National Health Service: 75th Anniversary

Lord Markham Excerpts

Thursday 30th November 2023 Lords Chamber

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

I would like to start by giving our side’s condolences to the family of Alistair Darling. I echo the points on him made by the noble Baroness, Lady Merron. The noble Lord, Lord Brooke, talked about the cross-party working. Alistair Darling was one of those people who, while clearly a Labour politician, approached things in a very objective, cross-party manner. I know he will be missed by all of us.

I thank the noble Lord, Lord Hunt, for tabling this debate, which has been fascinating. It started off with a very informed and fascinating history of the NHS from my noble friend Lord Lexden, which enshrined the point that the noble Lord, Lord Allan, made: it has given us all that wonderful freedom to go to bed at night and feel secure, and to make life choices about where we work and who we live with without that being a worry. I agree with the basic premise that that is the duty of any Government.

I am also kind of—I am not quite finding the right words to say, but I was really marked by the point that the noble Lords, Lord Hunt and Lord Brooke, and the noble Baroness, Lady Pitkeathley, were at the 50th anniversary and took part in these conversations. That is quite humbling, particularly since I found out, strangely enough, that I am currently the longest-serving Health Minister. I am not sure that I will make it to the 100th anniversary, but I will take the advice of the noble Lord, Lord Prentis, by trying not to walk in the middle of the road and get hit. If I do make the 100th, I will definitely follow the idea from the noble Lord, Lord Dubs, of having a party.

I welcome the debate. While I will try to answer the points raised, given the 75th anniversary, and as others have mentioned, it is important that we try to make this forward-looking and look at the innovation agenda, which the noble Lord, Lord Hunt, and the noble Baroness, Lady Taylor, mentioned.

I will also address squarely and up front the funding point, which was mentioned by the noble Baroness, Lady Crawley, and others. Rather than only putting a nickel into this, we are putting in 11% of GDP—by far the highest amount in history. Tony Blair has been mentioned a lot. I well remember the Wanless review in the early 2000s, which talked about increasing the spend to about 8%—my memory might not be quite right, but it was about 8% of GDP. I do not think that anyone would say today that 11% does not absolutely show our commitment.

It is comparable to all other European countries. In fact, there is only one country in the world which has a significantly higher spend: America. I want to put that record level of investment on the record. As many have mentioned, it is of course important that we allocate that and use those resources as well as possible. I was very struck by the points that the noble Baroness, Lady Tyler, made about the productivity conundrum, so to speak, and those that the noble Lord, Lord Drayson, made on the technology agenda and innovation. I hope to address some of those points a bit later.

I put all this into the context of our knowing today that a digitally mature trust will be 10% more efficient. We have done quite a bit of work on this; it will be 10% more efficient than other trusts in its output and efficiency. Since a few people mentioned the new hospitals plan, I should say that we know that a new hospital where you unite the best in technology with the best in physical real estate will be 20% more efficient in its output. That is not just in productivity; more importantly, probably, we are also seeing a 20% reduction in the length of stays. The one statistic that has impressed me the most, as I have gone around in the year or so that I have been in this job, is that for every week a patient spends in hospital they lose another 10% of their body mass if they are elderly, so their ability to go home—back to the normal environment—degrades day by day.

We have been talking about what we are trying to do with the technology agenda and the new hospitals programme, but we are all here because we care about patient care. That is vital. We all want people to get back into their home environment sooner. We all know that the problems often come when you are locked in for too long. Then you need a social care space and can get into the downward spiral that we all know about.

As someone actively involved in the new hospitals programme, I assure everyone that there are action steps happening on all 40 of those new hospitals. They are all very real. I will happily talk to anyone about any of them if they should wish it, and show them my photos from visits to many of them as well.

The noble Baroness, Lady Donaghy, made a very good point: often, it is the short cycles which are hard. One thing that has not been spoken about very much, but was very much part of our new hospitals plan and the announcement in May, was our moving to five-year capital cycles. That will be really important for that long-term planning; work is going on as we speak around having 25-year to 30-year capital cycles.

I am trying to address the points raised. The noble Baroness, Lady Merron, understandably mentioned the waiting lists, as others did. Obviously, that is an area of concern but we have made good progress in the area of two years and are making good progress in the area of 78 weeks. We are focusing on those areas where there is the most impact. Undoubtedly, industrial action has impacted this, which is why I think we are all pleased that we now have a likely deal with the consultants. I am hopeful that it will extend to the junior doctors as well, but we have been working hard on that. We are trying to get on top of it: in terms of supply, there are the 130 CDCs with their 5 million tests. There is also the use of technology, such as patient choice with the app and the FDP, and we will see big improvements in what that does.

Through all this, we have been talking about the 13 years in which Conservatives have been in charge of the NHS in England. Of course, there have been 25 years that one party has been in control in Wales. I noticed that no mention has been made of Wales. While none of us is happy with the waiting lists, I know for sure that they are a lot better in England than in Wales.

I turn to the 62-day backlog for cancer. We all know that time is of the essence in cancer. We are seeing a 27% reduction in that backlog since 2020 and a record level of referrals; we are treating 12,000 people per day. We are starting to hit the 75% target of diagnosing people within 28 days. To put this into context, we are treating 32% more people for cancer than we were prior to the pandemic. We know that fast diagnosis is key.

One of the key differences in inequalities in life expectancy, as raised by the right reverend Prelate the Bishop of London, is lung cancer. Of the nine-year disparity, one year is caused by lung cancer. That is why we have things such as mobile screening, which we take on the road to areas where lung cancer is most prevalent—for example, in some of the mining communities. Rather than the majority of people with lung cancer not being found until stage 4, when it is too late, in the areas where they have been doing this we are finding the majority of people in stage 1 or 2. That is so much better in terms of life chances. That is how we will achieve the target of detecting 75% of cancers by stage 1 or 2 by 2028. To give some context to that, we estimate that it will mean that 55,000 more people will be surviving as a result by then.

There has also been talk about waiting times for ambulances and A&E. While they are too high, I am glad to say that they are improving. We have been making sure that we have learned lessons. We are taking action for this winter by increasing supply, with 800 new ambulances, 5,000 more beds to increase capacity and the 10,000 virtual ward beds we will have in place. We are using technology, which I will come to later, to make sure that they are being most effectively used. We are making sure the hospitals are digitised. We have features such as those I saw in Maidstone, such as flight control, where you allow the clinicians to manage the flow of patients right the way through.

Key to all this and to the length of stay is discharge and the adult social care end. Quite rightly, as the noble Lord, Lord Prentis, said, the flow is important. It is vital not only on the social care side, but for the whole hospital and the UEC—urgent elective care—waiting lists. I have seen at first hand the impact of step-down areas. Patients can be put there early on, and everything is organised around that. I have seen the improvements that makes to the flow.

We are trying to learn the lessons of last year by getting the money and commitments out early. That is why we are making a commitment of £600 million extra spend. We told the local authorities and systems that in the summer, so they could plan now rather than hearing about it too late and not being able to impact it then. That is all part of an increase of up to £8.1 billion over the next two years—a 20% increase. Staff are at the centre of that, as mentioned by the noble Baroness, Lady Pitkeathley. It has been a difficult area, but we are now up in terms of staff versus last year. I accept that there is still a long way to go. My notes show that we have about a 15,000 increase in staff, but clearly, we need more within that.

Mental health is obviously a key part of this. As the noble Lord, Lord Davies, and others mentioned, now more than ever we are seeing a massive increase in the number of young people with mental health issues—we had a good debate on this the other day. As I have said, I am determined that we understand the reasons underneath that. Covid might be part of it, but there are also long-term reasons, such as social media, that we need to understand. As the noble Lord, Lord Davies, mentioned, we need to make sure we diagnose those early, because that is crucial, particularly for young children. As noble Lords know, I have personal experience of the importance of acting early on this.

On the mental health Bill, we are committed, as mentioned, to do as much as we can without the legislation—hopefully we can explain a lot of that when we have the round table. Although getting it in the manifesto might be above my pay grade, I personally agree to make sure that all my colleagues understand its importance today and in a year’s time or so, if we were to win a general election.

Many noble Lords—the noble Baroness, Lady Tyler, and the noble Lords, Lord Prentis and Lord Hunt, to mention a few—raised the importance of staffing and how everything is underpinned by it. The noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, in particular picked out—and I completely agree with them—that it is not just the clinicians but the managers, the admin and the non-clinical staff who are key to this as well.

I am a bit of a data anorak, and one of the things I did when I first came into my post was to try to understand all the differences in hospital performance, looking at certain areas’ demographics and whether they happened to have more funding through a quirk of the formula. I put in all sorts of variables, but we could only ever explain 50% of it—for the data anoraks, I say: the r² never came out higher than 0.5. The only conclusion that I and others could come to from that was—this is not earth shattering—the management and the leadership. I have had the privilege of visiting a lot of hospitals, and when you walk into one you know early on about the leadership—you can tell it on the tour and through the reaction, less from the leaders and more from the staff. You get a vibe about a place. I totally agree about the importance of that.

I come to the specialist areas. The noble Baroness, Lady Taylor, mentioned optometrists, and, funnily enough, I had this conversation with one the other day, and they mentioned that many of the early, indicating warnings are picked up when they take retina scans. That is why the long-term workforce plan is important, as are the extra training places. But, as the noble Lord, Lord Prentis, said and as I know from my experience with my mother, the other routes, such as apprenticeships, are just as important if we are going to get them there, because you should not need to be a graduate to be a nurse or clinician. As the noble Baroness, Lady Finlay, mentioned, it is vital that it is a rewarding and accommodating profession. Training and development are obviously part of that. I hope to talk more to noble Lords soon about using the estates for a lot more housing, because we know that can be a key recruitment and retention tool. Then there are things such as flexible rotas—hopefully, we will be able to use technology for that.

In terms of talking and working with the staff, I have to say that is something that is early days, but we are seeing the style and the engagement of the Secretary of State already and it is very welcome. Underpinning the long-term workforce plan, which many noble Lords have mentioned, is the move away from hospital treatment and into primary care and prevention. We know that that is the first line, and we are now close to achieving the 50 million increase in appointments—but we know, given the demand, that that is still not enough. That is where the Pharmacy First scheme will make a material difference, in expanding the supply of places where you can get the advice and treatments that you need.

I have seen some great examples of prevention, also mentioned by the noble Baroness, Lady Pitkeathley. Funnily enough, just yesterday I was talking to one of the doctors—I am sure that many of you know him—Sam Everington from east London. He was talking about how he was taking type 2 diabetes treatment totally out of the hospital environment, and the difference that it is making there. I have mentioned before the Redhill frequent flyers, looking at the people who are having the most hospital treatments and how they can get upstream of it all. Screening is important to that, which is exactly the point that the noble Lord, Lord Cashman, was making about the HIV screening programme. That needs to be welcomed—making sure that many more people are seeing that and understanding it.

The noble Baroness, Lady Taylor, talked about an active and healthy lifestyle and its role in social prescribing, which I completely agree with. I know that all noble Lords are on the same page here. The anti-smoking legislation that we are talking about is the biggest single thing that we can do towards that active lifestyle going forward.

