Nursing Courses: Reduction in Applications

Lord Markham Excerpts

Tuesday 19th September 2023 Lords Chamber

[Lord Hunt of Kings Heath]

To ask His Majesty’s Government what assessment they have made of the causes of a reduction of 16 per cent in applications to nursing courses in England compared to last year, according to UCAS data for the 2023 application cycle.

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

The drop in nursing applicants reflects an expected rebalancing following unprecedented demand for healthcare courses during the Covid-19 pandemic. Nursing is still a popular career choice. Applicant numbers remain 15% higher than pre-pandemic levels. We also continue to see growth in the number of people pursuing nursing apprenticeships. This is not final data; figures are accurate as at the end of June application deadline, but the application cycle remains open through clearing until mid-October.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister, but I think he would accept that any drop-off in applications is something to worry about, alongside the current drop-out rate for student nurses in the UK of around 24%. On that basis, surely the NHS workforce plan in relation to nursing is simply not sustainable. If the Minister does accept that, is there not a case for looking at writing off debt run up by student nurses through tuition fees if they commit to working in the NHS for a length of time?

[Lord Markham (Con)]

We are delivering on a number of routes to recruit nurses. Obviously, the graduate route is one route, which, as mentioned, is above pre-pandemic levels; apprenticeships is another route, which is proving very successful; and associates is another route again. So there are many routes in, and the result is that our applications are 20% up on pre-pandemic levels. We set ourselves a target of recruiting 50,000 more nurses by the end of this Parliament and we are currently on 45,000, so we are going to hit it.

[Baroness Manzoor (Con)]

My Lords, I welcome what my noble friend the Minister said regarding the number of nurses joining; nevertheless, the number of nurses leaving the NHS is higher than we would expect. Would my noble friend say exactly whether we are collating this information and understanding why those people are leaving, because they have a very valued skill?

[Lord Markham (Con)]

Yes, absolutely. Clearly, we want to recruit, but we also want to retain our workforce and again that is what the long-term workforce plan is all about—trying to look at a clear professional development path and other things we can help with, such as childcare support and the culture and leadership, and really make nursing a very successful and rewarding career structure. There is a lot to do on it, but I think there has been a lot of good progress as well.

[Lord Allan of Hallam (LD)]

My Lords, the NHS Long Term Workforce Plan will make funding available for an increased number of nurse training places, which is of course welcome, but the increase in capacity for the NHS will happen only if there are sufficiently qualified candidates applying for those places and completing the training. Would the Minister be willing to share the assumptions his department made about application and attrition rates when setting the targets in the workforce plan, so that we can compare those assumptions with reality as revealed by the numbers in the Question today?

[Lord Markham (Con)]

Yes, my understanding is that all the workings behind the long-term workforce plan are currently being analysed by another body— I am not quite sure whether it is the NAO, the ONS or whoever. The point is that all the modelling and the underlying assumptions are being analysed, and I believe there will then be a report on them so that everyone can see what we are trying to do and how reasonable those assumptions are.

[Lord Bradley (Lab)]

My Lords, the University of Salford, where I am chair of council, has seen applications for adult nursing down by 28%, children’s nursing down by 27% and mental health nursing down by 6%, with an overall drop of 23%. From the feedback the university is receiving, the main barrier is that the financial support needed to undertake a highly intensive course, which leaves little time for part-time working, is insufficient to meet the current cost of living. Does the Minister accept that this is a factor in the drop in applications, and will the Government review the financial package of support available to nursing applicants to ensure, as we have heard, that the NHS workforce plan is deliverable?

[Lord Markham (Con)]

Clearly, as the largest employer in the UK—if not most of the world—the NHS always has to be looking at the whole package that it is offering its staff to make it an attractive place to recruit good talent and retain it. The point that the noble Lord makes is absolutely correct, and those are all things that need to go into the mix. As I say, recent data is encouraging. We have increased the numbers by 45,000 and are on course to hit the 50,000 target, but, as ever, we need to be vigilant because we want to recruit a lot more.

[The Lord Bishop of Chichester]

My Lords, following on from the noble Lord who spoke about his university, the University of Chichester—in the diocese where I serve—is now developing practice-focused nursing courses, including a new nursing associate apprenticeship scheme, even though the cost of living in the south-east is a disincentive to seeking to work in the healthcare sector. However, the university is finding that the current funding and availability of external placements are restricting the growth of these courses, despite the university’s capacity to take more students. What measures are the Government taking to support education and placement expansion at the pace requested by the NHS Long Term Workforce Plan?

[Lord Markham (Con)]

The whole long-term workforce plan is supported by a £2.4 billion investment to make sure that we hit our ambitious targets. It takes into account things like apprenticeships: we want to see the proportion of people coming through the apprenticeship route increase from 9% to 28%. On nursing associates—noble Lords will remember that this is a subject close to my heart, because for my mother, who had children when she was very young, nursing was a route for her to get back into the workforce, so this is something that I am glad to see us now picking up again—we have seen nursing associates increase from 1,000 to 10,000 over the last few years. These are all key routes, which we are backing up with investment behind them.

[Lord Hampton (CB)]

My Lords, it appears that the reduction in student nurses was most prominent among mature students. Applications from those aged 30 to 34 dropped by 25%. Out of nearly 49,000 qualified entrants to teaching last year, fewer than 12,000 were over the age of 39. As someone who retrained as a teacher at the age of 50, can I ask what the Government are doing to attract more mature students to both professions—a group of people who might be under less financial pressure and are able to see these professions as the incredibly important and rewarding careers that they are?

[Lord Markham (Con)]

As I just mentioned, the whole point around nursing associates is to try to attract those more mature recruits as well. As I was trying to show with the example of my mother, there are lots of people who have a lot of value that they can give later on in their life. That is definitely the sense of direction that we are trying to achieve. I repeat that, while people are talking as if numbers are going down, across the field of graduates, apprenticeships and associates we are looking at a 20% increase since pre-pandemic levels.

[Lord Lucas (Con)]

My Lords, would my noble friend consider making it much easier for young people to get work experience in the NHS, so that they can see what a wonderful career it is, rather than having to rely on the chance of someone they know working in that industry?

[Lord Markham (Con)]

Absolutely. We are trying to adopt a modular approach so that you can have units that can build towards getting in there. For people who go into social care, for instance, there is a modular unit that can add towards going into nursing later on. That is a means of attracting people to nursing by having more routes in and making a career such as social care attractive in terms of career progression.

[Baroness Walmsley (LD)]

My Lords, the noble Lord, Lord Hunt, mentioned the attrition rate among student nurses, but I understand that the attrition rate among student mental health nurses is even greater. That is a particularly challenging specialist course, and one of the problems is that very often the clinical placements are a long way from where the student nurse lives. Is there any programme of support available to make sure that we do not lose the student nurses who undertake this very challenging route to nursing?

[Lord Markham (Con)]

The noble Baroness is quite correct that mental health is a particular case in point. When we introduced the £5,000 grant for all nurses each year, we gave additional add-ons, and mental health nurses get an add-on in addition to that £5,000 a year. We also increased the travel and accommodation costs allowance by 50% to cater for those who have to travel far and wide.

[Baroness Wheeler (Lab)]

My Lords, the figures on overall declining numbers are concerning, particularly since this is the second successive steep fall, with, as the Minister said, the Department of Health relying on the UCAS clearing system and future nurse apprenticeships to try to make up the numbers. What changes does the Minister consider need to be made to the NHS workforce plan in the light of escalating problems with both the recruitment and retention of key staff?

[Lord Markham (Con)]

I am sorry to keep coming back to the data, but it suggests a 45,000 increase, which shows that we are doing pretty well. A 20% increase across all the different fields since the pandemic also shows that we are doing a good job on recruitment. Clearly, we cannot rest on our laurels, so we need to look at all those routes in, but I do not understand why people characterise the numbers as dropping when in fact the data shows the overall increase is far greater.

National Health Service: Major Conditions Strategy

Lord Markham Excerpts

Monday 18th September 2023 Lords Chamber

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

My Lords, the Government are providing additional funding of £3.3 billion in 2023-24 and £3.3 billion in 2024-25 to support the NHS in England. The Government have not committed further additional funding specific to the major conditions strategy. However, as part of the strategy, we will be identifying innovative actions to help alleviate pressure on the NHS and support improvement within the current settlement, such as maximising the use of new technology to screen individuals for conditions.

[Baroness Wheeler (Lab)]

My Lords, the major conditions strategy has been well received in both approach and content, particularly the focus on primary and secondary prevention as part of a life-course approach, and bringing together a strategic framework for the six major conditions that drive over 60% of morbidity in England, including cancer, heart disease and stroke. However, key stakeholders have warned that, without adequate resources, NHS trusts and other bodies will struggle to deliver, especially given their current and future focus on trying to cope with ever-escalating waiting lists. Do the Government acknowledge this and how will January’s future strategy address it?

