Prioritising Early Childhood: Academy of Medical Sciences Report

Lord Patel Excerpts

Monday 11th March 2024 Lords Chamber

[Lord Markham (Con)]

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

[Lord Patel (CB)]

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

[Lord Markham (Con)]

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

Mental Health Patients: Discharge

Lord Patel Excerpts

Tuesday 5th March 2024 Lords Chamber

[Lord Markham (Con)]

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

[Lord Patel (CB)]

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

[Lord Markham (Con)]

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

Anaesthesia Associates and Physician Associates Order 2024

Lord Patel Excerpts

Monday 26th February 2024 Lords Chamber

Lastly, can the Minister give an estimate of when we can expect to see a draft order covering dental professionals? That is urgent because the GDC is essentially using 40 year-old mechanisms and procedures that are no longer fit for purpose, and it is in a context where more and more new models of dental practice and cosmetic dentistry are emerging—for example, remote orthodontics, where professional oversight is ostensibly being provided remotely, or non-UK providers of services offering “initial consultations” in hotel rooms. Such practices are affecting patient safety now, but the regulatory tools to address them do not yet exist. Flexibility is needed, and we cannot wait indefinitely for regulations to be brought forward.

[Lord Patel (CB)]

My Lords, I begin with a slight disagreement with the noble Lord, Lord Harris. I take his point about how dental professionals, not just dentists, are regulated by the GDC, but I agree with the comment from the noble Lord, Lord Lansley, about the impression it would give if other professions apart from doctors were regulated by the General Medical Council. Hitherto, the GMC has regulated only doctors, so it would have to be clear in the register how these people were differentiated. I am afraid that the solution of having a prefix on a register would not mean anything to patients.

In the past, if you walked around a hospital, it was easy to know who was a doctor, as they mostly wore white coats; who were the nurses, because they wore different uniforms, including the matron’s uniform, which was a different colour; and who was a trainee nurse, because they wore a pink uniform, which is why junior doctors referred to them as “pinkies”. Physiotherapists wore yet another colour of uniform. However, nowadays everyone wears suits or jackets or jerseys, so you cannot distinguish from that which profession is looking after you.

I take the point that the noble Lord, Lord Winston, made, that for all of us who have done surgery, a qualified, competent anaesthetist is our friend. But sometimes—as he and I have no doubt done—we operate on pretty vulnerable patients for whom the surgery is necessary but they are not a safe bet for anaesthesia, unless by an extremely competent anaesthetist. But I interpret the anaesthesia associate as someone who does not induce anaesthesia but only maintains anaesthetic under strict supervision by a qualified anaesthetist. And that is quite distinct from what a physician associate might do, because they might be involved in different ways in assisting the physician. The point made by the noble Lord, Lord Winston, is important because it is an example that shows up the importance of the scope of the practice of physician associates and anaesthesia associates.

It does not help—and this debate is an example of why so much concern has been expressed—when the NHS health careers website says, in relation to physician associates, that they will be trained in

“taking medical histories … performing physical examinations … diagnosing illnesses … seeing patients with long-term chronic conditions … performing diagnostic and therapeutic procedures … analysing test results … developing management plans”—

which I presume means patient management plans. If you see that, you can see why there are concerns and confusion over what their responsibilities will be and the limitation of the scope of their practice.

I absolutely appreciate the need for physician associates —I keep calling them assistants—and anaesthesia associates and the need for regulation, but I think this crosses the Rubicon since it is the General Medical Council that will regulate this. It is important that what it defines as the scope of the practice is understandable to patients and professionals clearly.

The noble Lord, Lord Hunt of Kings Heath, commented that he took the legislation through this House in 1999, and that Act will subsequently be the vehicle for SIs to be used for future regulation. I am sorry that some of us were not here at the time because some of us might have opposed it. An Act from nearly 25 years ago cannot be the one that continues to be used. If we are going to have further reforms of the regulation of doctors and nurses—where we are talking about 1.5 million health professionals, not 3,000 physician associates or anaesthesia associates—I hope we are not going to have an SI to do that, because there are lots of issues of regulation.