I have mentioned it a few times, but I really believe that what we do in terms of technology and the app will be key to this, in terms of people’s access to primary care. People can use the app as their front door, from which they will be guided to the right service—to the 111 service—and then directly make an appointment, be it with a doctor or nurse or with a pharmacy. We have seen already that because people are reminded on the app, the numbers of “do not attend” have gone down by 10%, when people make their appointments digitally in that way. Of course, that means a much more effective use of time. Talking of time, I notice that I am out of it, so I shall quickly finish up. I see massive ability in the app for people to take control of their health and give us that sort of data, so people have the information and trust behind it.

I could have written the speech made by the noble Lord, Lord Drayson, myself—and I quickly acknowledge everything that he said about the problem. He said that we have great examples of innovation and really difficult cases of how to scale that up. I am exaggerating slightly to make a point, but when they have a great example in one place, they say, “Fantastic, it works in X hospital, how can we get it elsewhere?” It is like, “Here’s the telephone directory with 140 trusts and the buyers—good luck”. A lot of what I am trying to do, as the noble Lord, Lord Drayson, mentioned, is to look at how we scale that up, and have a way to buy sensibly from the centre and get that spread out. In the area of digital therapeutics, that is obviously vital.

Given the time, it is probably time for me to sum up, as I say. As ever, I shall write to noble Lords in detail. I have not answered the points that the noble Lord, Lord Cashman, raised about international cosmetic operations, and others. Likewise, I have not addressed the fracture liaison services, and the points made by the noble Baroness, Lady Donaghy, and the noble Lord, Lord Lexden, so I shall make sure that that is properly followed up in writing.

I finish by echoing what the noble Lord, Lord Brooke, was saying, which is to try to take this out of the Punch and Judy and make it as cross-party as possible—

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the Minister understand that I will have no time at all to respond?

[Lord Markham (Con)]

I apologise: I will sit down this moment.

Health Care Services (Provider Selection Regime) Regulations 2023

Lord Markham Excerpts

Monday 27th November 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 19 October be approved.

Relevant documents: 1st Report from the Secondary Legislation Scrutiny Committee

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

My Lords, the Government are committed to giving patients better, more joined-up healthcare services. To do so, we need to ensure that we have the right procurement regime so that the NHS can best allocate resources which meet the needs of patients. These regulations do that. They would establish the provider selection regime on 1 January 2024.

This House knows that the challenges we face as a country are changing, and the NHS is changing to address them—an ageing population, an increase in people with multiple health conditions, and persistent inequalities in health outcomes. We must respond to these challenges. To meet them, we need to provide an enabling and empowering framework that allows the NHS to combine the value of competition with the benefits of collaboration in the interests of patients.

In March last year, the Health and Care Act 2022 was passed. It sought to bring together NHS organisations and partners to tackle issues in our health and care system. This instrument builds on that progress. In 2019, engagement across the NHS identified that the use of the current rules on procurement presented a bureaucratic barrier to bringing NHS organisations and partners together. NHS colleagues wanted a framework that allowed them to use the right approach for different scenarios; a framework that included competition without defaulting to it and which supported the increased need for the alignment of services, including those provided by non-statutory organisations in the voluntary sector, to join up care for patients. The Government developed the legislative framework in the light of these requests. Furthermore, in June 2019, the Health and Social Care Committee also agreed that this was the right approach to

“ease the burden procurement rules have placed on the NHS, ensuring commissioners have discretion over when to conduct a procurement process”.

As our colleagues in the NHS and across the health system have emphasised, we must seek to balance a system-driven approach to planning services while recognising the importance of provider diversity for service innovation and value. That is also why my officials have worked closely with a broad range of colleagues and organisations across the system, including both commissioners and providers of healthcare services, to prepare the instrument before you today. This work has included extensive consultation. In 2021, NHS England published a consultation on the detail of the policy behind this instrument. Of 420 responses received from NHS representative bodies and individuals, 70% of respondents agreed or strongly agreed with the detailed proposals set out in that consultation. In 2022, the department published a further consultation to help inform the detail of our regulations.

Finally, we have not neglected to do the analysis of impacts associated with this regime change. Our voluntary impact assessment shows that, in the most likely scenarios, introducing this instrument will deliver savings to the NHS by reducing bureaucracy. Although it is difficult to provide a precise figure ahead of monitoring this regime, those noble Lords who have read the assessment will be aware that our central estimate suggests that savings of up to £230 million are possible. While I am on this subject, I was very glad to see that the Secondary Legislation Scrutiny Committee welcomed our consultation and voluntary impact assessment in its report on this instrument.

To summarise, the instrument reflects engagement and careful balancing to present commissioners with the right options for procurement so that they can find the most collaborative, value-add solutions that will work for patients. Engagement with providers has told us that both more collaborative approaches to healthcare—where those with services to offer can get around the table, help break down barriers and promote provider diversity—and putting a contract out to tender are valuable and need to be in the commissioner’s toolkit. That is why this instrument reaffirms the role of competition in arranging services by providing explicitly for those processes, while also providing some flexibility to commissioners to adopt a more direct approach.

As many noble Lords will know, getting the balance of a framework right to promote the best culture and behaviour on the ground is tricky. I am glad, therefore, that we have worked so closely with providers and commissioners to find and test that balance. One result of that engagement was to agree to establish an independently chaired panel which will act as a non-statutory advisory body for contested decisions made under this regime. We intend that this will help commissioners think carefully about the approach that they take to procurement, and its justifications.

Furthermore, we must ensure that the system understands these rules so that it can have the best chance of promoting the right behaviour on the ground. That is why NHS England is leading an extensive programme of familiarisation with those draft regulations and the draft statutory guidance, which is available online. Of course, legislation and guidance are only part of the story of how the new legislation will influence outcomes. That is why the department is committed to monitoring and evaluating this new regime from its implementation.

For these reasons, I am content to move these draft regulations, which, subject to the approval of the House, would bring the provider selection regime into force. I beg to move.

[Lord Stevens of Birmingham (CB)]

My Lords, I welcome these regulations. They get the NHS off the hook from inappropriate compulsory competitive tendering of clinical services but also avoid throwing the baby out with the bathwater. Open procurement will remain an option where it is in patients’ and taxpayers’ interests.

In my previous experience, there have been several problems with the way in which the accretion of UK procurement rules and the EU procurement regime have tied the hands of the NHS. We have often had to go through the motions of competitive clinical procurements for services that would quite obviously be provided only in one place and by one part of the NHS—for example, billions of pounds-worth of specialised cardiac and cancer services for which it was blindingly obvious that the Germans and Italians would not turn up and try to replace Leeds General Infirmary or St Thomas’ Hospital. These regulations make these processes honest, in that when we embark on procurements, it will be for a good reason.

A related problem is that the legacy procurement rules have tended to lead to too much service fragmentation. We have seen examples where community nursing services have had to be tendered out but core general practice services have not, so getting the community nurses and GP practices working together has been much harder. One of the fragmenting consequences of the 2012 Act was that a lot of what had previously been NHS services became local authority-procured, and so sexual health services and health visitors were operating on a different procurement process through local authorities rather than through the local NHS. The Health and Care Act 2022 and these regulations overcome that problem. The NHS will still be subject to transparent and fair procurement, but it will now be much more flexible and proportionate.

The regulations are quite complex. Those noble Lords who have read through the materials may agree that it is fair to say that they will not command the attention of the pubs and clubs of Barnsley or Barnstaple, but they will make a huge difference to the way in which care is delivered right across the country.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I bring more cheer to the Minister by adding our support for these regulations—I thank him for bringing them before your Lordships’ House today—because the provision of this statutory instrument is to define and give relevant authorities greater flexibility to procure healthcare services. This will, I hope—I know that other noble Lords also hope this—benefit patients and service efficiency by better integrating services. Like the Minister, I am pleased to note that the policy behind these regulations has been informed by both a voluntary impact assessment and an extensive consultation that received 70% support from 420 respondents; this is welcome news.

It is the view of the Opposition that the NHS should be the preferred provider of commissioned healthcare services, not least because it embodies not just a public service ethos but efficiency, resilience and democratic accountability. It is also the case, particularly in the short term, that, in order to treat NHS patients and bring waiting lists down, the independent sector has an important role to play where a service cannot be provided by a public body because the capability or capacity just is not there.

Your Lordships’ House may recall that, when the Health and Social Care Act2012, which my noble friend Lord Hunt described as “wretched” on several occasions, went through its various stages in Parliament, these Benches argued that relevant authorities should have the appropriate flexibility to award contracts, which was something for which the Act did not provide. As my noble friend identified, the competitive tendering requirements of that Act did not serve the NHS, patients or the public at all well. Therefore, where we are today with the provider selection regime, which does allow for this, is as long overdue as it is welcome, as is seeing that good sense, flexibility and efficiency will now apply.

During the passage of the Health and Care Act 2022, these Benches also argued for the legislative provision to be made as outlined in these regulations. Although the Government did not take that on at that time, I am glad that the benefit of hindsight has prevailed and that the Opposition’s view, which was set out during the course of that debate, has now been set out in these regulations.

As the noble Lord, Lord Stevens, illustrated so well, these regulations recognise that it would not be an efficient use of resources in certain circumstances for relevant authorities to use competitive tendering, but that there continues and needs to be a procurement process that relevant authorities can and should use. As the Minister will be aware, concerns have continually been raised about the impact of the current procurement framework, which often places additional burdens on community and mental health providers in particular, where services have been much more likely to be subject to expensive and disruptive competitive tendering processes. I therefore welcome the alignment of the PSR’s aim with the spirit of collaboration within health and care systems, as well as the offer to commissioners and providers of a clear and transparent process by which procurement decisions can be made.

The PSR will offer a consistent model for both NHS and local government bodies to follow with regard to health services, and I hope that this will support local relationships and decision-making, as well as integrated care. However, it is important that national bodies engage with all organisations that will be subject to the new regime in an effort to smooth the transition to a new procurement framework.

I ask the Minister for more detail on how NHS England and the department will review the application of the PSR over the course of the next year to ensure that real-time feedback on the operation of the regime can be collected, as well as evaluated and, importantly, acted on as swiftly as possible. I make this point as it will be crucial to capture feedback on whether any difficulties arise for commissioning bodies in selecting which procurement process is the most appropriate across various different scenarios and circumstances, and whether any challenges arise for providers in the application of their approach.

My noble friend Lord Hunt emphasised the need for support, training and guidance—something that other noble Lords also emphasised. This is a point that the Minister would be well advised, as I am sure he is, to pay absolute attention to, so that we support those who work in NHS procurement and the NHS supply chain, not least because the combination of these regulations, other regulations and other Acts is something of a complex field. We should support and guide those who make the interpretation and the application, and, if necessary, adjust in real time any of that training, support and guidance. More information from the Minister about how this will be done will be extremely welcome.