[Lord Markham (Con)]

We are investing about 11% of the economy—£160 billion—in the NHS, and the conditions in the major conditions strategy account for 60% of all the causes of death and long-term illness. What we are really talking about is prioritising spend around prevention and personalised care, as the noble Baroness said, and channelling the money we are already investing towards those aims, on which I think the whole House agrees.

[Lord Allan of Hallam (LD)]

My Lords, in June, the Government announced a ring-fenced AI diagnostic fund of £21 million to support the major conditions strategy. Will the Minister update the House on progress with the rollout of that fund? What other steps are the Government taking to ensure that NHS patients in all parts of the country can benefit from the latest developments in artificial intelligence?

[Lord Markham (Con)]

AI is a key point. Take stroke, which is one of these conditions. I saw a very good example in the Royal Berkshire the other day of what we all know as the golden hour, and the results from it. The Royal Berkshire has AI scans that go straight to the responsible physician, who can say straightaway whether a thrombectomy, for instance, is needed, the timing of which is critical. That is now being used in that cluster of hospitals and will be one of the six key technologies, the roll out of which we will encourage across the board to others.

[Lord Black of Brentwood (Con)]

My Lords, osteoporosis must surely be included in the major conditions strategy, as fractures are the fourth-worst cause of premature death and disability in the UK, with as many people dying of fracture-related causes as lung cancer and diabetes. Does my noble friend agree that the inclusion of osteoporosis in the strategy would need to be backed up by investment in fracture liaison services to make it effective? Would not a two-year transformation budget of just £54 million to pump-prime universal coverage of FLS in England, which would quickly pay for itself, be a game-changer for patients, the NHS and the taxpayer?

[Lord Markham (Con)]

I thank my noble friend. I think that is covered by musculoskeletal conditions, which is one of the six major conditions we are looking at. Key to pathways is moving treatment away from individual silos to patient-based treatment that looks across the board. We know that 55 year-olds have, on average, at least one condition, and that 80% of those over 85 will have one, two or three of these conditions. We need to ensure that we look at this across the board, rather than in silos.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I understand the rationale for identifying these areas, but how will the Government ensure that integrated care boards do not deprioritise services for other clinical conditions, such as eye health or kidney disease, for which there is huge demand in the NHS, involving many patients?

[Lord Markham (Con)]

The strategy tries to provide a road map for how we want to do this. It starts with prevention, which I think we are all agreed on, then early diagnosis, quality treatment and then living or dying well with that condition. It is a philosophy: the idea is that we get it right in these six major areas with 60% morbidity, and then we roll it out across the board in all other areas. It is a way of treatment, really—a way of looking at the whole problem, centred around whole patient needs, that we will roll out to other conditions as well.

[Baroness Barker (LD)]

My Lords, if this is to become a reality rather than an aspiration it will require a huge increase in the number of community nurses. How do the Government think that will happen when the main incentives and career development for nurses lie within the acute sector?

[Lord Markham (Con)]

My Lords, the noble Baroness is absolutely correct. That is set out in the long-term workforce plan: a move much more upstream to prevention and primary care, of which community nurses will be a key part. The recruitment is in place for it all. Yes, a lot of people might see the action as being in the acute sector, but a lot of people really enjoy working in the community as part of their lifestyle. The hope and expectation is that it will appeal to a lot of people in those areas as well.

[Lord Aberdare (CB)]

My Lords, less survivable cancers such as pancreatic cancer are often characterised by vague, non-specific symptoms, making them hard to diagnose. Will the major conditions plan include making funds available for symptoms awareness campaigns to ensure that these signs of deadly cancers are not missed? Will it also cover increased funding for research aimed at increasing survival rates for pancreatic cancer, which is the deadliest common cancer? Survival rates have hardly changed in the past 50 years, whereas for leukaemia there has been a surge in survival rates following an increase in funding for research.

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[Lord Markham (Con)]

This is all about prevention—letting people understand when there is something not right within themselves and trusting them to know that. That is why the self-referral part of this is so important, rather than always having a GP as a kind of gateway to it all. Most people know their bodies better than anyone else does. If we can arm them with awareness and give them the ability to self-refer to these centres, we can get them diagnosed that much quicker.

[Viscount Stansgate (Lab)]

Does the Minister agree that in the broadest sense, this strategy would be aided by the Powers of Attorney Bill that passed in this House last week and will shortly reach the statute book? With the indulgence of the House, I pay tribute to my friend and colleague Stephen Metcalfe, the Member for South Basildon and East Thurrock, who steered the Bill through the other place, my noble friend Lord Ponsonby of Shulbrede and the noble and learned Lord, Lord Bellamy, both of whom are in their places, for getting government and opposition support. I thank the officials at the Ministry of Justice who worked for years to make it possible. Does the Minister agree that lasting powers of attorney as applied to health will make a difference to the better?

[Lord Markham (Con)]

Absolutely. The Government, and in particular my noble and learned friend Lord Bellamy on behalf of the whole MoJ team, fully support the noble Viscount’s remarks on the Powers of Attorney Bill and warmly thank him, Stephen Metcalfe MP and all the others for their efforts on the Bill.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, I congratulate the Minister on concentrating on the importance of person-centred care, particularly for people with long-term conditions. I declare an interest as chief executive of Cerebral Palsy Scotland. Cerebral palsy is a good example of this, because we actually have very good NICE guidelines for the treatment of adults with CP but there seems to be nothing we can do to ensure that integrated care boards around the country follow those guidelines. Can the Minister explain why?

[Lord Markham (Con)]

My noble friend is absolutely correct, in that we are setting out the whole emphasis of what we are trying to do here. It is really ingrained in those pathways. It is about culture and behaviour as a whole, rather than a silo-based scheme, looking at the whole patient. Once we have got those pathways set up properly, it is Ministers’ job—I have mentioned before that we each look after six or seven ICBs—to hold them to account and make sure they are following those pathways.

[Baroness Bennett of Manor Castle (GP)]

My Lords, on that whole- patient approach, in 2021 when the Office for Health Improvement and Disparities was launched, the then Secretary of State said that the Department of Health would be co-ordinating activity across government, looking at the wider drivers of good health—employment, housing, education and environment—lack of which often drives many major conditions. Can the Minister tell me how that co-ordination is going?

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[Lord Markham (Con)]

As mentioned, this is about looking at the whole patient, and that is why the ICB role in this, working with local authorities, is key. The environment in which people live is also key, as is tailoring our part of the jigsaw puzzle—health—towards this. One of the major elements that noble Lords have heard me talk about before is mobile lung cancer screening, which goes into neighbourhoods where it is known to be a problem, often the old mining communities or places where there are high levels of smoking and deprivation. That mobile screening technology has meant that instead of reaching only 60% of people by stage four of cancer, we are capturing 75% at stages one and two. This is about working with local authorities on whole health needs to ensure that our efforts are targeted in the right places.

Reinforced Autoclaved Aerated Concrete: Hospitals

Lord Markham Excerpts

Wednesday 13th September 2023 Lords Chamber

[The Lord Bishop of London]

To ask His Majesty’s Government what steps they will take to support NHS trusts with the cost of ensuring hospital sites are safe until reinforced autoclaved aerated concrete can be removed.

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

The NHS has had a mitigation plan in place since 2021 for hospital buildings with confirmed RAAC. That is backed by significant additional funding of £698 million for trusts to put in place necessary remediation and fail-safe measures. Additionally, in May, we announced that the seven most affected NHS hospitals will be replaced by 2030 through the new hospital programme.

[The Lord Bishop of London]

I thank the Minister for his Answer. The NHS Confederation and NHS Providers both point out that they welcome the new hospital programme. However, the issue with RAAC is part of a much bigger maintenance backlog. Some hospitals that are not the most critical will have to wait up to 12 years for the concrete to be removed. Given that timeline and the risk highlighted in recent days, will the Government consider accelerating the new hospital programme?

[Lord Markham (Con)]

First, we are doing everything we possibly can to make sure that the programme is accelerated as quickly as possible for good-safety reasons and for clinical reasons as well. In terms of the other hospitals, it is a case of making sure every step of the way that we have structural engineers and we take every safety measure. I managed to visit a lot of these hospitals over the summer and saw first hand the expert work they are doing there.

[Lord Allan of Hallam (LD)]

My Lords, to give credit where it is due, the DHSC has produced a very good fact sheet on RAAC in the NHS. I draw the Minister’s attention to the last line of it—the place where the bad news is usually buried. It says:

“Privately owned primary care estate is not part of the national programme. NHSE has issued RAAC guidance to private landlords who hold the responsibility for surveying and maintaining their own property”.


