National Health Service: 75th Anniversary

Baroness Walmsley Excerpts

Thursday 30th November 2023 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Lord, Lord Hunt of Kings Heath, on his excellent introductory speech. He hit all the nails very firmly on the head.

As the NHS reaches its 75th year, it is a very different and much larger beast than when it started out. The challenges are not just greater but different. On the upside, to a great extent we have conquered infectious diseases through vaccination and sanitation. Because of the success of medical science, our population is ageing, leading to greater demand for healthcare. On the other hand, we have a high level of health inequality and poverty, and a food system that does not provide a healthy diet for many people. Preventable diseases are now the greatest cause of illness and death. In 1948, people walked everywhere; many did manual labour, so obesity was rare; they ate seasonally and cooked their meals at home, and ultra-processed foods did not exist. But the air was not necessarily cleaner, because we burned coal to heat our homes. Today, we lead a very different life.

So, post-Covid, the NHS has five major challenges. There is the state of social care, causing too many people to enter hospital and stay there for too long. Linked to that, there is a crisis in ambulance service response times and A&E waiting times, causing excess deaths and harm. Many diseases, including cancer, are being diagnosed far later than they could be, leading to poor outcomes. Long waiting lists for urgent and elective care are leading to damage to the economy as people cannot work while they wait. There is too little preventive work to help people lead healthier lives.

The Government’s response is a focus on increasing the front-line workforce while ignoring the poor communication and system planning in the service. While we certainly need to train and retain more health professionals, especially in deprived areas, they are not the only people the workforce plan should be focusing on. We need system planners and communications experts. The money available for the NHS to tackle these problems is not infinite, which means we need greater productivity.

Nobel laureate Paul Krugman said:

“Productivity isn’t everything, but in the long run, it is almost everything”.

A crude definition of productivity is the ratio of inputs to outputs. Some think this is all about individuals working harder, but NHS staff are all already working extremely hard. It is not about working harder but working smarter. It is about improving outcomes. It is also not just about national initiatives. There is bound to be poor buy-in for national initiatives when staff on the ground often have a better idea of what could be done better. That is not to say there is no room for national initiatives, but they do not need to be designed by McKinsey.

There are problems with measuring real productivity in the NHS: how to adjust for the mix and quality of outputs and recognising the difference between outputs and outcomes. The NHS produces a wide variety of outputs. GP appointments are not the same as hip replacements, but the service has quite sophisticated statistical ways of dealing with this. It is harder to adjust for quality. Doing two knee replacements rather than one looks productive, but not if the second was needed only because the first was botched; and especially, as in the case of a lady I know, if the patient has to see the consultant three times before he will accept that there is something wrong. Then we must ask, is the outcome better as a result of the NHS having done something? The lesson here is that it is productive to listen to patients. Unfortunately, the NHS has cut back on patient-reported outcome measures, which are a valuable way to assess outcomes. My first question to the Minister is: are there plans to reinstate or replace PROMs?

A recent internal paper about productivity said that NHSE is

“very good at generating ideas”

for efficiency initiatives but does not have clear processes to evaluate them. It added:

“The overall volume of initiatives means it is very likely that the system is overwhelmed, which means that initiatives are not as effective as they could be. Moreover, a lot of the initiatives we are taking forward lack the buy-in from front-line staff that is needed to make changes stick”.


The system and infrastructures that support waiting list management include IT and tools for proactive patient tracking, as well as the processes that staff follow to efficiently and accurately co-ordinate pathways for patients on waiting lists. Millions of hours of clinicians’ time are wasted due to inadequate IT systems. A recent BMA report found that four in five doctors believe that improving IT infrastructure and digital technology would help to tackle backlogs. Can the Minister therefore say whether systems analysts and IT and AI specialists are included in the workforce plan, as well as medical professionals? We did not just win the Battle of Britain using pilots.

