Sexual and Reproductive Healthcare

Lord Markham Excerpts

Tuesday 19th March 2024 Lords Chamber

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

I start by adding my thanks to the noble Baroness, Lady Barker, for securing this debate and for all the work that she does in this important area. I was grateful for all the contributions, but I admit that it made me smile when the noble Lord, Lord Allan, asked whether the solution to the sexual health debate should be one of a bigger bed. I thought that was a very topical answer to it all, but I will come back to his bigger bed question on the long-term workforce plan later on.

I admit to a bit of surprise when hearing some words used in the debate: the noble Baroness, Lady Barker, used “crisis” and the noble Baroness, Lady Bennett, mentioned “broken Britain”. I can answer the question of the noble Baroness, Lady Merron, about the quality and availability of services for sexual health because, thanks to our very own House of Lords Library briefing, as I am sure all noble Lords saw, some very interesting and extensive research was produced by the European Parliamentary Forum for Sexual and Reproductive Rights in October 2023. It looked at 46 European countries on a whole range of subjects and, for instance, in the area of access to abortion services the UK came third out of 46. On contraception, we came first and on HPV prevention, we came third. On gender-based violence in education, we came first. If we add all those up, what was our overall ranking? First.

I am somewhat surprised because this is a reasoned and balanced place, and this came from the House of Lords Library. In the whole conversation we have had in this debate—in all the things mentioned—I was somewhat surprised that it was not mentioned anywhere that this body had done extensive research on it all and it put us first. It commended us time and again in that.

I was also surprised when HIV was mentioned a couple of times. The UN target is called 95-95-95, which is wanting 95% of cases to be diagnosed, wanting 95% to be treated and wanting to make sure that 95% of people with HIV have an undetectable viral load. The UK, and I think we are alone in this, hit the 95% level on diagnosis. On treatment, we hit 98% and on detectable viral loads, we hit 98%. I will check whether we are alone but we are definitely beating those UN targets.

The action taken by the Government—which was recently applauded during Elton John’s visit, as noble Lords will remember—includes standard things such as opt-out HIV testing in every circumstance where people are going into A&E. This has already detected 1,000 people with HIV who were previously undetected. That is absolutely ground-breaking in the world. We were also applauded for the action taken on HIV through PrEP. Call me old-fashioned, but I would rather look at the results we are achieving than at how much we are spending, and I hope noble Lords would join me in that. On the results, according to this independent source and against the UN HIV target, we undeniably come out very highly.

However, I do not want to appear complacent. Clearly, far fewer people are using condoms—often for very good reasons, because there is not the same fear of sexual disease and HIV. So there are societal changes, but that brings some challenges regarding sexually transmitted diseases—that is understood. We are trying to make our funds go as far as possible, not just in services today but in introducing contraception and those services to pharmacies. Pharmacy First is making this very accessible—we are already seeing good take-up, and we expect about 30% of people to get their contraception through Pharmacy First. That is a real example of how we are massively expanding access to the workforce.

The long-term workforce plan is absolutely a bigger bed strategy, and I take the point of the noble Lord, Lord Allan, that we clearly need to make sure that that provides the individual specialisms that are needed. The Government and I accept that work will need to be done to make sure that those specialisms result from that. But I think all noble Lords will agree that the bigger bed strategy is right, and improvements will come through across the board.

The noble Lord, Lord Hunt, referred to Sexwise. The steps we are trying to take are sensible, and the Government did this well when they consolidated a lot of their different websites into a single source. We want the primary source of information we are pointing people towards to be the NHS websites, and particularly the NHS app, which I think all noble Lords would agree is completely appropriate for younger people. At the same time, I absolutely take the sensible point the noble Lord made about a group being willing take over Sexwise. Funnily enough, I said exactly that: “Why can’t we give it a contract for £1 if it is difficult to give it away? Why can’t we do something pragmatic along those lines?” That is the challenge I have set: if it is a good service and someone is willing to do that, why would we not want to support that? But I hope noble Lords see that, in general, it is a sensible strategy in the digital age to consolidate your assets around the overall NHS umbrella and the NHS app.

In response to the noble Baroness, Lady Barker, we definitely want to build on the women’s health hubs. STI and HIV screenings are part of their specifications. In response to the noble Baroness, Lady Bennett, we have hepatitis B, HIV and syphilis as standard parts of the screening of pregnant women. That is seen as very important. I also absolutely agree about the importance of home testing in all this. As noble Lords will see, we are trying to use the NHS app as a vehicle for people to get home testing as they require.

The noble Baroness, Lady Bennett, asked about the advice behind focusing chlamydia screening on women rather than men. That is based on the scientific advice and evidence we have received that that is the best use of resources in this case.

I will write to the noble Lord, Lord Allan, on his very reasonable question about where young people get their information from in a letter detailing what we know. I accept that, if we do not have that information, we should find it out. Hopefully, we can come back on that. Likewise, I will need to come back further on what evidence we have to date on ICBs and the benefits of joint working. As ever, I will follow up on the detail in writing.

I am grateful for the opportunity for us to debate these things. This is one of those occasions where I can stand here in all honesty and say that, objectively, by a number of measures—looking at the results coming in, not at the funding—including from none other than the European Parliamentary Forum for Sexual & Reproductive Rights, Britain comes out at No. 1. That is something that we can all feel proud of.

Cancer: Staffing

Lord Markham Excerpts

Thursday 14th March 2024 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government, in the light of warnings by the Parliamentary and Health Service Ombudsman, what assessment they have made of the risk to cancer patients in England presented by the staffing levels, workloads and working conditions of healthcare professionals.

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

I express my regret about the cases referenced by the ombudsman. The department is taking steps to reduce cancer diagnosis and treatment waiting times across England and to improve survival rates across all cancer types. Through announcing the first ever NHS long-term workforce plan, we are taking meaningful steps to build the NHS workforce for the future. The Government are backing the plan, with over £2.4 billion of funding for additional education and training places.

[Baroness Merron (Lab)]

My Lords, the Minister will know that numerous complaints relating to patients with cancer that were investigated by the Parliamentary and Health Service Ombudsman included misdiagnosis, treatment delays, the mismanagement of conditions, poor communication and unsuitable end-of-life care. As the NHS is grappling with over 110,000 staff shortages, how is patient safety being compromised by the Government’s long delay in bringing forward the workforce plan? What immediate action will the Government take to deal with the continuing risk to cancer patients posed by a workforce that the ombudsman describes as “understaffed, under pressure and exhausted”?

[Lord Markham (Con)]

As the noble Baroness says, we see increasing the workforce as a core component here. I was speaking to the president of the Royal College of Radiologists about this the other day, and we obviously need to make sure that the workforce can be as effective as possible at what it does. We are doing a lot of new diagnosis, and 80% of all the medical AI technologies are in the radiography space, which is making a huge difference to diagnosis and productivity. It is clearly fundamental that we get the treatment to these people as quickly as possible.

[Baroness Meacher (CB)]

My Lords, does the Minister accept that there has been underfunding of the NHS for more than a decade now and that our cancer recovery rates do not compare with those of our competitors in Europe? Will he agree to have an urgent uplift in the funding of cancer services in particular over the next period, in order to try to lift our recovery rates up to those of Europe?

[Lord Markham (Con)]

Noble Lords have heard me say many times that we are investing roughly 10% of the economy into the health space, which is much more than ever before and comparable to nations around the world—apart from America, which stands significantly above. I am sure noble Lords saw the headline in the Times today that survival rates are at their best level ever, and there has been a 35% reduction in mortality rates for men and women over the last 10 or 15 years. So there is a lot of progress in this space, but I accept that we need to invest more—that is what the new CDCs, and the 7 million extra tests they are performing, are all about.

[Baroness McIntosh of Pickering (Con)]

My Lords, I remind the House of my interest with the Dispensing Doctors’ Association. Does my noble friend share my concern about the number of GPs, particularly those under 55, who are considering retirement in the next five years? How do the Government plan to fill the vacancies that will be created, to ensure that, particularly in rural areas, a fast track will exist for patients who are suffering from cancer for the earliest possible referral to hospital? I refer to the letter I wrote to our noble friend Lord Evans on this.

[Lord Markham (Con)]

I thank my noble friend and totally agree that GPs are the front line of our medical services. We are trying to do everything we can to make sure that they feel valued and are retained. The recent change to the pension law was all about addressing that very point, answering GPs’ number 1 concern in order to keep them. Their hard work has seen a 25% increase in the cancer referral rate: we treated 3 million people, up 600,000, over the last year, thanks to their work and the expansion in the diagnostic centres we have set up.

[Baroness Barker (LD)]

My Lords, does the Minister agree with us on these Benches that there should be a statutory two-month period between diagnosis and access to appropriate treatment for any cancer patient? In order to achieve that, there needs to be further investment in radiography training and an equitable distribution of trainee radiographers and qualified radiographers across the country. How will the Government ensure that that happens?

[Lord Markham (Con)]

As I mentioned, that was very much the big feature of the discussion that I had with the president of the Royal College of Radiologists just the other day. We have been growing the number of radiographers by about 3% every year, which is a good rate, and we look to increase that even further. The CDCs are about that. However, the actual demand is increasing by about 5% every year. Clearly, as well as recruitment, we need to make sure that we have effective diagnosis, and this is where the field of AI is very exciting. The radiographers are 100% behind it, because they really see the revolutionary effect it is bringing.

[Lord Turnberg (Lab)]

My Lords, we are certainly shortly of staff, and the problem is not increasing recruitment but enhancing retention. Staff are leaving because they are disillusioned and disaffected, and we do not treat them well enough. Any large business knows that, if you have a happy workforce, it will be productive. We certainly do not have that in the NHS. We certainly need to stop this dismissive attitude and enhance the conditions of their service, and it is not simply about pay. Does he agree?

[Lord Markham (Con)]

I totally agree that it is a range of things. I completely agree with the noble Lord that a good employer should be looking to make sure that employees have good working conditions and feel valued, and that there is an understanding culture in the workplace as well as decent pay. I say all this in the context that the workforce in the cancer space has actually increased by 56% since 2010, so it is not as if there have not been massive increases here. The actual number of treatments and diagnoses has gone up by more than 20% from pre-pandemic levels. So we are doing a lot in this space, but I agree with the noble Lord’s basic premise that we need to ensure that staff feel valued so they will want to carry on working.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest as being employed in part by the Velindre Cancer Centre in Cardiff. Do the Government recognise that continuity of care is absolutely essential for patients to be able to spot when things are changing and to allow sensitive conversations to occur? Will he therefore undertake to have urgent discussions with the Royal Colleges and with Health Education England to look at the training rotas for doctors who are working in oncology, allowing them to provide better continuity of care with less disruption to their own lifestyles, and better support? Will he also look at recommending that they might draw on the Welsh experience of Talk CPR, which allows early conversations about very difficult topics, providing video books and so on that patients can take home and then come back to see the same person again some time afterwards, providing continuity of care and better communication?

