United Kingdom: Future Pandemics

Lord Patel Excerpts

Monday 16th January 2023 Lords Chamber

[Lord Patel (CB)]

My Lords, the Minister is absolutely right that we led the world in sequencing the genomes of Covid-19, particularly identifying the variants worldwide. But since we have now closed down many of our sequencing facilities, how can we surveil internationally, particularly for emerging variants? For example, XBB1.5 is now emerging as the variant causing most of the infection, probably including in England. What is our surveillance mechanism for sequencing?

[Lord Markham (Con)]

Given the detailed nature of the question on sequencing, it probably deserves a detailed response. I will happily write on that. The 100 Days Mission—to deploy effective diagnostics, therapeutics and vaccines within 100 days—is all about having UKHSA ensure that we have a preserved capability to act when we need to.

NHS Winter Pressures

Lord Patel Excerpts

Tuesday 10th January 2023 Lords Chamber

[Lord Patel (CB)]

The Minister may not agree, but the NHS is in crisis. He may say that the situation is “challenging”, but it could not be more challenging. Although infection rates related to Covid, flu and other infections may have exacerbated the situation, the genesis of the crisis is not of today’s making. It has been in the making for years. It is related to lack of capacity. Does he agree that the emergency measures now being put in place are not likely to work? If they are not likely to work, what is plan B? Importantly, what is the long-term plan to ensure that this does not continue into the spring, summer or next winter?

[Lord Markham (Con)]

I absolutely think these measures will improve the situation; I would not be putting them forward if I did not believe that. At the same time, just as we put out plans in October and are amending them now, I will continue to amend our plans. I think that is a flexible, responsible approach: you have a plan, you adapt that plan, you invest and you continue to improve. That is what we will continue to see and do; we will see those improvements go through this year and into the next.

Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022

Lord Patel Excerpts

Monday 9th January 2023 Grand Committee

[Lord Harris of Haringey (Lab)]

My Lords, the noble Lord, Lord Hunt, has effectively declared my interest for me. However, just for the record, I declare that I am chair of the General Dental Council and have been for the last 15 months or so. I am grateful to the Minister for introducing and bringing forward this order. I think we will all benefit from the fact that he has some familial insight into the issues that we are looking at here and in other matters.

I hope that the Minister will accept that this order has been quite a long time coming. It was already long awaited when I was appointed 15 months ago, and the discussion has been going on since at least 2017. This particular order has been introduced twice in the past few months, before the present order; it had to be withdrawn and introduced again, for various technical reasons.

I start by saying clearly that the General Dental Council welcomes this order. However, I want to take this opportunity, in Grand Committee, to make it clear what this order does and does not do. As I think has been said by all noble Lords who have spoken so far, internationally qualified dental professionals make a vital contribution to the UK dental workforce. In recent years, more than one-third of newly registered dentists have qualified overseas, and current workforce pressures would be immeasurably greater without the contribution that they make. However, the current processes for international registration are cumbersome and inefficient. Existing legislation imposes considerable constraints on the GDC’s ability effectively and efficiently to assess the skill and knowledge of internationally qualified dental professionals. For dentists, there is an overseas registration examination with a very rigid structure and, because of the statutory framework, a very limited range of providers. This results in places not always being available for candidates who want to sit the exam.

Quite properly, nothing in this order reduces the high standards required of international candidates seeking to join the UK register. I am sure that the Minister will want to reaffirm that that remains the Government’s priority. Certainly, public protection is, and remains, central to the purpose of the General Dental Council. The standard applied to international candidates is, and should be, equivalent to that applied to people who register based on UK qualifications. Nobody will want to see those standards compromised, least of all the GDC, and the changes made by this order protect those standards but will enable modernised and more flexible approaches for assessing whether candidates have met them.

The order brings in some immediate changes, 21 days after it has been made—so we are probably talking about March this year. From that point, a number of changes will happen immediately. At the moment, the overseas registration examination is in two parts: the first is effectively a written process, and the second a practical test of skills. It is a requirement of the existing legislation that the second part must be concluded within five years of the first part. During the Covid pandemic, part 2 exams had to be suspended and, through no fault of their own, some candidates missed the opportunity to take part 2 because the five-year time limit had expired and therefore lost the opportunity to be registered, because you cannot simply start again. Those affected will now have restored to them the opportunity to sit the second part of the ORE. That is welcome, and it addresses an injustice for those affected as a consequence of the pandemic.