Sadly, there are too many examples of the skills of our health professionals being wasted because of inefficient systems planning and poor communications. A recent example concerns former BBC journalist Rory Cellan-Jones, who suffered a broken elbow and facial bruising following a fall. He spent two unnecessary days in hospital and calculated that 90% of the staff time spent on his case could have been avoided with better planning and communications. It was eight days after his accident before he received appropriate treatment. It was not just a question of communication between staff, but communication with him. He says in his blog:

“Getting information about one’s treatment seems like an obstacle race where the system is always one step ahead. … But communication between medical staff within and between hospitals also appears hopelessly inadequate, with the gulf between doctors and nurses particularly acute. I also sense that, in some cases, new computer systems are slowing not speeding information through the system. On Saturday morning, as we waited in the surgical assessment unit, four nurses gathered around a computer screen while a fifth explained … all the steps needed to check-in a patient and get them into a bed. It took about 20 minutes and appeared to be akin to mastering some complex video game”.


It also took four hours to get the paperwork for his discharge.

My Lords, I have experienced a similar situation and it grieves me to see our skilled professionals not being used in the most cost-effective way. What are the Government planning to do about this?

King’s Speech

Baroness Walmsley Excerpts

Thursday 9th November 2023 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I too thank the Minister for the tone of his introduction to this debate, but a King’s Speech is an opportunity for a Government to take stock of progress towards their objectives. One might therefore have expected that this Government would have looked at their earlier manifesto promises when drafting the gracious Speech and considering whether their 13-year tenure had in fact improved the health of the nation. Covid, of course, was an unexpected roadblock, but the very fact that it was unexpected is an issue in itself. One hopes that lessons are being learned from the Covid inquiry.

There are pluses and minuses in the Government’s thin programme for their last year in office. Like many other Lords, I regret that, despite all the work done on proposals for revising the Mental Health Act, including a White Paper, the Government have still not fulfilled the revision promised in successive manifestos, nor their promise to implement the recommendations of the Infected Blood Inquiry. Instead, despite that inquiry’s strong interim recommendations that compensation be paid now, the Government still insist on waiting until the final report.

There is, however, one measure in the gracious Speech of which I approve: the proposal to raise every year the age at which retailers can legally sell tobacco products to young people by one year. This does not ban smoking as such, but it should deter more people from starting. We know that most smokers start young and that tobacco is unique in that it either kills or shortens the lives of two-thirds of those who use it for any length of time. I have always supported measures to reduce smoking because it is different from all other ways in which people freely choose to damage their own health. It is addictive, harmful when used as recommended, can harm other people and costs us and the NHS millions every year. That is why there is overwhelming public support for, for example, the ban on smoking in enclosed public spaces.

There will also be consultation on measures to tackle the widespread illegal sale of disposable vapes to children. Vapes have their place. They are of value to adult smokers who wish to quit, and are rightly sometimes provided free on prescription, but I believe that the vaping industry has cooked its own goose by the reckless and widespread promotion—and sometimes the free supply—of single-use vapes to children. That undoubtedly has to stop, because these things are addictive and not without danger. The massive environmental damage done by these brightly coloured gadgets, with their sickly-sweet flavours and colours obviously aimed at children, has been well-rehearsed elsewhere, so I do not need to elaborate. I hope that, after the consultation, the Government will clamp down firmly on this already illegal practice. Of course, public health budgets have also been cut and this has resulted in fewer smoking cessation services, which must also be addressed.

The Government have announced an NHS workforce plan. This is a step in the right direction, but many of us would have preferred the proposal of the noble Baroness, Lady Cumberlege, during the Health and Care Act 2022, supported by us. This provided for an independent review of current supply, an assessment of need of the right staff in the right places in the future, and a plan for how to fulfil that need over five and 10 years. The Prime Minister mentioned doctors, nurses and dentists, and of course we need more of those, especially in disadvantaged areas. However, current resources could be used better. Many of the care problems that patients experience are about systems, processes and communication. There is much efficient good practice, and I agree with the noble Baroness, Lady Donaghy, about the very cost-effective fracture liaison clinics, which save a lot of time and NHS bed days but are available in only half of trusts—that is the problem. Will the Minister ensure that the workforce plan includes staff skilled in designing and implementing efficient systems and processes which make the most of the resources we have?

Taking stock means looking to the future and focusing on the major challenges to the NHS. Three things are needed. The first, as has been said, is sorting out social care and integrating it with health services. Despite Boris Johnson’s promise of an oven-ready plan, which never materialised, social care is still suffering from lack of funding and enough properly paid staff with opportunities to develop their skills. If there ever was an oven-ready plan, it is well past its sell-by date and should be thrown in the bin. The recent Covid inquiry has exposed how very important this is, especially at times of extra stress on the system, but it did not feature in the gracious Speech.