[Lord Hunt of Kings Heath (Lab)]

My Lords, to be fair, I said that that Act had been subsequently amended by the Health and Care Act 2022. If you do not have flexibility through regulation, you will never get anything done in relation to modernising health regulation. Governments simply do not find time in primary legislation to update regulation.

[Lord Patel (CB)]

I hope they do find time, because that allows for better scrutiny and better ability to amend, which we always claim to be our key role—to scrutinise and amend. It is a major piece of legislation to go through using SIs, and it is inappropriate to do so. Maybe we must consider how else we could do it in a way that maintains flexibility.

Moving on from that, as the noble Lord, Lord Harris, already mentioned, if this legislation is going to be the template for future legislation to regulate all health professionals, some issues will need to be discussed. This order does not require that health is considered as a category in the regulation of physician and anaesthesia associates. The statistics show that, when the GMC or, I presume, any other regulator investigates, it is a very stressful situation for the person involved. Some statistics suggest that one in three considers suicide; they are depressed by it. If the category of health is removed as a consideration when a person is investigated, as this order does, it is a backwards step. I need to ask the Minister why health has been removed as a consideration. If this is the template, I presume that this will also apply to other regulations in the future.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, the noble Lord, Lord Patel, just said many very important things, with which I agree, far better than I would. I thank the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, because this debate has revealed the importance of this order: it is not a minor regulatory matter that can be put through by an SI, in a back room. That it has created so much debate outside the Chamber indicates why it is important that we discuss this and that it is not nodded through behind the public’s back. I am glad of that.

I have been embroiled in discussions about this for some time. The noble Lord, Lord Hunt of Kings Heath, made a good point when he said that the discussion has become quite toxic. I thought it was perfectly reasonable to be worried about PAs and AAs; I did not anticipate this kind of savage attack on them. There has been a real scapegoating of these individuals, which is not how we should resolve this issue. We should also remember that doctors can be guilty of clinical negligence. We do not want to wander around pointing the finger at who is more negligent.

However, if there are preventable never events as a consequence of people not being fully equipped for the roles that they are asked to do—by the way, they are being asked, very often told, what to do when they are not really up to it, through no fault of their own—it is a matter for public concern. That is the way that accountability works and why we need to be very clear and have no muddle over what somebody is supposed to be doing, what they are not supposed to be doing, and what they can and cannot do.

There were a couple of things that confused me in the arguments made in the briefings we received. I lost the will to live in the rows going on about the differences between physician associates and physician assistants, as though “associate” or “assistant” was the key difference. I think the difficulty is when people think that any of them are physicians, because that means that they think they are doctors. That is the confusing bit and it shows that people can get lost in the midst of this.

It is also worth bearing in mind some context when it comes to the public. Most patients would prefer to see anyone at a doctor’s practice than wait for two weeks in pain. That makes the public vulnerable to having a lesser service. I understand that. I also thought that the noble Lord, Lord Patel, was absolutely right about a big team: when you are in hospital, you are surrounded by people wearing a million badges, different colours and lanyards. They all introduce themselves to you in great detail, but you do not care because you are ill. You want to lie back and trust them, and assume that a division of labour is going on.

Sometimes, when I was reading the briefings, it felt as though there might be a bit of vested interest about who was regulating who and what numbers were on the badges. This seemed to miss the point of the real concerns, which are whether there is sufficient clarity about the scope of PAs or AAs, or whatever we call them; that there is not too much mission creep; and that we have a clearly defined set of protocols and specific tasks allocated. I think it important that PAs in GP surgeries have a different set of protocols and scope than in hospitals—they are not the same, even though in both instances they are called PAs.

--- Later in debate ---

[Lord Markham (Con)]

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

[Lord Patel (CB)]

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

[Lord Markham (Con)]

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

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

NHS: Neurology Care

Lord Patel Excerpts

Monday 26th February 2024 Lords Chamber

[Lord Markham (Con)]

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

[Lord Patel (CB)]

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

[Lord Markham (Con)]

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

NHS: Dementia Commission Report

Lord Patel Excerpts

Thursday 22nd February 2024 Lords Chamber

[Lord Markham (Con)]

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

[Lord Patel (CB)]

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

[Lord Markham (Con)]

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

Premature Deaths: Heart and Circulatory Conditions

Lord Patel Excerpts

Tuesday 6th February 2024 Lords Chamber

[Lord Markham (Con)]

I thank the noble Baroness and draw attention to my register of interests: I am a shareholder in a small health company that does high-end heart tests for the private sector.

