that we will take it to court, and we will pursue that if we do not come to a negotiated settlement which is satisfactory.

[Lord Alton of Liverpool (CB)]

Can I take the Minister to the present rather than the past, and to two Written Answers which he gave to me yesterday on the 120 million items of PPE which are currently still stored in the People’s Republic of China and costing taxpayers £770,000 every single day—three-quarters of a million pounds, daily? I asked the Minister how much this has cost to date, but in telling me that the cost has been £16.3 million, he simply took the period of April to September. I would be grateful if he could produce a more complete set of figures and say how much longer we are going to go on paying £770,000 every day to companies linked to the People’s Republic of China, to the Chinese Communist Party, and to goods that have been made by slave labour in the Xinjiang region.

[Lord Markham (Con)]

I will happily provide those updated figures in writing; I thank the noble Lord for his question because it sparked a number of inquiries on my front. As he will be aware, I am only two months into this job. But one of those very questions—a hard question for us to think about—is the cost of storage versus, dare I say, scrapping it, because we have tried to donate all we can from it, and, God forbid, having to buy it again if there is another pandemic. In many cases it is cheaper right now to scrap it and buy it again at current prices. Of course, you cannot be certain whether prices could then get inflated again, but I hope your Lordships can tell from this answer that I am very much looking into the cost-benefit of the best approach.

[Baroness McIntosh of Pickering (Con)]

My Lords, will my noble friend pay tribute to Industrial Textiles & Plastics of Easingwold which, together with Barbour and Burberry, submitted an application to the Cabinet Office for a number of gowns, and are still waiting for a reply? They donated these gowns free at the point of use to local hospitals. I believe that they should have had a contract from the Government and am at a loss to understand why they did not. Is there any reason that the Cabinet Office failed to reply to them?

[Lord Markham (Con)]

I do not know why they did not reply. What I do know is that there were many companies like the ones mentioned who wanted to do their bit. They stepped up to the mark and provided all sorts of goods and services, sometimes at no cost and for no profit, because they all wanted to be part of the wartime effort. I will find out why they did not get a response.

[Lord Allan of Hallam (LD)]

My Lords, there is considerable public interest in understanding whether businesses were stepping forward at a time of crisis, sourcing PPE helpfully and passing it on to the NHS, with a minimum mark-up to cover their costs, or rather seeking to maximise profit. Will the Minister agree to publish sufficient information about the distribution of profit margins made across the community of suppliers for us to make that determination?

[Lord Markham (Con)]

I do not believe we could possibly have that information; obviously, we would need to know the cost base of these companies to supply it. I am afraid that I do not believe we can do that. Further to my last reply, some companies supplied things at a very reasonable margin and did a great job, but unfortunately, as we have seen in some of the examples, others were not so publicly spirited—let me put it that way.

Food and Feed (Miscellaneous Amendments) Regulations 2022

Lord Markham Excerpts

Tuesday 29th November 2022 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 24 October be approved.

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

This instrument is made under powers in the European Union (Withdrawal) Act 2018. It follows on from the previous EU exit instruments in the field of food and feed safety made since 2019. The Government’s priority is to ensure that we continue to maintain the high standards of food and feed safety and consumer protection we have established. The principal changes introduced by this instrument will ensure that national and GB-wide legislation continues to operate effectively following the UK’s exit from the EU.

The purpose of this instrument is to: amend England regulations in the fields of articles in contact with food, extraction solvents and animal feed to remove cross-references to EU directives and correct other EU exit-related inoperabilities; address a range of remaining deficiencies in retained direct EU legislation in the field of food and feed safety and hygiene to ensure the continued operability of this legislation after exiting the EU; address inoperabilities that have arisen as a consequence of previous deficiency amendments made pursuant to EUWA 2018; extend the tolerance period of three withdrawn genetically modified organisms, GMOs, for a further three years, until 31 December 2025, to align with the correction of a deficiency in retained EC regulation 619/2011; and provide for a time-limited transitional period for edible insects, specific to Great Britain. This will permit qualifying edible insects to remain on the market in GB after 31 December 2023 while applications for novel food authorisation are considered by the appropriate authority.

Let me be clear that this instrument does not introduce any changes that will impact the day-to-day operation of food and feed businesses, nor does it introduce any new regulatory burden. The essence of existing legislation is unchanged.

It is important to note that the devolved Governments have some shared and devolved legislative responsibilities in relation to food law. Both Scotland and Wales have provided their consent for the instrument. Amendments brought forward by the instrument do not apply to Northern Ireland. In accordance with the Northern Ireland protocol, EU regulations will continue to apply. However, the Northern Ireland Department of Health has been briefed. We have engaged positively with the devolved Governments throughout the development of the instrument, and I take this opportunity to note that their ongoing engagement has been warmly welcomed.

I take the opportunity to assure noble Lords that the overarching aim of these regulations is to provide continuity for business and to ensure that high standards of safety and quality for food and feed regulation will continue across the UK. The changes do not affect the essence of existing legislation. They address a range of deficiencies in retained direct EU legislation on food contact materials, extraction solvents and animal feed arising from EU exit. They will ensure that appropriate legislative provision is in place to extend the transitional period for the trace presence of withdrawn GMOs in food and feed. Finally, they will provide a time-limited transitional period for edible insects to remain on the market in GB.

Having effective and functional law in this area is key to ensuring that the high standards of food safety and consumer protection we enjoy in this country are maintained in the immediate and long term. I ask noble Lords to support the amendments proposed in this instrument to ensure the continuation of effective food and feed safety and public health controls. I commend the regulations to the House.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I thank the Minister for introducing the regulations and the thinking behind them. I accept the assurances that he has given. We on these Benches welcome the regulations, which are about trying to correct the drafting errors and inconsistencies that have inevitably emerged. I say that with no criticism; this is a complex area, and there is a need to tidy up regulations following exit from the European Union.

It is perhaps timely to take this opportunity to praise the work of the Food Standards Agency, and to note that it is one of the strange things about the changes introduced by the Government that Health Ministers now find themselves talking about animal feed. I am sure the Minister is delighted to do so, and I myself have certainly learned a lot today in preparation.