[Lord Markham (Con)]

First off, I completely agree about continuity of care—in any treatment, to be honest. I was just saying, in answer to a maternity question the other day, that continuity of care in the midwifery space is another vital example. On the question of learning lessons from what the noble Baroness mentioned, we have some meetings set up, so I look forward to discussing it further then.

[Lord Kakkar (CB)]

My Lords, I draw noble Lords’ attention to my registered interests. The Minister rightly identified an improvement in survival rates for those between their late 30s and 69 over the last 30 years. He also accepted the fact that those delivering cancer services are under a huge amount of pressure to ensure timely provision of that care. It is also essential to achieving long-term improvement in outcomes that we continue to innovate and that clinicians are provided the opportunity to participate in clinical research, which validates innovation and allows its adoption at scale and pace. Is the Minister content that we are doing enough to protect time for clinical research and participation by all healthcare professionals in those protocols to drive those advances in innovation?

[Lord Markham (Con)]

First, I completely agree on the need for and the vital importance of clinical research in all this. Providing clinicians with time does two things: it means that they get their incredibly valuable time, resources and brains on it; it also addresses the question asked earlier about retention. Of course, this is why a lot of clinicians want to be in this space, so they have time to do research as well. There are very good personal and medical reasons why they should be allowed to do that.

[Lord Dubs (Lab)]

My Lords, I should declare an interest in that my wife is receiving treatment from the Royal Marsden. Is it possible that the national statistics mask a great variation between hospitals such as the Marsden, which is absolutely top of the range, and some others? Is it worth looking at the differences and what we can learn from them?

[Lord Markham (Con)]

Yes. Funnily enough, I was having a similar conversation just yesterday about how we can use data to really understand some of the differences in performance because, as the noble Lord said, we have all heard of some brilliant examples in our NHS hospitals and we have all heard of some other examples which, as pointed out by the ombudsman, were unfortunately not so good. Understanding those centres of excellence and those that need more help is vital.

Prioritising Early Childhood: Academy of Medical Sciences Report

Lord Markham Excerpts

Monday 11th March 2024 Lords Chamber

[Lord Hunt of Kings Heath]

To ask His Majesty’s Government what assessment they have made of the report of the Academy of Medical Sciences Prioritising early childhood to promote the nation’s health, wellbeing and prosperity, published on 5 February, particularly regarding children under 5.

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

The Government welcome the report. We have taken significant action to improve children’s health in the early years. This includes reducing sugar in children’s food, supporting healthy diets for families from lower-income households through schemes such as Healthy Start, and investing record amounts into children’s and young people’s mental health services and around £300 million in the family hubs and Start for Life programmes. We are also improving children’s oral health through our dentistry recovery plan.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I pay tribute to my noble friend Lord McAvoy, who was an incredible parliamentary servant in both Houses over many years.

I thank the Minister, but he will be aware that we have a frightening number of people of working age who are not able to work because of long-term illness. The implication of the academy report is that we are storing up huge problems for the future. As one example, 20% of under-fives are obese or overweight. If the Government are so keen to take action, why have they postponed the implementation of their obesity strategy, which would start to take action against unhealthy food and encourage young people towards more exercise and a healthier lifestyle?

[Lord Markham (Con)]

First, I add condolences from myself and this side of the House for Lord McAvoy.

Secondly, I am grateful for the direction of the report. I think that we all agree that early investment in childhood, and in young people, is vital. That is what our vision for the first 1,001 critical days is all about. A lot of the things in the report are helpful. I must admit that I did not recognise that particular stat, because rather than it being one in five children suffering from obesity at age five, the latest report—and it is an extensive study—shows that it is less than one in 10. It is the lowest number since 2006-07. So, in the area of obesity, we can show that our plans are working. I say again: we have the lowest level of obesity among reception age children since 2006-07.

[Baroness Jenkin of Kennington (Con)]

My Lords, the Food, Diet and Obesity Select Committee, which is one of the new ad hoc committees, took evidence last week from specialists in childhood, early years, and school food. The situation is grave, as the noble Lord, Lord Hunt, said. Some 80% of the food that children eat is ultra-processed—we have no idea what the long-term consequences will be. May I encourage the Minister to look again at the figures and the ultra-processed foods that we are feeding children—the health consequences of which are not yet understood?

[Lord Markham (Con)]

I assure my noble friend that the numbers are correct; they are the lowest since 2006-07. I can also assure her that free school meals are at their highest level ever, at 33%. The whole idea behind those programmes, as well as the Healthy Start in school and the five-a-day, is to give children healthy diets early on, exactly as my noble friend says.

[Lord Allan of Hallam (LD)]

My Lords, I echo the condolences to Lord McAvoy’s family from these Benches. I always enjoyed working with him in another place.

On the Question before us, the Government have rightly been bigging up the digital revolution in the NHS, but many of the basic building blocks are still not there. Does the Minister agree that it would be helpful for the health of infants for there to be a digital red book, rather than relying on parents carrying around a physical one? Can he give a timescale for when we will move on from endless pilots and aspirational announcements to this being widely available?

--- Later in debate ---

[Lord Markham (Con)]

I totally agree. Funnily enough, I was talking to Minister Leadsom about this subject just this morning. It is complex, because all parents need proxy access so that they can get those digital records for their children automatically. It is something we are working towards. The Pharmacy First initiative, whereby you can write data from a pharmacist immediately into GP records, will help because it will give a road map to do that for children and babies from hospital. It is something we are working on, and I will give details of the timeline in writing.

[Lord Patel (CB)]

My Lords, I declare an interest. I am a fellow of the Academy of Medical Sciences, which produced this seminal report addressing issues related to child health. I will pick up two points that the Minister might comment on. Although he is implementing what we already know from research works in improving children’s health, we have no strategy for the implementation of good practice. My second point is about research into the early years. Diseases that people may develop later in life can occur as a result of epigenetic influences during the early years that alter the genome, yet research into childhood accounts for 5% of total government research funding.

[Lord Markham (Con)]

I totally agree about the importance of research and data. We have spent about £580 million on research in the children and young persons’ space since 2020. As per the earlier question, data is vital to this. I saw a fascinating example just a couple of weeks ago in the Cambridge Research Centre concerning young children. It is using data to construct what it calls “virtual children”, to look at rare diseases, how they progress and different treatments that can be tried. It is truly revolutionary and something I totally support.

[Lord Rooker (Lab)]

My Lords, I distinctly heard my noble friend Lord Hunt describe these children as obese and overweight. The Minister has addressed only obesity. You can be overweight without being obese, but it means you are on the way to obesity. That is the serious problem.

[Lord Markham (Con)]

I think we all agree that it is a very serious problem, so I do not want to diminish that. I was trying to demonstrate that the steps we are taking—there is a lot to do in this space—are having an effect. Noble Lords have heard me say before that our reformulation efforts mean that everything from Mars Bars and Snickers to all sorts of other foods are having the sugar content taken out, so we can make sure they are healthier for people to enjoy.

[Lord Bird (CB)]

My Lords, have the Government looked at the idea of bringing back something like Sure Start? I was involved in Sure Start, and I saw people breaking down poverty in their lives because of children coming in and mixing with other healthy children. It was wonderful. Can we look again at Sure Start?

--- Later in debate ---

[Lord Markham (Con)]

One of the recommendations of the report is a cross-cutting approach of the kind the noble Lord mentioned to avoid silos. The family hubs we are investing in alongside the Department for Education are trying to do exactly that sort of thing to make sure the healthy start for life exists.

[Baroness Merron (Lab)]

My Lords, these Benches will greatly miss my noble friend Lord McAvoy. I had the pleasure and education of serving with him as a Whip in the other place. May his memory be for a blessing.

The Academy of Medical Sciences report highlights the importance of continuity of maternity care, which can reduce the likelihood of pre-term birth by 24%. Given that premature babies are more likely to have complications that affect vision, hearing, movement, learning and behaviour, which will all impact later life, what steps are the Government taking to increase the number of women receiving dedicated midwifery support throughout their pregnancies?

[Lord Markham (Con)]

I agree with the noble Baroness and my noble friend Lady Cumberlege about the importance of continuity of care in the maternity space. We are investing resources as part of the long-term workforce plan to increase the number of people trained in maternity and in this area generally. To give another example, we are investing in family nurses by increasing the number of training places by 74%, because it is understood that we need the workforce to provide all these services in an ever more complex world.

[Lord Sterling of Plaistow (Con)]

My Lords, is not one of the problems that children today do not get anything like the exercise we used to do in the old days?

[Lord Markham (Con)]

Wearing the tie I was awarded for being man of the match in the rugby against the Irish parliament this weekend, which we won, I totally agree about the importance of exercise in all walks of life. Social prescribing is vital. We are expanding the number of PE services available for children, because exercise is vital.

[The Lord Bishop of Leicester]

My Lords, there is strong evidence that in the early 2000s increases in child benefits led to an increase in the amount parents spent on fruit and vegetables and books and toys for their children. What assessment have the Government made of the impact of the two-child limit on benefits and, in particular, on the health and well-being of the 1.5 million children affected?

[Lord Markham (Con)]

We recognise very much, as said in the report, the importance of poverty in all this. We have seen the number children in absolute poverty decrease by 400,000 since 2010, which is a significant reduction. The Chancellor’s announcement last week showed the importance we place on child benefit in getting money to people to help. It is a very important area.

Mental Health Patients: Discharge

Lord Markham Excerpts

Tuesday 5th March 2024 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what assessment they have made of the current level of (1) safety, and (2) patient and carer involvement, where mental health patients are discharged from inpatient settings and emergency departments.

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

In January, the Government published new statutory guidelines setting out how health and care systems can work effectively together to support a safe discharge process for mental health patients from hospital and ensure patient and carer involvement in discharge planning. This is particularly important given that the National Confidential Inquiry into Suicide and Safety in Mental Health has found that there is an increased risk of suicide within three days of discharge.

[Baroness Merron (Lab)]

My Lords, the Parliamentary and Health Service Ombudsman’s recent report found many failings in care around the discharge of mental health patients, with the most common being a lack of involvement of patients, their families and carers. With the pre-legislative scrutiny of the mental health Bill highlighting the need to address this preventable situation, and the Government still not bringing forward this crucial legislation, what immediate steps will the Government take to involve those who are essential to the care and safety of mental health patients?