I am aware that NHS Providers has worked with membership bodies for providers in the independent and voluntary sectors, the department and NHS England to make the case for the new regime to include a challenge function for decisions made by commissioning bodies to be reviewed and scrutinised if appropriate. Although the PSR panel does not have legally binding powers, does the Minister consider it appropriate to give providers some opportunity to challenge the application of the regime and raise legitimate concerns where appropriate?

As I said at the outset, I am glad to provide our support to these regulations. I hope that we can look forward to great improvements because of them in the years ahead.

[Lord Markham (Con)]

I thank noble Lords and welcome the support offered. I appreciate their understanding on my lack of comments on 2012 and all that. I also appreciate having the vast experience of the noble Lord, Lord Stevens, and wonder whether he could be here so that I can phone a friend on some of the questions we have, because I fear he may be far better qualified to answer a lot of them. I will take home the “Think like a patient, act like a taxpayer” mantra.

I think we all agree that, although this is welcome, it is complex. We are trying to set out an approach, knowing that really we want sensible people to act sensibly around the table and to co-operate with each other. We all know that it is very hard to put a rules-based system around that. As all noble Lords have mentioned, the training of staff in that is vital. I have some personal experience, as I know the noble Lord, Lord Hunt, does, of many of the people in this space, and I have to say that they are very good people. My experience is obviously much more on the national level, but clearly it needs to be taken down to the local level as well.

I believe we are publishing the strategic framework for NHS commercial tomorrow. That tries to set out the importance of commercial capability, and the investment and critical skills required. It will be accompanied by a programme that sets out what upskilling needs to be done and a programme, with support from the Crown Commercial Service, that I hope we can effectively use to upskill in the way that we all believe is necessary.

To answer the point by the noble Baroness, Lady Merron, whenever you are trying to put in place a value-based system, for want of a better word, in terms of culture, you have to have those guard-rails around making sure that there are appeals processes and lessons learned. My understanding of this independent panel is that companies or providers that feel they have been wrongly excluded will have the opportunity to appeal directly. I have challenged them quite strongly on that, given my experience in this space, and asked how much a company will really want to be awkward. Often you know that if you are being awkward and challenging, that might make life more difficult for you in future, so there are some difficulties involved there. A lot of companies often ask whether that challenge is really worth it. Getting that right, with the panel, is vital, so that it is welcoming and open and that, as the noble Baroness, Lady Merron, says, there is that “lessons learned” kind of constant review. At probably the year stage, we will look to understand how it has gone so far and what we can learn from it.

Having been involved in quite a few start-ups, I am also very aware of the point the noble Lord, Lord Hunt, made. Time really is money in these things; a regulatory process that is opaque or cumbersome is not very helpful. I acknowledge some of the issues the MHRA has had. That is what the £10 million investment behind it is trying to address. I know it is very much looking to act on this.

A very good example of that is what the MHRA is doing in the point-of-care space. One Brexit advantage that I have seen is the ability very quickly to set rules around point-of-care medicines, particularly around when you take a biopsy and then provide an individual patient with treatment according to that for a certain cancer. Clearly, if you follow the strict rules, you would have to be regulating that every single time, and that just would not work. The MHRA has introduced a sensible framework that tries to adopt an umbrella-type approach. I know that the MHRA understands the possibilities in this space and really wants to use this as an opportunity to show that we can be fleet of foot and leaders in that space from it all.

On the point raised about trusts sometimes having a conflict and the example provided by Specsavers, that is what the panels are supposed to be there for. It is important—I will check this out—that, in the rules, we are guiding the 42 ICBs on how they should manage some of those conflict situations and when they should put people aside. We have all managed it in our corporate and public lives, and there are rules about it. Just as we put the emphasis on noble Lords to declare interests and so on, clearly we must make sure that there are similar rules for the trust CEOs, but it is a point well made that we need to pick up. I look forward to going into some of these issues much more when we have the value-based procurement meeting shortly.

On how we can make the analysis available, I have seen a tool that the NHS has recently introduced which is very good in terms of being able to drill down straightaway and provide that analysis. That is a good base point. I will find out some more about how that needs to be tweaked, but there is a basic premise about making that information available—that is a sensible move. On the point made by the noble Baroness, Lady Merron, it should be used to arm providers with the ability to challenge the panels.

I welcome the input. Such is the knowledge base around this, I am happy to suggest that, in nine months or one year’s time, we have that round table where I will appreciate some of the skills here. We can ask how it has gone down so far. We can do that through a debate, but it is probably better done through a round table, so I would like to propose that so we can learn the lessons.

In summary, I welcome the points made and that noble Lords believe that this is the right direction, although it needs work along the way to make sure it stays going in the right direction and does what we hope it does. With that, I commend the draft regulations to the House.

Motion agreed.

Health Protection (Coronavirus, Testing Requirements and Standards) (England) (Amendment and Transitional Provision) Regulations 2023

Lord Markham Excerpts

Monday 27th November 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 19 September be approved.

Relevant document: 1st Report from Secondary Legislation Scrutiny Committee

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

My Lords, I draw the House’s attention to my declaration of interest in the company that I founded, which was accredited under these rules. The fact that it is accredited means I have some experience, which always helps in an area. It is not affected by these regulations, but I was keen to state that for the record.

The 2023 regulations update the legislation introduced in 2020 to impose requirements on private providers of Covid-19 diagnostic testing. Once they are implemented, private providers will need to be accredited by a signatory of the International Laboratory Accreditation Cooperation mutual recognition arrangement before they can supply testing. These measures replace the current three-stage UK Accreditation Service process with a simplified and streamlined one. They also remove requirements that are no longer necessary due to legislative developments that have taken place since 2020. The changes will empower consumers to choose a private testing service with confidence, continuing to improve safety and quality. During the Covid-19 pandemic, the Health Protection (Coronavirus, Testing Requirements and Standards) (England) Regulations 2020 focused on enabling providers who met appropriate quality standards to be able to rapidly enter the private testing market. This struck the appropriate balance at the time between protecting public health and growing the market quickly.

I am pleased that the worst of the pandemic is behind us, so the urgent need to grow the Covid-19 testing market quickly no longer applies. The department has therefore reviewed the 2020 regulations and proposes that all private providers must be fully accredited before providing testing services. This amendment will bring in requirements and standards that help to strengthen consistency, safety and high-quality Covid testing services.

I am pleased to be debating the statutory instrument that is necessary to implement our proposed updates to the existing legislation. The 2020 regulations introduced a three-stage accreditation process for organisations providing Covid testing commercially. The three-stage accreditation process requires providers to satisfy the UK Accreditation Service that they meet the relevant ISO standards within a set timeframe. Stage 1 requires the private provider to make an application to UKAS for accreditation and make a declaration to DHSC that they meet and will continue to meet certain minimum standards. Stage 2 requires the applicant to demonstrate, within four weeks of applying for accreditation, that they meet requirements published by UKAS. From January until June 2021, stage 3 required providers to complete their application within four months.

We wanted to ensure that a greater number of high-quality applicants were given sufficient opportunity to complete the process and reduce resourcing constraints on UKAS while maintaining quality control. In June 2021, we passed legislation to update stage 3. Applicants were now required to achieve a “positive recommendation” from UKAS within four months of completing stage 2. Provided they received this, they then had a further two months to achieve accreditation. Providers who fail to meet any of these deadlines, or fail to satisfy UKAS that they meet the relevant standards within this timetable, have to stop supplying testing. The purpose of this approach was to ensure that enough providers were able to enter the market soon enough to meet the public demand for testing. It ensured that we were not as a country left with insufficient testing capacity while still putting providers through an appropriate process.

Now I move to the substance of the regulations. The 2023 regulations implement several policies coming into force from 1 January 2024. First, private providers—diagnostic laboratories, sample collection and point-of-care testing—must be accredited against the appropriate ISO standard by a signatory to the International Laboratory Accreditation Cooperation mutual recognition arrangement before they can start supplying their service. This replaces the three-stage accreditation process. Since setting up this process, the Medical Devices Regulations 2002 were updated to prescribe a specific process for the validation of Covid-19 test devices. We therefore no longer need test validation measures in these regulations as well, so we are removing those. Secondly, the amendments reflect the publication of the updated ISO Standards 15189:2022. The amendments are forward-looking and do not affect private providers who applied under the previous ISO standards—ISO/IEC 17025:2017—before this instrument came into force. Lastly, this instrument removes the requirements to make a declaration to DHSC at the start of the application process and shifts the legal responsibilities for the clinical service to the private providers providing the clinical service, rather than the customer-facing part of the testing service.

The amendments will hold providers to high standards, by requiring them to be accredited before they can join the market. This will give confidence to individuals choosing Covid-19 testing services. The amendments also remove the additional requirements and administrative steps that were necessary in the early stages of the pandemic. Those who have already achieved accreditation will be unaffected by the change; that is, they will not need to reapply for accreditation under the new regulations. All private providers will be required, as normal, to transition to the new ISO standard by 6 December 2025 at the latest.

The amendments allow private providers who are accredited by a signatory of the International Laboratory Accreditation Cooperation mutual recognition arrangement to enter the market. The UK Accreditation Service is one of 90 accreditation bodies that have signed the arrangement. It enhances the acceptance of products and services across national borders. By accepting accreditation from these signatories, we help to remove barriers to trade such as the retesting or inspection of products.

Private providers must be accredited to the relevant ISO standards for clinical testing services. These standards were reviewed and updated in 2022 and transition proceedings have begun: the old standards will be revoked in 2025. The existing 2020 regulations do not reflect the updated ISO standard. So, if we did not make these amendments, providers who transition to the new ISO standards—as they are required to do—would not under our own rules be able to provide testing services. This is a clear lacuna that we need to address.

I am happy to be bringing forward this legislation today. These regulations will reduce bureaucracy whilst still delivering rigorous accreditation requirements, important for public health. I commend these regulations to the House.

[Lord Allan of Hallam (LD)]

My Lords, it is good to be able to debate a piece of legislation that is quite technical but still quite important. The regulations themselves are entirely sensible as tidying-up legislation after the coronavirus pandemic, but they trigger a few points that are worth putting on the record and seeking a response from the Minister on.

The first is just to note that it is good that we are following the international standards on this. I am sure all noble Lords experienced that period during the pandemic when there was confusion around which countries accepted whose tests and it became blindingly obvious that we needed international recognition. It is pleasing that we are following a standard that, as the Minister said, 90 bodies are now signed up to. It is good to have the confidence that when we pay for tests here in the United Kingdom, there is a good chance that they will have that international recognition. Does the Minister have a sense of whether other countries are following a similar path, where they implemented a special regime during the pandemic that they are now transitioning into a normal regime, just as we are doing today? Is the United Kingdom in step with other countries or are we ahead of or behind them? It would be interesting to know that; I assume the department has done some work around it.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I thank the Minister for introducing these regulations, to which we too are pleased to give our support. We have clearly moved on from where we were in 2020, when the original Covid regulations for testing service providers were agreed and “lateral flow device” was not a household term. Looking back to 2020, these Benches supported the regulations then because we recognised the urgent need to enable new service providers to meet the demand for testing services. We also noted that that had to be balanced with the importance of public health protections and regulations to build safeguards into the system and, so importantly, to give people the confidence that services could be trusted to keep them safe.