I turn to the regulations. The instrument generally maintains existing regulations and does not introduce new requirements, exactly as the Minister has said. I note that no concerns were raised by the Joint Committee on Statutory Instruments or the Secondary Legislation Scrutiny Committee, so I am sure that is cause for celebration on the Government Benches.

We in this country have a good food safety system, and this SI, as others may do, simply tries to ensure that that continues. The problem is of course that the world did not stop when it came to the implementation period completion day. As paragraph 7.13 of the Explanatory Memorandum tactfully puts it, “certain difficulties” emerge,

“especially in relation to the approval of new, or amendment of currently authorised, substances.”

Could the Minister help by elaborating on the difficulties that are posed and any potential costs? What happens with regard to trade when we operate to different standards from those of our near neighbours? The SI addresses the administrative challenge but does not seek to solve the problem.

Similarly, where the review process is described in paragraph 7.15, it would be helpful if the Minister could clarify the circumstances in which the Food Standards Agency will be required to review the operation and effect of the regulations. If, for example, a new extraction solvent is approved in the EU, does that automatically trigger a review? Will the Food Standards Agency be required to undertake additional processes to deliver on that? If so, has an assessment been done of whether the FSA has the capacity to undertake such duties, or can the Minister advise whether the FSA will be getting additional resources?

There is the issue of the “Do Not Eat” pictograph, which is referenced in paragraph 7.22. This states that we cannot use it because of “uncertainty” over the intellectual property rights applying to the ownership of the picture, which seems a bit strange because there must be similar cases of artwork where such provenance is uncertain. Was it asked whether we could use it, and was any uncertainty flagged up at the time? How much would a licence have cost? It is probably right to say that it seems a strange way to proceed if we cannot agree on joint use of an existing symbol to promote food safety. That suggests some problems on which the Minister may wish to comment.

I want also to reference the need to reinstate powers to extend the transitional period for the trace presence of withdrawn genetically modified organisms. There is considerable interest in genetic modification, as we know, and some concern that rules on imported products are inconsistent with rules governing domestic production. Can the Minister say a little about the scale of the issue? For example, just how much oilseed rape is there with traces of the withdrawn GM products referenced in this case?

If the Minister is not able to answer the detail of the points that I have raised, I will be pleased to hear from him in writing. We from these Benches certainly welcome the statutory instrument, and thank him and his team for their efforts.

[Lord Markham (Con)]

My Lords, it is my duty to close this important debate. Your Lordships perform an essential role in scrutinising the measures we have put forward today, and I thank all noble Lords for their contributions. Let me turn, as best I can, to answering some of the points raised. Where I do not quite succeed, I will gladly follow up in writing.

First, my noble friend Lady McIntosh of Pickering asked for an explanation about the pictograph. My understanding is that it is a picture which does not depend on a specific language to understand it. On what happens regarding the IP rights behind it, my understanding—again, I will confirm this—is that a number of questions were asked as to the ownership of those rights. The IP ownership was unclear, so the process for even trying to license it was not clear. That was the issue at hand, but I will come back with further detail on it.

Turning to the other questions, my noble friend Lady McIntosh asked how the SI will affect the retained EU law Bill. The Food Standards Agency is carefully considering the scope of the powers in the retained EU law Bill and whether they can be used to deliver a better, bespoke British system of food safety. Those will all be part of what we go through in the coming weeks and months.

On the labelling of GM and other foods, there are regulations requiring mandatory measures in the traceability and labelling of GM products. This is seen as necessary to inform a consumer about their choice whether to buy and eat GM food, so that will take place in all these cases. The noble Baroness, Lady Merron, asked about the level. My understanding is that it is a minor trace level, consistent with what exists today, but, again, I will follow up on the detail of that. We have been working with the FSA in these areas, which feels that it is in a position to answer and regulate in this area.

Perhaps my favourite question related to edible insects; I only wish I had known about this before “I’m a Celebrity… Get Me Out of Here!” They are apparently for human consumption. I can write on this if noble Lords let me know whether they would like the Latin or the English version, but they are apparently: the lesser mealworm, the house cricket, the yellow mealworm, the banded or decorated cricket, the bird grasshopper or desert locust, the migratory locust, and the black soldier fly. I will not try to read the Latin out for each of those, but I will happily put them down in writing.

I was asked why this could not be included in the precision breeding Bill. The wider question of the future of precision breeding and gene editing is not considered by this SI and would be a matter for the Secretary of State for Environment, Food and Rural Affairs. For now, the commercial cultivation of gene-edited plants and any food products derived from them will still need to be authorised in accordance with existing GMO rules.

On the question of the noble Baroness, Lady Bakewell of Hardington Mandeville, on safety going forward, as I said, our approach to food safety is and always will be underpinned by three principles: that UK food remains safe and what it says it is; that the high standard of food safety and consumer protection that we enjoy in this country is maintained; and that, following our exit from the EU, a robust and effective regulatory regime is in place, which means that business can continue as normal.

I hope that I have answered the detailed questions. Like the noble Baroness, Lady Merron, I did not expect to need to understand this as part of my brief, but it is part of the rich variety of my job. I thank noble Lords for their questions and their support, generally, for our proposals. To reiterate: these regulations are critical to ensure that the UK consumer continues to enjoy the high standards of safety and quality provided by UK food and feed regulations. This instrument makes no changes to policy or to how food and feed businesses are regulated, and it is limited to necessary amendments to ensure that.

[Baroness McIntosh of Pickering (Con)]

I press my noble friend on what the implementing authority will be.

[Lord Markham (Con)]

I apologise; I will definitely need to come back in writing on this, but my understanding is that, at a local level, it will be local authorities. I am grateful for noble Lords’ contributions and the sincerity of their views.

Motion agreed.

Adult Social Care

Lord Markham Excerpts

Thursday 24th November 2022 Lords Chamber

[Lord Scriven (LD)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and in so doing, I draw the attention of the House to my interests in the register.