That reads a bit like “not our problem”. Can the Minister assure the House that the department will ensure that those smaller primary care settings get surveys done quickly? How will the department be staying on top of that?

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[Lord Markham (Con)]

We have given guidance and are making sure that everyone understands exactly what they should be doing across the estate, whether we are the landlord or not. Clearly, there is a difference where we are the landlord because then it is our responsibility to do it. The prime example of this is that in the NHS Property Services GP estate—which is quite extensive—we are dealing with three RAAC GP surgeries. Where they are owned by other landlords, we need to make sure that they are on top of it and do the work without taking responsibility for it ourselves.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord mentioned 40 new hospitals by 2030, but he will be aware of the NAO report in July which made it clear that the original 40 target will not be met because of the substitution of the eight RAAC hospitals. Can the Minister tell us what is going to happen to the eight hospitals that were in the original programme and have now been delayed?

[Lord Markham (Con)]

I hope and trust that most of us would think that it was sensible to prioritise the RAAC hospitals. That meant that we had to move some others to the right-hand side of the budget envelope, so to speak. It is not publicised very much, but we now have an agreement with the Treasury to move to five-year capital cycles, like the Department for Transport, which I think is a real positive because we need long-term planning cycles. We are busy developing a 2030-35 programme now, which those hospitals that the noble Lord mentioned will be placed in.

[Baroness Brinton (LD)]

My Lords, I want to follow on from the question from the noble Lord, Lord Hunt. My local hospital, Watford General Hospital, has been top of the rebuild list for 20 years. The town was delighted with the news on 23 May that it would be part of that group and is not part of the eight. Last week, the council was informed that there is still no confirmation of when funding will be approved by the Treasury. The town knows that it will run out of the chance to rebuild Watford General by 2030 unless that funding is confirmed very soon. Can the Minister say when it will be confirmed?

[Lord Markham (Con)]

In every hospital—and Watford was one of the first ones I visited—there is a programme on which the draw-down of the funding depends; there is already a new car park there, for instance. I can assure the noble Baroness that the plans are in place to make sure that the draw-down is in time. I have also said on all the hospitals I have visited over the summer—I have seen about 20 or so—that I have a quarterback role where I have to project manage across them all and, where there are issues, they can approach me directly. I will raise today’s question with the Treasury and make sure that Watford is well in order.

[Baroness Merron (Lab)]

My Lords, as the Minister said in answer to an earlier question, the Government will replace only seven of the 27 NHS sites confirmed to have RAAC in their construction, while the other 20 are set to be monitored and mitigated until it can be removed. How long will it take to complete the removal on these 20 sites? What assessment has been made of the risk to patients?

[Lord Markham (Con)]

Three of those have already had the RAAC eliminated from them. The remaining ones are part of the programme and the commitment to have their RAAC eradicated by 2035, but in the meantime the remedial measures are there and that is what the £698 million is all about. I visited them first hand to see the work, and all credit to the team—they have become real experts on the subject. At every hospital I visited, you could see that the team were right on their game and understood very well what work they needed to do there, always using expert advice from the Institution of Structural Engineers and others.

[Lord Lexden (Con)]

My Lords, do the details that my noble friend gave in answer to the noble Lord, Lord Hunt, represent the current position in implementing the clear commitments given by Mr Johnson in the 2019 manifesto, which I do not think have advanced quite as swiftly as had been hoped?

[Lord Markham (Con)]

The commitment to 40 hospitals is absolutely there, but, as noble Lords have mentioned, we have prioritised the seven RAAC ones—in fact five of those were new, while two were already in the programme—which clearly have to be done by 2030. So, just as we moved those in, we moved the others into the cycle of 2030-35, but we will still be delivering 40 hospitals by 2030, albeit, because of the RAAC hospitals, of a slightly different complexion.

Children’s Health: Sugar

Lord Markham Excerpts

Tuesday 12th September 2023 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask His Majesty’s Government what assessment they have made of the impact of sugar on children’s health.

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

The Scientific Advisory Committee on Nutrition undertook a comprehensive assessment of sugar intake and health in its 2015 report Carbohydrates and Health. In 2023, it looked specifically at children aged one to five. SACN concluded that reducing the intake of sugar would lower the risk of tooth decay and weight gain in children and adolescents. The Government have an ambitious programme to reduce children’s sugar intake, which includes the soft drinks industry levy.

[Lord Brooke of Alverthorpe (Lab)]

I thank the Minister for his reply. One area where the Government have failed to take the action they should is to encourage the industry to reformulate food more than it is doing at the moment—to take out sugar and substitute the alternative, organic, healthy sweeteners that are available. Would the Government look into this and do some more work? Would they be prepared to invite companies that are willing to enter public/private partnerships to start doing that?

[Lord Markham (Con)]

First, I recognise all the work the noble Lord does in this space. Secondly, I completely agree that reformulation is the big prize as part of this. The House will remember me mention before that Mars, Galaxy, Bounty and Snickers have all reformulated their food, as has Mr Kipling and his “exceedingly good” cakes—they are compliant cakes as well. There is a lot being done here, but there is more to do. We meet the industry all the time and are very happy doing so.

[Lord McColl of Dulwich (Con)]

My Lords, is the Minister aware that, in Canada, thousands of children have been fed on whole milk for many years, and their problems with obesity do not exist? The food industry has deliberately promoted a low-fat diet. It is a lousy diet that tastes horrible; that is why they have had to shovel in such vast quantities of sugar. Could the Minister ensure that the Department of Health no longer advocates a low-fat diet? Fat going into the duodenum acts on the stomach, making it empty more slowly and therefore giving the feeling that the patient has had enough.

[Lord Markham (Con)]

I think one of the things that, hopefully, I have learned in the almost year that I have been answering Questions is when I know the answer to a question and when I do not. I am afraid this is one of the examples of the latter. I will happily look up the Canadian example of the use of whole milk and write to the noble Lord on it.

[Lord Krebs (CB)]

My Lords, I declare my interests, as recorded in the register. I was very pleased to hear the Minister refer to the soft drinks industry levy, which has been a very successful way of reducing sugar consumption in soft drinks. Therefore, do the Government have plans to extend that levy to other products that contain a lot of sugar? That would be a very effective way of reducing sugar consumption.

[Lord Markham (Con)]

The noble Lord is correct; that has been a success story. Overall, we have seen a 46% reduction of sugar, while at the same time sales of drinks in that category have gone up by 21%—that is 60%-plus if you combine the two. We are now looking at other moves that can help. The movement of product positioning to remove the so-called “pester power” is a key step forward in this. Of all the modelling that has been done, that is the thing that it is thought will reduce calories by the most—by 96%. That is the current focus; it has been in place for almost a year and early evidence is that it is working, but as ever we must keep everything under review.

[Baroness Walmsley (LD)]

My Lords, for the 4 million children in food poverty, the quality of their school lunch is crucial to their health and development. But the school food standard has not been reviewed since 2014, and nobody checks whether schools are adhering to it anyway. With so many children going hungry, is it not time that the standard of school food was brought up to date with the latest research on the impact of sugar and other nutrients?

[Lord Markham (Con)]

The noble Baroness is absolutely correct. What we give children in schools is a key thing that the Government can affect. That is why I am delighted that the level of free school meals, at 33%, is the highest on record, making sure that they have good nutritious food. But the noble Baroness is correct: there was a review taking place in 2019, which was one of the casualties of Covid. I know that it is now one of the things that we are thinking, as we recover from Covid, that we need to look at again.

[Lord Tomlinson (Lab)]

My Lords, the Minister has spoken passionately about reducing the intake of sugar by younger people. Are His Majesty’s Government intending to admit obese children with type 2 diabetes to the two-year pilot study of the new drug Wegovy?

[Lord Markham (Con)]

My understanding—and I will confirm this afterwards—is that, to begin with, always with these sorts of treatments, you want to make sure that you are doing it in a safer type of environment. Generally, having adults doing it is a better place to start. Clearly, if that works the way we think, and we can trust that it will work, then you have opportunities to expand beyond that. The other thing I would like to say on this is that, actually, an active life is very important—activity and sports are a very important component of this. Interestingly, it has been shown that an active life increases life expectancy by one to two years, so that is an important feature in all this as well.

[Lord Hampton (CB)]

My Lords, as a design technology teacher now teaching food nutrition as well, can I ask whether, rather than sugars, of which the risks are well known, the Government will update NHS advice on ultra-processed food, particularly its website? These seem to pose a much higher risk to health, particularly as they are often marketed as the healthy option.