As the Minister outlined, the regulations apply to clinical Covid-19 testing services such as diagnostic laboratories or those that carry out point-of-care testing. The regulations will mean that these services are no longer subject to the additional requirements introduced early in the pandemic and, as such, reflect an update to meet us where we are now. They also reflect the update to the international standards since last year.

It is important to acknowledge what the regulations will not change. As the Minister said, providers will still be required to seek accreditation against the appropriate ISO standard. Test devices will still need to meet the requirements set out in the Medical Devices Regulations 2002, just as they did before the pandemic. In my view, this strikes the right balance. As the UK Health Security Agency has noted, accreditation was not mandatory prior to the pandemic but NHS England and Public Health England endorsed all medical laboratories being accredited with the United Kingdom Accreditation Service. The process for laboratories to achieve accredited status took anywhere between six and 12 months. Given the changes we are discussing, how long does the Minister expect the accreditation process to take now?

As it is so important that we learn lessons from the past and apply them to the future, I have a few questions on this generality to the Minister. What confidence does he have that new providers will be able to meet the various deadlines to meet the new ISO requirements? How will the regulations we are discussing be enforced? Does the United Kingdom Accreditation Service have the resources it needs for enforcement? How many fines have been issued to non-compliant providers since the 2020 regulations came into force?

I am sure that the Minister will agree that it pays to think about the state of the market now. How many UKHSA-accredited providers were there at the pandemic’s peak, and how many are there now? As some companies wind down their Covid-19 testing capacities because of reduced demand, what assessment has the department made of how the market is changing and how such diagnostic capabilities could be deployed to meet other ends?

In concluding, I take the opportunity to ask the Minister about one of the biggest scandals among private providers during the pandemic: that relating to the company Immensa. Local public health experts were baffled as to why an NHS Test and Trace contract had been given to the company while high-quality diagnostic services, such as those at the University of Birmingham, were being wound down. Immensa was awarded more than £100 million in a contract to carry out Covid testing in September 2021, without going through the normal tendering process. It was subsequently found to have been one of 50 firms that had been put into the priority lane for test and trace contracts worth billions. It was also found that PCR test results from Immensa’s Wolverhampton lab had misreported around 40,000 positive results as negative between September and October 2021, leading to significant additional infections at a critical time and an estimated 20 extra deaths.

I have specific questions on this issue and I would be grateful if the Minister could respond to me, if not now then in writing. Neither Immensa Health Clinic Ltd nor its related company Dante Labs Ltd was accredited by UKAS at the time of the scandal, despite the regulations that we are amending today. Immensa was a new entrant to the market and was supposed to go through the three-stage process, yet it was awarded vast sums of public money to rapidly expand the capacity of NHS Test and Trace in the autumn of 2021. One would expect high standards from a private provider in exchange, but that did not appear to be the case. An investigation by UKHSA found that, despite requirements for accreditation being written into the contract, the department and NHS Test and Trace decided that they would not apply. As such, Immensa was not accredited at the time of the false negatives scandal, even though the department claimed otherwise. Is the Minister able to confirm what actually happened in this case?

The findings of the UKHSA report risk undermining the rest of the system, if providers could not be encouraged to circumvent the correct process and there were no consequences as a result. Why were the department and NHS Test and Trace so determined that special measures should be put in place for this provider? I am not aware of any consequences for any officials or Ministers responsible for the shocking findings of the UKHSA investigation. Perhaps the Minister can confirm whether this was the case and, if so, why? Given the tens of millions of pounds of public money involved in the scandal and the dire consequences of the mistakes, can the Minister advise your Lordships’ House what efforts the Government have made to get the money back?

In conclusion, these Benches support the statutory instrument. We very much agree that now is absolutely the appropriate time to review the exceptional measures that were taken early in the pandemic while ensuring that appropriate regulation and confidence remains in place.

[Lord Markham (Con)]

I thank noble Lords for their responses and generally for the support they offer for what we are trying to do here. As I say, for a lot of my answers I will draw from personal experience. The whole of that time was extraordinary, as we know. To my knowledge, it was the first time where you had a situation in which masses of people could be tested for something. However, it needed laboratory-based testing, and suddenly the amount of volume needed for the general public was completely out of anyone’s imagination as regards the volume of the market. I remember trying to understand the rules at the time, as somebody who might set up such a company to do this, and I quickly found out that there were no rules, in that nobody had ever quite envisaged such a situation and the only rule that existed was around getting an ISO process, which typically took 12 to 18 months.

What the Government did there—again, I am speaking from the other side of the fence—was to create a good process of trying to funnel people, starting off with quite easy ways to get you through the funnel because they wanted to expand it as much as possible, but then effectively making it progressively harder while still trying to keep the good suppliers in the mix. By and large they did a decent job on that. I saw some providers completely gaming the system, in that they kept ticking the boxes as long as they were allowed to tick them and then as soon as it came to a hard task, for want of a better word, they folded up shop. There was definitely some of that, and the funnel sorted out some of the wheat from the chaff along the way, but at the same time I will not pretend it was a perfect process.

I say all this from sitting on the other side of the fence and having to jump through necessary hoops, but I actually think it was a decent process at the end of the day. As ever, I will come back in writing on all this, but my understanding was that it was a fairly similar process to that followed by other countries, and they are now going through a fairly similar process to regularise this.

As I said, I absolutely looked at the difference in outcomes versus existing regimes, and I am under no doubt that, if we kept the rules of the existing regimes, the supply would not have expanded in the way required at the time. On what the Government were trying to achieve, the evidence shows that they achieved a decent outcome, where, by and large, the quality outcomes were pretty good, although not perfect—the noble Baroness brought up a good example of where it definitely was not perfect. By and large, they did a decent job on that.

Learning Disabilities and Autism: Solitary Confinement in Hospital

Lord Markham Excerpts

Thursday 23rd November 2023 Lords Chamber

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

I add my thanks to the noble Baroness, Lady Hollins, and other noble Lords for their moving, personal and passionate—especially in the case of the noble Lord, Lord Touhig—contributions, from which I have learned a lot. When the timetable came out and I saw two mental health debates together, I must admit to thinking, “That’s going to be a long day. How wise is it to timetable them together?” Actually, having the debates back to back has worked really well, and there has been a real synergy of subjects. It worked and it has added to my education.

I understand the point raised by the noble Baronesses, Lady Wheeler and Lady Watkins, and others, around the delay to reforming the Mental Health Act and their disappointment. I would like to respond to some of those points with things that I hope we can do. This will very much be a feature of the follow-up round table. To answer the question from the noble Baroness, Lady Wheeler, on how we design that, to be honest, it is up to us, and I will happily chat to her afterwards about how we want to use those forums. I definitely have a commitment from Minister Caulfield to part of that, so we can go into the detail afterwards.

I echo the point that the noble Lord, Lord Addington, made on prevention. This struck a chord with me, as I learned early in my personal experience that a normal response often gets a negative reaction. If something happens, people generally respond in a certain way, but with autism we learn that we sometimes have to completely rewire the way that we respond. We know that what we think of as a normal response can have adverse consequences.

I will resist the temptation to trot out the statistics, as the noble Lord, Lord Addington, said, but I will say that there is a recognition from the increase in the numbers of people trained in schools that it is vitally necessary. There has been a lot of growth in it, but I accept that there needs to be more and that it needs to be across the board, as the noble Lord said. A million people have taken the Oliver McGowan training, but there are next steps in that. It needs to be across health and other settings, such as education, as I mentioned, and the police.

We spoke about early support hubs in another debate, and there is a vital role for communities there. I was asked a Question last week about black and ethnic minority people being far more likely to find themselves in segregation or these sorts of circumstances. As it was explained to me, a lot of that is because they do not feel that the early support hubs are suitable for them. For whatever reason, they are not going to them. We need to do a lot of work, and in the community as well, to break down that resistance and some of the reasons that they do not go there, because those early support hubs are a key part of any prevention.

I will directly address the points about how, where there is that circumstance of solitary treatment, we can try to minimise it and really respond. The first thing that came to me, from the noble Baroness, Lady Hollins, and others, is that we really need to increase the barriers to entry, for want of a better phrase, and make them as high as possible, so that it really is a last resort. I personally like the idea of the Secretary of State’s approval. There are some logistical issues there, such as if it is out of hours or whatever. The suggestion was made of the Secretary of State’s approval being needed if it is beyond 48 hours, at which point I can see practically and logistically that you could make that work a bit better. Having the Secretary of State’s approval before someone goes in could be hard logistically, but having it beyond 48 hours allows for that planning.

I was toing and froing with the team during the debate, and I think we can have a productive conversation around it, particularly on the point that the noble Lord, Lord Allan, made. I have had some personal experience of this: in the department, I sign off all consultancy agreements on the use of consultants, contractors and everything else. I normally sign nearly all of them off, but the main point is that a lot of them probably never come to my door, because the DGs and managers who are putting them up know that they must be absolutely watertight in their cases to do it. I believe that this would be a similar mechanism of prevention, so I will definitely take it away.

On the reviews and the CQC, we want to have it all up and running next year, obviously as early in the year as possible. I will come back to be more specific on that timing. The funding, as mentioned, is for two years, but I like the suggestion that we all know that, as long as solitary confinement is happening, we will need something like this. First, we need to increase the barriers to entry but, secondly, where solitary confinement is needed, we need to increase the review process. That is the role of the CQC and the ICETRs, but it is also about the use of the data, as suggested. I do not know how much the FDP can be used in this, but I saw an example this morning of it being used quite well in the discharge space, where it is linking in with social care and the local authorities. There are some good grounds there, and I will definitely pose the question.

There is acceptance that people sometimes need to be treated in solitary confinement. If they do, it is all about reviewing and accountability, as the noble Baroness, Lady Hollins, said. On that, as my noble friend Lady Browning and the noble Baroness, Lady Wheeler, said, it is about making sure that the CQC is notified within 48 hours, so that it is on the case and reviewing it. That is another vital cog in accountability.

I was told that they plan to enter into a consultation on that as quickly as possible. I was told that they thought the timing for that was January 2025. Quite honestly, I have gone back and said two things: do we really need to consult and, if we do, does it really need to be as long as January 2025? Again, I will come back on both of those things and maybe these are some of the things we can talk some more about in the round table.

Thirdly, if we are in the circumstance whereby solitary confinement is deemed to be the right treatment method, obviously we come on to quality, and the point was made there about making sure that the quality is right, in that circumstance. Obviously, the CQC has a role in that and the Health Services Safety Investigations Body, or HSSIB, clearly has a vital role to play in all of that. We do understand that there was a feeling that the Government were not acting quickly enough in our response to the paper written by the noble Baroness, Lady Hollins, so, again, we will come back further on that.

I hope that reassures noble Lords to some extent that there are things that we can do, and plan to do, in the meantime—absent the mental health Bill—and, again, I want to use the round table to talk about that, explore it and make sure it is as actionable as possible. As I said, as ever, I will write to make sure that I have picked up all the points made in detail. I would like to end by again thanking the noble Baroness, Lady Hollins, and all other noble Lords for their contributions to what I found was another very good debate.