The second is the need for more prevention of ill health. Preventable diseases, as has been said, are now the major causes of death, since modern sanitation and vaccination have conquered many of the communicable diseases. If Wes Streeting focuses on this, he will get my support. The three main factors needed here are action on healthy diets, clean air and healthy homes. The Government are failing on healthy diets despite having legislated for, but not implemented, several important measures that would have helped people make good food choices. Everyone, especially children, should have access to good, affordable food, and the Government should be doing a lot more to ensure that.

We have had many debates on clean air, but the legal limit for particulates in our air in the UK is still much higher than in other developed countries. Dirty air kills people through respiratory and cardiac diseases and interferes with the development of children’s brains. More action is needed on this now, rather than using it as a wedge issue at by-elections. Unhealthy, damp, cold homes also lead to respiratory diseases. It is a national disgrace that too many lower-income families are living in homes with mould growing on the walls and cannot pay their heating bills, and I did not hear anything positive in the gracious Speech about this.

The last factor is earlier diagnosis and treatment, and here there has been some progress. I welcome the units going around the country to check for early liver cancer, heart valve disease, lung cancer, et cetera, but what is needed is widespread access to treatment. I want to mention minimally invasive cancer therapies. These were invented here and are highly cost-effective. Can the Minister let us know what progress there is in extending these right across the country, instead of in only about half of it?

Children’s Health: Ultra-processed Foods

Baroness Walmsley Excerpts

Wednesday 25th October 2023 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I agree with every word of the noble Baroness’s excellent speech, as noble Lords will hear. We humans have evolved, along with our diets and our gut microbiome, over millennia. Ultra-processed foods, however, are the new kids on the block, and their availability and ubiquity in our diets correspond exactly to the increase in diet-related diseases. Figures show that 60% of the UK diet is UPF, and it could be worse for children. That corresponds with serious concerns about height and weight revealed by the UK child measurement programme. It is pretty obvious that something is going wrong.

Whenever I raise the topic of ultra-processed foods with the Minister, he replies that the Government cannot take action because it is difficult to define them, since brown bread is an ultra-processed food. I would like to tackle that head on. Brown bread could be ultra-processed, but it does not have to be—it certainly is not in my kitchen. So let us look at definitions. You could say that UPF contains things you would not find in a normal kitchen. That is helpful, but not enough. More helpful is the NOVA system, which puts foods into four categories, only the fourth of which is ultra-processed. Brown bread is not always found in that group.

NOVA provides a framework for assessing the degree and purpose of processing, and the relation between dietary patterns and health outcomes. It should be seen as complementary to nutrient-based approaches. Some national Governments have already begun to introduce policies informed by NOVA.

Foods and diets are of course complex. Lots of HFSS foods—high in fat, salt and sugar—are UPF, which is often called junk food, and lots of UPF are HFSS, so it is important to untangle the two. One piece of research did that neatly. Two groups of people were given diets for a week that were comparable in fat, sugar, salt and quality and told they could eat as much as they liked. One diet was made of minimally processed foods and the other UPF. Those on UPF ate 500 calories more than the others and gained weight. When they swapped the two groups around, the same thing happened. Dozens more studies have controlled for fat, salt, sugar and diet quality and have still found ultra-processed diets to be strongly associated with poor health. Other research shows that UPF are designed to make people eat more. They are soft and easily digested, taste good, are energy dense and, as has been said, some people become addicted to them.

Not every UPF is bad; it is the quantity and the overarching dietary pattern that matter. Our priority should be rebalancing the diet as a whole, and that is where government dietary guidelines come in. In the UK, reformulation has long been the focus of policy but, given the overlap between UPF and HFSS, reformulation should be only a first step to addressing the health outcomes associated with ultra-processed dietary patterns.

Part of the issue is profit maximisation. The business model is this: you take cheap commodity ingredients, deconstruct them and put them together in a different way, bind them with cosmetic additives and then brand and market the product with the aim of increasing sales and normalising consumption. In a capitalist economy, financial resources flow to the sectors that are the most profitable, and UPF is hugely profitable.