[Lord Markham (Con)]

Many noble Lords will recall the Question we had on this before. It is the actual ingredients that are the problem. Ultra-processed foods, in and of themselves, are not a good definition because bread is an example of an ultra-processed food. The problem is that many of these are high in fat, sugar and salt, and that is what we need to be tackling. That is what we are going after, not the definition of ultra-processed foods per se.

[Lord Allan of Hallam (LD)]

My Lords, the Minister has told us previously that the Government are going slow on their ban on junk food advertising because they want to give time to manufacturers to reformulate their products. For many of us, this is disappointing because, as long as the food continues to be advertised, there will be excessive consumption. Could the Minister give us a progress update, so that we can get to the point where these foods, which are bad for health, will no longer be promoted—particularly in front of children?

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[Lord Markham (Con)]

Yes, as I mentioned previously, our modelling shows that roughly 95% of the calorific reduction that we are expecting will come from the movement of the product positioning. The evidence, almost at the end of the first year, is that this is working. Effectively, the category of non-high HFSS products has gone up by about 16% while products high in fat, sugar and salt have gone down. We know that supermarkets are taking the lead in doing this voluntarily, in terms of the so-called BOGOF, or “buy one get one free”, promotions. Tesco and Sainsbury’s have already stopped that on a voluntary basis and, as I mentioned earlier, the companies are also reformulating their foods. There is a lot of progress in a lot of areas.

[Baroness Merron (Lab)]

My Lords, children from the most deprived areas are four times more likely to be obese and three times more likely to have dental decay than those in the least deprived, with sugar as a key contributor to poor health and future prospects. Does the Minister agree that targeting excessive sugar intake at earlier stages will have more impact on the more deprived communities and, if so, how do the Government propose to do this?

[Lord Markham (Con)]

Yes, the noble Baroness is absolutely correct, and that is why in the major conditions survey we have an ambition to reduce sugar intake by 20%, working right across the board and especially with baby food manufacturers. As I set out earlier, there are a range of things that we have already done: the sugar tax reduced intake by 46%, and the movement of the so-called “pester power” has made a big impact. We are seeing companies reformulate food. But it is something we will keep under review, and we will do more if we need to.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I declare my interest as the president of the British Fluoridation Society. Coming to oral health, is he alarmed at the number of intensive dental treatments that children need because of the rise in decay? Could he update the House on any speed up in fluoridation schemes?

[Lord Markham (Con)]

The noble Lord is absolutely correct. As many are aware, the most common reason for six to 10 year-olds to go into an A&E visit is tooth decay. The noble Lord will recall that we passed an SI quite recently expanding opportunities for water fluoridisation. I know that is now increasing and I will happily follow up with the detail in writing.

NHS: Staff Numbers

Lord Markham Excerpts

Tuesday 12th September 2023 Lords Chamber

[Lord Clark of Windermere]

To ask His Majesty’s Government what plans they have to increase the number of staff working in the NHS.

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

A record number of staff are working in the NHS, including more than 6,000 more doctors and more than 16,400 more nurses than last year. We have backed the NHS long-term workforce plan with more than £2.4 billion over five years. This will put us on course to double the number of medical school training places, almost double the number of adult nursing training places and increase the number of GP training places by 50% by 2031. It will also ensure that the NHS workforce is put on a sustainable footing for the future.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer, but he knows that there is a dire shortage of staff right across the NHS, with 47,000 nursing vacancies. The recruitment of nurses to training places is down 13% this year. Some 170,000 workers in the NHS left their jobs last year, mainly under stress. Today, we have the news that a survey found that 32% of students who are currently in medical school have said that they intend to emigrate on completing their studies. I repeat what I asked in my Question: what plans do the Government have to increase the number of staff working in the NHS?

[Lord Markham (Con)]

The whole House will, I think, recognise that we have extensive plans that are, as I said, backed by £2.4 billion. That is what the long-term workforce plan was all about. There were many requests for us to put it in place and that is what we have delivered. All of this comes in the context of 63,000 more members of staff over the past year—actually, around 280,000 more members of staff since 2010. Those are substantial increases. Do we need to do more? Yes. Is that what the long-term workforce plan is all about? Yes.

[Lord Dobbs (Con)]

My Lords, those within the NHS must be allowed to work safely. Has my noble friend seen the reports today? A third of female surgeons have been sexually assaulted by other doctors within their workplaces, sometimes while they are actually operating on people. It is as unbelievable as it is appalling. What plans does my noble friend have for getting to the bottom of this, finding out the truth of these allegations and holding responsible those who are responsible for the safety of working practices within the NHS? In its recent dealings with him, did the British Medical Association mention this terrible issue—or have its interests been concentrated solely on money?

[Lord Markham (Con)]

I thank my noble friend. Like all of us, I am sure, I was appalled to hear about that study. The most fundamental purpose of any employer is the safety and well-being of their staff, obviously, and I am afraid that the hospitals that allowed that to happen and allowed that culture to take place clearly failed. Clearly, we need to get to the bottom of that. As I often say, it starts with the leadership in each hospital and the culture that is built up within each college. Those are the people who need to be looking at themselves in the mirror and asking whether they have the right culture to make sure that everyone feels safe in the workplace.

[Lord Allan of Hallam (LD)]

My Lords, we know that the Minister is a big fan of data dashboards for tracking such things as the flow of patients through hospitals. Does he agree that such a dashboard would be an excellent way for us to track the Government’s progress against all the various targets that they have put into their workforce plan? Will he commit to producing one?

[Lord Markham (Con)]

I believe that the whole point of the workforce plan is that every couple of years there is a review of our progress against it and how it needs to be adapted, since it is a moving feast. So, absolutely, it is vital and something we are working on. Overall, the things that we said that we would do we are on course for. We said that we would increase the number of nurses by 50,000 over the course of this Parliament. It is currently 47,000. We said that we would increase doctors’ appointments by 50 million. That is currently on track. So a lot of good work has already happened. A lot of targets have been hit. Yes, there is more to be done and we are happy to track it.

[Lord Patel (CB)]

My Lords, it is currently predicted that there will be a shortage of about 4,000 fully trained anaesthetists by 2025. The Government’s plan to expand anaesthesia associate training will also need anaesthetists to supervise the trainees in the workplace. However, currently there is a bottleneck at a certain level of the training of anaesthetists. That bottleneck can be resolved by increasing the number of training slots. Why do we not do that?

[Lord Markham (Con)]

In every area, anaesthetists being a very good example, we need to be looking at where the bottlenecks are and moving to free up those situations. I think we would all agree that with practitioners such as anaesthetists and in other areas, it is a very sensible approach to make sure that the most highly skilled are focused on the most highly skilled jobs and that they can have people underneath them who can be trained to work within that. So hearing that there is a certain amount of opposition from certain colleges and the BMA to those sorts of roles is quite disappointing. I hope they would accept that this is a key way of addressing the issue.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, can I take the Minister back to the original Question from my noble friend Lord Clark? He put before the House some quite startling statistics about the number of medical staff—particularly but not exclusively doctors —who are leaving following or shortly after the completion of their training, either for other countries or for private practice? What view does he take of that drain away from the National Health Service and the effective loss of the investment that the country makes in the very expensive training of clinicians?

[Lord Markham (Con)]

My first point on that is to ask what the real facts are. Five years on from qualification, around 95% of doctors are still registered with the General Medical Council and still practising in the UK. So the fact is that retention is very high. That notwithstanding, we want to do everything that we can to retain people, and professional development is what the long-term workforce plan is all about. Also, we all know that pensions were a big reason for a lot of the brain drain and doctors leaving the profession, and that was something we were quite radical in supporting and changing. We are going through this bit by bit, asking what key things we need to do to retain our staff and resolve this.

[Lord Forsyth of Drumlean (Con)]

My Lords, I have seen press reports that suggest, from future projections, that one in 11 people in the workforce will end up being employed by the NHS. Does the Minister really believe that this is sustainable? What plans does he have to avoid what would be a completely impossible situation for the economy?

[Lord Markham (Con)]

Yes, I am aware of this. Health spending equates to roughly 11% of the GDP of our country. Not surprisingly, the number of people in the workforce reflect that. It is absolutely mind-blowing; the amount of investment going into this space is bigger than the economy of Greece. Without a doubt, we have to make productivity improvements and look to technology, AI and all the things we can do to improve output and make sure that that total is not just ever-increasing.

[Baroness Merron (Lab)]

My Lords, the Government’s workforce plan is silent on having enough properly maintained treatment facilities, buildings and equipment, all of which have become increasingly inadequate. Could the Minister confirm what assessment has been made of the physical capacity requirements to deliver the NHS workforce plan? How will he ensure that staff have what they need to do their job?