Mental Health: Children and Young People

Lord Markham Excerpts

Thursday 23rd November 2023 Lords Chamber

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

I thank all noble Lords for their contributions to this debate. Before replying, I add my congratulations to the noble and learned Baroness, Lady Hale, on her maiden speech. I am sorry that no one was able to add to the Yorkshire hat trick and, speaking as a Brighton boy, I cannot get much further away than that. I found the reasons for the delay fascinating; it was an education for me, as I did not quite realise her involvement in so many things. For me, it was well worth the wait, and it is a personal honour to be able to reply after such a distinguished and accomplished speaker. I invite her, along with all other speakers, to join—as the noble Baroness, Lady Wheeler, mentioned—the round table that I have organised with the Minister, Maria Caulfield, where we can follow up some of the themes brought out today in more detail. I would be delighted if the noble and learned Baroness were able to add her experience to that round table.

I also thank the noble Earl, Lord Russell, for enabling us to have this debate. He has heartfelt and personal reasons for the debate; as many noble Lords will know, I have my own personal experience and reasons. As the noble Lord, Lord Allan, said, it is normal. I had the misfortune of going to a funeral last week of one of my school friends, whose brother had mental health issues. As we were talking on the way down in the car, we were updating each other on all our families, and we realised that every single one of our families had one of their children or someone in the household with mental health issues.

Is the reason for that Covid, as the noble Lord, Lord Laming, mentioned? Is it some of the online reasons, as mentioned by the noble Baroness, Lady Hollins, and the noble Lord, Lord Allan? Is it gambling? I have to say to the right reverend Prelate the Bishop of St Albans that the gambling aspect of it all was something that I had not probably thought through enough, but I found that fascinating as well. Is it the cost of living, as mentioned by the noble Baroness, Lady Tyler? Is it the increase in the number of ghost children—I apologise for using that phrase, but it is the easiest way to sum it up—as mentioned by the noble Lords, Lord Storey and Lord Laming? Is it eating disorders?

I always like these debates to result in substantive action rather than being a talking shop, so that really led me to take away an action point. I was proud to be titled the Minister of Follow-through by the noble Lord, Lord Allan, yesterday, so I will follow that up. I would like to see whether we have done any research, through the NIHR, to really understand what factors and causes are behind what is a massive increase in the number of young people requiring mental health support, as the noble Earl, Lord Russell, says and we all acknowledge. I have seen various figures; the one I was cited was that it had gone from one in nine to one in six. Whichever way you look at it, it is a massive increase. We really need to understand those reasons, because it is often only when you understand the causes that you can look at how to address them. I will do some personal work, but if the research is not there I propose—and I will speak to people about this—that this is something that the NIHR should do, because it is vital that we understand those reasons. As all noble Lords have said, prevention is of course key to this.

Obviously, I hope that many of the reasons are transitory—maybe many were caused by Covid so we are seeing a big jump up now but will see a reduction afterwards. But the reason for needing to understand it is that it goes to the long-term funding we might need. If they are not just transitory reasons, and this is now the new normal, so to speak, then we need to do exactly as the noble Lord, Lord Allan, said, and think about a whole provision of child services in the mental health space, in the same way we do in the physical health space. I think we all agree that we need to do that to a degree regardless, but it is the level of that. That goes again to the points made by the noble Baronesses, Lady Wheeler and Lady Tyler, about the long-term workforce plan and understanding how many mental health staff we need to make sure we are training and equipping. Specifically, while I mention that, I will write to noble Lords on the mental health dashboard and when that is being updated.

I think we are absolutely united on the need for early detection in all this. The noble Baroness, Lady Hollins, gave the example of Emma, in the autism space, but we have all said it in various guises. We have made good progress on mental health provision and identification in schools, which has gone up from about a quarter to over a third of schools, with a target of over 50% in the next year to 18 months. However, I think we all agree that we need to go further and that it needs to be 100% of schools.

Also on early detection, I have been interested in some of the pilots in Bradford, which are starting to look at children’s school results and how they respond to the SATs and other things to see whether that could be an early indicator of some of the issues. I recently saw a fantastic example in the Boston children’s hospital, where they look at how children play online, digitally, on their iPads. With dyslexia, for example, the problem is often that it is only when children are five or six and have been taught to read that such things show up, but there they have started to see how children of two or three interact through pattern recognition, with blocks and other games devised for that. They look at their playing patterns to see whether those can be good early indicators.

I have personal experience of this. I am fortunate that my wife was an early years special needs schoolteacher, and she was able to identify very early on and make sure that our son had that early support. I firmly believe that that stood him in good stead in later life. So early detection starts with the parents. If I had not been so fortunate, 25 years ago, to have a wife who understood these sorts of things, I would not have known. As the noble Baroness, Lady Hollins, said, it starts with parenting programmes and making sure that the early support hubs are a good way into that. I echo and support our commitment to early detection.

You also need early support, as all speakers have said. The ICSs are the right place to do that because they look system-wide. As we know, schools are also a vital part of this, and the £2.3 billion of funding that we put into this space is designed specifically for 350,000 extra places for young people in the community—and I think we all agree that the community is the right place. Obviously, in the next debate, tabled by the noble Baroness, Lady Hollins, we will talk about some of the issues around in-patient treatment, but I think we all absolutely agree about the need for community treatment. My understanding is that these early support hubs are very much like mental health drop-in centres, as the noble Lord, Lord Allan, mentioned, and that is what they are designed to do. As the noble Baroness, Lady Tyler, said, the innovation programme looks promising, but we need to make sure that this is rolled out. ICB early support hubs are very much part of the first line of defence, for want of a better phrase. To me, the 350,000 extra spaces and the funding we are trying to put in are a very important part of that.

As the right reverend Prelate the Bishop of St Albans said, we have set up gambling clinics to try to address this from some of those angles. However—and this goes back to the research—we need to look at some of the wider angles. My noble friend Lord Evans was just saying that AFC Wimbledon has tried to get football clubs to remove the sponsorship of gambling companies, which a load of Premier League clubs have. Straightaway, that normalises gambling from a very young age. Those are some of the wider society solutions that we need to look at in all of this.

We have 70 eating disorder teams, and we need to look at whether we need to expand that, given what we know about the issues involved in a lot of eating disorders. This all comes back to the long-term workforce plan, which many Members mentioned, and making sure that we have the support there.

A couple of noble Lords mentioned the Major Conditions Strategy. My understanding is that it is not supposed to be seen as an either/or. It is about trying to understand that, because a lot of people have more than one major condition, instead of us approaching things as silos we have to look at a whole-person solution, and so we would look at their mental health as much as their physical health. I accept the perception that any major conditions strategy generally focuses more on the elderly, so I will take back that we need to make sure that it is not delivered in that way and does not prevent the sorts of things we need to do for young people.

The noble Baroness, Lady Tyler, asked about CAMHS. A lot of the funding I was speaking about and the 350,000 extra spaces are all about trying to make sure that we meet that four-week target. It is recognised that the sooner you can get people mental health support, the better; that is obviously even more important for a young person in that context. I will look into the points raised about support into adulthood, to make sure that that handover happens properly.

I hope I have given a flavour of what we are trying to do. As the noble Earl, Lord Russell, said right at the beginning, it starts with recognising that there has been a fundamental change. That needs to be reflected in our response. As I was saying earlier, I am attempting to try and understand what is behind that so we can get to some of the root causes.

I encourage all speakers to join the round table with the Minister, so I will invite people to that. I know I am never able to respond to all the points in my speech, so I will write to all the speakers, covering all the points raised in the questions. I thank the noble and learned Baroness, Lady Hale, for making her maiden speech, the noble Earl, Lord Russell, in particular for his words, and all noble Lords for their contributions. I have learned a lot from the debate and thoroughly enjoyed it.

My understanding is that we are going straight into the next debate, so I hope noble Lords will excuse me for taking a quick bathroom break beforehand.

Adult Social Care

Lord Markham Excerpts

Wednesday 22nd November 2023 Lords Chamber

[The Lord Bishop of London]

To ask His Majesty’s Government what assessment they have made of the financial situation facing adult social care leaders and providers, following information published by the Association of Directors of Adult Social Care Services that 83 per cent of councils expect to overspend by an average of 3.5 per cent on adult social care in 2023-24.

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

The department carries out regular assessments of the financial pressures facing adult social care. Since the spending review, the Government have made available up to £8.1 billion in additional funding over two years to support adult social care and discharge. This includes an additional £570 million announced in July. This will put the adult social care system on a stronger financial footing and improve the quality of and access to care.

[The Lord Bishop of London]

The autumn survey of the Association of Directors of Adult Social Services paints a worrying picture of the state of adult social care: a third of directors of adult social care services said that they have been asked to make additional savings to their budgets, on top of the £1 billion of savings that they are expected to make by 2024-25. The Homecare Association’s deficit report, published on the same day, states that providers are being paid less than the work costs and cannot pay their employees a competitive salary. In this context, can the Minister explain what outcomes social care users can expect to see as a result of the investments he spoke of?

[Lord Markham (Con)]

I thank ADASS for its report. The outcomes we are seeing show a number of things: as well as the £8.1 billion investment we put in, we have brought down waiting lists for assessment by 13% since the peak level. We are seeing high levels of satisfaction with a lot of the work we are doing; 83% of people say that they are satisfied with the services they are receiving. Yes, there is a lot more to be done, but there is a lot of good progress as well.

[Lord Forsyth of Drumlean (Con)]

My Lords, in July 2019, the Government promised that they would fix the crisis in social care. When does my noble friend think that that will be redeemed?

[Lord Markham (Con)]

Always at this point, I find that the best tactic is to offer my noble friend a meeting. The People at the Heart of Care 10-year plan is exactly what we are trying to design here. I mentioned some of the progress that is being made: we have seen recruitment go up and an increase in staffing, and we have a put in place a qualification for staff, so that they feel there is a career structure for them. The number of people is going up year on year. Yes, there is a lot to do, but we are getting there.

[Baroness Pitkeathley (Lab)]

My Lords, according to the same survey cited by the right reverend Prelate, 68% of directors reported unpaid carers having break- downs because of burnout from stress, and half a million home care hours had not been delivered because of a lack of staff. Carers UK published a survey showing that 25% of unpaid carers are going without food and heating because of the demands of caring. When will the Government commit to a national strategy for carers to address some of these problems?

[Lord Markham (Con)]

We realise that they are the hidden army, and they are tremendously valued. I think noble Lords know that I have some personal experience of this. We have tried to put some measures in place for payments; I perfectly accept that it is not the same as a full wage, but payments have been put in place. We are also introducing respite care, so we are taking steps in that direction to recognise the vital service they all provide.

[Lord Allan of Hallam (LD)]

My Lords, I know the Minister is keen to ensure that people who are fit to leave hospital can do so quickly, but is he concerned that local government spending restrictions, imposed because of the state of the finances highlighted in the Question from the right reverend Prelate, may lead to more delayed discharges this coming winter? What steps are the Government taking to ensure that that does not happen—a hospital saying that a patient should leave, but the local authority saying that there is nowhere to go?