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

The Government have noted the findings in the report. Our priority is for everyone who is entitled to adult social care services to get the right support they need, at the right time and in the right place. The Government recognise the immediate pressures adult social care is facing, which is why the Chancellor has announced up to £2.8 billion of additional funding in 2023-24 and £4.7 billion in 2024-25.

[Lord Scriven (LD)]

My Lords, the extra money is to be welcomed, but two years’ extra funding is not a viable and sustainable response to the problems facing the social care system. Does the Minister agree with the Conservative chair of the LGA Community Wellbeing Board, Councillor David Fothergill, who says:

“Adult social care will remain in a crisis state until a comprehensive plan is in place to fully fund the care needed”?


If he does, when will that comprehensive funded plan be forthcoming?

[Lord Markham (Con)]

I think we all agree on the vital necessity of adult social care—I think the noble Lord has heard me say it many times from this Dispatch Box—and that is what the £2.8 billion and £4.7 billion are about over the two years. The noble Lord is correct that we need to look longer-term, because the whole health service and the care of our elderly are obviously dependent on us getting this right.

[Baroness Wheeler (Lab)]

My Lords, the backlog of care assessments, estimated at 500,000 by ADASS, lies at the heart of the complaints coming through to the ombudsman. They are all about assessment delays for people and their carers, not enough funding or staffing to deliver those assessments that are agreed and failures in home care and care home support. The latest NHS figures show that 145,226 people in England have died waiting for social care over the past five years, and nearly 29,000 previous self-funders have made a new request for council social care support because they have depleted their funds. Can the Minister tell the House exactly what impact the 200,000 more care packages to be delivered in place of the two-year cap delay will have on the huge backlog of assessments and what percentage of the original money earmarked for social care this actually represents?

[Lord Markham (Con)]

I thank the noble Baroness. As mentioned, 200,000 care packages is a significant number and will make a significant impact on everything we are talking about here, and that is in conjunction with all the other measures we have put in place, including the £500 million discharge fund this year. In terms of the precise percentages of those allocations, I will quite happily commit to write on that, but I can say to your Lordships that the £4.7 billion represents a 22% increase in 2024-25. By any standards, I think that people would agree that a 22% increase is a significant amount.

[Lord Forsyth of Drumlean (Con)]

My Lords, has my noble friend read the report of this House’s Economic Affairs Committee entitled Social Care Funding: Time to End a National Scandal published some years ago? In particular, the point is made in the report that to try to fund social care by allowing for an increase in council tax is highly regressive and inequitable because the tax base of the local authorities is least where the demand is greatest.

[Lord Markham (Con)]

I have not read the report, which was published a few years ago—I will always stand up and say when I have read something and when I have not, and will not pretend to have read something that I have not. But I am aware of the issue. I was a local councillor many moons ago and am aware of the issue of the narrow tax base on which we are sometimes asking to draw, so it is a much wider question. That is why I am glad that a lot of this funding has come from central government as a down payment towards that. As I have mentioned many times, I accept that we need to find some long-term solutions in this space.

[Lord Turnberg (Lab)]

My Lords, the question of pay is very important of course, but the other element is the respect and self-respect that a professional is due. That can come only if they have a nationally recognised training programme, qualification and registration, none of which they have. Will the noble Lord think about how we might achieve that? At least that will bring more people into the profession.

[Lord Markham (Con)]

I agree with the noble Lord that we need to make this an appealing profession and, as the noble Lord says, that involves more than just pay. We know that retention is vital, so I agree that having it properly recognised professionally is the direction of travel. At the same time, I am very glad to say that, for a lot of the money we are talking about—the £2.8 billion next year, for instance—some 70% will trickle down into wages, so I am pleased that it will actually be felt in the pockets of the carers, which again will help with recruitment and retention.

[Lord Kirkhope of Harrogate (Con)]

Can my noble friend advise us what is in place from the Government to look into the necessary social care of those mental patients who have had to be discharged from institutions and elsewhere, where the history is a very poor one. I speak as a former mental health commissioner. I feel that it is very sad that the community is not able to take care of people who should not be in institutions but in the community. What are the Government doing about this?

[Lord Markham (Con)]

I thank my noble friend. I think we agree that, where care can be considered and put in place in the community, that has to be the best place to do it. These funds are not just limited to care homes. The whole reason that they are allocated through local authorities is that it allows them to put the money where it is most needed in their local area. I have to say at this point that, despite all the issues we talk about, 89% of people are satisfied with the care they receive and 64% or so are very or extremely satisfied. In the context of all this, we have to recognise that the numbers are showing us that this is a service that people are satisfied with.

[Lord Blunkett (Lab)]

My Lords, in following up the question raised by the noble Lord, Lord Forsyth, perhaps the Minister could outline to us the ratio of spend over the next two years in relation to what is being raised from council tax and what is actually coming from the Exchequer.

[Lord Markham (Con)]

Of the £2.8 billion increase next year, £1 billion is coming through the grant, with the other £1.8 billion available for the local authorities. In 2024-25, of that £4.7 billion, £1.7 billion is coming through the central grant.

[The Lord Bishop of London]

My Lords, the Archbishops’ commission on social care, which will be publishing its report next year, is also concerned about the inequitable funding when funding is raised through council tax. Can the Minister indicate how central money will reduce this inequality to accessing care and whether the Government are doing any evaluation of that?

[Lord Markham (Con)]

Obviously, the central grant is raised through general taxation and so is distributed and raised in the way we all know. We can all have a question as to what the balance should be between the two. At the same time, I think we all believe in localism and we all believe, as part of that, that local authorities are the best placed to make decisions. That means that they have some of those fundraising abilities, so they can put more funds into the area where it is required. Whether we have the balance right is something we need to keep under control, but right now the most pressing thing is putting in more money for next year and the year after, and I am very glad—and I hope the whole House will welcome—that we have committed to do that. We put our money where our mouth is to create 200,000 new care packages.

[Baroness Brinton (LD)]

My Lords, surely the most pressing thing is the emergency winter fund to help remove and reduce delayed discharges this year. The Secretary of State for Health has said that he wants to reduce the bureaucracy, so why are the rules for accessing the emergency winter fund so complex that the Health Service Journal is full of local authority and senior NHS staff saying that they do not understand why the Government are insisting on this bureaucracy?