[Lord Markham (Con)]

The noble Baroness is absolutely correct: a workforce plan needs to be backed up with the physical real estate to deliver it. As noble Lords are aware, I am responsible for the new hospitals programme, which is part of that. In primary care, much of the long-term workforce plan is all about getting upstream of the problem in terms of prevention, and clearly we need to make sure that the physical real estate is there to support that. So the next steps will be to make sure that the capital meets the long-term workforce plan.

[Baroness Jolly (LD)]

My Lords, the NHS needs more recruits, but can the Minister tell the House where there are pressing shortages that adversely affect patient care and when he anticipates that the problem will be sorted?

[Lord Markham (Con)]

As I say, the long-term workforce plan puts this on the right footing, going forward. There are big increases in the number of staff, so it is not like we have not been working hard on this area already. By any definition, 63,000 more staff over the last year is a prime example of that. So we are addressing this, but I am not going to pretend to the House that this can be done once, lightly and quickly; it is part of a long-term programme, which the long-term workforce plan is all about.

Countess of Chester Hospital Inquiry

Lord Markham Excerpts

Tuesday 5th September 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, we have all been appalled at what happened at the Countess of Chester Hospital, and we would also like to extend our sympathy to all those affected, especially those parents of children who were taken from them. Those were losses that we now know that could, and should, have been prevented. I echo the comments of the noble Baroness, Lady Merron, in praise of those doctors who did raise concerns and fought to have them taken seriously. The accounts that we have seen of legitimate concerns either being ignored, or in some cases being actively suppressed, are truly shocking and represent a call to action that we must heed.

The inquiry is welcome, and will cover a lot of important ground, and I will not try to pre-empt their work today. Instead, I want to focus on one aspect where the department could act now without cutting across the work of the inquiry, and that is the role of NHS trust non-executive directors. This is something which the patient safety commissioner also highlighted in her statement on the Letby case. She said of NHS non-executive directors that

“it is vital that they are able to ask the right questions and escalate concerns where needed.”

The relationship between non-executive directors on a board and senior management teams in any organisation involves the delicate balance of responsibilities. Would the Minister agree that NHS trust non-executive directors should see patient safety as a priority responsibility—perhaps the single most important among their broad set of duties? Would he also agree that it is a healthy and positive situation if trust managers feel that they are under scrutiny from their non-executive directors on safety issues and believe that they will be pulled up if they are not fully open with them? We saw in this case claims of management not presenting the full sets of facts to their boards. They must be entirely candid with their non-executive directors and must expect to be challenged; that is the culture we want to see on trust boards, not one of cover-up and misleading.

In this context, could the Minister confirm whether the department will take steps now to reinforce with trust boards the importance of non-executive directors being able to raise safety issues? Importantly, will they be providing non-executive directors with training on how to perform this function effectively, so that they understand the best ways in which to challenge executives where necessary?

As I said at the outset, we welcome the inquiry from these benches, but I hope that the Government will not wait until the inquiry has completed its work to start making changes, and that they will be equally committed to making changes now where these would improve governance, and that the Minister can confirm that they are looking at strengthening the role of non-executive directors on NHS trust boards.

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

I would like to thank the comments, and the spirit of the comments, made by noble Lords. I start by adding my condolences to the parents and families in question. As we all know as parents, it is the most horrible thing we could ever imagine happening to us.

Clearly, the inquiry will find out the full facts of the matter, but at the same time it is important that lessons are learned quickly. To the point of the noble Baroness, Lady Merron, the families will continue to be consulted throughout this time. We would all agree that what happened is unforgivable, and we should praise the doctors for the work that they did and the courage that it took to bring it forward. I am convinced, as mentioned by the noble Lord, Lord Allan, that we need to make sure that we are doing sensible things in the meantime to ensure that we learn those lessons quickly. The foremost responsibility—the first line of defence as I like to call it—is the role of the board and the NEDs.

Speaking to colleagues about this, Chris Whitty was just saying that any sensible statistician and someone with sound common sense should have been able to say that there is something seriously awry here. We must all ensure that the boards are equipped to be able to challenge in the right way. That does take training, but it is important to make very clear to them that their primary duty must, beyond anything else, be the safety of the patients in that hospital. That has to be the first line of defence. There are things that we need to do to help them, including training—and to the noble Baroness’s point, that they are equipped with the records of those people so that it is known whether they are fit and proper people. One of the questions that I have asked, and got answered, is that I know there is a list so that, when you are looking to employ people, you know now whether a person is not a fit and proper person. As happened in this case, people moved on to other trusts in intervening periods, and there must be a mechanism where the trust can annually review, or review even more frequently, whether they are fit and proper through past cases that have just come to light, so that they have the ability to act.

It is our role to arm those boards, and give them the information and training to be that first line of defence. Tragically, we know in this case that first line of defence failed. These actions should bolster that first line of defence, but we also need to look at some of the second lines of defence. Medical examiners are a good way forward. From April 2024, they will now oversee all deaths that have not been put to coroners. I am told that this happens quite regularly already in the hospital setting; the challenge is more in the primary care setting. Along with other lines of defence, there is the duty of candour, allied with the freedom to speak up, so that we are gaining knowledge from the staff and people on the front line. Again, it is clear in this case that, while doctors were very brave in bringing it up, a lid was kept on it for too long. Clearly, we need to do more in terms of that whole approach of them feeling emboldened to speak up.

At the same time, the steps being taken in terms of the Getting It Right First Time programme and the health and safety investigations board and CQC are all good steps in that direction. But what is vital is that we do not, by putting in those central measures, somehow give boards the feeling that the first responsibility does not lie with them. It is the most important job that they can do, and the last thing that any of us would want is the feeling that they do not have to worry so much about that, because there are these other bodies looking into it. Absolutely fundamental to all of this is that they realise that it is their primary duty and that we in the centre are arming them to do that properly.

I hope that gives a good sense of the direction of travel we are going in, and I hope it accords very much with the points made. As to whether we should be going further in terms of registers to make that regulatory, we are absolutely open to that. It is just about trying to work out the practicalities and where the right level is. There are, however, some things, such as making sure this fit and proper persons list is up and running. That is something that we can do very quickly and are doing tomorrow. Clearly, there will be other opportunities for questions that I am taking in a moment. As ever, I will follow up all of this with a detailed reply. Most of all, I want to give a moment’s pause.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare that I am registered with the General Medical Council. I am a doctor and I have been involved in providing some support to the Nuffield review into disagreements in care of critically ill children, which is about to report. As the noble Baroness, Lady Merron, pointed out, this is unbearably and unbelievably terrible. I watched the whole story unfold almost with a sense of disbelief, except the awful thing is that one can believe it happened as it did, with the suppression of the whistleblowers.

That is what I want to pick up from the point made by the noble Lord, Lord Allan: we do not have a senior doctor on every board. The training of a doctor is different from the training of a nurse, a manager or an HR manager. That understanding of statistics is different. When a doctor tries to raise a concern but hits a brick wall, they need to be able to go directly to another doctor on the board to explore what they want to raise and because that other doctor is also subject to the GMC’s requirements. I quote from the GMC’s duties of a doctor:

“You must take prompt action if you think patient safety, dignity or comfort is being compromised”—


“must” being the key word. It was easier for staff to raise issues in the days when there was a senior doctor on the board. It did not always work, but I hope the Government will look at that as an action that could be taken much more rapidly. The GMC also says that doctors must contribute to adverse event recognition.

Again, as has been pointed out, these things have happened before: we had the Robert Francis report into Mid Staffs and the Bristol inquiry into heart surgery. Those people who have been whistleblowers have been traumatised, but nobody has been as completely destroyed as the parents when they know that their child has been killed. Child bereavement is overwhelmingly terrible, but when you know that it was from the action of another person it is even more impossible to come to terms with it.

I hope the Government really will look at whether some urgent intermediate action can be taken, and whether they can have discussions with the GMC so that doctors who are reported to the GMC as being difficult because they are raising concerns are not treated with some of the problems that have arisen, where we have seen doctor suicides and so on when they have been inappropriately referred. I hope the Government will seriously consider whether there needs to be a senior doctor on every board, both in hospital and a provision in the community. Even the appraisal systems that are in place do not seem to be working adequately to protect whistleblowers.

[Lord Markham (Con)]

I thank the noble Baroness for bringing her knowledge and skills to this. Bringing senior doctors very much goes along with the sentiment that we were all trying to express about equipping boards in the right way to be the first line of defence in bringing such things up. I know that many boards have doctors on them, but the noble Baroness raised a very good point; it is something that we should take back. From my point of view, I absolutely see the sense in making sure we do that.

[The Lord Bishop of London]

My Lords, I also declare my interests as noted in the register, specifically as a previous Chief Nursing Officer for England and as a non-executive director of a number of NHS trusts for a number of years. I also extend my sympathy and prayers to those who have been impacted by these awful and unimaginable atrocities.