[Lord Markham (Con)]

The noble Lord is absolutely correct that the flow through the hospital is vital to A&E and other wait times. That is why we have announced things such as the virtual ward: the 10,000 beds are designed to get people out of the hospital and into a care environment where they still feel supported, thereby using technology to help take the strain. The point about this year, and the whole reason why we announced the £600 million extra investment over the summer, is that we learned the lessons of the previous year, recognising that the earlier we can get this money to the local authorities, the better they can spend it to put the provision in place.

[Baroness Blackwood of North Oxford (Con)]

My Lords, investment is welcome but reform is also vital. The NAO’s autumn report noted that my noble friend’s department ended its charging reform programme board and

“has not established an overarching programme to coordinate”

reform activity. It is instead delivering reform

“through a series of 27 projects which report to the director-general … via nine separate programme boards”.

Can my noble friend investigate this to see if there could be better co-ordination of reform to ensure that it is delivered more effectively?

[Lord Markham (Con)]

My noble friend is correct, in that having so many local authority and private sector providers means it is a confusing space in which to bring all this together. The People at the Heart of Care White Paper is trying to co-ordinate that and at the same time provide a career structure, because we know that the bedrock of all this is the staffing, and this needs to be an attractive space for people to work in. Therefore, giving them that recognised, transferable qualification which they can take into nursing and other areas as needed is vital in ensuring that we have the workforce to underpin this.

[Baroness Wheeler (Lab)]

My Lords, the NAO’s recent figures show that so far, only 7.5% of the much-vaunted £265 million allocated by government to addressing social care staffing shortages and recruitment for 2023-25 has been spent due to the DHSC staff recruitment freeze; and the training workforce development programme has also stalled because the department has not managed to set up the necessary systems to administer provider payments. What is the Minister’s response to this and the ADASS survey finding that government investment in social care so far has just stopped the ship sinking and has not moved local authorities out of the storm they are trying to navigate?

--- Later in debate ---

[Lord Markham (Con)]

As I say, we are seeing staff increases. I accept that there is a lot to do in this space, but there has been a 1% increase this year, so we have turned things round quite substantially. Overall, the number of patients being cared for in this way went up by 15,000 in the last year. As the ADASS survey showed, there has been a decrease in the waiting lists, down 13% from the peak, so we have turned a corner and we will see further improvements.

[Lord Watts (Lab)]

My Lords, the Minister said that waiting lists have gone down by 13%. Can he tell us by how much they went up over the previous 12 years?

[Lord Markham (Con)]

I do not have the figures for those 12 years, but I will happily send them to the noble Lord.

[Lord Young of Cookham (Con)]

My Lords, further to the original Question from the right reverend Prelate, is not the real problem facing the care sector that of recruiting and retaining care workers, who can often earn much more in a local supermarket than in a nursing or residential home? What action are the Government taking to make this a more attractive profession for people to go into?

[Lord Markham (Con)]

My noble friend is correct; they are the bedrock and are valued, and it is important that we make them feel valued. As I said, we are reforming the process in order to give them a qualification, which means that that work in the social care setting will be transferable between positions. In addition, if they want to go further into the medical service, be it nursing or other areas, a modular qualification system will enable them to build towards that, so that they not only feel valued but are in a long-term career structure.

[Lord Weir of Ballyholme (DUP)]

My Lords, many families seeking adult social care can find that availability and quality are patchy; and particularly for those living in rural areas, the help they receive can effectively be a postcode lottery. What steps are the Government taking to drive consistency and equality throughout the system, so that every family can receive the level of adult social care that is needed for their loved ones?

[Lord Markham (Con)]

That is a good point. We have given the CQC responsibility for measuring local authority provision of care. Overall, we are seeing a high satisfaction rate—89%—and the number of complaints went down by 16% in the last year, so these things are making a difference.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Lord agree that if we are truly going to fix the problem, as the noble Lord, Lord Forsyth, said and as Prime Minister Johnson promised, we have to deal with the issue of self-funders, who are having to pay thousands of pounds over years without any support from the state above a very limited means-test level? When will the Government come forward with proper proposals to deal with this?

--- Later in debate ---

[Lord Markham (Con)]

I think we all accept the points made by the noble Lord and my noble friend. By way of context, after 2019, the huge disruption of Covid came right in the middle of this, with all that that meant for the dislocation of the health service. We have to accept that that is a factor. The market sustainability and improvement fund tried to ensure that the amount local authorities pay for fees is fairer, as there is cross-subsidisation of those who pay privately. I accept that, in terms of the overall objectives set in 2019, there is more work to do, but that is still the Government’s ambition.

Mental Health Act 1983

Lord Markham Excerpts

Tuesday 21st November 2023 Lords Chamber

[Lord Bradley]

To ask His Majesty’s Government what plans they have to reform the Mental Health Act 1983.

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

We are committed to improving the care and treatment of people detained under the Mental Health Act, including taking forward non-legislative commitments such as culturally appropriate advocacy, as well as continuing to expand and transform NHS mental health services. I am grateful to the noble Lord and his colleagues on the Joint Committee for their work on the Bill to date, and I assure him that it remains our intention to bring forward a Bill when parliamentary time allows.

[Lord Bradley (Lab)]

My Lords, for over six years, the Government have promised to reform the 1983 Act, from manifesto commitments to the Wessely report, draft Bills and consultations, and now the Joint Committee which reported to this House in January of this year— 11 months ago. Then, to the astonishment and no little anger of thousands of people with mental ill health, autism and learning disabilities, who have been supported by their tremendous advocates, there has been deafening silence from the Government. Now the proposed Bill has been completely dropped from the legislative programme. There is a real feeling of frustration across the country about this situation. Will the Minister now give a real explanation so that we can try and restore the breakdown of trust that has come about from this situation?

[Lord Markham (Con)]

I understand the frustration and disappointment about the fact that the Bill has not been brought forward. I am keen to focus on what we can do in the meantime. Of course the Bill is trying to decrease the rate of detention and, within that, decrease the racial disparities, such as the fact that a black person is four times more likely to be detained than a white person. There are a number of things that I hope we will be able to discuss more, particularly in the debates on Thursday as well, such as the things we have introduced in pilots, like the culturally appropriate advocacy. That really can make a difference here and now.

[Baroness Buscombe (Con)]

As the chairman of the inquiry, I reassure noble Lords that my noble friend the Minister is very aware of our frustration. However, I am pleased to hear—I am sure others are too—that, along with others in the department, he is looking to see what we can achieve without primary legislation. Could he and his officials focus on the further development and implementation of, for example, advanced choice documents, which would really make a difference to the dignity and choice that people with mental health issues thoroughly deserve? Could he also, as he touched on, really research and respond to why a highly disproportionate number of black men are unfairly detained?

[Lord Markham (Con)]

I thank my noble friend for her question and for her work on this. The advanced choice documents are a perfect example, like a birth plan, of where people can put in place what their hopes are for the future. There are good examples at King’s College and at South London and Maudsley of what they are doing in this direction, and I am really keen to learn from those and expand them further. I am also keen to invite all the participants to a round table that Mental Health Minister Caulfield has agreed as well, where we can really talk about the action that we can take on the ground to implement as many things as we can to rectify the problems in this space.

[Baroness Hollins (CB)]

My Lords, 40 years ago, as a young consultant psychiatrist, I argued against the inclusion of learning disabilities and autism in the 1983 Act—it is out of date; these are not mental disorders. Does the Minister agree that it is time to take this Bill forward seriously?

[Lord Markham (Con)]

We are all agreed on the intent behind what we were trying to do with the Bill. On learning difficulties and autism, the most important thing we are trying to do is to make sure that the CQC, within 48 hours of a person being put into segregation, is investigating and doing an independent review on whether that is the best place for them. Like the noble Baroness, I share the feeling—we all think it—that it is much better that they are treated in the community, where they can be.

[Baroness Barker (LD)]

My Lords, mental health legislation relies on good data; we do not have good enough data about the detention of people from different groups. Does the Minister agree with the committee that a step forward that could be taken now is the appointment of a responsible person in each organisation with a duty to record not only the detention of people under the Mental Health Act but the demographic data surrounding it?

[Lord Markham (Con)]

Yes. The data, and fundamentally understanding what is beneath it, is key to all this. We have put an executive lead on each trust board to look at exactly these sorts of issues, including the data, so I am happy to take that forward.

[Baroness Merron (Lab)]

My Lords, the provisions of the Mental Health Act have no clear definition of a safe place in which a sectioned patient may be taken while awaiting medical assessment. That often results in vulnerable people being taken to police stations and forcibly detained by the police. What assessment have the Government made of the frequency of this continuing due to the Government’s failure to reform the Mental Health Act—something that Labour, if we win the next election, will put right? How will the Government ensure that patients are no longer detained in such inappropriate and punitive environments?

[Lord Markham (Con)]

I appreciate the feeling that our response on minimal standards—in our reply, I think, to the report by the noble Baroness, Lady Hollins —did not go far enough to make sure that those patients are in the right quality setting for them, so the noble Baroness, Lady Merron, has made an important point. I was going through with the team what we can do to make sure that that is right. As I mentioned before, the fact that the CQC now has responsibility for those independent reviews will mean that it will look not only at whether it is right that the patients are in those in-patient environments but at whether it is the right environment as an actual place.

[Baroness Berridge (Con)]

My Lords, the committee heard about disproportionality, particularly with community treatment orders, which are about 11 times more likely to be imposed on someone from an ethnic-minority background. Can my noble friend the Minister look at that, and maybe meet with colleagues in other departments to see whether there is a legislative opportunity to sort that out by putting that provision into a different piece of legislation?

[Lord Markham (Con)]

Yes. I have tried to get into this further, and my understanding is that lot of the trouble is that there is often a fear from black and ethnic-minority people of the existing institutions that can help people early on. As we all know, with mental health difficulties, we have to act quickly. A lot of this is about getting everyone in society open to the idea that the earlier they can go to these sorts of places, instead of trying to brave their way through, the better. That is one of the key things to do to make sure that we do not then see problems down the pipeline, including the disparity whereby a black person is 11 times more likely to have community reviews and the disparity in detentions.

[Baroness Watkins of Tavistock (CB)]

My Lords, I think that other noble Lords will welcome the idea of sitting down at a round table to look at the future. In particular, what do the Government intend to do to invest in children’s and adolescents’ mental health services to make them accessible in schools? Early intervention will prevent a high proportion of people needing to be sectioned later on.

[Lord Markham (Con)]

The noble Baroness is absolutely correct. With the mental health units to detect problems early, we are now at around 35%; last year it was only 25% but in the next 18 months or so we should be at 50%, which is higher than ever before. I freely accept that 50% is not 100% but it is clearly a step in the right direction. The £2.3 billion investment we are putting in means 350,000 extra places for young people as well.

[Lord Allan of Hallam (LD)]

The Government keep telling us that they plan to take other measures to improve mental health outcomes in the absence of the legislation. I hope the Minister will understand why, having been let down on the promised Bill, we want to see the colour of the Government’s money. Can he go back to his department and ask it to produce a list, with details and dates, of all the measures it intends to take to improve mental health practices via statutory instrument and new guidance in this parliamentary Session?