[Lord Markham (Con)]

Believe me, I am no fan of complexity. At the same time, I want to make sure, as I am sure we all do, that the funding goes to the places of most need and is really being spent on the areas that it is being spent on. Having said that, I will take away those comments at face value and will look into the complexity because, clearly, that is in no one’s interest.

[Baroness Altmann (Con)]

My Lords, the crisis in social care has been worsening since I was advising the Dilnot commission in 2011. What plans do the Government have to improve the situation rather than watch it deteriorate? Age UK estimates that there are about 2 million elderly people needing care who are not receiving it, so 200,000 care packages are hardly going to make enough difference.

[Lord Markham (Con)]

I thank my noble friend. As the population grows older, we must look at how to cater for these areas. We have been having real-term increases year after year of 2.5%, and 22% by 2024-25 is a substantial increase by any measure. At the same time, satisfaction levels are high. Do we need to do more? Clearly, we need to keep up in this space.

Tobacco Control Plan

Lord Markham Excerpts

Wednesday 23rd November 2022 Lords Chamber

[Lord Faulkner of Worcester]

To ask His Majesty’s Government when they intend to publish their Tobacco Control Plan; and whether it is still their intention that England shall be smoke-free by 2030.

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

Following the publication of the Khan review into smoke-free policies, we are taking stock of whether a fresh tobacco control plan is the best way to respond to its independent recommendations. The Government remain fully committed to the ambition of a smoke-free England by 2030, and we will provide an update on our plans to meet that target in due course.

[Lord Faulkner of Worcester (Lab)]

My Lords, I think this is the first time the Minister has answered a Question about tobacco control; I welcome him to this debate. He will know that this House has led the way in putting forward and implementing measures that have led to a significant drop in smoking levels, certainly since 2002. There is cross-party consensus that we should go on in this way.

The Minister’s predecessor, the noble Lord, Lord Kamall —I am pleased to see him in his place—is on the record in both March and April as saying not only that the Government are committed to a smoke-free 2030, as confirmed by the Minister this afternoon, but that the new tobacco plan will be published this year. Does the Minister accept that, to achieve the smoke-free target and reduce the appalling inequalities in life expectancy caused by smoking, it will be necessary to implement the recommendations in Javed Khan’s independent review, particularly those based on the “polluter pays” principle?

[Lord Markham (Con)]

First, I thank the noble Lord for all his work to reduce smoking; I am grateful for it every time I walk into a smoke-free environment in the evening. As he said, a cross-party approach has achieved many great things. As the noble Lord knows, there are some quite radical things in the Khan review, such as increasing the smoking age every year, which would in effect ban smoking altogether. There are many pros and cons to the prohibition argument, but it is something we take very seriously and we will publish our response. I assure noble Lords that we are going to tackle this issue.

[Lord Lansley (Con)]

My Lords, does my noble friend recall that in the former coalition Government, we made considerable progress in reducing smoking in this country, not least by focusing on the level of initiation of smoking among young people? We banned vending machines, for example. Will the Government consider raising from 18 the age at which young people can buy cigarettes?

[Lord Markham (Con)]

I agree with my noble friend. The key age group to attack, so to speak, is 16 to 18-year-olds, which is often when the smoking habit begins. We must look seriously at every step we can take to reduce smoking in that age group. I am also aware that 18 is the age of consent, of being able to do lots of things, and changing that for smoking would obviously be quite a radical step, but everything is on the table as we review the best way forward.

[Lord Rennard (LD)]

My Lords, the Health Foundation recently published figures showing that the budgets for tobacco control and smoking cessation have been cut in real terms by 41%. Is not part of the answer to funding treatment for addiction to tobacco, alcohol and gambling the extension of the “polluter pays” principle? What is the argument against a levy on the very large profits of the tobacco companies, in order to pay towards helping their customers who want to quit?

[Lord Markham (Con)]

There are a number of ways we can tackle this, price, obviously, being one of the main ways, along with taxation. The noble Lord will be aware that we increase the tax by 2% every year, and cigarettes prices here are now the highest in Europe. We are still providing funding of £73 million per year to help 100,000 people stop smoking. But it is not always money that counts. Anti-smoking campaigns, branding restrictions and taxation are all other elements which are proving successful.

[Lord Palmer (CB)]

My Lords, have His Majesty’s Government estimated the loss to the Treasury if England became smoke-free?

[Lord Markham (Con)]

I am not aware of those figures, but the general feeling is that the savings to the health system would far outweigh them. I would always err in favour of doing everything we can to reduce smoking, whatever the impact on the tax we raise, because the savings on the health side are far, far greater.

[Baroness Merron (Lab)]

My Lords, despite the Government pledging to explore additional measures to clamp down on the sale of e-cigarettes to under-18s, no plan has yet materialised, while vaping among 11 to 18 year-olds has more than doubled. What assessment have the Government made of this alarming trend, and what action is being considered to keep children and young people away from this gateway to a smoking habit?

[Lord Markham (Con)]

This is a difficult area. On the one hand, I think we all agree that vaping is much better than smoking, so we are trying to get the message out to people to stop smoking and use vaping if need be. At the same time, we do not want vaping to be a gateway, as she says. Giving those mixed messages is never an easy thing to do, which is why we must consider as part of the Khan review the best way to get that message out. The recent Cochrane review shows that vaping is as safe as all other methods of stopping smoking, such as patches, so it should be our key way of stopping smoking.

[Lord Geddes (Con)]

My Lords, as much as I enjoy my non-political friendship with the noble Lord, Lord Faulkner of Worcester, I totally disagree with the premise behind his Question. Why should Big Brother tell me what I can and cannot do in respect of something I have been doing for 67 years?

--- Later in debate ---

[Lord Markham (Con)]

I am not sure whether that question is for me, but I will try my best. As ever on these things, there is a carrot and a stick. Cross-party, we have introduced carrot measures—the anti-smoking campaigns—and stick measures such as pricing and restrictions. That has worked very well to date. We have halved the smoking rate over the last 15 years, and we must continue to work on carrot-and-stick measures to reduce it further.