It is fitting that February is Heart Month. The concern that the noble Baroness raises is exactly the one that noble Lords will have heard me speak about. This is precisely the concern that Chris Whitty, our Chief Medical Officer, was worried about during Covid, with missed appointments because people stopped going to see their doctor meaning that we missed things such as high blood pressure and high cholesterol. To tackle the problem urgently, as the noble Baroness suggests, we have put 7,500 blood pressure checkers in pharmacies. They have done 2 million checks to date. We have sent 270,000 blood pressure monitors to houses and have instigated mid-life NHS health checks to look specifically at early heart indicators so that we can try to tackle the problem that the pandemic caused.

[Lord Patel (CB)]

My Lords, we have had lots of plans and initiatives for reducing deaths from heart disease. Despite that, variation in both preventive care and outcomes have persisted for years now. They are exaggerated by deprivation and ethnicity.

Let me give two examples. First, 40% of people with high blood pressure have failed to be diagnosed— I know that the Government have an initiative for pharmacies checking blood pressure—and, even when they are diagnosed, 10% of them do not get the appropriate medication. Secondly, there are examples of people suffering from atrial fibrillation not getting the appropriate anti-coagulation treatment; we then find that 60% of the strokes that occur in these patients are because they have not been properly medicated.

It is these variations in care and prevention that we need to tackle. It is disappointing to see that some of the ICB plans do not take on the need to reduce this variation, particularly in deprived areas.

NHS: Fracture Liaison Services

Lord Patel Excerpts

Monday 5th February 2024 Lords Chamber

[Lord Markham (Con)]

I thank the noble Lord. His interventions around the communications side are always welcome, because we recognise that it is one thing having a service and another thing making sure that the world knows about it. I will go and find out more and write to the noble Lord.

[Lord Patel (CB)]

My Lords, the fracture liaison service originally started in Glasgow, with the particular intention of identifying mostly women who had a higher risk of fractures from osteoporosis. In England and Wales, a fracture liaison service audit has been established now for several years. How do the Government receive the learning from those audits and how do they implement the learning that they receive?

[Lord Markham (Con)]

The noble Lord is correct; there has been some good evidence gained. As I mentioned previously, it shows that the probability of suffering from a fracture if you have been in a clinic is 10%—some studies have shown as much as 30% to 40%. It also shows, as my noble friend Lord Black was saying, that there is actually a good cost saving: it is thought that £65 million per annum will give a return of more than £100 million. There are some very good statistics around this, and I assure noble Lords that we are making a strong case for their expansion.

Smoking

Lord Patel Excerpts

Thursday 25th January 2024 Lords Chamber

[Lord Patel (CB)]

My Lords—

[Baroness Blackstone (Lab)]

My Lords, I refer to my interests as set out in the register. Would the Minister agree that smoking in pregnancy has enormously damaging effects, leading to much poorer birth outcomes than for mothers who do not smoke? Would he also agree that incentives to pregnant women not to smoke have been very effective? In the light of this, could he give a guarantee that the existing scheme, which comes to an end this year, will be continued with adequate resources, so that it is not in any way disrupted?

[Lord Markham (Con)]

I totally agree with the noble Baroness on the importance of stopping smoking—always, but especially during pregnancy. In fact, we have a maternity debate coming straight after this, where this will be one of the things that we discuss. I hope, from showing that we are putting all this spend in place, that we are backing everything that works. As long as the anti-smoking in pregnancy measure continues to work, that will be one of the major features to make sure that we are continuing to stop all activity, but especially in pregnant ladies.

[Lord Patel (CB)]

My Lords, in the light of the last question, I will change my question. What assessment have the Government made of the long-term harm that vaping will cause, particularly to young people?

[Lord Markham (Con)]

The honest answer is that we do not know yet, and that is a problem. As we know, a number of these things take time to play through. That is why we want to make sure we take a precautionary approach. In this legislation, we aim to really stop anything that is targeted at young people in terms of vaping. We see vaping as an important tool to help people quit smoking, but we are equally sure that we never want anyone to start vaping. That is why we will also look at banning anything that targets young people, such as flavouring and packaging. We want to stop anything targeted at youth vaping.