The second immediate change, which my noble friend Lord Hunt of Kings Heath has referred to, is that new applications to the dental care professional register must be based on the primary qualification appropriate for the professional title being applied for. That stops a loophole whereby applicants who are qualified only as dentists have been seeking to register as a DCP. The Committee needs to know that there has been a flood of such applications in the last year: some 1,075 international candidates for registration as DCPs have been approved, which is more than the total number currently on the DCP register from any source. That enables them to practise in this country without going through the more appropriate ORE process for registration as a dentist. There is also now a considerable backlog of applications all seeking to make use of the loophole before it is closed to new applicants 21 days after the order is made. This change is important and overdue. The lack of clarity about what individuals are qualified to carry out in terms of their professional duties is not helpful, and therefore the loophole needs to be closed. The delays and the flood of applications to try to avoid the deadline are causing considerable operational issues for the GDC in managing all overseas registration, and indeed registrations of UK-qualified dentists.

At the same time, the order is going to give the GDC some new powers, although they will take some time to have practical effect. The requirement for assessments of international dentist applications to be conducted by a dental authority—effectively, a dental school—will be removed. Over time, that will give the GDC much greater flexibility in procuring providers and potentially in designing new assessment models. For example, it might be possible to look at the question of whether the first stage of the overseas registration examination has to be taken in this country or whether it could be taken overseas. That flexibility will be sensible, given the current problems in finding suitable providers. However, it is important to stress that this will not have an immediate effect while current contracts remain in place.

The GDC will also gain the power to make detailed rules about how applicants should be assessed. There will be a requirement to consult on these rules and, critically, the current requirement for Privy Council approval will be removed. The practical effect is that the rules can be more flexible and responsive to changing environments, not the least of which is that the fee can reflect the cost, which at the moment is not necessarily the case until it has received Privy Council approval.

The point is that the order is a vital enabler of reform but does not in itself deliver it. Removing the overly prescriptive constraints is a vital first step towards creating a more effective system but it does not and cannot provide an immediate increase in the dental workforce. The rule-making powers in the order do not come fully into effect for 12 months, and even then it will take time to develop new approaches, consult on new draft rules and procure the supply of the necessary services. Alongside that we have the continuing uncertainty about the different provisions that currently apply to people who can currently benefit from the continuing recognition of EU qualifications. If the Government choose to close that route as a result of the review that they are required to undertake this year, significant additional capacity will be required in the GDC’s assessment processes. Any indication today from the Minister as to whether the existing arrangements for applicants from the EEA will continue would be most welcome.

The order provides provisions for the GDC to explore alternative processes for the recognition of international qualifications. Incidentally, it should not be confused with the powers included in the Professional Qualifications Act that allow for the mutual recognition of qualifications through international agreements: they are outside the scope of this order.

Enabling the recognition of international qualifications is not as straightforward as it might at first appear—and there is certainly no quick solution. New processes for the quality assurance of education and training to secure public protection will be needed, alongside new fee structures. This type of recognition may need to be specific to an institution and qualification. It is not, therefore, a quick solution to workforce challenges. The approach taken would have to be fair to those who undertake the UK qualifications, and indeed to the institutions providing them. Also, any route to recognition would need to be applicable globally and take into account the very different standards and approaches to qualifications around the world.

The key point is that none of these changes will solve the wider problems of access to NHS dentistry. The role of the GDC is to register dentists and dental care professionals who are fit to practise in the UK. But there is a separate process before they can work in the NHS. They still need to go through the performers list validation by experience process to practise in the NHS for each UK nation in which they want to practise. So streamlining the ORE process does not in itself deliver more NHS dentistry. I appreciate that the Minister did not assert that that would be the case, but I have heard that view expressed in various quarters, perhaps by former Ministers, which makes it necessary to reinforce the point.