So what to do? Research definitively demonstrates that existing guidelines are inadequate—there is not a word about UPF in government guidelines—so will the Government amend their guidelines to promote the consumption of minimally-processed foods, improve the food in schools and public settings, and implement the existing legislation on advertising junk food on TV and online and relating to “buy one, get one free”? Many people on lower incomes rely on cheap UPF, so policy should not place further burdens on them.

Domestic Violence and Brain Injury

Baroness Walmsley Excerpts

Monday 23rd October 2023 Lords Chamber

[Lord Markham (Con)]

Yes, on both counts. Unfortunately, domestic violence is something that affects all sorts of people from all sorts of backgrounds and minorities. About 5.7% of women and 3% of men, and a lot of children, are thought to suffer domestic violence. I am absolutely happy to give that undertaking.

[Baroness Walmsley (LD)]

My Lords, the Minister has clearly noticed the care taken by both players and officials during the Rugby World Cup to avoid head injury. However, there is no referee on behalf of women suffering brain injury during domestic violence. Will the Government support training programmes, such as those run by Headway, for professionals dealing with survivors and victims, and ensure that that training is extended to the police? Will they ensure that, at the end of those programmes, the trainees have resources to which to signpost victims?

[Lord Markham (Con)]

The noble Baroness is correct. We need to make sure that all our front-line services are trained to identify potential brain injuries—that is A&E, GP surgeries, the police and schools. There is already a programme in schools for children affected by domestic violence. We have also made sure that every ICB has to appoint a domestic violence and sexual abuse lead, so that they can identify these sorts of issues.

Nursing Courses: Reduction in Applications

Baroness Walmsley Excerpts

Tuesday 19th September 2023 Lords Chamber

[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.

Children’s Health: Sugar

Baroness Walmsley Excerpts

Tuesday 12th September 2023 Lords Chamber

[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.

Folic Acid Fortification

Baroness Walmsley Excerpts

Tuesday 25th July 2023 Lords Chamber

[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

Baroness Walmsley Excerpts

Tuesday 25th July 2023 Lords Chamber

[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.

Food: Two-For-One Offers

Baroness Walmsley Excerpts

Wednesday 19th July 2023 Lords Chamber

Asked by

[Baroness Walmsley]

To ask His Majesty’s Government on the basis of what health evidence, if any, they have postponed the planned ban on two-for-one offers for foods high in fat, salt and sugar.

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

The volume price promotion restrictions have been delayed for two years while we prioritise the implementation of the location restrictions. This is the most impactful policy for reducing children’s calorie consumption, and accounts for 96% of the expected health benefits of the promotions policy. Kantar data suggests that it is working. The evidence suggests that this will have the biggest impact on tackling obesity.

[Baroness Walmsley (LD)]

I thank the Minister for his reply, but according to the Food Foundation’s most recent Broken Plate report, the most deprived 20% of families would have to spend half of their disposable income on food to comply with the Government’s healthy diet advice. Bearing that in mind, why are the Government continuing to allow retailers to sell HFSS foods, which can make people ill, at a discount? Do the government really want to encourage people to buy cheap food that could, in the end, kill them?

[Lord Markham (Con)]

First, I thank the noble Baroness for her tireless work in this space. I think we have shown that our restrictions are absolutely placed to inform and educate people so that they can have a healthy diet. I mentioned what we have done on location—the so-called pester power avoidance. It is estimated that these measures will reduce calorific intake by 96%. That is the prize that we are looking at here.

NHS National Health Inequalities Improvement Programme

Baroness Walmsley Excerpts

Thursday 25th May 2023 Lords Chamber

[Lord Markham (Con)]

First, I wish my noble friend a happy birthday. I totally support her question. The most important thing with regard to inequalities—funnily enough, this was the answer to an earlier question—is the use of free school meals. I think we can all welcome the fact that 37.5% of children now receive free school meals and therefore a nutritious start to life. Clearly, that is the best way to make sure that children, particularly those with potential inequalities, are getting a healthy start in life, as well as the under-fours clubs to make sure that they get healthy food.

[Baroness Walmsley (LD)]

My Lords, according to Henry Dimbleby, the Government’s public food procurement system is dominated by a few very large corporations, creating little incentive for innovation or improvement. Can the Minister give us an update on the trials in south-west England, in which small, local, high-quality food suppliers can get into public procurement—for example, to schools and hospitals? I understand that early evidence reports better quality and choice at no increased cost.

[Lord Kamall (Con)]

My Lords—