Sodium Valproate and Pelvic Mesh

Baroness Brinton Excerpts

Monday 25th March 2024 Lords Chamber

[Lord Markham (Con)]

My noble friend is correct on this. Probably the best way to do that is to come back in detail in writing, because it is vitally important.

[Baroness Brinton (LD)]

My Lords, in response to the noble Lord, Lord Hunt, the Minister said that Minister Caulfield had commissioned this report, but he misses out at least three years of work earlier. There was the report of the noble Baroness, Lady Cumberlege, and there was a long debate during the passage of the Health and Care Act when Nadine Dorries said she would look at commissioning something and then refused to do so. This is not recent history. Will the Minister please give this House a date on which the Government will come back to Parliament with a response?

[Lord Markham (Con)]

The point I was making was that Minister Caulfield absolutely agreed with the point the noble Baroness makes that the delay had been too long, and so it was she who came forward and said that she wanted to commission the Patient Safety Commissioner to report exactly in this area. So that was her being proactive on all this. In the same way, she says that she is determined to get a response back in the next few months. I cannot give a specific date yet, because it is a complicated area which involves industry, many government departments and the devolved authorities. However, as the Chancellor said, this remains a top priority area for both the Chancellor personally and the Government.

Anaesthesia Associates and Physician Associates Order 2024

Baroness Brinton Excerpts

Monday 26th February 2024 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare that I am a doctor registered with the General Medical Council, a member of the BMA and a fellow of the Royal College of General Practitioners and the Royal College of Physicians.

We have physician associates and anaesthesia associates seeing patients, examining them and advising them, who are as yet unregulated. All responsibility for their behaviour rests with the doctor who is their supervisor from whom they have delegated responsibility. The professional scope of practice for these associates can vary widely across the country. It is determined at a local level and patients have no idea about the variation.

There is a golden thread in clinical care that the most experienced person delegates down. They delegate down tasks that they know the relevant team member has the skills to undertake. A key skill in medicine, gained with extensive experience, is the integration of all the relevant information, evaluation of risk and prioritisation. Currently a problem in the whole of the NHS is that we expect staff to refer upwards and the boundaries are unclear.

A case of non-accidental injury in a child has been brought to my notice where the expert evidence was provided by a physician associate whose relevant experience is unclear at best. This blurring is misleading to non-medical professionals, including the police, judiciary and legal professionals. Supervision must be mandatory and stipulated in the GMC’s Good Medical Practice.

The junior doctors’ discontent, which we have heard about already from the noble Baroness, Lady Bennett, is boiling over. After training, medical graduates emerge with huge student debts to work a 40-hour week for just over £32,300, only to find that after a two-year postgraduate programme a physician associate typically earns between £3,000 and £11,000 more, for only 37.5 hours a week. All this has inflamed tensions—although I would say that direct verbal attacks on physician associates and anaesthesia associates, who have trained in good faith and with good intent, are not appropriate and I would not condone them.

Doctors are the only healthcare professionals who must undergo extensive, nationally stipulated postgraduate training before being appointed to a permanent senior role. Without long-term job security, these juniors rotate through departments, sometimes commuting many miles. They find that they do not belong and do not feel part of the team or valued, while patients miss out on continuity of care.

Very importantly, patients seen by a physician associate sometimes think that they have seen a doctor. The term “physician associate” gets muddled with the specialty and associate specialist doctor, who often has years of experience. Can the Minister clarify whether the term “physician associate”, which is so misleading, will become a protected title after this order passes? How can the name then be changed to revert to the more accurate “physicians’ assistant”? Currently, no medical titles are protected: “doctor” is not and grades up to and including consultant are not, which is another source of confusion. How is that going to be cleared up?

The cost-efficacy basis for these posts has been questioned in a recent paper, showing how the cost of one consultant anaesthetist supervising two operating theatres with an anaesthesia associate in each—that is, three staff—is more expensive than having two consultants doing one list each. The risk is higher if a problem arises in both theatres, especially in an anaesthetic emergency, when deterioration and brain damage can happen in minutes.

This crisis has been 20 years coming because we failed to expand medical school places or to register these new healthcare roles and define their scope of practice. What is the solution?