I join others in welcoming that this is now a statutory inquiry. I also support the points made by the noble Baroness, Lady Merron, particularly around NHS manager regulation. I ask the Minister whether, when the Government look at that regulation, they will consider that it should go beyond the NHS executive, who themselves are managers, so providing external scrutiny.

The NHS has sought to improve patient safety for decades. It has also sought to improve people’s ability to be whistleblowers through a number of reports— I was involved in the publication of some of them. There are policies, guidelines and NHS bodies. A number of policies are even referred to in the Statement, some of which are now up to eight years old. My question to the Minister is whether the review will look at why those policies, procedures and bodies that are already in place, with the aspiration of improving patient safety and enabling people to whistleblow, were not enough to prevent this. The question that goes alongside that is whether the review will look at culture. It is not just about the policies and procedures; what was the culture that enabled this to happen? How might we recognise it and prevent it happening again?

[Lord Markham (Con)]

Again, I thank the right reverend Prelate for the sentiment of her reply. On whether we should be looking at the regulations beyond the executive, all these things are very much in the mix, for want of a better word, to ensure we have the right ones there. On the question of why the bodies that are in place did not catch it, obviously we will learn more as the inquiry goes along, but one of the major things for me when I looked at this was the fact that, because a lot of those cases did not go to a coroner, the medical examiner system was not fully in place at that point, so there was no other set of eyes in all that. I have to believe that if the medical examiners had looked at that they would have picked it up incredibly quickly. The fact that is now being put in place so that everything will have to be overviewed by a medical examiner or a coroner will be a key issue in all this.

There is an issue around the culture. I have a quote from a report by Sir Gordon Messenger, which is a perfect example on this and absolutely covers that point. It says that the culture that is set down by these places can often cause these problems. It is clear that, in the case of this hospital, the culture was not right. He said:

“We heard too frequently that poor inter-personal behaviours and attitudes were experienced in the workplace. Although by no means everywhere, acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system, as evidenced by staff surveys and several publicised examples of poor practice. This exists at the micro-level, in individual workplaces, and across sectors, where the enduring lack of parity of esteem, conditions and status between healthcare and social care remains a blight on effective collaborative working”.


That sums up a lot of the problem with the culture. The board, in terms of its training and equipment, is where staff surveys and feedback should act as one of the early warning mechanisms that we should look to put in place.

[Baroness Stuart of Edgbaston (CB)]

My Lords, I reinforce the points made by the noble Lord, Lord Allan, and the noble Baroness, Lady Finlay, about the importance of boards and patient safety being a key factor that they ought to take responsibility for. I will make a wider point. As health is a devolved matter and we are talking about the NHS in England, I urge the Minister to have comparisons of best practice: talk to the devolved Administrations, see what happens in Scotland, Wales and Northern Ireland, both for the way in which we can learn from each other’s experiences but also so we can arrive at common standards that can be accepted across the United Kingdom. Similarly, if any registers are being set up, these should not be confined to just England but should be UK-wide.

[Lord Markham (Con)]

I thank the noble Baroness; that is a good point. We clearly need to be looking at best practice across the board. That is not limited to any one devolved authority, but means learning from each of them and, I think, somehow making sure that hopefully they can learn from the terrible events that have taken place here—so they are putting that in place as well. For me, one of the main failings that we are now putting right is the medical examiners, which I want to make sure are spread out across all the devolved authorities. Clearly it is up to them whether they take it or not, but we should absolutely be making sure that we are cross-fertilising some of those key learnings, so they go both ways.

Folic Acid Fortification

Lord Markham Excerpts

Tuesday 25th July 2023 Lords Chamber

[Lord Rooker]

To ask His Majesty’s Government whether it remains their policy to reduce the number of pregnancies affected by neural tube defects through mandatory folic fortification of bread flour.

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

My Lords, the Government remain firmly committed to proceeding with a policy of mandatory fortification of non-wholemeal wheat flour with folic acid to help prevent neural tube defects in foetuses. As I have previously updated noble Lords, this policy is being delivered as part of the wider review of the Bread and Flour Regulations. Having consulted, we are finalising policy decisions; we expect to publish a response this summer and lay new legislation early in 2024, subject to clearances.

[Lord Rooker (Lab)]

I remind the Minister that it is now 35 weeks since the consultation on the Bread and Flour Regulations closed. The last time they were reviewed, in 2013, the Government’s decision was announced within 20 weeks of the closure. It is now four years since the Government consulted on fortification of bread flour with folic acid, and it will be two years this September since they made their seminal decision actually to do it. So, we have just lost another two years, which means another 300 babies born with lifelong illnesses, and 1,600 terminations.

When will we get some action? We have lost two years since the previous decision, when it was announced that we were going forward. The Minister has already indicated—he was clever to do so—in answer to the previous Question that he has a problem with Northern Ireland. It is a pity that the noble Lord, Lord Dodds, is not here, because then we would get the facts on Northern Ireland. If that is the excuse, it will not be good enough.

[Lord Markham (Con)]

I first thank the noble Lord, Lord Rooker, for his tireless and passionate campaigning on this issue, which he is right to do. As I have learned, the situation is complex. We had 369 consultation responses, and more than 13,000 different SKU items—products containing flour—will be affected. We are not just talking about bread; pizza, lasagne, cakes and sauces are all affected, so you have to change the labelling of all those. We are trying to bring them all on board in a sensible manner, and to get this right quickly. We believe that a lot of people will voluntarily take this up much quicker. When you are talking about changing labels on the 22 billion items that are sold each year, you obviously need to look at how to do that practically and within a reasonable timeframe.

[Lord Cormack (Con)]

My Lords, my noble friend was right to acknowledge the indefatigable campaigning of the noble Lord, Lord Rooker, but will he please not rely upon these government phrases “shortly”, “in due course” and “soon”? Perhaps he could tell us which of those comes first. We feel that we are being fobbed off and that the delay is inordinate. He talked about early 2024, but will it really be early 2024? According to me, January is early 2024.

[Lord Markham (Con)]

I thank my noble friend, and I agree. I hate the words “in due course” because they mean “whenever”. While I freely admit to using words such as “soon” and “imminent”, “in due course” is not a term I use, and I understand the point being made. The consultation will be published late in the summer. It is a complex area, and I have said that I want to get personally involved now; I want to make sure that we get the balance right between the many competing interests. The legislation is planned for early 2024. All I can do on my side is to undertake to push that forward as much as possible.

[Lord Allan of Hallam (LD)]

My Lords, the Minister said in reply to a previous question that a lot of the industry is already voluntarily adding folic acid to bread and other foodstuffs. Of course, “a lot” is a well-known scientific term for “more than a little”. I invite the Minister to offer us a more precise figure. Does the department know what percentage of bread and similar products are currently fortified on a voluntary basis? If not, could it carry out a survey so that we can have that number?

[Lord Markham (Con)]

Probably the best thing to do is for me to give the noble Lord the detailed information we do have and try to find out more. I am told that “a lot” means the majority of bread products, but I will give the noble Lord a more precise answer.

[Baroness Hayman (CB)]

I ask the Minister not to be too downhearted about the complexities he faces, according to the department. In the more than 30 years since the MRC’s ground-breaking research on this subject, more than 80 countries have managed to fortify their flour. Not one has reported adverse effects; not one has withdrawn that fortification. As I have said before, I had four young children when this evidence first came out; I now have four grandchildren the same age and, honestly, I do not want to stay here until I have great-grandchildren. So can we have some action soon?

[Lord Markham (Con)]

Yes, the noble Baroness is correct, and the point made by the noble Lord, Lord Rooker—that each year’s delay involves another 200 or so babies—was very well made. The beauty of this process is that it makes me shine a light on this issue, so I will be working on quite hard on it.

[Baroness Merron (Lab)]

My Lords, the last time this issue was raised in the Chamber, the Minister put delays down to co-ordination with the devolved Administrations and consultation with the EU due to Northern Ireland—which he referred to in the previous Question—before allowing industry to get on board. Just yesterday, noble Lords debated two statutory instruments that apply to the devolved Administrations, including one specific to Northern Ireland. Can the Minister explain why timely co-ordination across the nations has been possible on tobacco products and pharmacies but not on folic acid in flour, in respect of which time is obviously of the essence, given the importance of the neural health of babies?