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

My Lords, the Minister will be aware that the tobacco industry is very adept at getting round regulations. In 1986, John Home Robertson’s Bill made illegal the use of tobacco pouches that people put in their mouths as substitutes. I understand that synthetic nicotine pouches are now being used to get round that law, so what are the Government doing to stop this?

[Lord Markham (Con)]

I will need to write to the noble Lord on that. I am aware that different methods exist, but I think we are all united on the need to do everything we can to prevent any circumvention.

[Lord Naseby (Con)]

Is not any plan meaningless when at least a third of the market is supplied by illegal imports? His Majesty’s Government appear not to have done anything to stop this, and it is the young people in our country who are smoking the cheap, illegally imported cigarettes.

[Lord Markham (Con)]

We are working very hard with HMRC on this. I think we can all agree that one thing that Brexit was good on was restricting the number of cigarettes that people can bring in legally from other parts of Europe.

[Noble Lords]

Oh!

[Lord Markham (Con)]

I will take everything I can. Clearly, we need to stop cigarettes coming in by all illegal means.

[Lord Brooke of Alverthorpe (Lab)]

The Government also lose a lot of income through illegal importation. If the Government are working very hard indeed to prevent it, can the noble Lord please spell out what they are doing? As I understand it, the number of staff involved at the ports is being cut.

[Lord Markham (Con)]

I do not have the figures on that, so I will need to give the noble Lord a detailed reply.

NHS Waiting Times

Lord Markham Excerpts

Tuesday 22nd November 2022 Lords Chamber

[Baroness Merron (Lab)]

With the permission of my noble friend Lord Hunt of Kings Heath, and on his behalf, I beg leave to ask the Question standing in his name on the Order Paper.

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

In February 2022, we published the elective recovery plan, setting ambitious targets to recover services, backed by more than £8 billion in funding from 2022-23 to 2024-25 and supported by a £5.9 billion investment in new beds, equipment and technology. We are providing an additional £3.3 billion in 2023-24 and 2024-25 to ensure that the NHS can take rapid action to improve performance, including urgent and emergency care and getting elective performance back towards pre-pandemic levels.

[Baroness Merron (Lab)]

My Lords, last week’s report from the National Audit Office laid waste to the idea that all of the NHS’s current woes are down to the pandemic. By 2019, NHS England had not met the elective waiting time performance standard for four years, nor its full set of eight operational standards for cancer services for six years. Following the Government’s announcement last week of a review into NHS efficiency, can the Minister confirm whether the Government are still committed to their 18-week target between GP referral and consultant-led treatment, as well as their other targets around A&E waiting times, ambulance responses and cancer treatment?

[Lord Markham (Con)]

I thank the noble Baroness. With reference to past performance, that is what the spending increases were all about. They were an acceptance that we need to do more in this space, and we are doing more. The pandemic clearly brought unprecedented circumstances and that is why we have announced more funding to get on top of that in the next few years, tackling all the areas that the noble Baroness mentioned in terms of A&E wait times, GPs and all the rest.

[Baroness Chisholm of Owlpen (Con)]

My Lords, we know that part of the problem is that ambulances are going to A&E departments but are not able to deposit their patients in A&E. We know that there is a blockage at the other end in social care, with people not being able to be discharged fast enough back into the community or into care homes. Until that is sorted out, I cannot see how we are ever going to sort out the waiting lists. Can my noble friend the Minister tell me what might happen that will perhaps make those problems better?

[Lord Markham (Con)]

I thank my noble friend. Adult social care, as many have heard me say before in this House, is a crucial part of this, because it is all about the flow. That is why I was delighted that, in addition to the £500 million discharge fund for this year, we have secured up to £2.8 billion of funding for next year. That is in addition to the 7,000 extra beds and the tailored help for the 15 worst-performing hospitals with the ambulances, so we have a complete answer to all these areas.

[Lord Patel (CB)]

My Lords, patients with complex and long-term conditions are finding it increasingly difficult to access the care that they need, resulting, as the British Heart Foundation report indicated, in 10,000 excess deaths in people suffering from chronic cardiac conditions. The Minister referred recently to the system being a failure. Does he agree that we need a system that develops care for these patients, one that is accessible and timely, in community and primary care settings?

[Lord Markham (Con)]

I agree with the noble Lord that cardiovascular is one important area in which, over the last few years, patients have not received the number of check-ups that we want, so it is an area on which we want to focus—not just through checks in GP centres but in the community. We all know that it is very easy to take blood pressure and have blood pressure machines. As a team, we are looking at precisely those kinds of measures to make sure that we can get the preventive screening in up front, so we can identify these people before problems occur.

[Baroness Brinton (LD)]

The Minister referred to the worst-performing hospitals and ambulance trusts, but news from the Health Service Journal today has shown that the longest waiting times are mainly in rural, deprived areas, with an elderly population that is much higher than in the rest of the country. Can the Minister say what special resources will be provided for those areas—rather than just using words like “worst”, which punish them unnecessarily?

[Lord Markham (Con)]

I thank the noble Baroness. If I have used a poor choice of words, I apologise. What we are looking at is identifying the areas where we most need to focus resources to solve wait times. That might be because it is a rural area or it might be, candidly, because it is not performing so well. The point that I was trying to make is that there is targeted support. We spent £150 million on ambulance performance and new facilities last year, and it is something that we will continue to do if those rural areas and other areas need the spend.

[Lord Watts (Lab)]

My Lords, will the Minister deal with the issue of 18 weeks? Are the Government still committed to that policy? If they are, when does he think it will be achieved?

[Lord Markham (Con)]

We are committed to timely appointments. The whole point about the community diagnostic centres that were set up—and we have set up more than 90—is so that patients can be referred straight to those centres and get their screening and tests straightaway, getting them more quickly and, I hope, getting peace of mind more quickly as well.

[Baroness Meacher (CB)]

My Lords, I very much welcome the recent change, which enabled GPs to refer patients direct for assessments instead of having to refer to a consultant, and for the consultant then to refer, which I think saved about 30 days. What other procedural changes are the Government considering that would further reduce waiting times, without actually costing more money, and save doctors time—for example, patient self-assessments in the home, which we pioneered in east London 30 years ago?