[Lord Markham (Con)]

Yes. I am happy for the noble Lord to come to the round table and put those points himself as well.

[Baroness Browning (Con)]

My noble friend will be aware that autism is not a mental health condition but a communication disorder. However, of course like everybody else, people on the autistic spectrum can develop mental health problems as well. What assessment has the department made or could it make, quite urgently, of just how able and experienced psychiatrists around the country are at disaggregating between an autistic person having a meltdown and a mental health condition? If they get it wrong, as often happens, the consequences of the treatment that follows are devastating.

[Lord Markham (Con)]

My noble friend is absolutely correct, and from personal experience I know the importance of getting that early diagnosis right. I am quite happy to write in detail exactly what we are doing in this space.

Black and Minority Ethnic Babies: Mortality Rates

Lord Markham Excerpts

Wednesday 15th November 2023 Lords Chamber

[Baroness Thornton]

To ask His Majesty’s Government what steps they are taking to reduce the mortality rates of black and minority ethnic babies, following the publication of research from the National Child Mortality Database.

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

The Government are committed to tackling disparities for parents and babies. We are addressing this through the National Health Service three-year delivery plan for maternity and neonatal services, which sets out how care will be made more equitable for women, babies and families. Support is also provided through the universal public health programmes and programmes that target vulnerable families.

[Baroness Thornton (Lab)]

My Lords, what is very worrying in a rich country such as the UK, with a universal, mature healthcare system, is that this figure of infant mortality rates for babies and children from black and minority ethnic backgrounds is going up and not down. What does the Minister believe the drivers of this data show and how will the Government reverse it? For example, the Apgar score for testing the health of babies, which is a skin tone test, does not work for black and brown babies.

[Lord Markham (Con)]

I thank the noble Baroness for her Question and for her work in this space. I have tried to delve into the numbers. It seems that roughly half the reasons why black and ethnic minority people have higher death rates are to do with socioeconomic and lifestyle factors: where they live, levels of obesity, drinking, smoking and those sorts of factors. Clearly, behind that there is a lot that needs to be done in terms of education and support, folic acid in bread and folic acid generally. The other half is more to do with racial factors. English as a second language is a key thing behind that. I hate to make generalisations, but the fact that black and ethnic minority mothers can often be less assertive means that clearly there you need training of staff to take more time, listen more, make sure that they are understanding and asking the questions to find out whether the issues are there.

[Lord Sewell of Sanderstead (Con)]

My Lords, to what extent is the research programme of the Office for Health Improvement and Disparities looking into this area of health disparities in childbirth and death in childbirth?

[Lord Markham (Con)]

The database from which all the evidence and data have come has just been published. That is exactly why we are publishing the database: so that we can understand the reasons behind it. We are also tying that to the NIHR to see what research is needed in those areas.

[Lord Allan of Hallam (LD)]

My Lords, behind every figure in the national child mortality database lies a personal family tragedy, which we all need to try to understand and reduce as far as we can, as the Minister said. The regional breakdown of the figures shows that there is much less variation between different ethnicities in London than in other English regions. Will the Minister look into that to see whether there are things we can learn from London—perhaps there the staff follow procedures where they are more responsive to people from varied cultural and ethnic backgrounds —so that those lessons can be applied in the rest of England?

[Lord Markham (Con)]

Yes, absolutely. One main reason for that is that in London there is generally a more ethnically representative mix of staff, who are better placed to understand and work in that way. Clearly, we need to increase training as well as recruitment across the rest of the country to make sure that they achieve the same levels.

[Baroness Chakrabarti (Lab)]

My Lords, the Minister will know how highly regarded he is in this place as one of the most caring members of the Government, but what does he say to the comments of the president of the Royal College of Paediatrics and Child Health about how troubling these figures are in a wealthy nation such as ours and about child poverty in this country being a driver of child mortality? What will the Government do about that?

[Lord Markham (Con)]

That is specifically what the Best Start for Life programme is all about. It is a joint Department of Health and DfE £300 million initiative focused on the 75 most deprived areas and local authorities. As the noble Baroness might be aware, the whole reason Andrea Leadsom wanted to come back as a Minister—I was talking to her about this yesterday—was to drive this programme, which she is passionately behind. That work is being done through family hubs, making sure that the whole family is involved and bringing in the dads. That sort of action is very much focused on making sure we tackle this.

[Baroness Blackwood of North Oxford (Con)]

My Lords, every year 4,000 babies die due to pregnancy-specific conditions such as pre-term birth and pre-eclampsia, but 73% of drugs given to pregnant women do not have any safety information and only one drug has been developed specifically for use in pregnancy over the last 30 years. During that time, 600 drugs have been developed for cardiac conditions. Will the Minister look at the report Safe and Effective Medicines for Use in Pregnancy: A Call to Action from the University of Birmingham, which offers sensible and effective ways to put this right and reduce deaths in pregnancy?

[Lord Markham (Con)]

Yes, I would be very happy to take up my noble friend’s suggestion and will make sure that the regulators, NICE and the MHRA, are linked into that as well.

[Baroness Whitaker (Lab)]

My Lords, research has shown that the mortality rate among Gypsy, Roma and Traveller children is far higher than among any other minority-ethnic group, yet this is hardly ever reflected in any account of the situation. Will the Minister get his department to recognise more explicitly the disproportionate mortality rate in this often unrepresented ethnic-minority group?

[Lord Markham (Con)]

Yes. Obviously, we want to find every group and then understand the targeted action around them. Noble Lords will have often heard me say that one of the most effective bits of joined-up government I have ever seen was the Troubled Families initiative, led by the noble Baroness, Lady Casey, and I am interested in the 13 local authority pilots that are using wraparound services to identify community groups and troubled families in particular and provide them with cross-government help.

[Baroness Manzoor (Con)]

My Lords, my noble friend will know that over the last four years the NHS workforce has grown by over 14%, but in the workforce for midwives there is a shortage of 2,500, according to the Royal College of Midwives. Can the Minister say what the Government are doing to ensure that we have sufficient midwives on the wards and, more particularly, a diverse workforce from ethnic minorities who will become midwives and health visitors? The numbers do not look great and of course this plugs in to the prevention strategy the Government have in place.

[Lord Markham (Con)]

Yes, it absolutely does fit into it. We have increased the number of maternity staff by about 14% since 2010, and the long-term workforce plan is all about making spaces for 1,000 extra students and having many routes into it. Noble Lords have often heard me talk about how my mother got into nursing as an older mum—she got into maternity services. There are apprenticeships and later-life opportunities. You should not only be a graduate; you often know much more about life when you are that bit older, especially if you are a mum.

[Lord Scriven (LD)]

My Lords, child mortality rates in all high-income countries, apart from this one, are improving. What is it about this country that is causing this, and what evidence do the Government have to show that there is a specific problem here? What measures will be used to tackle this, and by what dates will this be done?

[Lord Markham (Con)]

I have specifically investigated infant mortality rates. If you look at it, you see the increase is in pre-24-week term cases. Post 24 weeks, the number of cases has remained stable, the data has shown. I have been trying to drill down to understand why it happens within less than 24 weeks. Clearly, more work needs to be done. We are also changing the way this is being measured. We are looking for more indications of whether there are early signs of life, and if there are no early signs of life, that is not recorded as a death. Now there is a lot more investigation to understand those early signs of life, so the change in measurement could be increasing the numbers. I am happy to go into more detail on that.

[Baroness Lister of Burtersett (Lab)]

My Lords, further to the question from my noble friend Lady Chakrabarti, the recent Joseph Rowntree Foundation report on destitution found that minority ethnic groups are disproportionately affected by destitution. What steps are the Government taking directly to reduce destitution among this group?

[Lord Markham (Con)]

Again, noble Lords will know that housing, to my mind, is key to so much of that, and the whole building programmes and the million extra houses are a key part of that. If you look into health across the board, you see that the homeless, for instance, use and need A&E services more than ever. Clearly, it is a root cause we need to tackle.

Autism: In-patient Care in Mental Health Hospitals

Lord Markham Excerpts

Tuesday 14th November 2023 Lords Chamber

[Lord Touhig (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare an interest as a vice-president of the National Autistic Society.

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

My Lords, this year we are investing £121 million in community support for autistic people and people with a learning disability. This will support reductions in the numbers of autistic in-patients in mental health hospitals in line with the NHS long-term plan commitments. To ensure that autistic people receive quality care in these settings, we are rolling out a National Autism Trainer Programme and have published guidance on sensory adaptations in health environments.

[Lord Touhig (Lab)]

The King’s Speech was an opportunity for the Government to introduce the mental health Bill, ending the scandal of autistic people being locked up in mental health hospitals, sometimes for decades. By shelving the Bill, the Government have failed thousands of autistic people and their families, who are devastated that there continues to be no legal protection against unnecessary detentions; I believe that is an attack on their human rights. The Minister is well respected across this House as a caring and compassionate individual, but I must press him on this. Will he please explain why His Majesty’s Government do not see the Bill as a priority, and as an opportunity to end a most evil practice?

[Lord Markham (Con)]

I thank the noble Lord for his kind words about me; I understand the situation. The Government are committed to implementing those changes and we are looking for opportunities to introduce them. I understand his disappointment that the Bill is not in the current programme of legislation. What I am committed to doing is making sure that as many features as possible from the Bill are implemented through action on the ground; the care and treatment reviews are a vital part of that today. Following the report from the noble Baroness, Lady Hollins, we are also making sure that we have regular CQC reviews over the next few years. We are delivering good action in this space, but I understand his feelings.

[Baroness Browning (Con)]

My Lords, like the noble Lord, Lord Touhig, I am a vice-president of the National Autistic Society. I also remind the House of my interests in the register and my family interest in this subject. The reason why a lot of autistic people become in-patients in mental health hospitals is the lack of real understanding and training of healthcare professionals in that field. It is a lot better in the big conurbations than in the countryside. Autism is not a mental health condition but, as my noble friend the Minister will know, one of the problems that the Government will face if they are to help to get people out of these institutions is that, like the rest of us, people with autism can develop mental health conditions; autistic-related anxiety is a very common one. Psychologists—one finds more of them than psychiatrists out in the community—cannot prescribe; it has to be a psychiatrist who prescribes. Until you get the right number of trained professionals out in the community—namely, psychiatrists with a specialism in autism; it is no good having just your average jobbing psychiatrist—those people are doomed to stay. I urge my noble friend to look at the levels of availability for the right professionals, to release these people from the incarceration they should never have suffered in the first place.

[Lord Markham (Con)]

I and the whole House would agree with my noble friend that having the right people making the right assessments on the right place for those people to be treated is key to all this. We are rolling out training through the National Autism Trainer Programme, in which we have invested £20 million to ensure improvements in autistic diagnostic pathways and people’s capability to achieve them. We are now rolling out the Oliver McGowan training to over 1 million people and looking at rolling out stage 2. However, I agree with her that these actions are vital.