[Lord Markham (Con)]

I thank the noble Baroness for that question; as I am rapidly learning, this is a complicated area. For the benefit of noble Lords who were not present yesterday, the tobacco arrangements are part of the Windsor agreement, so we passed primary legislation to allow us to make those changes. On the items before us, which involve secondary legislation, my understanding—if I am wrong, I will make a correction in writing—is that the co-operation of each of the devolved authorities is needed. That is why we are not able to proceed in Northern Ireland without its involvement. The plan is that we will go forward with GB-only measures if we have to. For obvious reasons, we would prefer not to do that; we want Northern Ireland to benefit from these changes as well but, as I have learned, it is a complex area.

[Lord Balfe (Con)]

My Lords, when I became president of the British Dietetic Association—the dieticians’ trade union—this was one of its priorities. When I stood down five years later it was still a priority. My noble friend Lord Rooker has pursued this relentlessly, but what we are overlooking, I am afraid, is that every year more and more babies are born with this defect. Some 80 countries have managed it; what has impeded us for such a long time? I echo my noble friend Lord Cormack’s question: will “early” next year really be early?

[Lord Markham (Con)]

As I have said, there are complications. The MHRA, for instance, has raised concerns about the side-effects of certain folic acid levels in respect of anti-epilepsy drugs. We are going through various medical areas and checking that we do not have unintended consequences, and these are some of the issues that have been taking time to deal with. I am not trying to give excuses, but to allow noble Lords to understand some of the complexities involved. As I have mentioned, the plan is very much to lay legislation in early 2024. We then have to give notice periods to the EU and the World Trade Organization, so, in order to achieve complete transparency for noble Lords, I am afraid there will be a two-year implementation timeframe from then. But rest assured that I will be pushing hard on this.

[Baroness Walmsley (LD)]

My Lords, we have heard that there are millions of products, but also that some manufacturers have implemented this policy voluntarily. Industry has had years of notice that this is going to happen. Surely it is for the Government to legislate and industry to comply.

[Lord Markham (Con)]

Yes, and as I have said, a lot of companies are doing that. What we are really talking about is a backstop for “edge” products that are not fast-moving. There are a lot of products out there already, so relabelling takes some time. I would hope and expect to see most of this implemented pretty quickly, as soon as we get into the new year.

As I am out of time and this will probably be the last thing I say, I wish everyone a happy Summer Recess.

Respiratory Syncytial Virus

Lord Markham Excerpts

Tuesday 25th July 2023 Lords Chamber

[Baroness Ritchie of Downpatrick]

To ask His Majesty’s Government, following advice issued by the Joint Committee on Vaccination and Immunisation on 7 June, whether they are planning to undertake an immunisation programme against respiratory syncytial virus before winter; and if not, what are the barriers to doing so.

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

My Lords, officials are currently developing policy options based on Joint Committee on Vaccination and Immunisation, or JCVI, advice regarding an expanded RSV vaccination programme for infants and older children. While officials are working at speed, challenges such as procurement negotiations, system readiness and delivery capacity mean that a universal programme in time for this winter is not possible. The department is working with partners to mitigate those challenges and to support implementation as soon as possible.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, I thank the Minister for his Answer, albeit a little disappointing. When will that policy position on the introduction of the RSV immunisation programme be submitted to Ministers? When will the business case, including funding priorities, for the introduction of such an RSV immunisation programme be developed and put to the Treasury? Does the Department of Health plan to accept the joint industry offer to work with manufacturers to overcome barriers to rapid implementation?

[Lord Markham (Con)]

I thank the noble Baroness. The issue is that the current jab, palivizumab, is very expensive and lasts for only one month at a time, so it is logistically quite difficult. Promisingly, a new jab, nirsevimab, has just been agreed by the JCVI. It offers six months’ protection, is more effective and is lower in cost, so that is the one we are looking to roll out to more people. At the same time, there is a promising Pfizer jab which can be given to mothers. There are good new vaccines coming along; the issue is whether they are going to be licensed in time for us to be able to use them this winter.

[Baroness Walmsley (LD)]

When immunisation is rolled out, will there be a public information programme to ensure a high level of uptake among people who are eligible for it? In the meantime, in the absence of a test, what advice is being given to people who believe they may have RSV? Should they go to their local pharmacist or to their GP?

[Lord Markham (Con)]

It depends on the type of jab. For instance, the maternal jab can be given to the mother as part of her prenatal check-ups. Either way, if it is for her or for the baby, there will be an education campaign. The other at-risk group is, as I am sure the noble Baroness knows, the over-75s. We are looking at a targeted programme for them as well, which they can go to their GP to find out about.

[Lord Kamall (Con)]

Further to the noble Baroness’s question about public information, we found previously when rolling out vaccines, not just for this but for Covid, that there were certain communities which were difficult to reach or to persuade to take up the vaccine. As an extension to the question from the noble Baroness, what more is being done to encourage people in those communities who are reluctant to be vaccinated to come forward, or to go to meet them in their communities and take the vaccine to them?

[Lord Markham (Con)]

We had this question on MMR just the other day. Some groups are much harder to reach than others. Very young children are the prime at-risk group. There, it is much easier because, naturally, they are seen by their GP and medical staff either prenatally, if it is maternal, or post in terms of the baby check-ups. The group that we are talking more about here is post 75 year-olds, and there those education programmes will be put in place.

[Baroness Wheeler (Lab)]

My Lords, the JCVI advice endorses the vaccine programme for 75 year-olds and for ages above, but we know that evidence shows that there is serious underestimation of RSV infections among older adults and an urgent need to improve testing and treatment of, in particular, those with congenital lung or heart disease or spinal muscular atrophy. What steps are the Government taking to raise awareness among these key groups and to develop information and monitoring systems that identify those most at risk?

[Lord Markham (Con)]

This is where nirsevimab is very promising, in that it gives six months’ protection. The problem with the previous jab is that it needed monthly injections and was only 50% effective. We are talking about 70%-plus effective now, which makes it more practical to have that sort of rollout. To date, we have been looking at the very targeted group of 75 year-olds only, particularly as each course costs £2,000 and has to be given monthly over the winter months. Now that we are opening up to this injection, which is much cheaper and lasts for six months, we can look at a broader range, and then there is a much more general education programme to go with it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister comment more generally on vaccine manufacturing in the UK, which comes into play here? During Covid, we learned that having our own vaccine manufacturing capacity was important. Is that the Government’s position going forward?

[Lord Markham (Con)]

The noble Lord is correct. I have two good examples of that, BioNTech and Moderna, where as part of commercial arrangements for us to buy large amounts of Covid vaccines from them they are making investments in UK plants. It will not always be practical, but those examples are billion pound-plus investments which I think we all agree are welcome news.

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

My Lords, following the previous Question, it is great to have a Minister who knows what he is talking about. Does he agree that it is important that we have the same kind of policies in all parts of the United Kingdom in relation to vaccination and immunisation? What discussions is he having with his counterparts in Scotland, Wales and Northern Ireland?

[Lord Markham (Con)]

First, I thank noble Lord. That is the nicest thing anybody has ever said to me; I think I want to go on holiday at this point. This is a devolved matter, but it is something on which we are working very closely with the devolved Administrations. I must admit, as we discussed yesterday, that there is concern about the Northern Ireland Administration. Obviously, the Executive and Assembly not meeting at the moment makes some areas more difficult. We had examples of that yesterday, and we are about to have one in a minute when we talk about the fortification of bread. However, where we can, we are working closely with our colleagues.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, in his initial response to me, the Minister indicated that the policy papers were being drawn up. What policy options are being considered?

[Lord Markham (Con)]

The hope is that there will be two effective and cost-effective vaccines, nirsevimab and the Pfizer maternal jab. Those are much more effective and give longer periods of protection than the current monthly jab—they give six months’ protection. They are open to a mass campaign, particularly for young children, who are the most at-risk group. That allows us to have a negotiation with both parties with some healthy competitive tension so that we can get the best price, because we know that either one will do the job quite well. Where we can reach a successfully negotiated outcome, we hope that will set us up either to do either a year-round programme, if it really is very cost effective, or, if it is still quite expensive, to focus on the winter months, because that is the time when young children are most at risk if they have just been born. Those negotiations are live, and I will be happy to update the House as we learn more.

[The Lord Bishop of Carlisle]

My Lords, I, too, welcome the Minister’s detailed knowledge of this subject. Testing it even further, if I may, can I ask him whether His Majesty’s Government have made any assessment of the usefulness of glycolipid research in countering not only RSV but other viral illnesses, including influenza and Covid-19?

[Lord Markham (Con)]

I fear I might have been taken to the limit of my knowledge. I would like to think I know when to stop and to offer to follow up in writing.

Tobacco and Related Products (Amendment) (Northern Ireland) Regulations 2023

Lord Markham Excerpts

Tuesday 25th July 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 12 and 29 June be approved.

Relevant document: 45th Report from the Secondary Legislation Scrutiny Committee. Considered in Grand Committee on 24 July.

Motions agreed.