I fear this order will not solve all the problems. Yes, physician associates and anaesthesia associates must be regulated. It seems an outrage that people with such responsibility have been around for 20 years, unregulated, and a decade after that was recommended. The General Medical Council, in taking responsibility for regulation, must keep the register completely and clearly separate from that of medically qualified doctors. Can the Minister confirm that this clarity will be a legal requirement?

I tabled my regret amendment because it must be clearly on the record that the concerns exist, that some current regulation around the Medical Act needs updating urgently and that the GMC must be held accountable to Parliament, as has been explained by the Minister. Regulation is essential, but it is not the end of the issue; it is only the beginning.

The GMC must tackle the inappropriate way that some courses are advertised, which state that they train PAs

“to work as a safe and competent medically trained healthcare professional”

or to

“be a medically trained, generalist healthcare professional”

—which sounds awfully like a GP to me. Some courses describe working under a senior physician, but others say nothing about supervision. The anaesthesia associate courses differ slightly. They make it clear that, at present in the UK, only doctors who have specialist training in anaesthesia can administer anaesthetics and that the anaesthesia associate works as part of the anaesthetic team.

Next, the scope of practice must be clearly defined and agreed at national level, so that any employer is aware of what the associates should be doing and how the senior doctors must supervise them on site. Employers must also ensure that all patients know the qualification level of the person seeing them. Seven-day services are essential for patients.

Medical postgraduate training itself is in crisis. The royal medical colleges, the Academy of Royal Medical Colleges and the GMC must get together urgently to address postgraduate training. Perhaps it could be shortened, with post consultant-level fellowships to develop highly specialised skills and bring innovation to healthcare. Lifelong learning is essential; it is the essence of growing a good medical workforce in the long term. Medical schools, as they welcome the increased numbers, must look at how those who might wish to convert to a medical degree can be credited with their prior learning and experience, and tackle regulatory blocks in funding and timing.

Importantly, the title must be reviewed. The terms “physician assistant” and “anaesthesia assistant”, in use until 2014, clearly denoted the role as having delegated responsibilities from a supervisor. If “physician associate” and “anaesthesia associate” are to be protected terms, then we need a designation of medicine that clearly identifies a medical degree—similar to the American MD designation, for example. Patients must know who has seen them.

To summarise: patients must know the level of training of the person whom they have seen. Physician associates and anaesthesia associates must be regulated with appraisal and ongoing learning, including revalidation. The scope of practice of this new workstream must be defined to ensure that they have clear boundaries and supervision must be defined as being closely supervised on site to ensure patient safety. People must not be misled into believing that they are completely independent practitioners.

[Baroness Brinton (LD)]

My Lords, I am grateful to follow both the noble Baronesses, Lady Bennett and Lady Finlay of Llandaff, and I have been crossing out large chunks of what I was going to say, which I hope will be helpful to Members of your Lordships’ House.

As both of the other noble Lords have, I want to start by saying that this is not an attempt to discredit the many PAs and AAs who do an extremely good job. We need to understand that, and we need to understand that our health system must change and modernise. The issue is what is happening in our NHS and how the role of PAs and AAs is impacting not just on patients—I will come to the detail of that in a minute—but on the working of supervising doctors and junior doctors. All of those groups are in crisis, and this just seems to be adding further problems.

I echo the points made by, I think, the noble Baroness, Lady Bennett, about the Secondary Legislation Scrutiny Committee, which the Minister referred to in his introduction. In the committee’s report to us, it says three times that the Explanatory Memorandum assumed understanding and that it was not good enough. I ask the Minister if he will work with his officials to ensure that any more Explanatory Memorandums that come forward, not just on this issue but on others, are very clear and do not assume prior knowledge.

All of us have said that PAs and AAs—I am not going to keep saying physician associate and anaesthesia associate because it takes too much time—are not a replacement for doctors, though not one of us believes that that is the case. I am going to start with the title. The Royal College of Physicians and the Faculty of Physician Associates, which sits within the RCP, has guidance on the associate title and introduction guidance for PAs, supervisors, employers and organisations. What it says is in complete contradiction to what is happening on the ground:

“It is our view that, when a PA introduces themselves to a patient or staff member, they must make it clear at the start of the interaction that they are a physician associate, as well as explain the use of the term ‘PA’ … PAs must correct patients and staff if they refer to them as a … doctor, nurse or other professionally protected role title. This includes verbal, written and other forms of communication”.