More significantly, if the NHS dental contract fails sufficiently to incentivise UK-qualified dentists to provide NHS dental services, it is not immediately obvious that overseas-qualified individuals faced with the same set of incentives will choose differently from their UK-qualified counterparts. The BDA in a recent briefing warned that

“NHS dentistry is facing existential threat”,

that even before the pandemic

“only enough dentistry was commissioned for half the population in England”

and that the proposed package of changes to the NHS contract announced by the Government in November was “modest” and “marginal” and would

“do little to arrest the exodus of dentists from the service, or address the crisis in patient access.”

Those were the BDA’s words, but I hope that the Minister will be able to give us some assurance on the nature of the discussions that will take place on the future of NHS dentistry and the NHS contract.

To conclude, these changes in the international registrations order are welcome, but they will not address the fundamental issues.

[Lord Patel (CB)]

My Lords, I will be very brief, because many of the points I might have made were more eloquently made by the noble Lord who just spoke.

The only thing I will say is that, from my experience when I chaired the previous assessor of postgraduate medical training, the Specialist Training Authority, which was established following the EU rules, the same problems occur in recognising equivalence of training. It is easier to recognise a qualification, but when you recognise equivalence of training, it has to take into account, as already elucidated, not just the knowledge but the experience and skills that practitioners can have.

It is even more difficult when you try to certify somebody or accredit somebody with a qualification that is highly specialised—including in dentistry. For instance, they might not be a general dentist but you might want to recruit them because they have specific, high-quality training in a very specialised area. Assessing their equivalence is then made that much more difficult. So the points are well made about an order that I welcome for its simplicity—but it does have drawbacks that need to be addressed, and one way to do that would be to give the General Dental Council more authority to implement its own processes to assess qualifications, experience and training.

I turn now to the nursing and midwifery side, which is a slightly different issue. We should distinguish between qualifications and certifications. While we train nurses as graduate nurses—and that applies to midwives too—not all countries have graduate programmes in nursing and midwifery. They are trained and certified to be fully trained midwives, and having the Nursing and Midwifery Council to assess qualifications, experience and training makes it that much more difficult.

National Health Service (NHS Payment Scheme—Consultation) (No. 2) Regulations 2022

Lord Patel Excerpts

Monday 9th January 2023 Grand Committee

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

My Lords, I start by wishing everyone a happy new year and welcoming the noble Lord, Lord Allan of Hallam, to his position. It gives me great pleasure to speak in this debate and I welcome the opportunity to discuss these draft regulations.

The Health and Care Act 2022 marks an important step in the Government’s ambitious health and care agenda. Noble Lords will be fully aware of how wide-ranging a piece of legislation it is. I think we can all agree with its overall objectives; making it easier for health and care organisations to provide joined-up care is vital.

With the introduction of integrated care systems came the opportunity to review how the financial frameworks in the NHS worked and tailor them to make them consistent with the new integrated approach. The Health and Care Act replaces the NHS national tariff payment system with the NHS payment scheme by inserting new Sections 114A to 114F into the Health and Social Care Act 2012. As with the tariff, the NHS payment scheme will set rules around how commissioners establish the amount to pay providers for healthcare for the NHS. It does not set the amount of money available but intends to make sure that available resources are used as effectively and efficiently as possible.

Before a new payment scheme can be published, NHS England has a duty under the Health and Social Care Act 2012 to consult on the proposals for the new scheme, as it did with the tariff. NHS England is required to consult each integrated care board, each relevant provider and other such persons it considers appropriate. It opened the consultation on the proposals for the 2023 to 2025 payment scheme on 23 December 2022, which is scheduled to close on Friday 27 January 2023.

This brings me to the purpose of these regulations, which is relevant to how those consulted respond and what this means for NHS England. The purpose of this SI is to set these objection percentage thresholds at 66%, which will be reached if the requisite percentage of either integrated care boards or providers object. I believe this is a proportionate level to ensure that a qualified majority can require NHS England to reconsider its proposals, while minor objections cannot stop them. I also consider laying these regulations to be a relatively administrative process. The objection percentages are not changing compared to previous consultations on the tariff; we are maintaining the status quo with 66%. I commend these regulations to the Committee.