[Lord Markham (Con)]

The noble Baroness is correct; the question is of the utmost importance. It is about putting more care into the community—that is why we have put £1 billion of extra spend into community support for mental health. Some 160 local mental health infrastructure schemes are being set up, with 19 in place already, and they are starting to work. The crisis cafés have resulted in an 8% decrease in admissions, while the telephone helpline has resulted in a 12% decrease.

[Baroness Manzoor (Con)]

My Lords, my noble friend will be aware of the link between mental health and homelessness. He will also be aware that 50% and more of those who suffer from mental health illness have been homeless for over a year. What action are the Government taking to work with other government departments to ensure that this issue can be alleviated as soon as possible, and what help and mental health services are these homeless people entitled to?

[Lord Markham (Con)]

My noble friend is correct. In fact, 48% of the reasons for the delayed discharge of mental health patients is because of a lack of suitable housing. That is why we have introduced the specialist housing fund; we are working with Homes England and DHLUC so that supported housing runs alongside more support in the community from the extra mental health services.

[Lord Allan of Hallam (LD)]

My Lords, the Government have said that the additional discharge fund includes support for mental health in-patients leaving hospital. I believe that local areas are required to report fortnightly to the Government on the use of these funds. How much of the additional discharge fund has actually been spent on mental health patients? Does the Minister agree that it is important to have that information in the public domain, given concern that mental health services are treated as second-rate?

[Lord Markham (Con)]

The noble Lord is correct. I agree that it is important that the funds are spent on discharging mental health patients at a community level. I do not have the percentage figures to hand, but I will make sure that I provide them to him.

[Lord Bradley (Lab)]

My Lords, I declare my interests as in the register. Does the Minister think that there are lessons to be learned from the excellent RECONNECT programme by NHS England? It is being rolled out across the country and tries to ensure that vulnerable people, such as those with mental health conditions, are reconnected to local services, and that their release from custodial settings can be successfully undertaken.

[Lord Markham (Con)]

Yes, in a word. We must try to make sure that each integrated care board has a mental health lead in place and that the services are rolled out. Much of the strength of the ICBs is that they can look after the needs of their area in ways that they know best. At the same time, where there is good practice, we must make sure that it is rolled out as well.

[Lord Patel (CB)]

My Lords, suicide is the second highest cause of maternal deaths in England. All such deaths are preventable, because mothers at risk can easily be recognised antenatally, and certainly postnatally. What actions will the Government take to prevent these deaths?

[Lord Markham (Con)]

Like many of us, I am sure, I have had very good personal experience of the midwifery service at community level. I know that there have been some challenges post Covid, but midwives are on the front line in understanding and recognising some issues. I should have mentioned earlier that there will be a round table with the Minister on mental health issues, following the one a few months ago, and this is one of the areas we should bring up with her.

[Baroness Berridge (Con)]

My Lords, as a member of the Joint Committee scrutinising the Bill, it was clear to me that one of the problems was that there is a statutory list of next of kin which does not match the reality of some people’s lives, so there were provisions to introduce a nominated person. It does not matter how good the guidance is. How are we circumventing the statutory requirement for next of kin to be involved?

[Lord Markham (Con)]

Again, like many noble Lords, I understand the disappointment that there has not been the time for the mental health Bill. This is what the round tables are about: exploring with Maria Caulfield, the Mental Health Minister, how we can ensure that we implement as many of these things as possible. We had round 1 and we will set up round 2 shortly. I suggest we take it up then.

[Baroness Pitkeathley (Lab)]

My Lords, one of the problems that carers in these circumstances always report at the point of discharge is that the professionals dealing with the patient are reluctant to share information with the person who is expected to provide care. Although I recognise the sensitivity of these issues and the need for confidentiality, does the Minister agree that if you expect someone to provide care in these circumstances you should at least provide them with the requisite information?

[Lord Markham (Con)]

In a word, yes. We had the rapid review of data in mental health settings. Not surprisingly, in mental health, as in a lot of other settings, ensuring that there is the flow of information so that carers get the right information is paramount.

[Lord Kirkhope of Harrogate (Con)]

My Lords, as a former mental health commissioner, I know that the default position regarding long-term in-patients back in the 1980s and 1990s was to ensure they were given a place in the community. As a result, successive Governments closed down many of our institutions. Can my noble friend comment on the balance between present institutional care and its desirability for many in-patients, and in-patients who are regarded as being in the community but are not necessarily protected sufficiently when they are?

[Lord Markham (Con)]

There is, quite rightly, a balance to be struck. For people with learning difficulties and autism, which noble Lords have debated before, we set a 50% target for that reduction—not 100% because, as has been mentioned, it is not always appropriate as a number of people in those situations need additional support. However, as a general sense of direction I think we all agree that, where we can put support into communities, that is the right thing to do. That is what the £1 billion extra investment is about.

[Baroness Uddin (Non-Afl)]

My Lords, I declare my interest as a former practitioner. I have spoken before about the disproportionate numbers of black and Asian men in the system using mental health services. There is a gross disconnect between the amount of funding available and the services that they receive, particularly regarding carers’ involvement. We must admit that the amount of medication that they are given is not often monitored successfully after discharge. Maybe that is one of the reasons why there is a high suicide rate. How can the Minister ensure that, when patients are discharged to the services of social workers, they are not put in extremely expensive mental health provision or private healthcare housing, which is often not needed? The services are wasting huge amounts of money. Will the Minister look at the disconnect between social services and the healthcare system to ensure that the money is used effectively?

--- Later in debate ---

[Lord Markham (Con)]

Yes, I am happy to look at that. I am on board with what the noble Baroness said, as I am sure all noble Lords are, about wanting to ensure that every pound we spend is well spent. I am aware of the racial disparities that she mentioned, as all noble Lords are. We are looking to address that issue, but in a cost-efficient way.

NHS: Neurology Care

Lord Markham Excerpts

Monday 26th February 2024 Lords Chamber

[Lord Londesborough]

To ask His Majesty’s Government what assessment they have made of the NHS’s resourcing and capacity to provide specialist care, in line with that provided to cancer and cardiac patients, for those living with neurological conditions.

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

My Lords, integrated care boards are responsible for commissioning most services for people with neurological conditions. NHS England has established the neuroscience transformation programme, a multi-year clinically led programme aimed at improving specialised adult neuroscience services in England. The programme has developed a new model of integrated care for neuroscience services to support ICBs to deliver the right service at the right time for all neurology patients, including providing care closer to home. A toolkit is being developed to support ICBs to understand and implement this new model.

[Lord Londesborough (CB)]

My Lords, there are 11 million people in the UK living with neurological conditions—the cause of more deaths than cancer and heart disease combined and the greatest cause of lifetime disability. The NHS is clearly not set up to provide the specialist care needed. France and Germany have more than four full-time consultant neurologists per 100,000 people; here, it is just over one. Across the UK, there are no full neuro units to be found in the majority of our counties. The consequential wastage of healthcare resource by non-specialist care, plus the social and economic burdens, is put at £96 billion by the Economist in a findings report released today. Can the Minister tell us: what are the plans to address this critical imbalance?

[Lord Markham (Con)]

I thank the noble Lord. I had the opportunity to join the Neurology Alliance forum today, which was quite timely. I think its approach is entirely right in looking at what we can do to help people get on with an active life and back into the workforce, understanding that the economic impact of that is key. We have set up the neuroscience transformation programme, which the Neurology Alliance is on board with, which we think will tackle many of the issues that the noble Lord mentions.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, I declare an interest as chair of the Scottish Government’s advisory committee on neurological conditions and as chief executive of Cerebral Palsy Scotland. People with neurological conditions are faced with navigating a very complicated maze of services straddling primary care, secondary care and social care. Some conditions have well-defined pathways; many other conditions, such as cerebral palsy, do not. If the Government are not going to look at an overall neurological strategy such as the one that we have in Scotland, what practical steps will they take to help people with neurological conditions navigate these confusing services, so that they get the right support at the right time?

[Lord Markham (Con)]

My noble friend is correct. The important step towards this was our appointment of the first national clinical director of neurology over the last year. The task force put out a progressive neurological conditions toolkit which sets out the pathways exactly as my noble friend mentions. It shows the treatments for over 600 conditions. This is a complex area so it is vital that the pathways are understood in each area and patients can understand how to navigate them.

[Lord Allan of Hallam (LD)]

My Lords, the Government have created a new occupational health task force, which is welcome, but it will not help somebody to stay in their job or get back to work if they face a wait of many months to see a neurologist because that is what their condition requires. Can the Minister confirm that he will be working with his colleagues in DWP to ensure that the neurology capacity is there to see referrals from occupational health services more quickly?

[Lord Markham (Con)]

Yes, absolutely. Of course, this is what the CDCs are about as well in trying to get that diagnosis capacity. At the Neurological Alliance forum I was just at, the main thing was needing help with early diagnosis, because getting treatment is key to it all and, also, seeing whether we can sometimes refer people directly to the CDCs so that the GP is not always the bottleneck.

[Baroness Merron (Lab)]

My Lords, as Lord Cormack was a fellow of Lincoln, as I am, I pay tribute today to his considerable contribution to the City of Lincoln, as well as to this House and to the other place. May his memory be for a blessing.

The Neurological Alliance has expressed concern about the lack of clarity over whether new therapies for those affected by neurological conditions and their changing needs have been factored into the workforce plan. Can the Minister set out how the workforce plan will respond to these changing circumstances both for those with neurological conditions and those with other conditions?

[Lord Markham (Con)]

I echo the noble Baroness’s comments regarding Lord Cormack.

In terms of the long-term workforce plan, I was talking this morning to the national clinical lead in this area and to Professor Steve Powis. The next stage in terms of the detail is looking at the individual specialties and neuroscience experts are part of that. In the last five years, we have seen an increase of about 20% or so in this space but understanding that need going forward is the next stage in the long-term workforce plan.

[Baroness Blackwood of North Oxford (Con)]

My Lords, I echo the comments about Lord Cormack—we are all going to miss him dreadfully in this Chamber.

There are about 600,000 people in the UK living with epilepsy. An epileptic seizure can cause significant disability and, in the worst instances, death. Only half of those living with epilepsy are seizure free, but this could rise to 70% if all those with epilepsy were targeted to the right treatments. Can the Minister say what plans the department has to improve epileptic treatment in the UK with improved specialist care?