[Lord Markham (Con)]

I thank the noble Baroness. There are a number of areas where we can do this. I point to the possibility for home testing a lot more. Covid was a perfect example, whereby it became commonplace. Rather than samples being sent away to a laboratory, we came up with lateral flow devices and were able to do it cheaply and pretty accurately, although not quite as accurately. That is a perfect example of using technology to do more home-type diagnosis.

[Lord Kamall (Con)]

My Lords, in learning from best practice in other countries, are my noble friend, the department or the NHS aware of the pioneering work of Dr Shetty in Bangalore, who has pioneered production-line surgery for certain procedures? Are the Government considering that at the moment? If not, why not?

[Lord Markham (Con)]

I thank my noble friend for that. While I am not familiar with that exact case, I saw a very good, probably quite similar, example in Chase Farm Hospital, which has four operating theatres in a sort of barn. It has a complete production line for elective hip replacements and so on to get that capacity and efficiency.

[Lord Kakkar (CB)]

My Lords, I draw noble Lords’ attention to my registered interests. The Minister will be aware that innovation, be it therapeutic or in models of care, is essential to improve efficiency and efficacy in the delivery of NHS services. Is he content that there is sufficient protection in the NHS budget to drive that adoption of innovation and ensure that staff are properly trained for its application?

[Lord Markham (Con)]

I thank the noble Lord. As I have said previously, innovation, and being able to back that up with investment, is key. The House will see that we have protected a lot of the research funds so that we can do exactly that. That is the direction of travel. The new hospital programme, which I look after, is very much about looking at best practice and innovation around the world and making sure that we employ the best in our new hospitals and across all our trusts.

[Lord Reid of Cardowan (Lab)]

My Lords, the Minister is relatively new to his department, but even in the number of weeks he has been there, he must recognise that, whatever statistics on inputs he announces at the Dispatch Box, it is not working. There was a time, two decades ago, when we managed as a Government to reduce the maximum waiting time from three years to 18 weeks and the numbers on the waiting list from 1 million to 500,000. There are now 7.2 million on the waiting list—incidentally, there were 4.2 million before Covid. Whatever the Government have been doing for 10 years is not working and people are remaining in pain for prolonged periods, quite apart from the effect on the economy. Will the Minister institute an immediate review centred particularly around patient choice, which is the only thing that will drive down waiting times and waiting lists? It should never have been abandoned in the way it has been by the Government.

[Lord Markham (Con)]

I believe that customers—call them patients—should drive performance and improvements. Inputs are important, but I totally agree that in a performance culture outputs are very important. I give credit to the work done in the early 2000s, from which I have tried to learn in the short time I have been here, to really bear down and create a performance culture to get waiting lists down by holding trusts, and now the new ICB CEOs, to account. That is definitely the direction of travel, and I am very happy to learn from things that have worked well in the past.

NHS: Waiting Lists and Increased Spending

Lord Markham Excerpts

Tuesday 22nd November 2022 Lords Chamber

[Lord Balfe]

To ask His Majesty’s Government what assessment they have made of the statement by the Institute for Fiscal Studies on 15 November that NHS waiting lists have risen in 2022 alongside increased spending on NHS England.

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

The Government continually assess data and reports on waiting lists from a wide range of sources, including the Institute for Fiscal Studies. The IFS statement confirms that the Government are right to support and challenge NHS England to continue to identify and address factors that constrain further activity, and to reduce waiting lists. The Autumn Statement announced a further £3.3 billion for 2023-24 and 2024-25 to enable rapid action to improve emergency, elective and primary care performance.

[Lord Balfe (Con)]

My Lords, I thank the Minister for his reply. Last week, the Institute for Fiscal Studies said that

“NHS spending in England is, in real terms, 12% above its 2019 level. Yet it is getting fewer people off waiting lists and into hospital treatment than it was … in 2019.”

We used to have a slogan: “Labour isn’t working”. The NHS is no longer working. The Royal College of Obstetricians and Gynaecologists has asked me whether we could ring-fence its money. I do not think we can. Can some of the hundreds of civil servants on six-figure salaries in his department get down to sorting out what is clearly a dysfunctional department?

[Lord Markham (Con)]

My noble friend is correct. Efficiency is very important, as pointed out in a previous Question. I have done some work in this space, and there are some trusts that are absolutely on the path to the 130% increase in elective treatments compared with 2019, for which the funding is in place. There are other trusts that are not. Clearly, my job and the job of all the department’s civil servants is to understand why that is and to challenge those trusts that are not; to support them where they need that support; and to ensure they are introducing best practice and innovation in order to make sure they all get back towards that level. There are some very good performers and others that are not so good.

[Lord Stirrup (CB)]

My Lords, we hear a lot in this House about the recruitment of doctors and nurses. However, any organisation facing the kind of challenges confronting the NHS would ordinarily be doing its utmost to retain its talent. The NHS, in many ways, seems to be doing the opposite. When will it develop a comprehensive strategy for the retention of its experienced clinical personnel, without whom it would simply be unable to function?

[Lord Markham (Con)]

I thank the noble and gallant Lord for his question. I was delighted to see in the Chancellor’s Statement a commitment to a workforce strategy for five, 10 and 15 years, something that all of us in this House have been asking for. It will look at all the needs in respect of recruitment and, crucially, retention. That is very much part of the agenda.

[Lord Woodley (Lab)]

My Lords, the current shortage of 60,000 nurses is devastating, and its impact on waiting lists even more so. It is obvious—to me, anyway—that the main cause of this staffing crisis is low pay, with many nurses opting to leave for jobs in supermarkets and other sectors for better wages. Does the Minister accept that the best way to tackle these problems is to allow more qualified nurses into the UK from the EU and beyond, grow the economy and fill the gaps in the skills that the NHS needs? Most importantly, we need to pay our heroes, who we all clapped for, a decent living wage to live on.