[Baroness Hollins (CB)]

My Lords, the tragedy is that so many admissions are due to failings in adult social care. Mencap’s analysis of the latest NHS Digital statistics shows that only 45% of ICSs have met the adult in-patient rate promised by March 2020 and that 26% of ICSs are going in the wrong direction. Can the Minister update the House on future plans for building the right support after March 2024? In the absence of mental health and adult social care Bills in the gracious Speech, what plans are there to fully implement the recommendations in my report, which he kindly mentioned, published by the Department of Health on 8 November? So many of those recommendations were dependent on a code of practice to the current Mental Health Act being reopened.

--- Later in debate ---

[Lord Markham (Con)]

I thank the noble Baroness for her report and the meeting that we had to follow it up. Probably the best way forward on this is that a lot of things we are doing and can do can be done absent the Bill. I should be happy to sit down with her and talk through what we can do and where we can go further to make sure that everything that we were trying to put into legislation we can effectively make happen anyway, because we are all agreed as a House absolutely on the direction of travel in which we want to go.

[Baroness Barker (LD)]

My Lords, what is being done to change the commissioning systems and contracts that currently incentivise providers of medium and long- term secure accommodation to keep people in hospital, rather than equip them to go back into the community?

[Lord Markham (Con)]

I will come back in more detail on the contractual arrangements, but the point that the noble Baroness raises on making sure that there are no perverse incentives to do that has to be right. The now CQC-led reviews that we have agreed to put in place as part of continuing the recommendations of the noble Baroness, Lady Hollins, happen frequently. In the case of adults, there is a review every six months, if appropriate, and, in the case of children, every three months to make sure that every step of the way we ask whether this is really the right place for them to be.

[Lord Sahota (Lab)]

My Lords, these days, more and more parents would like to have purpose-built accommodation for their autistic children. At this moment, they are unable to have that because they cannot access an adaptation grant, also known as a disability facility grant. That needs to change so that parents can build independent self-contained accommodation for their autistic children, which can be done only through legislation and extra funding. Will the Government look into this?

[Lord Markham (Con)]

I am aware of the point that the noble Lord makes. About 48% of the reasons why people are not discharged are because of a lack of suitable housing. It is something on which we are working closely with Homes England and DLUHC, to make sure that we can utilise as much of the affordable housing grant as possible. I was not aware that legislation needed to be changed but I will happily look into that to see if it is the case.

[Baroness Meacher (CB)]

My Lords, is the Minister aware of the critical importance of early intensive education for severely autistic children? I hope so. I was involved in such an initiative some years ago and it is remarkable how a child with no speech and tremendous deficits can ultimately go to a normal school, and the prospects to then lead a reasonably normal life are enhanced enormously.

[Lord Markham (Con)]

Yes, I have some personal experience here and I know how vital it is to find out early, so you can put together the tools. I have seen some really interesting things. The Bradford pilot looked at children’s scores and whether that was an early indicator. I was at Boston Children’s Hospital a few weeks ago, which is looking at the way that children play on apps and whether that can give indications of whether there is some neurodiversity. There is absolutely the intention of early diagnosis.

[Baroness Wheeler (Lab)]

Thankfully, my Lords, understanding of and support for autism have changed substantially since the now 40 year-old Mental Health Act, especially about being clear on what an autism-friendly environment looks like and should be, although sadly that is not often found in mental health settings and ATUs. Did the Government’s decision to abandon the new mental health Bill this Session include an assessment of the impact this would have on patients? This is particularly urgent now that changes to the code of practice, recommended by the excellent report on long-term segregation by the noble Baroness, Lady Hollins, will not be considered until we deal with the Bill. How and when will the Government deliver the significant changes needed?

[Lord Markham (Con)]

I think we are all agreed on the action; there was was an intensive and involved process by the whole House when it came to agreeing the action. That is why I am keen to ensure that we implement as much of it as possible that does not require legislation, which we are doing. I am happy for the noble Baroness to join me at the meeting with the noble Baroness, Lady Hollins, when we can look at the practical steps to see what is possible.

Children’s Hospices: Funding

Lord Markham Excerpts

Tuesday 14th November 2023 Lords Chamber

[Lord Hunt of Kings Heath]

To ask His Majesty’s Government whether they are on target to provide £25 million for children’s hospices for 2023-24; and whether they intend to repeat this on an annual basis uprated in line with inflation and allocated directly to each children’s hospice.

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

The Government and NHS England recognise the vital role that hospices play in delivering high-quality, personalised palliative and end-of-life care for all ages. The children and young people’s hospice grant plays an important role in enabling that to happen. As such, grant allocations of £25 million have been paid in full to hospices in 2023-24. A further £25 million has been announced for 2024-25, with the funding allocation mechanism currently being worked through by NHS England.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister. He will be aware that 80% of the income that goes to children’s hospices comes from fundraising. With the cost of living problems we have at the moment, that is increasingly difficult, so the £25 million grant is a lifeline. Do the Government accept that making this grant permanent, so that hospices know about it going forward, and uprating it by the rate of inflation will give enormous help in stabilising the finances of children’s hospices?

[Lord Markham (Con)]

First, I absolutely recognise the noble Lord’s point that 80% of hospices’ funding comes through charities, so they represent an excellent resource for us. That is why we are pleased to confirm the £25 million for next year. The debate, which I am sure we will get into more later, is about making it a direct grant. We generally think that ICBs are best placed to take control of health services in their area, and it is about trying to get the right balance between making direct grants for the provision of places and saying that ICBs know what is best for their area and should cater for them in that way. I would be happy to talk further about that balance with the noble Lord.

[Lord Patel (CB)]

My Lords, should we not be ashamed that care for children at the end of their short lives is funded by village fetes, cake shops and elderly marathon runners instead of by central government? The total cost of 34 children’s hospices is £130 million and the totality of it should be funded centrally, not as unguaranteed £25 million grants every year. We should be ashamed of this.

[Lord Markham (Con)]

To put this into context again, only about 6% of children’s deaths occur in hospices, so 94% happen in other settings. I want to get that right for the context of all this. There are many parts to this; hospices are quite close to my heart and I want to donate to them charitably. There are many parts of society where we think there is a role for charities to add value and enhance the system, rather than their being crowded out by government-funded sources all the time.

[The Lord Bishop of Worcester]

My Lords, I am grateful for this announcement. We have a wonderful hospice in Worcester, the Acorns Children’s Hospice, which does extraordinary work with young people. Does the Minister accept that, although a minority of children die in hospices, the number of children cared for by them greatly exceeds that. Their work is invaluable.

[Lord Markham (Con)]

Yes, it is. I was surprised to find out that, for instance, the number of young people living with life-limiting conditions was 33,000 in 2001-02 and is over 90,000 today. That is the case because we generally have much better treatments for those children. That is obviously good news, but it means that lots more people with such conditions have to be cared for and we need to make sure that they are.

[Lord Wigley (PC)]

My Lords, as a former trustee of Hope House Children’s Hospices, I draw the Minister’s attention to the clinical guidance published by NICE, which showed that for every £1 spent by the public sector in supporting end-of-life care for infants, children and young people, non-cash savings worth almost £3 would be released back into the NHS. Will the Government commit to provide, ongoing, the necessary funding to sustain hospices and maximise the benefit for the NHS and, most of all, for the dependent families?

[Lord Markham (Con)]

As I said, we absolutely agree on the vital role of it all. The amount of funding that we placed there a few years ago was £15 million, so it has gone up by about 67%. It is excellent value for money, and it is excellent that we managed to get the care and energy of the voluntary sector into it. That is the model that I think we all believe in.

[Lord Balfe (Con)]

My Lords, I declare an interest as the joint chair of the all-party group whose secretariat is Together for Short Lives. The thing that is of great difficulty in this sector is uncertainty. In the interests of permanence and certainty, will the Minister include a dedicated long-term strategy in the Government’s mandate to NHS England that addresses the palliative care needed for children and young people so that the sector can have an assured future?

[Lord Markham (Con)]

My noble friend is correct; it is a long-term part of the statutory requirements of all ICBs to provide palliative care, so it is written into that NHSE mandate. It has to review all 42 ICB arrangements, and we make sure that in each setting they have the 24/7 care set-up required of them.

[Lord Allan of Hallam (LD)]

My Lords, following on from the Minister’s answer to the noble Lord’s supplementary question, most integrated care boards will have only a very small number of residents who need services from local children’s hospices. Given that, it raises concerns that spending on those services will not be prioritised at that very local level. Does the Minister accept that there is a case for integrated care boards to band together at the regional level and fund hospice services that way?

[Lord Markham (Con)]

Yes, absolutely. Again, there is a balance we are trying to get over here, because we are all agreed on the importance of what they are trying to do. At the same time, we believe that ICBs, generally, are the right people make provision at a local level, because they know best what is required in their area. Clearly, where it makes sense for them to band together, that has to be sensible.

[Baroness Wheeler (Lab)]

My Lords, most of us will have the amazing work of our own local children’s hospice in mind today in response to this Question. Ours in Surrey is the care and support that the Shooting Star Children’s Hospices provide for babies, children and young people with life-limiting conditions, and their families. We fully support the children’s hospice grant going directly to a hospice. It is the most cost-effective way; it overcomes the patchy performance of many ICBs and their CCG predecessors on hospice funding, and it avoids hospices having to engage with multiple ICSs when their services go across areas. What actions are the Government taking to ensure that ICBs meet the NICE standards in supporting children’s hospice care and against ICBs that have made no attempt to access the current grant arrangements?

[Lord Markham (Con)]

As I mentioned, it is a statutory requirement for every ICB. NHS England is responsible and is reviewing those arrangements in all 42 trusts. At the same time, this is an element which the CQC follows up to ensure that care is in place. I echo the House’s feelings that the results of the voluntary sector and the hospices are excellent. We need to ensure they get the proper support.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest as having set up training in paediatric palliative medicine in the UK and internationally. Together for Short Lives data shows that about £15,000 per annum is spent on children and young people in the active caseload, which is probably almost 10,000 young people having care from hospices, some of them for many years. Given that there are service specifications and guidelines, can the Minister be a bit more explicit as to how those are monitored to ensure that service specifications really do meet the needs of the children and that hospice services are integrated with local paediatric services, given that such children often have multiple and complex needs?

[Lord Markham (Con)]

As I said, it is a responsibility for all of them, but I will happily give the noble Baroness a detailed reply so that it is very clear exactly what they are doing to make sure that happens.

[Lord Forsyth of Drumlean (Con)]

My Lords, a bazillion years ago when I was the Scottish Health Minister pre-devolution, we introduced a pound-for-pound match-funding system for hospices. That worked brilliantly because it meant that hospices could raise more cash and the Government provided support for organisations that depend on being voluntary. Would my noble friend consider doing that, not just for children’s hospices but for the movement as a whole, which does such fantastic work?

[Lord Markham (Con)]

My noble friend makes an excellent point. My understanding is exactly in this vein: £7 million was paid in match funding to children’s hospices in exactly the way he mentioned. As to whether we should be doing that more widely, it is a good idea, and I am happy to take it away and come back on it.