[Lord Markham (Con)]

I thank my noble friend, and I proudly wear the Epilepsy Action badge from the meeting I was just at. As my noble friend says, it is all about trying to get that early diagnosis. If you can get that and help people get the right treatments, that is exactly the right direction of travel because it can make a huge difference to outcomes. The progressive neurological condition toolkit I mentioned earlier sets out that pathway and the model of integrated care for all the ICBs, which they will all then be held to account on to make sure patients with all these conditions—and there are 600 of them including epilepsy—are getting the right treatment in their neighbourhood.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests in palliative care. Do the Government recognise that many of the patients with neurological disease are living with palliative care symptoms such as pain, breathlessness, worry and fatigue, which could be managed in the community with good integration between palliative care services and neurological services? Therefore, have the Government given specific commissioning guidance to integrated care boards to ensure that they look to see how the integration is developing in their own areas to enable these patients to improve their quality of life and their ability to live actively for as long as possible?

[Lord Markham (Con)]

Yes, that is precisely what I was referring to: the progressive neurological condition toolkit is all about the pathways for that integrated approach to it all. Again, there are 15 million people affected—I think this statistic was mentioned earlier—and one in five deaths come from related conditions, so making sure we have that integration with palliative care as well as the other services is key.

[Baroness Barker (LD)]

My Lords, neurological conditions require diagnosis by a specialist. Thereafter, the individuals need the input of people from all the different disciplines of the NHS. At the moment, the expectation to manage that falls upon GPs, and they cannot manage it. The key people who can are specialist nurses, and we have a severe deficit of specialist nurses for several neurological conditions. Can the Minister say how that deficit is to be addressed by the workforce plan?

[Lord Markham (Con)]

I thank the noble Baroness. Yes, the point about epilepsy nurses was made very clear to me just half an hour ago, and I quizzed both the national clinical director of neurology and Professor Stephen Powis on that subject this morning. I was assured that the next stage of the long-term workforce plan goes into that level of detail. I have made a commitment to the House to share some of that data, so we can make sure that it really is covered properly.

[Lord Patel (CB)]

My Lords, as human beings we are one biological system. A disease in one system often impacts another: for instance, chronic cardiac failure often results in cognitive dysfunction and people with neurological conditions often have associated cancers. While this Question is about funding for neurological diseases—and in the last two weeks, we have had Questions about funding for cardiovascular disease, cancers and others—what the whole thing shows is that we have one system failure in the health service. The only way that might be addressed is to get some out-of-the-box thinking. Does the Minister agree?

[Lord Markham (Con)]

I hope the noble Lord knows me well enough to know that I am always up for some out-of-the-box thinking. We are putting a lot of resources into this space. When we talk about dementia, which is captured in this, the commitment I gave last week was to bring in the expert panel, so that we can start to really understand this because early diagnosis is absolutely key. There is some out-of-the-box thinking there. Again, just now I was caught by the spinal muscular atrophy people; they were saying that if we could add that to the baby pinprick test, for instance, we could make sure that babies never suffer those symptoms later in their life, in many cases. I am absolutely up for that out-of-the-box thinking.

Anaesthesia Associates and Physician Associates Order 2024

Lord Markham Excerpts

Monday 26th February 2024 Lords Chamber

Moved by

[Lord Markham]

That the draft Order laid before the House on 13 December 2023 be approved.

Relevant document: 10th Report from the Secondary Legislation Scrutiny Committee (special attention drawn to the instrument)

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

My Lords, I note that the noble Baronesses, Lady Finlay and Lady Brinton, have laid regret amendments and that the noble Baroness, Lady Bennett, has laid a fatal amendment relating to this order concerning professional titles, supervision requirements and the General Medical Council as the regulator, along with constitutional concerns about how parliamentary oversight of regulatory bodies will be maintained in the future. These are important points that I will turn to shortly. I thank the noble Lords who took the time to engage with me on this order at a briefing session last week, when we had a very helpful discussion on the key issues.

Anaesthesia associates and physician associates are already a valued and integral part of the multidisciplinary healthcare team. We acknowledge that there have been some concerns around the AA and PA roles, but regulating these professions will help to increase the contribution that they can make to the UK healthcare sector while improving patient safety and professional accountability. As well as bringing AAs and PAs into regulation by the General Medical Council, this order paves the way for full-scale reform of the regulatory frameworks for all the healthcare professional regulators. This is a rare and significant opportunity to deliver a large-scale programme of reform that will implement improvements to patient and public safety, the system of professional regulation and the health and care workforce.

This order will give the GMC powers to register AAs and PAs it assesses to be appropriately qualified and competent; to set standards of practice, education and training and requirements for continual professional development and conduct for AAs and PAs; to approve AA and PA education and training programmes; and to operate fitness to practise procedures to investigate concerns and, if necessary, prevent or restrict an associate practising. The legislation provides a high-level framework for the GMC to regulate AAs and PAs and, importantly, gives the GMC autonomy to set out the details of its regulatory procedures in rules.

The GMC has committed to developing rules and processes for regulating AAs and PAs that will be subject to public consultation to enable regulation to begin by the end of this year. Once regulation begins, in keeping with the approach taken to bring other healthcare roles, such as dental nurses and dental technicians, into regulation, there will be a two-year transition period that will enable individuals to continue to work and use their relevant professional title while they go through the process of registering with the GMC. After the transition period, it will be a criminal offence to practise as an AA or PA without being registered with the GMC.

I now turn to the fatal amendment tabled by the noble Baroness, Lady Bennett, and specifically to the concern that this order represents a significant constitutional change without the required parliamentary oversight. I thank the Secondary Legislation Scrutiny Committee for its comments on this topic.

I highlight that the delegated arrangements that give Parliament broad powers to make changes to the regulatory landscape via secondary legislation have been operating effectively for more than two decades. It is important to note that prior to the Health Act 1999 there had been growing public, parliamentary and professional concerns about the healthcare professional regulators and the delivery of public and patient protection. Important reforms had been delayed by the need for primary legislation to overhaul a number of Acts dating back to the middle of the 19th century. The delegated powers afforded by Section 60 of the 1999 Act allowed a start to be made on the large task of modernising and rationalising this legislation. These powers have facilitated some important changes and improvements to healthcare regulation, including bringing nursing associates into regulation and introducing revalidation for doctors.

In using the powers under Section 60 of the Health Act, the Government are required to consult publicly for three months on any draft legislation they intend to lay. In addition to a legislative consultation, in March 2021 the Government undertook a three-month policy consultation that invited views on the aims of this work. These consultations and the extensive engagement conducted throughout the project have been clear that one of the primary aims of the legislation is to bring anaesthesia associates and physician associates into statutory regulation by the GMC.

Following the legislative consultation, the legislation is subject to the affirmative parliamentary procedure. This requires the legislation to be debated in both Houses of Parliament and is why we are here today. This is a necessary and proper procedural requirement allowing for parliamentary consideration and scrutiny of the legislation.

The Government have sought, at every stage of the process, to engage a wide and diverse range of interested parties and to be clear on what this work will achieve. In addition to the helpful discussions I had with noble Lords at last week’s briefing session, it is my sincere hope that this evening’s debate will be a further example of this vital engagement and that fellow Peers will feel reassured.

I turn to the order itself. The principles set out in this order have long been sought by the regulators and were recommended by the Law Commission in 2014. At present, for a majority of healthcare regulators, the requirement for parliamentary approval of changes to their rules means that they are less able to respond quickly to amend their processes to reflect emerging workforce trends or concerns. We are providing the GMC with greater autonomy to set out the details of its regulatory procedures in relation to AAs and PAs in rules it publishes itself. The GMC will still be required to consult on its rules but will not need to secure the approval of Parliament or the Privy Council, giving increased flexibility to rapidly adapt its processes and procedures to changing requirements.

Although the order increases the number of areas that the GMC has autonomy over in respect of its day-to-day functions in relation to AAs and PAs, we recognise that there needs to be a system of checks and balances in place to ensure that the GMC continues to act in accordance with the needs of patients, registrants and the wider healthcare sector. The legislation places a number of duties on the GMC to ensure that the new powers are used reasonably and proportionately. For example, it must discharge its functions under this order in a way that is transparent, accountable, proportionate and consistent.

The GMC will remain accountable for any function, or part of a function, it delegates to another regulator or third party. Although the GMC already has the power to set its own fees for medical practitioners, and the same power is proposed for AAs and PAs, we are also introducing a requirement for the GMC to include in its annual report the evidence it has considered of the likely impact of any changes made to fees.

We are also retaining current accountability mechanisms. For example, the GMC will continue to submit annual reports to the Privy Council and copies will be laid before each House of Parliament, which will enable Peers and MPs to scrutinise the regulator’s activities and raise any issues in the House. There is also the Health and Social Care Select Committee, which can hold the GMC to account. As noble Lords know, it has held hearings with the GMC and other professional regulatory bodies on a number of occasions to oversee their work.

The Professional Standards Authority for Health and Social Care—the PSA—oversees the 10 health and care professional regulators and is an independent organisation accountable to the UK Parliament. It carries out performance reviews on all the regulators to see whether they have met the standards of good regulation and publishes its findings. It also has an escalation policy that would allow the PSA to escalate serious or intractable concerns to others, particularly the Government and Parliament. Finally, the Privy Council has a power to direct the GMC where it has failed to carry out its statutory functions using its default powers. I hope these points on how oversight and scrutiny of the healthcare regulators will be maintained in future will reassure the noble Baroness, Lady Bennett, and address the issues that were raised in the Secondary Legislation Scrutiny Committee’s report.

I turn to the role titles, which are referred to in the regret amendments tabled by the noble Baronesses, Lady Brinton and Lady Finlay, and the fatal amendment tabled by the noble Baroness, Lady Bennett. They have been the topic of much debate online, specifically about the use of the word “associate” rather than “assistant”. It is worth noting that AAs and PAs have been practising in the NHS for around 20 years, with the “associate” term being in use since 2019 and 2014 respectively. The titles reflect the fact that, as with nursing associates, they are part of a multidisciplinary team of healthcare professionals from various disciplines working together to deliver co-ordinated patient care.

As set out in National Institute for Health and Care Excellence—NICE—guidelines, all healthcare professionals should introduce themselves and explain their role to the patient regardless of their job title. In addition, in advance of regulation the GMC has published interim standards for AAs and PAs, which make it clear that professionals should always introduce their role to patients and set out their responsibilities in the team.

The noble Baroness, Lady Brinton, also outlined concerns in her regret amendment around the decision for the GMC to take up the regulation of the AA and PA roles. The assessment of the appropriate regulatory body for AA and PA regulation was completed in 2019 following a public consultation. The majority of respondents to that consultation were in favour of the GMC taking on regulation, including the professional bodies representing the roles and the medical royal colleges, including the Royal College of Anaesthetists, the Royal College of General Practitioners and the Royal College of Physicians.

