Adult Social Care: Staffing

Lord Bishop of London Excerpts

Tuesday 12th December 2023 Lords Chamber

[Lord Markham (Con)]

My noble friend is correct: on average, it is about 74% or 75% of a local authority budget. I think we would all agree that that is not a good situation, because obviously a local authority has a number of matters it needs to deal with. This is one of the issues around long-term reform that we will need to consider.

[The Lord Bishop of London]

My Lords, we are very familiar with the pressure on the social care workforce. As the Minister pointed out, we have seen vacancies fall within the social care sector, which is very welcome, but that is supported by the recruitment of 70,000 staff from overseas. I am glad that the health and care sector is exempt from the new visa charges, because we are clearly reliant on assistance from overseas. However, given that they are no longer able to bring dependents on their visa, have the Government considered the impact that this will have on recruiting workers from overseas into the social care sector?

[Lord Markham (Con)]

We have tried to adopt a balanced approach here. While we all understand the necessity in the healthcare sector, I think most of us would agree that 750,000 net migration is a very high number. The balance we have struck is to protect this sector. Our figures generally show that we will be able to keep the recruitment coming. We are now moving on to part 2 of the reform, through the other things we are doing, particularly around qualifications—we know that people who are qualified are far more likely to stay in a social care setting. That is what the whole investment is about. It will be rolled out next year and will fund hundreds of thousands of places. I think it will make a real difference to the motivation, recruitment and retention of staff.

National Health Service: 75th Anniversary

Lord Bishop of London Excerpts

Thursday 30th November 2023 Lords Chamber

[The Lord Bishop of London]

My Lords, I declare my interests in the register. It is a privilege to participate in this debate about one of our most valued institutions and to follow some excellent contributions. One of the focuses of my work in this House has been reducing health inequalities. The NHS was founded in the face of extreme inequality, in the hope that financial means would not be the sole determinant of health. The universal service that is free at the point of use is something we can be extremely proud of.

The 75th anniversary of the NHS is very close to the 75th anniversary of the Windrush generation, which I will celebrate today. As we know, many of the passengers on HMT “Empire Windrush” took up roles in the NHS, which launched just two weeks later. When experiencing workforce shortages from 1948 onwards, British politicians visited the Caribbean as part of a recruitment programme that had 16 agencies in the British colonies by 1955. By 1977, 66% of overseas student nurses and midwives originated from the Caribbean. In the face of overt racism and unequal opportunities for professional development, their contribution has been truly extraordinary. Without it, the health service would not be what it is today.

I am sure much of our nation would say that the true treasure of the NHS is its workforce, whose example should be a great encouragement to all of us. In this House, I have not held back from highlighting the challenges that the workforce currently face: significant vacancies, sometimes poor working conditions and enormous pressure. The industrial action we have seen is a product of the erosion of trust between the front line and this Government. Since the passing of the minimum service levels Act in the last Session, what ongoing work is being done to build relationships of trust with the unions and other bodies to ensure that the concerns and needs of the workforce are truly listened to?

As I have said before in your Lordships’ House, the global majority heritage staff continue to face troubling challenges. The Care Quality Commission’s State of Care report highlights instances of tolerated discrimination and a lower chance of being represented in leadership and managerial roles. There are over 256,000 black and minority-ethnic nurses and midwives, but they are overrepresented in bands 1 to 5. When I was the Government’s Chief Nursing Officer for England, I commissioned the government Chief Nursing Officer’s black and minority-ethnic advisory group, which it was a joy meet with on its 22nd anniversary. The most recent race equality standard report from the NHS shows that there is progress heading in the right direction; although it is slow, it should celebrated.

Amid the celebration of this great institution, many challenges remain. The strain placed on the service is clear in key areas, including the number of people waiting for care and the significant workforce challenges. But there are also challenges with our health, distinct from our healthcare. Some 50% of people in the most deprived areas report poor health by the ages of 55 to 59, which is over two decades earlier than in the least deprived areas. It remains an injustice that where exactly you live can change the length of your healthy life in such a serious way. In light of this, what consultation has taken place with other departments to seize the opportunity of the Major Conditions Strategy to give new focus on health inequalities?

It is good to see the new integrated care systems becoming more established. I hope that we will see real progress in place-based and community-focused preventive care. Research published recently by the NHS Confederation shows that every £1 invested in community and primary care brings back £14 to the economy, compared to £11 per £1 for acute services. It is through working for a healthier population that the pressure will be lifted off the NHS and the opportunity to address health inequalities will be realised. I commend the small-scale projects happening in London, where I am. The community health and well-being worker model, which is being rolled out in Westminster, is already encouraging the uptake of health screenings that would otherwise not happen, management of low-level health conditions and promoting well-being. There is much to celebrate about the NHS but, as we have heard, there remains work to be done if we are to press ahead in the same spirit as the architects of the NHS 75 years ago.

Adult Social Care

Lord Bishop of London Excerpts

Wednesday 22nd November 2023 Lords Chamber

Asked by

[The Lord Bishop of London]

To ask His Majesty’s Government what assessment they have made of the financial situation facing adult social care leaders and providers, following information published by the Association of Directors of Adult Social Care Services that 83 per cent of councils expect to overspend by an average of 3.5 per cent on adult social care in 2023-24.