Like other noble Lords, I have been inundated with letters from doctors and patients saying that they have been misled—not in the deliberate sense, but that PAs have not been correcting the record when someone has called them a doctor. The BMA, in its very helpful briefing, said that:

“To patients, PAs and AAs and doctors may look the same and appear to be doing a similar job”.


The problem, as the noble Baroness, Lady Finlay, said, is that the title is confusing. “Physician associate” perhaps implies that they have the same level of expertise as doctors. Unfortunately, as the noble Baroness, Lady Bennett, said, this has already led to a tragedy. Emily Chesterton died, aged 30, after two appointments with a PA who she believed was a GP, where mistakes were made.

A further difficulty, particularly in GP practices, is that GPs are beginning to worry that they are going to spend their entire time supervising PAs, as well as seeing patients with chronic diseases, and will not see ordinary people at all. Trainee GPs are worried about how they are going to be supervised. How is the Minister going to ensure that the issues of supervising and training, which are very serious, will be dealt with after the passage of this SI—because I do not think any of us are planning to call a vote today?

We have heard that, across acute trusts and GP surgeries, doctors have reported 70 instances of avoidable patient harm and near misses caused by PAs. That includes fatalities, missed diagnoses resulting in terminal diseases, missed DVTs, sepsis, heart attacks and haemorrhages. Missed cancer diagnoses in primary care has therefore emerged as a significant issue. In England, 74 acute trusts have replaced doctors with PAs on the doctors’ rota. Even if those PAs are supervised, that means that doctors who should be seeing patients are supervising more and more people. It is not a zero-sum game. One trust—I think it was Leeds, from memory—had a paper on how much more beneficial PAs were on the rota because they were much cheaper than doctors.

Doctors at 24 trusts reported witnessing PAs illegally prescribing medications, including controlled drugs. That is a particular worry because they are not permitted, under their current training and qualifications, to prescribe any drugs. That must be done by the doctor. The PA can recommend to the doctor what they think, but it should be signed off by a doctor. In addition, 42 acute trusts in England have witnessed PAs introducing themselves as doctor or failing to correct errors.

We have heard about a number of issues. I conclude by saying that, earlier on today, on the Victims and Prisoners Bill, we were talking about the duty of candour, which the NHS introduced nearly a decade ago. One issue related to this is that every regulated member of staff must report whenever they believe that something has happened that either possibly will cause damage or has caused damage. One of the good things about regulation for PAs and AAs is that they will come under the duty of candour. However, in all the cases that we have been told about where things have gone wrong, there is no evidence that there were reports to the CQC by the supervising doctors about things going wrong. Therefore, yet again I say to the Minister that my real concern is about current practice inside our extremely pressed and busy NHS, to make it safe. Just providing regulation for PAs and AAs will not in itself do that. I hope that he can help your Lordships’ House to understand.

--- Later in debate ---

Tabled by

[Baroness Brinton]

At end to insert “but regrets that the Government has failed to respond adequately to concerns over provisions in the draft Order about (1) the regulation of ‘physician associates’ and ‘anaesthesia associates’ by the General Medical Council instead of another regulator, and (2) the use of these professional titles, which risks confusion for patients over the difference between doctors and other healthcare professionals, with potential implications for patient safety.”

Amendment to the Motion not moved.

NHS App: Medical Records

Baroness Brinton Excerpts

Tuesday 19th December 2023 Lords Chamber

[Lord Markham (Con)]

Absolutely; it is about getting that balance correct. I welcomed the support of all sides of the House when we were introducing the FDP. A lot of work was done with noble Lords on that. The fact that the federated data platform was as well received as it was in the circumstances is because of support from all Members of the House on all sides, knowing the vital role of data in improving health outcomes.