Tobacco and Related Products (Amendment) (Northern Ireland) Regulations 2023

Lord Markham Excerpts

Monday 24th July 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Tobacco and Related Products (Amendment) (Northern Ireland) Regulations 2023.

Relevant document: 45th 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 purpose of this instrument is to implement the EU Commission delegated directive (EU) 2022/2100 of 29 June 2022, which amends directive 2014/40/EU—the tobacco products directive—to withdraw certain exemptions in respect of heated tobacco products placed on the Northern Ireland market.

The instrument amends the Tobacco and Related Products Regulations 2016—the TRPR—in relation to Northern Ireland. The regulations will apply to producers, suppliers, retailers and wholesalers that produce or supply heated tobacco products for consumption in Northern Ireland. Subject to the regulations being approved by Parliament, they are due to come into force on 23 October 2023.

The regulations apply to Northern Ireland only and are made for the purposes of dealing with matters arising from the Windsor Framework. The SI implements a change so that, from 23 October 2023, heated tobacco products can no longer have a characterising flavour, such as menthol, vanilla and fruit flavours. This is not a ban on heated tobacco, but it will limit the flavours available. A characterising flavour ban is already in place for cigarettes and hand-rolling tobacco in the TRPR.

We do not need to make changes in light of the Commission delegated directive’s requirement for heated tobacco products to contain health warnings and information messages if they combust. If heated tobacco products that involve a combustion process were placed on the UK market, they would be regulated as tobacco products for smoking and subject to existing regulations in the TRPR that require these products to contain a combined health warning and information message. There are currently no heated tobacco products on the GB or Northern Ireland markets that involve a combustion process and, as such, they are subject to the labelling requirements applicable to smokeless tobacco products.

A full impact assessment has not been prepared for this instrument because the costs involved for business fall below the threshold for producing one.

Heated tobacco products on the UK market are produced and manufactured outside the UK by the tobacco industry. The characterising flavour ban will limit the products it can produce and supply to the Northern Ireland market and may impact on profits, in what is a relatively small market for the industry in Northern Ireland.

The DHSC has communicated with the tobacco industry, Northern Ireland retail representatives and enforcement agencies regarding the proposed changes. There is no significant impact on the public sector. Each district council in Northern Ireland will enforce the new requirements. They are not expected to be a significant burden on district councils, given the low use of heated tobacco products in Northern Ireland.

I am content to bring forward this legislation today. These regulations allow us to honour our current commitments under the Windsor Framework and will have limited impact on Northern Ireland business. I commend these regulations to the Committee.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, I thank the Minister for his presentation of the statutory instrument. I have to declare an interest: I am a member of the Secondary Legislation Scrutiny Committee, and we discussed this SI. There was no dissent from it and there was general support, but we drew it to the attention of your Lordships’ House.

I am a supporter of the Windsor Framework, and any shilly-shallying around it can lead to uncertainty in Northern Ireland. It is important that we and the people of Northern Ireland, particularly businesses, can avail themselves of the economic opportunities in relation to access to the UK internal market and the EU single market.

--- Later in debate ---

[Baroness Merron (Lab)]

I start by thanking the Minister for introducing these regulations, which we welcome, and expressing my appreciation for the way he set out their application, the summary of which is that, from October, it will be illegal in Northern Ireland to produce or sell heated tobacco products that have what is called a “characterising flavour”. As the Minister explained, this change is happening because of the requirements of the Windsor Framework and in response to a policy change implemented by the EU—more of that later.

With regard to heated tobacco products, unsurprisingly, some in the tobacco industry have claimed that they are less harmful than conventional smoking. Has the Minister had time to review the analysis by the University of Bath, which has shown that most of the studies referred to in order to back up said claim were either affiliated with or funded by the tobacco industry? Surely that raises a considerable flag. Conversely, the European Respiratory Society has pointed to independent research showing that heated tobacco products emit substantial levels of toxicity as well as other irritant substances. Although the use of these harmful products is said to be very low in Northern Ireland, they are increasingly being marketed, without evidence, as a healthier alternative to smoking.

On that point, I would like to pursue the questions that have been asked by noble Lords in the course of this debate about whether there are plans to adopt similar legislation here so that there is parity between England and Northern Ireland; and whether there have been discussions with the other devolved Administrations in order to ensure that there is parity in legislation and, therefore, not the problems across borders that have been described. The noble Lord, Lord Dodds, explored this matter extremely well. I was particularly taken with the obvious practical example that somebody can purchase a product here and take it to Northern Ireland. What is the implication of that? That is going to happen all the time; it is just a fact. I am sure that all noble Lords will be interested to hear the Minister’s response on that.

Have the Government made any assessment of the prevalence of heated tobacco product use across the rest of the United Kingdom, principally in England, along with the wider health implications of such use? Perhaps the Minister could also outline what action his department is taking to combat the increased marketing of such products—marketing that is often underpinned by spurious tobacco industry-backed research, as I referred to earlier.

As was spoken to by the noble Baroness, Lady Ritchie, and the noble Lord, Lord Allan, can the Minister set out how the Government will assist Northern Ireland in the implementation of the ban, particularly given the possibility of illegal importation from England? It certainly seems strange—this point has come out in the debate—that, following the implementation of the draft regulations, there will be more stringent legislation in place to clamp down on heated tobacco products in Northern Ireland than in the rest of the United Kingdom. Can the Minister assist us in trying to understand how that will help? Are the Government considering implementing a ban on these products in their tobacco control plan, which was promised by the end of 2021? That leads me to the question of when—indeed, whether—we will ever see it published?

I want briefly to highlight concerns in relation to children and young people in particular. I note that the Secondary Legislation Scrutiny Committee referred to the fact that it was in the light of increased sales volumes among under-25s that the EU amended its legislation on heated tobacco products. In this regard, the Health and Social Care Committee in the other place recently took evidence from not only health experts but the industry. It made for interesting reading. The committee heard evidence that the topic of conversation for young people in the playground was often the different flavours that they were trying, such as

“Gummy Bear, Slushy and … Unicorn Milk and Unicorn Frappé”.

This was also referred to by the noble Lord, Lord Allan. These are different flavourings that are clearly not aimed at an adult audience. While we are talking about vanilla and other flavours in heated tobacco products, does the Minister agree that it will not be long before we see them being extended to products that are deliberately constructed to be attractive to children to get them to take up smoking? What is the strategy to deal with this?

It is absolutely crucial, in dealing with tobacco control and ensuring that we reduce harm to the health of people of all ages, that we look ahead. I hope that these regulations and the debate around them, including noble Lords’ contributions, will again alert the Minister to the need to anticipate future developments in tobacco products, not just in Northern Ireland but across the whole of the United Kingdom.

[Lord Markham (Con)]

I thank noble Lords for their contributions. As ever, they showed that there are interesting intricacies in every part of health; it is one of my key learnings over the past nine or 10 months that I have been in this role.

I want to clear up one thing. I admit that there was a bit of confusion on my part, as well. As the noble Lord, Lord Allan, said, we are not talking about vapes here—we are talking about heated tobacco. There is a heated tobacco stick, which basically heats to temperatures lower than that of a cigarette and releases an aerosol. I am sorry if noble Lords knew that already, but I thought that was worth clarifying. Because of that, this product is used by a very small number of people. It is estimated that less than 0.5% of smokers use this product; if you apply that to the population, it is 0.065%. I hope that this gives some sort of clarification behind our decision, when we talk about whether we did an impact assessment, because we are talking about very small numbers being involved here.

--- Later in debate ---

[Baroness Ritchie of Downpatrick (Lab)]

I thank the Minister for giving way. In relation to what he said about the transport of these substances, I indicated the issue of regulation, as did the noble Lord, Lord Allan. In the past, during our troubled history, cigarettes were used as a form of smuggling, and also used as contraband by paramilitary organisations. The Minister says there is only minor use of these cartridges, for want of a better description—but I have seen them sold along with cigarettes in locked-up containers in shops, and young people purchasing them, particularly the fruit-flavoured ones. If they do not have access to that, how will they be able to get them? What mitigation and control measures will be put in place to prevent them becoming like contraband and being abused by erstwhile paramilitary organisations?

[Lord Markham (Con)]

I thank the noble Baroness for that remark. I think that I probably need to give that a detailed response as well. The point I was trying to make was that these heated tobacco products are a very small part of the market to begin with and the flavoured versions are even smaller again. While the noble Baroness is correct that that potential is there, the amount is very small indeed, but I will give her a detailed response on that.

I have tried to answer the specific points raised; as I say, I will follow up in more detail in writing. We have to honour the regulations set out by our commitments under the Windsor Framework agreement. With that, I commend these regulations to the Committee.

Motion agreed.