Maternity Services

Lord Patel Excerpts

Thursday 25th January 2024 Lords Chamber

[Lord Patel (CB)]

My Lords, I thank the noble Baroness, Lady Taylor of Bolton, for initiating the debate today on maternity services in England—or should I say, as has already been mentioned, the woeful state of maternity services in England as evidenced by a series of recent reports on their failings. Although we are debating maternity services, what we are really talking about is the state of care the nation is willing to provide for the mothers of the nation and their babies—the future citizens who will shape our nation.

I should say at the outset that I am well aware that good quality maternity services depend on the care and expertise that the key profession—midwives—provides. The rest of us, including obstetricians like me, are there to support them. I therefore fully subscribe to all the comments made about shortages of midwives and the quality of midwife care.

Before I go any further, I need to declare my interest: I am a lifelong obstetrician. I spent 37 years of my working life being one, and every minute of it was a joy and a pleasure. I would go back to it tomorrow if they let me—but they will not. I am also a fellow of several Royal Colleges, but that is totally irrelevant.

I am pleased to take this opportunity to put on record my eternal gratitude to all the thousands of mothers who afforded me the privilege of being a part of their lives at the most important time of their lives: during their pregnancy and the birth of their baby. I learned that pregnancy and childbirth give a whole new meaning to the word “beautiful”.

I had a special interest in looking after mothers who had preexisting conditions that could affect their pregnancy and the unborn baby, or who developed complications that may have threatened their pregnancy and the life of their baby. I was privileged to be able to do so. Understandably, these mothers were anxious and hoped all would go well. I remember one occasion when I delivered the healthy baby of a first-time mother who had diabetes and had had quite a challenging time during her pregnancy, to say the least. I noticed the pleasure on her face—I have seen it a thousand times; it is quite remarkable when a mother sees her baby for the first time—and I asked her how she felt. After thinking for a minute, she said: “I know the days will be shorter and the nights longer; clothes will be shabbier, but the future will be happier. I will forget the past. The baby will make love stronger. I was a woman yesterday; I am a mother today”. I will never forget that. To witness the joy in her face was a privilege. Sadly, according to recent reports, this is not the case for hundreds, if not thousands, of mothers. It should not be so. We should be ashamed that it is so for even one mother—but it is so for thousands, according to the reports already mentioned.

I was fortunate to be part of a team of professionals—midwives, obstetricians, anaesthetists, neonatologists and others—who were all committed to providing the best possible personalised care to all mothers and their babies. We never lost a mother in three decades, and had zero tolerance to intrapartum stillbirths. Weekly perinatal meetings were mandatory for all to attend to make sure that adverse events were fully discussed, learned from and never repeated.

The Government believe, as was noted by the noble Baroness, Lady Cumberlege, that the NHS is one of the safest places in the world to give birth. Minister, it was. In the past, our maternity services were where others came to learn. Why were our maternity units regarded as the best? It was because, as now, dedicated professionals provided safe, compassionate care to mothers and their babies, and took pride in doing so; and, importantly, they were left alone to get on with it.

Multiple reports from the CQC, as has already been mentioned, and independent investigations into several maternity units in England have shown that care is not safe, resulting in unacceptably high levels of harm to mothers and their babies. We all know that there are more such reports to come. While workforce shortages, pressures of work, lack of communication, and poor governance are all cited as possible problems, and they undoubtably are and need to be addressed, I believe that the genesis of the long-standing problems is deeper and goes further back. Therefore, I support absolutely the plea made by the noble Baroness, Lady Cumberlege, for a new beginning for maternity services.

The response from the Government and organisations responsible for the delivery of maternity services to adverse reports is to produce more documents about what they will do—set up a task force, a workforce plan that may deliver in five or 10 years, safety organisations, three-year plans, long-term plans, and much more. These lack implementation plans or regular outputs to demonstrate success.