[Lord Patel (CB)]

My Lords, I thank the Minister for his comments. I too wish everybody a happy new year. My question is quite simple, and it reflects the discussions we had during the debate on the Act that we passed: is 66%, which is two-thirds, too high a level for the objections? It is a higher order to achieve than, let us say, 60%.

While we await the tariff, I reiterate, so that it is on record, that the important bit is not the level at which the trusts and ICSs can object but how the tariff will vary according to the needs of the population. When we had the debate, we focused on existing inequalities in health and how to minimise and reduce them. One way of doing that is to address the needs of the population who have greater need in healthcare, and therefore the tariff needs to be different. It is a high order to require 66% of ICSs, trusts or providers to object.

I would like the Minister to confirm that the tariffs will reflect the need for the levelling-up agenda to improve healthcare, particularly in more deprived populations, and to comment on why 66%, which is two-thirds, was chosen.

[Lord Allan of Hallam (LD)]

My Lords, I am pleased to be able to take the reins from my noble friend Lady Brinton, starting with this short but important statutory instrument. I echo the happy new year wishes and thank the Minister for his welcome. I understand that a key function that we perform in this House is to ensure that legislation is implemented in the way that Parliament intended as we put flesh on the bones of primary legislation through statutory instruments such as the one we are considering today.

Today’s statutory instrument is a small element of an important part of our modern health service infrastructure: the mechanism for pricing services within the NHS’s internal market. It was a prompt for me to read more pages of tariffs and rules than I ever intended or wished to do, which is mind-boggling and fascinating in equal measure. The subject of our debate today is not the substance of the payment scheme but rather the trigger for when the scheme might be reviewed if there are objections.

As the Minister pointed out, the Government’s intention is to maintain a 66% objection rate for triggering a further consultation period, which is unexceptional as it maintains the previous level. However, like the noble Lord, Lord Patel, I am curious as to why 66% was picked, particularly as I understand that it will not trigger a referral to the Competition and Markets Authority, which would have been a major step, but simply a further consultation period. There may be an argument for why a 51% or 60% threshold would not be appropriate, given that the threshold triggers something less significant than the previous regime.

I am also curious about the experience that we have had over the last decade or so while the other tariff scheme has been in place. Does the Minister have data on the levels of objections received in previous consultations? I suspect that they were much lower than the level we are talking about here but, as we review the scheme, it would be interesting for us to understand whether we were previously getting 10% objection levels, or 50%. I assume that there must be some experience of that within the National Health Service.

Like the noble Lord, Lord Patel, I would like more words about why 66% remains the effective level, and some information about objection levels we have experienced previously. That would be helpful to put our minds at rest, but I think we are all broadly supportive of the instrument as it stands.

Plastics: Health Research

Lord Patel Excerpts

Monday 19th December 2022 Lords Chamber

[Lord Markham (Con)]

The phrase I used was that there is “limited evidence” in this space. I reiterate that if a good research proposal is put forward, funds are available there. The only point of difference on this is that I do not believe we should ring-fence a definite amount each year when the evidence does not yet exist that it is a health risk.

[Lord Patel (CB)]

My Lords, the Minister suggested that his scientific advisors told him that there was no evidence. Finding “no evidence” does not scientifically prove that there is no evidence. It has been said several times that if a scientific proposal was put forward, it would be looked at. Accepting that plastic pollution is a problem, should the NIHR not put out tenders inviting research proposals?

[Lord Markham (Con)]

Again, my wording was “limited evidence”. There are many demands. It feels as though every day I am up here being asked to spend money on something else. As a responsible Minister, I must prioritise spend in areas where it is needed. At the moment, I am being guided by the science, which tells me that there is very limited evidence in this space. If a good proposal is put forward, we will welcome it and look into it. Until then, this is not good use of public money.

Hospital Beds: Social Care

Lord Patel Excerpts

Monday 19th December 2022 Lords Chamber

[Lord Markham (Con)]

I thank the noble Baroness. We are all seeing different shapes and forms of describing how we need a local care system set up by the integrated care boards that can have an overview of all the needs in their area. That is exactly what we are doing, and exactly what the Patricia Hewitt review is reviewing. It will give advice on how best to do that by looking at the best needs of mental health care patients, or any other kind of patient, to make sure that the proper institutions and places are set up to give them the up-front support so that, as the noble Baroness said, they never need to go to hospital in the first place.