[Lord Markham (Con)]

I thank the noble Lord. For the record, there are 29,000 extra nurses since 2019-20, so we are well on course for the 50,000 increase. At the same time, we do need to recruit from overseas, and that is very much part of the plan. Again, this will go into the workforce strategy, but I completely agree that we should be looking to recruit from around the world, which we are. I am delighted that we are adding more and more people to the essential workers list, so to speak, to enable us to do that, because we all know that the workforce plan will show that we need to recruit people and retain them.

[Baroness Brinton (LD)]

My Lords, the last time the figure of 92% of patients being seen within 18 weeks was achieved was in 2016. Since then, the numbers who are waiting have doubled: it is now 7.1 million. What does the Minister say to the 16 year-old in Shrewsbury who has just been told that he has to wait nearly three years for a first appointment at his local hospital? The hospital says that it has recruitment problems. When will we see the details of this workforce plan, particularly for rural areas?

[Lord Markham (Con)]

I thank the noble Baroness. As I say, we have committed to that workforce plan, and it will be detailed. We will look at every place in every part of the country because we understand that that is needed, and it is part of the critical plan to get on top of the 7.1 million waiting list. As I think we have accepted, it is not a quick win; it will get higher before it gets lower again. Clearly, however, we need to get on top of it, and we are focused on it. It is very much about the plan and the new spending plans that we put in place to address it.

[Baroness Wheatcroft (CB)]

My Lords, last year NHS trusts paid an interest bill of almost £500 million on PFI hospital contracts. This year, that bill will rise again. Can the Minister tell us what proportion of the increase in NHS budgets will go just to pay interest charges on these dreadful contracts, and what plans he has to try to renegotiate them?

[Lord Markham (Con)]

I thank the noble Baroness; I will need to get back to her in writing on the detail of that. However, looking into the PFI contracts is very much part of my agenda; I had a meeting on that just last week, and we are reviewing it.

[Lord Brownlow of Shurlock Row (Con)]

My Lords, with the increasing conflict between inputs and outputs that the noble Lord, Lord Reid, mentioned earlier, does my noble friend the Minister agree that the need and time for a royal commission on the NHS is fast approaching?

[Lord Markham (Con)]

I thank my noble friend. To be honest with him, I am hoping we can act quicker than that—that is absolutely the plan. I can tell him that we know the areas where they are performing and they are on the elective recovery plan, and we know those that are not. I do not need a royal commission to tell me that. To my mind, it is about understanding what those hospitals are doing well and putting in place focused action and support to help those that are behind the plan.

[Baroness Merron (Lab)]

My Lords, on an earlier Question, I and other noble Lords asked the Minister if the Government were still committed to their target of 18-weeks between GP referral and consultant-led treatment, and their other targets for A&E waiting times, ambulance responses and cancer treatment. I offer the Minister another opportunity to say to your Lordships’ House whether this is the case.

[Lord Markham (Con)]

I thank the noble Baroness. As I am sure the House is aware from the statements of the Chancellor and the Health Secretary, in a lot of areas we are trying to make sure that we place fewer targets on the health professions and GPs and allow them to manage. At the same time, we make sure that if they are not performing, action is taken, but generally we trust them to manage. The beauty of Google is that I have been able to check the 18-week target, and it is a statutory commitment, so I can give that assurance. However, on the others, we are making sure that we look at the performance measures that really matter.

[Lord Howarth of Newport (Lab) [V]]

My Lords, whatever efficiencies are achieved, given that the growth in demand for NHS services will continue to exceed the growth of our ailing economy, should not the Government be making a major commitment to preventive strategies to stop people becoming ill or injured in the first place? With the Government’s reversion to austerity, however, has not the prospect deteriorated for the investment needed in public health and non-clinical approaches such as the successful warm home prescription pilot? How can we hope that the Government will systematically address the social determinants of health, such as poor housing?

--- Later in debate ---

[Lord Markham (Con)]

I thank the noble Lord, and I agree that prevention is better than cure. I refer to the earlier Question and analysis by Chris Whitty, the Chief Medical Officer, who pointed out his concerns about cardiovascular health arising from people not having had the check-ups they should have had during the pandemic. I completely agree that there are some very cost-effective measures which can really help with the prevention agenda, such as heart blood pressure machines and lateral flow screening devices that can be sent to homes. We are looking at that issue, because I agree that prevention is better than cure.

Health: Pancreatic Cancer

Lord Markham Excerpts

Monday 21st November 2022 Lords Chamber

[Lord Black of Brentwood]

To ask His Majesty’s Government what steps they are taking to improve survival rates for pancreatic cancer.

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

Improving early diagnosis is incredibly important to help boost cancer survival, and the Government are committed to the NHS Long Term Plan ambition of diagnosing 75% of cancers at stage 1 or 2 by 2028. Pancreatic cancer is difficult to diagnose due its unspecific symptoms. To help diagnose these cancers, we have opened 91 community diagnostic centres and 96 non-specific symptoms pathways which are transforming the way those with symptoms not specific to one cancer are diagnosed.

[Lord Black of Brentwood (Con)]

My Lords, this is Pancreatic Cancer Awareness Month, a time to remember those who have died prematurely of this cruel and unforgiving disease, but also a time angrily to reflect on the shocking statistics that surround this least-survivable and quickest-killing cancer: three in five pancreatic cancers are diagnosed at a late stage—worse than any other cancer; half of those diagnosed die within three months—worse than any other cancer; almost 60% of people are diagnosed in A&E—worse than any other cancer. These statistics are shameful. Would my noble friend tell us what has happened to the 10-year cancer plan, which is so vital in this area, and commit to a strategy within it to ensure early diagnosis of pancreatic cancer patients within 21 days of presenting with symptoms? Will he explain why there is so little investment in research in this area—just 3% of the total UK cancer research budget—when we vitally need a test to stop this horrible disease in its tracks?

[Lord Markham (Con)]

My noble friend is correct: pancreatic is probably one of the cruellest of cancers. We have a 10-year cancer plan; to answer his question, we are going through 5,000 responses, and we are analysing them and will report back shortly. On research, we are performing over 70 different pancreatic cancer studies. Key to all of this is not just early diagnosis; more important than ever, in this awareness month, is making sure that people are aware and go to their doctors early if they have any concerns at all.