The GMC is the right regulator for these roles. Regulation will give the GMC responsibility and oversight of AAs and PAs, in addition to doctors, allowing it to take a holistic approach to education, training and standards. This will enable a more coherent and co-ordinated approach to regulation and, by making it easier for employers, patients and the public to understand the relationship between the roles of associates and doctors, help to embed them in the workforce.

--- Later in debate ---

[Lord Markham (Con)]

I thank all the noble Lords for their contributions. The wide range of views and experience shows the House at its best. On the serious point of the noble Baroness, Lady Bennett, about making sure that there was a full debate, I hope noble Lords feel that this is a good example of where we have had a full and thorough debate.

I am glad to say that, within all those contributions, there was a general agreement on the importance of these roles and the vital contribution that they can make. They can allow doctors to work to the top of their profession—my noble friend Lord Bethell made that point. As the noble Lord, Lord Scriven, rightly said, they are a supplement to doctors. I hope that, when you have support and allow people to work to the top of their professions, that will cover some of the points that my noble friend Lady Harding and the noble Baroness, Lady Watkins, made about good management, making general practitioners and doctors feel valued in their roles, and making them feel that they are being offered these support service. That is very much within the scope of practice here. Oh, I now see that the noble Baroness, Lady Watkins, is on the Woolsack; I was looking all over for her and thinking, “Surely my speech is not so boring that I have lost her already”.

I hope noble Lords feel reassured by all this and that, as drawn out in the numbers referenced by my noble friend Lord Bethell, this represents only 8% of the GP workforce, so it is very much a supplemental role rather than a substitute.

All speakers echoed the point made passionately by the noble Lord, Lord Hunt, that PAs and AAs play a valued role—one always grounded, as my noble friend Lord Lansley said, in the central role: the doctor or the anaesthetist themselves.

As my noble friends Lady Harding and Lady Bloomfield said, this seeks to regulate them properly, with much clearer regulations, a defined scope of practice and the flexibility to adapt. The noble Baroness, Lady Merron, asked the very fair question of why this has taken so long; the honest answer is that I do not know, but the whole point of this is to build in flexibility. With all the will in the world, as we have seen, if it required primary legislation then, for whatever reason, there would not be time available in Parliament to make the changes quickly enough for the required flexibility. That is what we are trying to do with this order.

The noble Baroness, Lady Bennett, said that she wants to make sure all voices have been heard. I hope those voices have been well heard. During the 18 months that I have been in this role, I have had more correspondence on this than on anything else. She mentioned the Observer article on the long-term workforce plan; I assure her that there is no back-pedalling on this. The target is for incremental increases in the numbers each year. Funnily enough, the frustration expressed to me by Minister Stephenson today is that we are not only hitting the targets for this year but exceeding them. There is definitely no back-pedalling; rather, we are exceeding our targets.

I assure the noble Baroness, Lady Merron, that we do not intend to impinge at all on specialisms. Following on from the Oral Question today, the next stage is to try to get into the detail of the specialisms.

On the points raised by the noble Baroness, Lady Finlay, there is some confusion around the protected titles. As we all know, “doctor” and “consultant” are not protected titles today; you can call yourself a doctor if you have a PhD, and I called myself a consultant once when I worked as a strategic consultant. There is confusion. On the point raised by the noble Baroness, Lady Watkins—I see that she has now popped up by the Throne; it is like “Where’s Wally?”—we need to look at an overhaul of titles, full stop, and at some of the acronyms, such as AAs, as mentioned by the noble Lord, Lord Allan. The idea is that all of this will be part of a full GMC consultation process over the next couple of years on this reformed legislation; we will look at all these points there.

There are separate registers. As mentioned, it is intended that there will be separate prefixes of PA and AA in the registration numbers, but I fully accept that it will not mean anything to a member of the public that a serial number is PA1234. It is a good point that there should be a more thorough consultation on the use of titles, because it is absolutely a confusing picture.

The noble Lord, Lord Harris, with his experience of the GDC, showed that having one regulatory body looking after everything provides clarity. That is valuable, but, as the noble Baroness, Lady Brinton, said, our Explanatory Memorandum needs to be clearer, and so I make that commitment.

--- Later in debate ---

[Lord Harris of Haringey (Lab)]

It is in your order.

[Lord Markham (Con)]

That is something I will pick up on. On the point raised by the noble Baroness, Lady Fox, I say that the GMC, with the CQC, should be able to give the ongoing quality assurance.

The noble Lord, Lord Hunt, said very well that the discussion on mistakes has not been useful. We are all aware that, regrettably, mistakes happen in all areas, and we need to make sure that we understand and learn from them, rather than using them to point fingers. Moving into the regulated space, where there is duty of candour, is useful.

I do not think anyone could be failed to be moved by the passion with which the noble Lord, Lord Winston, spoke about his experience. It was a very telling story. As reassurance I cite the noble Lord, Lord Patel, on the scope of the practice: it is one anaesthetist to two AAs, and the role of the AA is very much to maintain, as he explained well. In a similar way, the PAs really do need to work under GP supervision. The numbers are set out in the long-term workforce plan. We have a foot on the throttle for those training places, particularly in regulating them. We will make sure that things are properly managed so they cannot get out of control.

I absolutely agree with the points made by the noble Baronesses, Lady Watkins, Lady Harding and Lady Bloomfield, that this is a people management issue, and a lot of the heat from this debate is a feeling from junior doctors and others that they are unloved and uncared for. I freely admit that there is a wider issue that we need to look at, concerning things like hot meals; clearly, it is something trusts need to look at it as well.

I echo the points made by the noble Lord, Lord Hunt, that passing this order is the best way to ensure the safety of patients. As we develop, there is perhaps scope to be more ambitious, but let us try to do this step by step, to make sure we really are happy and that the scope of practice works. As ever in a debate as long as this—it has been a very thorough one—I will write to fill in any details that I have not managed to cover. At this point, I hope and trust I have provided sufficient answers to the questions, and have demonstrated—

[Baroness Finlay of Llandaff (CB)]

I hesitate to rise because the House clearly wants to end the debate, but I am not sure whether the Minister, in summing up, said whether the titles of physician associate and anaesthesia associate will be protected titles when the order goes through. Are they negotiable? I ask that question specifically because I had a lot of discussions with different people involved in this, particularly the GMC, and I have been concerned that if those are the only protected titles of all the grades registered by the General Medical Council, we may be storing up further problems for the future. If this is to be a protected title, can the Minister provide assurance that further statutory instruments could be brought forward if, in the light of the consultation advised by the noble Lord, Lord Allan, a different title is suggested? Could it then be changed?

[Lord Markham (Con)]

It is a protected title. The point I was trying to make about the general overhaul and understanding of the titles, however, is that there will be the scope to do this, as doctors and consultants are not protected titles today. I think we need to develop clarity on that, which is why the further reforms and SI changes will set out to protect other titles as well.

[Lord Patel (CB)]

Sorry about prolonging the debate, but is that the only protected title of all healthcare professionals?

[Lord Markham (Con)]

My understanding is that currently none of the titles is protected. These are the first set of titles that will be protected as a part of the secondary legislation that we are passing. The idea is to understand the hierarchy of titles and start to introduce the protections. I am happy to follow up in writing in more depth on all of this. I thank the noble Lord for his intervention.

Hopefully, this order will provide a standardised framework of governance and assurance for clinical practice and professional conduct for AAs and PAs. It will enhance patient safety and enable AAs and PAs to make a greater contribution to patient care. I beg to move.

NHS: Dementia Commission Report

Lord Markham Excerpts

Thursday 22nd February 2024 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government what actions they are taking in response to the NHS Innovation and Life Sciences Commission’s Dementia Commission: 2023 Report.

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

We welcome the Dementia Commission: 2023 Report and are taking steps to address each of the recommendations. The Government remain committed to improving dementia diagnosis rates and providing high-quality care and support following a diagnosis. The Government have committed to double funding for dementia research to £160 million per year by the end of 2024-25. We welcome all research that will help us to improve how we diagnose and care for people with living with dementia.

[Baroness Wheeler (Lab)]

My Lords, the commission’s wide-ranging and comprehensive report is very welcome, but it heavily reinforces the urgent need for radical change in the way we diagnose, treat and care for dementia patients and support their families and carers. To ensure timely, speeded-up diagnosis, the training of primary care practitioners in dementia-specific symptoms and diagnostic methods is crucial. What steps are the Government taking to strengthen general practice and community pharmacy in this regard so that individuals with dementia can receive appropriate care and support as early as possible?

[Lord Markham]

I thank the noble Baroness for this Question. As ever, I have found that one of the real strengths of being in this position is that the questioning here makes me explore an area. This has been another area which I have enjoyed and found fascinating. Early detection is absolutely key, and what I have been learning from that is that, yes, we need to arm primary care staff and a potentially vital front line in terms of primary care staff are opticians, because retinal scans are a really good way to early diagnose. Apparently, people more than ever will have a frequent eye check. I have pulled together a panel to understand this more, and I invite the noble Baroness and others so that we can look at the latest research and really understand this more.

[Baroness Manzoor (Con)]

My Lords, I welcome the additional sums of money that the Government are putting into this service, which is very important, but, as the Minister will be aware, and as he indicated in his response to the noble Baroness, Lady Wheeler, around 36% of those with this condition are undiagnosed, and that rises to around 50% in some authorities. The Minister will be aware that some exciting new drugs are coming on to the market that help to delay the onset of this terrible condition. What are the Government doing to raise awareness so that there is early diagnosis and those with the condition can access those services much sooner?

[Lord Markham (Con)]

My Lords, I thank my noble friend, who is absolutely right. This is where things such as the Barbara Windsor Dementia Mission have been successful in raising awareness, as she states. The challenge in all this, as I have learned, is that because it is such a slow-moving disease it is difficult to see how it progresses. Apparently, it has one of the lowest failure rates in terms of drugs because it is really hard to monitor the progress behind it. That is why work is being done, such as retina scans, where you can measure data objectively. There is real hope in all this, and it means that we need to make all primary care workers aware of the situation.

[Lord Allan of Hallam (LD)]

My Lords, the commission recommends the creation of dynamic care records for dementia patients and their carers. We know from experience that information projects such as this work best when they have a clear owner who wakes up every morning worrying about delivering them. Who in the NHS owns the delivery of dynamic care records for dementia patients? If that person turns out not to exist when he goes to look for them, would he consider appointing someone?

[Lord Markham (Con)]

Yes, that is a very good point. For me, as I have looked into this, the reason for assembling the panel that we can all interrogate is that we have the value of different noble Lords in this House who can add those points to it. What the noble Lord said sounds sensible. The honest answer is that I do not know whether there is such a person today, but let us use this as an opportunity to find out, because I think there should be.