The quality of maternity services is a bellwether for the quality of services in the rest of the NHS. Levels of maternal and perinatal deaths are good indicators of the quality of maternity services, as evidenced by several of the investigations. In this respect, as has already been mentioned, the latest maternal mortality report is a cause for concern in many ways. Confidential inquiries into maternal deaths were formally established in 1954, although their predecessor existed from 1928: it is the world’s longest-running successful audit system of healthcare and is a good barometer of the performance of the maternity service.

As has been mentioned, the latest report from MBRRACE of deaths between January 2020 and December 2022 shows that the rate of maternal deaths was 13.41 deaths per 100,000 maternities. That is the highest in the last two decades and much higher than the rate of 8.79 among the 2017-2019 cohort. Even after removing deaths due to Covid-19, the rate is significantly higher than among that cohort. The UK now has one of the highest maternal mortality rates in the developed world, compared with Norway’s 2.79, Germany’s 4.0—which, by the way, has remained static for 20 years—and France’s 6.0. We are way behind.

The main causes are important. The first is thromboembolic disease. We require a clear strategy for how we are going to reduce this, because it has remained the number one cause now for decades. I urge the professionals—the Royal College of Midwives and the general practitioners, obstetricians and psychiatrists—to come together to produce clear guidelines on how these deaths will be reduced. The second is cardiac disease. These deaths are preventable. Third, importantly and very tragically, are suicide deaths. These are vulnerable women whose mental health condition is not difficult to recognise during the antenatal period. They are women who might be abused in the house; women who are further abused when they take home a baby. We should not, as a society or as professionals, fail them, but we do. These 39 suicide deaths are tragic deaths: all maternal deaths are tragic, but these are particularly so. They are preventable and we should address that.

Maternal deaths also show up gross inequalities related to ethnicity and deprivation, as has already been mentioned several times. Black mothers have four times the risk, Asian mothers have twice the risk and mothers from deprived populations have twice the risk. These are not new or surprise findings, as mentioned by the noble Baroness, Lady Taylor of Bolton: inequalities in care and outcomes have been well documented for a long time. The Government have produced plans to try to reduce these, but none has shown any results. Can the Minister say which of the plethora of initiatives to reduce harm, deaths and inequalities in maternal health have had any effect? What benefits have been derived from the work of the Maternity Inequalities Oversight Forum, the Maternity and Neonatal Care National Oversight Group, the Maternity Disparities Taskforce, or the several other initiatives, in reducing inequalities and the deaths of mothers and babies and improving maternity services?

What we do have are repeated reports of high-profile organisational failures, soaring clinical negligence claims, huge variations in outcomes and in the culture of care, workforce challenges, inequalities in care and outcomes linked to ethnicity and depravation, rising maternal and perinatal deaths, and serious safety issues, to the point that the regulator, the CQC, says that England’s maternity units currently have the poorest safety ratings of any hospital services it inspects. Does this not all add up to a service that needs radical reform? Is it not time we had a root-and-branch independent review of maternity services that brings about the changes needed to have a world-class service that is compassionate, safe and delivers world-leading outcomes for mothers and babies? Can the Minister say why we should not have such a review, as part of his answer as to what difference all the initiatives so far have made to improve the service, with real figures to demonstrate it? I know he is fond of data as evidence.

Adult Social Care: Staffing

Lord Patel Excerpts

Tuesday 12th December 2023 Lords Chamber

[Lord Markham (Con)]

Charging reform is still part of the Government’s commitment. At the same time, I think we all recognise that, largely as a result of the pandemic, we had to stabilise the social care situation first. That is what the £8.1 billion in funding has been all about and what the investment and recruitment have been for—so that we can stabilise first. I am glad to say that we are reaching a more stable footing. For the first time, staffing went up over last year and, likewise, the number of people in social care went up. We have to stabilise before we move on to the reform. I think we would all agree that the speed of reform needs to be a bit quicker, but it is sensible that we stabilise the situation first.

[Lord Patel (CB)]

My Lords, in the Government’s search for long-term sustainable funding for adult social care, what assessment have they made of the successful models that operate in Germany and Japan, for instance?

[Lord Markham (Con)]

The shorthand for the German system is the “double doughnut”, which tries to give wraparound care. We can learn many things from that system, which is why a part 2 reform needs to happen here. I accept that we are clearly not there yet.