[Lord Turnberg (Lab)]

My Lords, one of the problems of this nasty cancer is that, by the time any symptoms occur, it is often too late. We desperately need some sort of screening test. Recent research has suggested that we may be able to pick it up in the bloodstream using a so-called liquid biopsy. What research is being done on this now?

[Lord Markham (Con)]

I understand that the leader in this field is GRAIL. This blood screening is happening in America right now, and NICE is undertaking studies in this field to see whether it should be brought to the UK. We will have its findings. I agree that pancreatic cancer is an area where early detection is key. It is not just about the screening but about people going to their doctor if they have any concerns at all, as I say. We have non-specific symptoms pathways to help doctors to detect what is wrong.

[Lord Aberdare (CB)]

My Lords, the UK ranks 29th of 33 countries for five-year pancreatic cancer survival rates. At the very least, we should ensure that pancreatic cancer patients get the best possible treatments in the short time usually available to them, with over half dying within three months. One such treatment is pancreatic enzyme replacement therapy—PERT—which helps them to eat and digest their food, but only about half of pancreatic cancer sufferers are offered this treatment. What are the Government doing to understand why this is the case and to ensure that all pancreatic cancer patients who need PERT are offered it?

[Lord Markham (Con)]

I thank the noble Lord. This case has also been brought forward by the noble Lord, Lord Moynihan, who could not be here today, but he is very keen on this as well. We have now put PERT into NICE guidelines, so it should be offered. I am meeting my noble friend Lord Moynihan to make sure that these things are being taken up, and I would be happy to extend that invitation to the noble Lord.

[Lord Forsyth of Drumlean (Con)]

My Lords, the Government’s current campaign to encourage people to go and see their GP if they have symptoms is commendable, but how can this help when people are waiting months to get scans and then weeks to get the results of their scan? What can be done about this?

[Lord Markham (Con)]

This is where we see the diagnostic centres being a key area in this. We have set up 91 community diagnostic centres. In addition, in 2020 we had only 12 non-specific symptoms pathways; we are now rolling those out to 96, so that 75% of the population will be covered by March 2023, with a target of 100% by March 2024.

[Baroness Merron (Lab)]

My Lords, the UK is lagging behind comparative European nations on cancer survival rates. In the landmark How Good is the NHS? report, the UK came last on pancreatic cancer survival rates. Could the Minister give a view as to why the UK compares so unfavourably to elsewhere? How will the recent comments of the Health Secretary about changes to national targets affect waiting times and survival rates for patients with pancreatic cancer?

[Lord Markham (Con)]

We are very clear on the need for speed in cancer treatment; that is one target that will not change, because we know its importance in all this. With pancreatic cancer, we are where we were with prostate cancer about 10 or 15 years ago, and I am glad to see that we have made great strides on that with initiatives such as the Movember campaign and the action on that. Candidly, we are not where we need to be on pancreatic cancer, and we need to adopt those sorts of awareness campaigns, as well as fast action on screening, to improve our performance.

[Baroness Brinton (LD)]

My Lords, 30 years ago cervical screening was developed and introduced; prior to that, cancer of the cervix was as impossible to detect and to find as pancreatic cancer. Will the Minister say whether research will be provided to ensure that screening for pancreatic cancer can be introduced as soon as it is confirmed, because screening was the real game-changer for cervical cancer?

[Lord Markham (Con)]

I agree that screening programmes are, without doubt, the way forward. I mentioned earlier the 73 different pancreatic cancer research studies, of which screening is a very important element, so I totally agree that that should be our top priority.

[Lord Kakkar (CB)]

My Lords, I declare my interests in the register. Clinical research is fundamental to ensuring the evaluation and rapid adoption of new therapeutic interventions that could improve survival rates in diseases such as pancreatic cancer, but operational pressures in the NHS are having an impact on the ability to conduct that clinical research. Is the Minister content that there is sufficient emphasis and support to maintain the infrastructure for clinical research and the capacity to deliver translational, early-stage and later-stage trials in pancreatic cancer?

--- Later in debate ---

[Lord Markham (Con)]

My understanding is that we do have the capacity for these research trials. Also, on workforce in the cancer space, we have invested £50 million, so we are actually 200 people over our target on that. This is part of the Chancellor’s announcement about the long-term workforce study, which I know will be welcomed by many in this House, where we will be looking, area by area, at exactly what workforce needs we have—and we have a recruitment plan against that.

[Lord Kamall (Con)]

My Lords, in response to an earlier question, my noble friend the Minister talked about the need for more awareness in advance of identifying appropriate screening methods. Given that it is now Pancreatic Cancer Awareness Month, what else are the Government and the NHS doing outside that to ensure there is more awareness for patients to come forward for potential pancreatic cancer?

[Lord Markham (Con)]

I thank my noble friend. Key to this is the Help Us to Help You campaign, which reaches out to lots of different communities, including a number of minority communities. At the same time, we have rolled out the early cancer diagnosis service to GPs, where they are looking out for some of those warning signs, even when people are there for a regular appointment. Clearly, as has been said by other speakers today, a lot more needs to be done; it is a journey, but awareness is the vital first part of that journey. On that point, I thank the Pancreatic Cancer UK charity, which has been excellent in this field.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the Minister has just referred to awareness, to which he has referred many times in the course of this Question. Would he accept that, for some people, it is difficult to understand what you need to be aware of—particularly with a disease which is, as far as I am hearing today, largely asymptomatic for a good part of its early progression? Can he tell the House where people, who perhaps need to be aware, should look for the things that they need to be aware of?

[Lord Markham (Con)]

The noble Baroness is correct: the problem about the so-called invisible diseases—of which cervical cancer is another example—is that you do not know quite what you should be looking for. That is why I mentioned earlier the non-specific symptoms pathways, which are exactly designed for those sorts of things, whereby general checks are included in the area so that, although people do not even go along with a specific symptom, they are starting to be screened. That needs to be rolled out further. As I mentioned before, this would cover 75% of the population by March 2023; clearly, we need to be at 100%, with the target of March 2024 for that.