[Lord Patel (CB)]

My Lords, there are several important points in development that should allow us to better manage people with dementia. The first is early diagnosis, as has been mentioned, but we need greater input into research in developing biomarkers that detect early development of the disease. Having done so, we then need drugs that will be effective in early phases of the disease—so-called disease-modifying treatments. Some of those have recently been given accelerated approval in the United States and Japan, but they are very expensive drugs. As we discussed last week, one of the drugs for small-cell lung cancer failed at the final endpoint, so we have to be guarded. For instance, the drug lecanemab, which has been approved, would use up half the pharmaceutical costs of all the 27 countries of Europe. These two things are important, and I hope that the forum that is developing will address those issues of research.

[Lord Markham (Con)]

As ever, my colleague the noble Lord is correct. The blood biomarkers are central to this. We have set up the NIHR biomarker challenge to try to understand those, and my understanding is that a Swedish blood test is quite promising. NICE is bound to approve the two early-stage drugs that the noble Lord mentioned over the summer, in July and September, but then we need to look at scale-up issues. Often, we are talking about having to deliver them through drips, which means a whole workforce scale-up. So there are a lot of issues around this that the noble Lord rightly brings up, and I hope the panel can discuss them further.

[Lord Kamall (Con)]

My Lords, I would like to ask the Minister about the role of music therapy in helping dementia patients. It is well known that when someone listens to music, sometimes it takes them back to a place and time immediately. There has been research on the role of music therapy. I quickly skim-read the report but did not see music therapy mentioned in any way or in detail. If I am wrong, perhaps the Minister can correct me, but could he also tell me about the role that music therapy can play?

[Lord Markham (Con)]

My noble friend is correct; I did not see reference in my noble friend Lord O’Shaughnessy’s report to music therapy either. I am familiar with some of the principles behind it. My personal experience myself with the elderly dementia patient that I cared for was that bringing my five year-old son along took them out of their position and made them care for that child and forget about their own situation. Those sorts of therapies—and music is similar—have a vital role that we will look into further as part of this plan.

[Lord Scriven (LD)]

My Lords, the Alzheimer’s Society has a good report out called Dementia: What Every Commissioner Needs to Know, about Alzheimer’s care. What is the Government’s view on ensuring that ICBs across the country have a minimum standard of commissioning levels for people with dementia?

[Lord Markham (Con)]

We have set out a dementia good care planning guide to exactly those commissioners because, as ever, we need uniformity in these areas. Part of the strength of ICBs is that they have freedom to deliver local services, but we have to make sure that they are always achieving at least the minimum levels that the noble Lord referred to. That is what the guidelines are about, and we are setting monitoring against that to make sure that they are delivering on it.

[Baroness Watkins of Tavistock (CB)]

My Lords, I have two questions. First, I understand that NICE will review rather than approve the drugs in question. Secondly, it appears that they extend life but that the end of life is still very similar, so what do the Government intend to do to ensure that carers have sufficient respite and that there is a standard ratio of Admiral nurses to support families, certainly for the next decade until science gives us the answer?

[Lord Markham (Con)]

The noble Baroness is correct that the science is unfortunately not there yet. That is why we are investing £160 million a year in research, because more needs to be done. In the meantime, and I suspect for ever, we will need to make sure that support networks are around this space, and the voluntary care sector, for want of a better phrase, is a vital part of that. We are making moves towards it; we are giving respite care and making some payments. I freely admit that there is more we could be doing in this space, but we have done quite a bit as well.

[Baroness Seccombe (Con)]

My Lords, my husband, having had two strokes, was part of a project called OPTIMA, so he left his brain to that project. When the report was sent to me, OPTIMA assured me that my husband had had vascular dementia, not Alzheimer’s.

[Lord Markham (Con)]

Again, everything that can add to our knowledge has to be a good thing.

[Baroness Altmann (Con)]

My Lords, with an ageing population it is inevitable that this illness is going to increase in prevalence across the population. Do the Government have any intention of building into their strategy for caring for dementia the support, perhaps in the workplace, that might be needed, particularly for older women, who tend to be predominantly carers, maybe via insurance in the workplace for respite and for carer’s leave, in order to ensure that this is not such a strain on both the families and the public purse?

[Lord Markham (Con)]

There is recognition in all these things that the workplace has a role here. I have looked at treatments and outcomes in the G7 countries, and Japan is often a good example of having care in the workplace, as my noble friend is aware. As so often, it is about making people realise that this is everyone’s problem to deal with. I will do more work to understand what we are doing to arm employers for that, and I will come back to my noble friend.

NHS Dentistry

Lord Markham Excerpts

Monday 19th February 2024 Lords Chamber

[Lord Young of Cookham]

To ask His Majesty’s Government what assessment they have made of the availability of NHS dentistry.

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

My Lords, since the pandemic this Government have taken decisive action to recover services. There are signs of recovery, with the amount of activity delivered and the number of patients seen increasing, but there is more to do. Our recently published plan to recover and reform NHS dentistry will make dental services faster, simpler and fairer for patients and will fund around 2.5 million additional appointments and more than 1.5 million additional courses of dental treatment.

[Lord Young of Cookham (Con)]

My Lords, I welcome the recent Statement but, with 80% of NHS dentists not accepting new patients and with 190 hospital operations every day removing rotten teeth from children, clearly a fresh initiative was needed. However, the dysfunctional, discredited 2006 dental contract, which is driving NHS dentists out of the business, and which was described by the Select Committee in another place as not fit for purpose, remains in place. When will it be reformed? Given that everyone has a right to register with a GP and if they cannot find one the ICB has to find one, why is there not an equivalent right to register with a dentist if dentistry is an integral part of the NHS?

[Lord Markham (Con)]

I thank my noble friend for raising this and declare my interest as my wife is a dentist, although she is not currently practising. It is accepted that we have made sensible improvements to the dental contract, but a fundamental longer-term overhaul is needed. In terms of the ability to get registered with a dentist, that is what the mobile trucks are all about. We realise that in certain areas it is difficult to get that registration. The idea is for mobile trucks to go into a neighbourhood where there is a particular shortage to resolve the problem.

[Lord Birt (CB)]

My Lords, while working at No. 10 in the early noughties, I was involved in a strategic review of the NHS and was shocked, at the time, to discover how poor the long-term workforce capacity planning was. The total number of dentists currently working in NHS England—around 25,000—has not changed by more than tens or hundreds over the last five years. In that period, more dentists have left than joined. At the same time, fewer than 1,000 dental students have been enrolled each year. Precisely how many dentists do we need to bring NHS capacity in line with demand? In what year, again precisely, will that point be reached?

[Lord Markham (Con)]

The noble Lord is correct in talking about the supply challenges. That is what the long-term workforce plan is all about, and why we are committing to a 40% increase in training places by 2030. The other issue that he rightly raises is the balance between the cost-effectiveness of providing private versus national health dentistry. The problem is that it is often seen as more lucrative for a dentist to go down the private sector route. That is why we are trying to rebalance that and have introduced an increase in the minimum charge to £28 for a unit of dental activity, and £50 for a new patient, to try to bring services back more in favour of the NHS.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare my interests as president of the British Fluoridation Society. The Academy of Medical Sciences reported very recently that nearly a quarter of five year-olds have tooth decay. Unless we deal with this there will be many more queues and great difficulties with access. The Minister will know that shortly there will be a consultation in the north-east to introduce fluoride. Surely the current situation demands that we extend this throughout the country.

[Lord Markham (Con)]

Yes, the noble Lord is correct that there is very good evidence of the effectiveness of water fluoridation, and the report as recently as 2022 showed there are no side-effects. The north-east will increase the number of recipients by about 1.6 million people, and there is a process that that needs to go through but I totally agree that we should expand it as far as we can.

[Lord Allan of Hallam (LD)]

My Lords, further to the question asked by the noble Lord, Lord Birt, I point out that we have very good data on the number of dentists engaged in NHS activity. It shows a pattern of falling numbers—down to 24,151 in the last financial year. Does the Minister agree that it is fair for us to judge the success or failure of the Government’s new plan on whether that number increases? Does he have a target for where the Government intend it to reach?

[Lord Markham (Con)]

The absolute measure that everyone cares about is output—the number of treatments—and this plan is all about increasing the number of appointments by 2.5 million. In the last year alone, we increased the number of treatments from 26 million to 33 million. There is more to do, granted, but the real measure of success is how many treatments we get done, which is a function not just of the number of dentists but of their productivity, and of the number of them we can persuade to provide NHS rather than private sector services.

[Lord Lansley (Con)]

Can the Minister confirm that it is nearly 13 years since the then Secretary of State, and his noble friend Lord Howe, initiated negotiations for a new dental contract? We still need that contract, because it would shift towards paying dentists for outcomes for their patients rather than for units of dental activity. It is when we have a shortage of dentists that we need to shift to outcomes and preventive work, to improve the balance of work that dentists must do and reduce demands on the total dental workforce.

[Lord Markham (Con)]

Yes, it is all about outcomes and output. As I mentioned, there have been sensible moves recently in terms of the contract—the £50 for new patients; increasing minimum levels; and ensuring that dentists get more payment for doing, for example, three fillings versus one. I also agree that some fundamental work needs to be done in this space.

[Baroness Merron (Lab)]

My Lords, the Minister has previously suggested that the 15 mobile dental vans would be able to address emergency situations as well as scheduled appointments. How will this work in practice, particularly in view of the size of the areas each van will cover? How will the Government meet the immediate need for thousands more appointments for emergency dental treatment?

[Lord Markham (Con)]

There will be a schedule of when the mobile vehicles will visit each area, with the ability to pre-book so, if someone calls up with an issue, they will know that a truck will come to their area in a week or two’s time. That is the idea, or people can queue to receive those services as well. I hope this will be successful. It has worked quite well in some areas already. The case will prove itself and the 14 will be just the start. We can do much more from that, because we all agree that we need to expand supply.

[Baroness Finlay of Llandaff (CB)]

Given that over 8,800 new oral cancers were diagnosed last year, and a fifth of those were in people under the age of 65, do the Government recognise that it is a false economy not to increase dentistry provision, dental hygienist screening for oral cancers and advice on prevention, such as by cutting down on smoking and so on? The cost of treating this, and of early morbidity to the country, is huge.

[Lord Markham (Con)]

Yes, absolutely. That goes back to my noble friend’s point about outcomes. I know that a lot of places, if they are fortunate enough to have an NHS dentist, give you check-ups every six months as a matter of course. In fact, NICE says that if you are in good oral health you will need that only every 24 months, with the idea being that you can create more space for other people to come in, because prevention and screening are vital in all this as well.