[Lord Patel (CB)]

My Lords, while recognising the current problems caused by bed blockages in NHS hospitals due to capacity and social care issues, does the Minister agree with the report from the Health Foundation, which, looking ahead, suggests that, because of changing demography and disease patterns in future, we will require between 25,000 and 40,000 more beds in the NHS if we are going to cope with the pressures on both the NHS and social care? What plans do the Government have to address that?

[Lord Markham (Con)]

We are absolutely aware that we need long-term plans and forecasts. That is also one of the things that the healthcare workforce plan will take into account: it will look at exactly where the capacity needs to be on a regional basis going forward so that we have the right number of hospital beds and social care places for an elderly and growing demographic in terms of age groups.

NHS Waiting Times

Lord Patel Excerpts

Tuesday 22nd November 2022 Lords Chamber

[Lord Markham (Con)]

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

[Lord Patel (CB)]

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

[Lord Markham (Con)]

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

Ambulance Delays

Lord Patel Excerpts

Wednesday 9th November 2022 Lords Chamber

[Lord Markham (Con)]

The government pledge of 50 million additional appointments is across the country. It is the job of the ICBs to make sure that each area is well catered for; the idea is that this is felt in every area, including rural areas. I am glad to say that we are making good progress on our target to increase appointments by 50 million and, rest assured, I am working with the integrated care boards and their systems to ensure that they touch every part of England, including rural areas.

[Lord Patel (CB)]

My Lords, the Minister said that this is a systems failure. Who in the Government is responsible and when will the system be fixed?

[Lord Markham (Con)]

I think I said this is a systems issue. It is something on which we—including me and the Secretary of State—are very focused, because we need to address it across the piece. That is what the ABCD plan is all about. I am very confident that, over the coming weeks and months, we will start to see improvements from the investment we are making in 7,000 more beds and £500 million more into adult social care discharge.

British Heart Foundation: Tipping Point Report

Lord Patel Excerpts

Tuesday 8th November 2022 Lords Chamber

[Lord Markham (Con)]

I will check on that. I have been told that it is being done as part of that. It is available in a large number of pharmacies now and we have sent out hundreds of thousands of blood pressure monitors, so people can do it from home. It is fully understood that it is a vital part of early monitoring and we have a three-pronged strategy to make sure that we can measure people’s blood pressure at every point of contact.

[Lord Patel (CB)]

My Lords, the report identifies shortcomings in the delivery of primary and community care for patients with cardiac disease, which is a systems failure. I have no doubt that there will be similar findings for patients who suffer from other chronic diseases. Does the Minister agree that it is time to look at a systems change in the delivery of primary and community care, incorporating advances in technology and digital healthcare that would improve access for patients?

[Lord Markham (Con)]

Yes, we all agree that prevention is better than cure. One of the few benefits of Covid was that millions of people downloaded the NHS app. People are using that for self-diagnosis now, in exactly the way that has been mentioned. In October alone, 500,000 people used the app for self-diagnosis, the healthy heart blood pressure MoT and diabetes checking. That is part of this and it is all part of our five-year healthier life plan, which, as mentioned, is very much focused on MoTs from age 40 onwards, so that we can diagnose these problems early. Our focus should absolutely be on prevention rather than cure.

NHS: Nurses

Lord Patel Excerpts

Tuesday 1st November 2022 Lords Chamber

[Lord Patel (CB)]

My Lords, shortages of NHS staff, whether they be nurses, physiotherapists, doctors, dentists or community nurses, results in poor service. What plans do the Government have to make primary and community care more sustainable in the long term?

[Lord Markham (Con)]

The plans are very much those that we are doing, which I believe are successful. As mentioned before, it is not just that the number of nurses has gone up by 29,000; we have seen significant increases in doctors and the other medical professions as well. We should remember that we have 200,000 more people working now within the profession than in 2010. That is not to say that we will rest on our laurels; I completely agree that we need to carry on expanding supply to ensure that we properly meet the demand.