[Baroness Brinton (LD)]

My Lords, following the question from my noble friend Lord Allan about a red team, in the past not health data but personal financial data has been sold by subsidiaries or contractors of UK firms based abroad. I notice that we now have a deal with America on health data and GDPR. Is that true for other countries, such as India? Personal data, particularly medical data, would be seen as very valuable.

[Lord Markham (Con)]

The fundamental principle underlying all this is that none of the data leaves the control. The data controllers today—be it GPs, the NHS or the hospital—stay as they are, and any use of that data has to be approved outside of that. The noble Baroness is absolutely correct. We want to make sure that it is not used for any purposes that are not going to improve health outcomes, such as the ones we have talked about.

Suicide Prevention Strategy

Baroness Brinton Excerpts

Thursday 26th October 2023 Lords Chamber

[Lord Markham (Con)]

I thank the noble Baroness for her support for the suicide prevention strategy. It tries to look at the themes behind this issue, of which working to give effective support, communication and training is absolutely key—as is making sure that that is followed up on. The other thing that I want to pull out from the report is the real feeling, in terms of the seven key themes, that suicide prevention is everyone’s business and is something that we all need to be aware of and could learn more about.

[Baroness Brinton (LD)]

My Lords, the Minister has outlined how important it is to learn from the experience of people who have considered suicide. Last week, an Information Rights Tribunal asked the DWP to publish its secret report on suicide rates among vulnerable claimants; it has not yet been published despite the fact that it was written in 2019. Can the Minister explain why it still has not been published? If not—I appreciate that this falls under the DWP—can he write to me, because it is clear that we need to learn the lessons of what went wrong?

[Lord Markham (Con)]

Absolutely. I would be happy to write to the noble Baroness.

Reinforced Autoclaved Aerated Concrete: Hospitals

Baroness Brinton Excerpts

Wednesday 13th September 2023 Lords Chamber

[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.

MMR Vaccine

Baroness Brinton Excerpts

Thursday 20th July 2023 Lords Chamber

[Baroness Brinton (LD) [V]]

My Lords, the NHS says that susceptibility is not just among the under-twos; it is particularly high among 19 to 25 year-olds whose parents were affected by the unfounded Wakefield stories two decades ago, and many may still not be vaccinated. What is the NHS doing to reach this cohort, including at further education colleges and universities, to ensure that they are fully vaccinated before they start their own families? Catching measles when pregnant can cause miscarriage, stillbirth, premature birth and low birth weight.

[Lord Markham (Con)]

The noble Baroness is correct. The unfortunate Wakefield effect had quite an impact on that cohort of people, so the campaigns have been targeted particularly at specific communities in particular areas. Outreach campaigns are being done as part of that, looking at every area where it can be done. Sometimes that involves looking at colleges and sometimes it involves going specifically to community centres themselves.

NHS Long-term Workforce Plan

Baroness Brinton Excerpts

Tuesday 4th July 2023 Lords Chamber

[The Deputy Speaker (Baroness McIntosh of Hudnall) (Lab)]

My Lords, the noble Baroness, Lady Brinton, is contributing remotely.

[Baroness Brinton (LD) [V]]

My Lords, while this NHS plan is welcome, can the Minister say whether this Government will undertake to commit to the plan and, crucially, to its funding and not change the number of education and training places, as happened last year and in too many previous years, causing chaos in planning for doctors, nurses and allied healthcare professionals? On hospital training places for junior doctors after they have finished their medical school courses, last year 790 medical graduates could not begin their junior doctor in-hospital training because the NHS did not have enough placements. Given that university medical school places are already capped and highly competitive, this is a complete waste of newly qualified medical graduates.

[Lord Markham (Con)]

It is absolutely a pipeline; some people might say, “Why are you not doing more earlier in this plan?”, but, as the noble Baroness says, there is no point training a lot of people at the university end if you do not have junior doctor places later in the system. That is why we are trying to get a sensible ramp-up so that we can build capacity into those places, recognising the point that the noble Baroness makes. On the numbers in the plan, we have set down £2.4 billion for the first five years of training and development, but the point about it being a live plan is that we will update it every two years. Given the data—this is an NHS document, not a Department of Health one—I would expect those numbers to change, as I would be amazed if we got it spot on first time. The whole point about making this an NHS living document that we can use and which updates is that we can all stick to the plan.