[Baroness Jolly (LD)]

My Lords, I live in Cornwall, where there are now very few NHS dentists and many people are resorting to do-it-yourself. What plan does the Department of Health have to ensure that all in Cornwall have access to a dentist as and when needed? A kit is available from the high street for less than £10, but this does not buy any expertise or guarantee of success.

[Lord Markham (Con)]

The noble Baroness is quite correct. Cornwall is one of the areas where we piloted the mobile services. It is probably not the number one area, but it is fair to say that it is one of the main areas where we are putting in more resources for precisely that reason.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I shall switch sides of the country. The campaign group Toothless in England was founded in Suffolk and is calling for contracts for NHS dentists to cover the real costs. It says that this is the only way to solve the drought of dentists in places such as Waveney Valley, where one in three people has been unable to secure an appointment over two years.

[Lord Markham (Con)]

These plans were welcomed by Toothless in England, which was good to see, as well as by Healthwatch. I know personally that making it economic for dentists to work in the NHS rather than in the private sector, or getting that balance right, is fundamental. The changes are a good first step towards that but more probably needs to be done.

Medical Devices (In Vitro Diagnostic Devices etc.) (Amendment) Regulations 2023

Lord Markham Excerpts

Wednesday 7th February 2024 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 14 November 2023 be approved. Considered in Grand Committee on 6 February.

Motion agreed.

NHS Dentistry: Recovery and Reform

Lord Markham Excerpts

Wednesday 7th February 2024 Lords Chamber

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

My Lords, I start by declaring my interest that my wife, who is present today, is a dentist—although she is not currently practising. With the leave of the House, I shall now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health and Social Care. The Statement is as follows:

“With your permission, Mr Speaker, I would like to make a Statement on our plan to recover and reform NHS dentistry. First, on behalf of the entire House and my department, I send our very best wishes to His Majesty the King. His decision to share his diagnosis will be welcomed by anyone whose life has been touched by cancer. I know that we are all very much looking forward to seeing him make a speedy recovery and resume his public duties.

Turning now to dentistry, thanks to a once-in-a-generation pandemic between 2020 and 2022, 7 million patients across England did not come forward for appointments with NHS dentists. Since then, we have taken decisive action to recover services. We have made reforms to the dental contract, so that practices are paid more fairly for caring for NHS patients with more complex needs. We have made sure that dentists update the NHS website regularly so that the public know that they are taking on new patients. This has delivered results, with 1 million more people seeing an NHS dentist last year than in the year before. However, we know that too many, particularly those living in rural or coastal communities, are still struggling to find appointments. This recovery plan will put that right by making NHS dental care faster, simpler and fairer for patients and staff. It is built on three key pillars, which I will address in turn.

First, we will help anyone who needs to see an NHS dentist to do so, wherever they live and whatever their background. To do this, we must incentivise dentists across the country to care for more NHS patients. That is why I am delighted to tell the House that for the coming year, we are offering dentists two new payments on top of their usual payments for care— £15 for every check-up they perform on NHS patients who have not been seen over the past two years, and £50 for every new NHS patient they treat who has not been seen over the same period—because we know that patients who do not have a relationship with a dentist find it harder to get care. That is not a long-term ambition: our new patient premium will be available from next month.

We are also increasing the minimum payment that dentists receive for delivering NHS treatments. This will support practices with the lowest unit of dental activity rates, or UDA, to provide more NHS care. However, we know that in many of our rural, remote and isolated communities, dentists themselves are in short supply. That is why, starting this year, up to 240 dentists will receive golden hello payments worth up to £20,000 when they commit themselves to working in one of those areas for at least three years. These dentists will give patients the care they need faster, make dental provision fairer and tackle health inequalities.

We are also delivering dentistry to our most remote regions without delay. This year, we will deploy dental vans to more isolated, rural and coastal areas. Staffed by NHS dentists, they will offer check-ups and simple treatments such as fillings. This model has been tried and tested successfully across many regions. For example, last year in Cornwall, a mobile van visited five harbours, treating more than 100 fishermen and their families. We will be rolling out up to 15 vans across Devon, Gloucestershire, Somerset, Norfolk, Suffolk, Lincolnshire, Cambridgeshire, Dorset, Cornwall, North Yorkshire and Northamptonshire. This move has been welcomed by Healthwatch, the Nuffield Trust and the College of General Dentistry. We will let patients know when vans will be in their area, so they can get the care they need faster.

These reforms will empower NHS dentists to treat more than 1 million more people and deliver 2.5 million more appointments. As the chief executive of National Voices, a group of major health and care charities, said:

‘This extra money … should help thousands of people who have been unable to see a dentist in the last two years to get the care they need’.


These reforms are just the beginning. This recovery plan will also drive forward reforms to make NHS dentistry sustainable for our children and our grandchildren.

That brings me to the second pillar: growing and upskilling our workforce for the long term. Our long-term workforce plan, the first in NHS history, gives us strong foundations on which to build. By 2031, training places for dentists will increase by 40% and places for dental hygienists and therapists, who can perform simple tasks such as fillings, will also rise by 40%. More dentists and more dental therapists will mean more care for NHS patients.

I am delighted to tell the House today that we are going further in three key ways. First, we will consult on a tie-in to NHS work for dentistry graduates, because right now too many are choosing to deliver private work over valuable NHS care. More than 35,000 dentists in England are registered with the General Dental Council, but last year almost one-third worked exclusively in the private sector. Training those dentists is a significant investment for taxpayers, and they rightly expect it to result in the strongest possible NHS care. That is why, this spring, we will launch a consultation on a tie-in for graduate dentists and how this could deliver more NHS care and better value for taxpayers.

Secondly, we will take full advantage of our dental professionals’ skills. Today, even though they have the right training, without written direction from a dentist, dental therapists cannot do things such as administer antibiotics. This year, we will change this, making life simpler for dentists and making care faster for patients. As the president of the College of General Dentistry has said, the

‘use of the full range of skills of all team members will enable the delivery of more care and make NHS dentistry more attractive to dental professionals’.

Thirdly, we will recruit more international dentists to the NHS. We have a plan to do this by working with the General Dental Council to get more international dentists taking exams and to get them on to the register sooner, and to explore the creation of a new provisional registration status so that, under the supervision of a dentist who is already on the register, highly skilled international dentists can start treating patients sooner, rather than working as hygienists while they are waiting to join the register.

I turn now to our plan’s third pillar, which is prioritising prevention and giving children a healthy smile for life. This begins by supporting parents to give their children the best possible start. That is why family hubs up and down the country will offer parents-to-be expert advice on looking after their baby’s teeth and gums. As those babies grow up, we will support parents and nurseries in making sure that, before every child starts primary school, brushing their teeth is part of their routine.

The evidence is clear: the earlier good habits are built, the longer they will last. Seeing a dentist regularly is vital for children’s health, but, since the pandemic, too many have been unable to do that. That is why this year we are taking care directly to children. We will deploy mobile dental teams to schools in areas with a shortage of NHS dentists. They will apply a preventive fluoride varnish to more than 165,000 reception-age children’s teeth, strengthening them early and preventing decay. Our Smile for Life programme has already been endorsed by the College of General Dentistry.

Six million people in England already benefit from water fluoridation. In order to go further in protecting children’s teeth, we will consult on strengthening more of our country’s water with fluoride. Again, the evidence is clear: in some of the most deprived parts of England, enhancing fluoride levels could reduce the number of teeth that are extracted because of decay by up to 56%. That is why, through the Health and Care Act, we made it simpler to add fluoride to more of our water supply. As a first step, this year we will launch a consultation on expanding water fluoridation across the north-east—an expansion that would give 1.6 million more people access to water that strengthens their teeth, preventing tooth decay and tackling inequality.

This is our Government’s plan to recover and reform dental care: dental training places up by 40%; 2.5 million more appointments; dental vans treating more patients; more dentists in remote areas; more dentists taking on NHS patients; better support for families and better care for children; patient access up and inequity coming down. It will make life simpler and treatment faster and fairer for patients and staff. We have taken the difficult decisions, and we have now delivered a long-term plan to make dental care faster, simpler, and fairer for people across the country”.

--- Later in debate ---

[Lord Allan of Hallam (LD)]

My Lords, from these Benches, I also echo our best wishes to His Majesty the King. We hope that he makes a speedy recovery.

In responding to this Statement, I also reach for that familiar phrase of it being a sticking plaster, before heading in the direction of dental metaphors. Rather than a scale and polish, it seems to me that this is something of a temporary filling when, as the noble Baroness, Lady Merron, says, NHS dentistry needs serious root canal work.

I feel for the Minister because I know he cares about dentistry and understands the scale of the problem. He has to sell the temporary filling hard in the hope that we will trust the Government to deliver on the more comprehensive course of treatment that is in the consulting on and exploring part of the document.

There are three elements in that long-term part of the plan on which I hope the Minister can comment further today or later in writing. First, we are told that the Government will ring-fence the £3 billion of NHS dentistry budgets from 2024-25 which have been underspent because of the lack of dentists willing to work at NHS rates. We cannot see this changing overnight, even with what is announced today. How will this ring-fencing work if an integrated care board has still not been able to get the take-up of the contracts that it wants? What kinds of things could they use these underspends for? Will these include additional local financial incentives on top of the ones we are discussing at a national level today?

Secondly, it is important to realise the benefits of people with dental qualifications moving to the UK. I know that the Minister would wholeheartedly agree. The policy document promotes the idea of a provisional registration of overseas qualified dentists while they are waiting for their full GDC registration. The phrasing in the Statement and in the document is quite hesitant. It talks about the Government working towards introducing legislation. Can the Minister give us more information about the complexity of the legislative changes that will be required and their likely timescale?

Thirdly, failures in emergency care both cause severe patient distress and additional work for NHS hospitals. The noble Baroness, Lady Merron, has already pointed out that many children are referred to hospital for emergency treatment. I looked at the description on the Smile Together website—a good service in Cornwall cited in the plan. It says that:

“Smile Together is commissioned by NHS England to provide urgent and emergency dental care to patients who would otherwise be unable to access treatment. Demand for this service is very high and the criteria set by our commissioners is very strict. We therefore offer emergency appointments that are independent of our NHS service”,


and people who call in who are unable to get an NHS appointment and do not wish to wait and try again the next day can basically go private. I am not sure we want to be in a situation where people needing emergency care are left hanging on the phone day in, day out, or face having to go for the private option. I hope the Minister can explain what the Government intend to do around emergency care. I hope he will agree that making sure people can get NHS emergency care will be better for both the patient and the NHS.

A temporary filling is designed to last a few weeks—or months at most—or perhaps until an election. We are grateful for the temporary relief it provides, but we know that more work is needed, and this has to be done urgently if we are to fix NHS for the long term.

[Lord Markham (Con)]

I thank noble Lords for their comments. First, the thing that brings us together is the desire on all sides to expand capacity. That is something that we are all behind. I hope that I can bring out the themes in this regard—the plans that we are talking about are designed to do exactly that.

The noble Baroness, Lady Merron, asked how the golden hellos will work. The idea is that it will be in the 12 most needy areas, and the ICBs will have the flexibility in how they attract people there. It might be existing dentists who they want to take from another area, or it might be private sector dentists or dentists who are just graduating. It is about making sure that they have the ability to bring those people into the areas of most need.

The mobile vans have proved quite successful already in areas such as Cornwall, where they have already been. They are designed to hit exactly those areas where it is hard to seed new dental practices, because there is a dental desert there, for want of a better word. Each of those vans alone should be able to do about 10,000 appointments a year, which is quite a sizeable number. Of course, what that does is put it in the areas of most need. The beauty of it—if beauty is the right word—is that, when you are talking about emergency-type situations, you will be able to tell exactly where they are.

The other thing that is important, with regard to all the payment mechanisms and how that will work, is that the dentists working in these vans are salaried. The idea is that we know that in those instances it is absolutely going to work in terms of the incentives. While we think that the patient premium absolutely will help in terms of access, and we know that the hardest one is getting them to see patients for the first time and that is what the additional £50 is all about, by bringing in these salaried people we can absolutely guarantee that those new people will be seen in those situations.

What I note from all this is that these are very concrete plans to create 2.5 million new treatments. I noticed that the noble Baroness, Lady Merron, mentioned the Labour plan of 700,000 extra, so I shall let noble Lords draw their own conclusions as to which one is more extensive. But to try to answer the question around ring-fencing, what this is all designed to do is to make sure that the contracted number of UDAs that we want to happen is delivered. Noble Lords will have heard me say before that the problem often is that it is not delivered because the dentists then go and try to sell to the private sector instead. So this is all designed to underpin that: first, by making it more attractive for those dentists to offer it to patients, in terms of the patient premium of £50, and the increase in the UDA price; and, secondly, by supplementing that with salaried staff, so you can absolutely make sure that it is being delivered in those circumstances. That is what we are trying to do—because we know that the UDAs are there in terms of the expansion, and we did see a large expansion last year. We increased the number of treatments from 26 million to 33 million, a 23% increase—so we have managed to do it. But we are talking here about wanting to do more of it, of course.

As for whether this is a temporary filling or a long-term fix, of course the long-term workforce plan is all about a long-term fix, making sure that we have the supply in place so we can supply the NHS services needed on a long-term basis. That is where we are talking about the 40% increase, and about making it easier to bring people in from overseas, to answer the question from the noble Lord, Lord Allan. As noble Lords know, I have a personal interest. I would not have a wife—or this particular wife—if she had not managed to become a dentist from overseas. But what I saw from all of that was that it is a two-stage process. It was one thing for her to be allowed to become a private dentist. I had to fill in the forms myself, and it was pretty hard. But it was an altogether new process then to become an NHS dentist. To be honest, the conclusion after all that was, “Why would I bother to do this? If I can already be a private sector dentist, why would I jump through a load more hoops to then become an NHS dentist?” It is designed to try to iron out those differences and not act as a disincentive in those situations.

To answer the question, those mobile vans, in terms of SMILE4LIFE, are there to make sure that they get people off on the right foot. The family hubs are for training would-be mothers about looking after gums and teeth. But also, crucially, it is about using those mobile services in the areas where they are most needed, putting in the fluoride varnish for 165,000 reception-age kids—so aged from four to five. That means really starting to get the right start to life in all this.

I hope that what we are seeing here is a comprehensive set of plans, expanding supply in terms of the golden hellos, mobile vans and increasing treatments, as well as the long-term workforce plan for increasing staffing. We are making it more attractive for dentists to provide NHS dental services in terms of the patient premiums. These will all start very quickly—in March, for instance. It is also about increasing the UDAs and making sure that our children get the right start to life, in terms of SMILE4LIFE, and making sure that their teeth are clean from a very young age.

There is a lot to do—I perfectly accept that—but I believe that what we have here is taking the right steps to achieve it.

[Lord Young of Cookham (Con)]

My Lords, I felt that today’s Statement deserved a slightly warmer welcome than it has received so far, particularly from the noble Baroness. At a time of enormous pressure on public expenditure, more resources have been found to target the people in the areas who need dental treatment.

I shall raise an issue that has not been raised in exchanges so far. The single most effective public health measure that the Government could take to reduce tooth decay, particularly among children, is to add fluoride to the water supply in those parts of the country where it does not occur naturally. The Health and Care Act 2022 transferred the responsibility from local authorities to my noble friend’s department. Since then, until today, nothing has happened. I welcome the announcement that there will be consultation on extending fluoride to the areas in the north-east where tooth decay happens to be at its highest. Can my noble friend give some idea of the timescale of that consultation and whether there are any plans to extend fluoride to other parts of the country where it is urgently needed as a public health measure?

[Lord Markham (Con)]

I thank my noble friend. He is absolutely correct that the benefits of water fluoridation are well proven. The consultation for the north-east of England, which will bring in 1.6 million people to this, is starting very shortly. The idea behind that is that we can really try to get moving quite quickly on that. I was surprised to learn that the level of water fluoridation in England today is only at about 6 million people. I know that a lot of people think that their water supply has fluoridation, but there is obviously a long way to go on that. The 1.6 million in the north-east is a good extension to that, but there is a lot more that we plan to do in this space.

[Lord Harris of Haringey (Lab)]

My Lords, I declare my interests as chair of the General Dental Council. I welcome the fact that this plan has now arrived—it has been a very long time coming. Of course, the council’s role is to maintain a register of dentists and ensure that all the dentists on that list are of an appropriate standard and fit to practise in this country. I am not going to comment on the level of investment, but I make the point that increasing the number of dentists on the register does not in itself increase the number of people who practise in the NHS. I think that the British Dental Association uses an analogy about a bucket with a hole in it. The point is that, if the situation is one in which dentists, whether they qualified here or abroad, feel that the rewards that they get from being an NHS dentist are insufficient, we will continue to see that drift away from NHS dentistry.

My specific point is about the question of overseas registration. The Statement highlighted the fact that 30% of those on the register are qualified from overseas. I should say that nearly 50% of those who joined the register in 2022 are from overseas, so that gives some idea of the direction of travel. To facilitate that, the GDC has trebled the number of places for people taking their ORE part 1 examinations. On the specific proposal about provisional registration, which the General Dental Council will welcome, I hope it is recognised that, if somebody is provisionally registered, they must be supervised. This will require a structure within both the NHS and private practice to make sure that there are adequate levels of supervision available and an adequate number of dentists to do that. Can the Minister tell us how that will happen?

[Lord Markham (Con)]

I thank the noble Lord, particularly for his great knowledge and work with the GDC. I absolutely accept the basic point about the leaky bucket, for want of a better phrase; we are losing a lot of dentists to private. At the end of the day it is about the economics, and clearly we need to make sure that doing NHS work pays. In part that is what the patient premium is designed to do, as is increasing the value of UDAs to £28. There is also an acceptance that we need to look at some of the more long-term measures to make sure that it is economic to do that. The salaried staff I mentioned earlier will help with that as well.

The noble Lord is absolutely correct—again, I have some personal experience of all this—about having that mentoring scheme. Even if a dentist has been operating overseas for a number of years, learning a lot of the techniques and methods here is very beneficial. It is absolutely recognised that such mentoring is required. On the detail of how that is being planned, I will set out in my letter to everyone how exactly that will be achieved.

[Lord Hacking (Lab)]

My Lords, I have been very reassured by the Minister’s Statement and by my noble friend speaking on behalf of my party. It is very good to hear that dentistry is at last being given much greater attention at National Health Service level. I welcome the type of detail that has been brought out in this short debate; for example, bringing more fluoride into our water supplies and the elementary thing of getting a child to clean his or her teeth with proper toothpaste as a morning act before going out to school or elsewhere.

Many years ago my wife, who is a qualified consultant, was in Pakistan with a team of English doctors and surgeons to demonstrate heart surgery. I, in a kind of parliamentary capacity, was asked to make a visit to a certain place, Murree. This involved going through a number of villages in Pakistan. Of all the infirmities among the villagers, and there were a lot, the most conspicuous were infirmities of the teeth. It was a nightmare to look at.

This is some reassurance. We are absolutely right to pay proper attention to dentistry, and I most welcome the Minister’s Statement and the words of my noble friend speaking on behalf of my party.

[Lord Markham (Con)]

I thank the noble Lord for his comments. I agree that we all too often see such circumstances. As many as half the children in A&E come in for reasons of problems with their teeth. That absolutely illustrates, in a similar way to the noble Lord’s experience in Pakistan, that it really is vital to get on top of these problems. The hope, and the plan, is very much that these are the first steps in making sure that we achieve that.

[Baroness Taylor of Stevenage (Lab)]

My Lords, I take the point from the noble Lord, Lord Young, about money being found for dentistry in straitened circumstances. However, in the past 14 years, a whole generation of younger children who are now around six to 10 years old have had almost no access to dental treatment, resulting in the poor health and dental health that we heard about from my noble friend Lady Merron and the noble Lord, Lord Allan. What efforts will the Government make to ensure that the backlog of dental treatment that those children need will be assessed properly, with the appropriate treatment given as quickly as possible? Otherwise, we will have further health problems in future as those children go into their teenage years.

[Lord Markham (Con)]

On the targeting and how we are using those mobile vans, the thinking is that they will be rolled out quite quickly—in about six months or so. We are absolutely looking to target those areas with backlogs, such as where we know that the distance to an NHS dentist is further than normal, where there is low access according to GP patient surveys or where there is a low number of dentists per patients. This is exactly set up to try to make sure that we are going into those areas where there is the biggest backlog. Turning up in those locations and allowing people to queue up and receive a service on that day allows access very quickly to the people who really need it. At the same time, when they are calling up because they might need dental services, we can tell them, “A mobile van will be in your areas in two weeks; we can book you an appointment now”. That is designed to really hit those backlog areas. I suspect—this is just me speculating—that such will be the success of these that this will a model that we will look to roll out more widely in future.

[Lord Young of Norwood Green (Lab)]

My Lords—