NHS Procurement: Palantir Contract

Baroness Brinton Excerpts

Thursday 22nd June 2023 Lords Chamber

Asked by

[Baroness Brinton]

To ask His Majesty’s Government, in light of the contract awarded to Palantir, what plans it has to ensure that NHS contracts are procured through a public and transparent tender system as outlined in the Procurement Bill.

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

All NHS contracts are procured using correct procedures. This is a new transition contract with Palantir, with new and improved contract terms, including robust exit and transition schedules to support transition from Palantir to the new federated data platform supplier. This contract includes additional terms, such as termination for convenience and a six-month break clause. The contract was procured by a compliant and transparent direct award tender process, using a Crown Commercial Service framework agreement.

[Baroness Brinton (LD)]

My Lords, it is not the first closed contract used that way, particularly for Palantir, since 2020. Ministers deliberately excluded the NHS from the new rules in the Procurement Bill, giving the Secretary of State for Health the powers to create regulations, resulting in untransparent closed contracts such as the £24 million Palantir contract just granted. Unlike every other public body and government department, senior NHS leaders are excluded from any restrictions when they move to providers, as happened last year when two senior staff moved to Palantir. These NHS practices are the exact opposite of what the Government hope to achieve in the Procurement Bill. Will Ministers please reconsider bringing the NHS under the Procurement Bill?

[Lord Markham (Con)]

This was a very sensible move to ensure that the tender process we are going through at the moment allows us to transition to whoever wins the federated data platform. That is a sensible way to do it. It was done according to the Crown Office pre-tendering framework agreement, which is very transparent and well set out. It is normal in these situations that, when you need transition arrangements, you do not want hospitals left in the lurch. You need a transition so that, whoever wins the new bid, hospitals are safe in the meantime.

Sodium Valproate

Baroness Brinton Excerpts

Monday 5th June 2023 Lords Chamber

[Lord Markham (Con)]

The noble Baroness is correct. First, the MHRA is working on guidelines which say that you must always dispense in the original packaging, come what may. In the meantime, secondly, all pharmacists should absolutely be putting leaflets in, whatever the packaging. Thirdly, everyone should have to sign an acceptance form so that they are going into this with their eyes open and understand the risks. Every year they are supposed to renew that acceptance form to make sure that, while it may be necessary in some cases, everyone goes into it with their eyes open to the risks.

[Baroness Brinton (LD)]

My Lords, in 2020 after the publication of the report by the noble Baroness, Lady Cumberlege, we had many debates in your Lordships’ House about the role of and the support for the Patient Safety Commissioner. She had not heard what her budget for the current financial year was at the beginning of May and said that, even leaving that aside, she would not be able to do her job properly. To follow the course of how patients with sodium valproate are supported and treated, she will need that resource. Will the Government review the resource needed for her to do this and many other tasks in her important role?

[Lord Markham (Con)]

My understanding from speaking to Minister Caulfield on exactly this subject this morning is that she has recently spoken to the Patient Safety Commissioner, who is happy that she has the resource that she now requires to do this part of the study.

Long Covid

Baroness Brinton Excerpts

Tuesday 25th April 2023 Lords Chamber

[The Senior Deputy Speaker (Lord Gardiner of Kimble)]

My Lords, the noble Baroness, Lady Brinton, is taking part remotely.

[Baroness Brinton (LD) [V]]

My Lords, 2 million people currently reporting symptoms of long Covid is a shocking 3.1% of the population, with over a million people having had it for at least one year. There are some very successful models for assessment and treatment, but some clinics still assume that long Covid is like ME/chronic fatigue and do not investigate for microclots and heart and lung problems. Why is there not a gold standard for assessments and treatment of long Covid in England as there is in a number of other countries, including Scotland?

[Lord Markham (Con)]

I thank the noble Baroness. My understanding is that the 90 specialist adult centres and 14 specialist children’s centres have care pathways which they are supposed to adhere to. Therefore, I hope that the instances which the noble Baroness brings up are the exception, but I am happy to investigate because I think we all agree that a consistent care pathway is vital in this space.