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

The department carries out regular assessments of the financial pressures facing adult social care. Since the spending review, the Government have made available up to £8.1 billion in additional funding over two years to support adult social care and discharge. This includes an additional £570 million announced in July. This will put the adult social care system on a stronger financial footing and improve the quality of and access to care.

[The Lord Bishop of London]

The autumn survey of the Association of Directors of Adult Social Services paints a worrying picture of the state of adult social care: a third of directors of adult social care services said that they have been asked to make additional savings to their budgets, on top of the £1 billion of savings that they are expected to make by 2024-25. The Homecare Association’s deficit report, published on the same day, states that providers are being paid less than the work costs and cannot pay their employees a competitive salary. In this context, can the Minister explain what outcomes social care users can expect to see as a result of the investments he spoke of?

[Lord Markham (Con)]

I thank ADASS for its report. The outcomes we are seeing show a number of things: as well as the £8.1 billion investment we put in, we have brought down waiting lists for assessment by 13% since the peak level. We are seeing high levels of satisfaction with a lot of the work we are doing; 83% of people say that they are satisfied with the services they are receiving. Yes, there is a lot more to be done, but there is a lot of good progress as well.

King’s Speech

Lord Bishop of London Excerpts

Thursday 9th November 2023 Lords Chamber

[The Lord Bishop of London]

My Lords, it is a pleasure to participate in this debate on the gracious Speech. I declare my interests as recorded in the register.

I begin by joining noble Lords across the House in welcoming the indication in the Speech that the Government will legislate for a ban on smoking. As we have heard, smoking is the single biggest preventable killer in the UK, but it is also an example of pronounced health inequality. The Chief Medical Officer gave this evidence to the Commons Health and Social Care Select Committee:

“Smoking is usually twice as high in people with lower incomes and more than twice as high in people living with mental health issues”.


He went on to say:

“The cigarette industry goes absolutely unerringly for the most vulnerable in society”.


So I welcome the decision by the Government, which will undoubtedly account for significant reductions in preventable cancers. However, there are many things that determine our health, and we have been discussing the social determinants of health for years. They were highlighted as early as 1980 in the Black report, yet we seem to be having the same conversations about the same statistics, with the same consensus again and again. The differences in life expectancy and healthy life expectancy remain truly shocking.

The failure to publish the health inequalities White Paper in the previous Session is lamentable, and I seek assurances from the Minister that health inequalities will be a key focus of the major conditions strategy. For the NHS to have the future that the Minister speaks about, we are dependent on reducing inequalities in health. Inequalities in health outcomes between racial and ethnic groups also persist. The most recent CQC State of Care report highlights these, especially in maternal and neonatal care and in mental health care. The report lists instances in which patients are not listened to and how their symptoms are not recognised due to the poor teaching of certain conditions that present in ethnic minority patients. The CQC report also highlights, as did the noble Baroness, Lady Watkins, that there are ethnic differences in the detention of mental health patients.

I add my voice to the disappointment that a mental health Bill has not been brought forward as part of the gracious Speech. As we have heard, reform of the Mental Health Act is long overdue, and the inequalities that people face under it need serious attention. There is much work to be done here, including in resourcing community care and increasing patients’ ability to make choices about their care. The Joint Committee on the draft Bill found that this would be a significant factor in the reduction of detention and inequalities. It is a great shame that the work already undertaken is not being taken forward.

We are all aware that the health service is straining. I too welcome the long-term workforce plan, but there are questions that remain unanswered, and I expect that its implementation will be challenging. The NHS staff experience remains one of exhaustion, overwork and understaffing, and I continue to remain concerned about the state of industrial relations following the Strikes (Minimum Service Levels) Act. If we are to exercise choice in our future, as the Minister rightly said, we need a workforce that is not tired, is appropriately trained and is valued.

Some 22 years ago, I commissioned the Chief Nursing Officer’s Black and Minority Ethnic Advisory Group, which has carried out truly inspiring work. However, the work is not done. The CQC report highlights the experience of not just ethnic-minority patients but staff. Midwives from ethnic-minority groups described a culture of tolerated discrimination and unchallenged stereotyping. This is something that we all need to work to reduce.

It is disappointing to see no mention of social care in the gracious Speech. Skills for Care’s latest report estimated a 28.3% staff turnover rate in 2022-23. With 400,000 people working in social care over the age of 55 and likely to retire within the next 10 years, we are desperate for a workforce strategy. Carers are finding it difficult to get by in the cost of living crisis, and the sector represents 5% of the entire economy.

The Archbishops’ Commission on Reimagining Care sets out the type of ambitious vision that I had hoped to see in the gracious Speech. The commission identified the need for a fundamental change in the way in which care is thought about, organised and delivered, with a national care covenant at the heart of a new approach that truly incorporates the views, voices and experiences of the people most affected. Social care should enable everyone, regardless of age or ability, to lead a life of purpose and fulfilment.

I also note the disappointment of many that the gracious Speech did not contain news of a ban on conversion therapy. The General Synod of the Church of England voted to call on the Government to ban conversion therapies in 2017; it remains firm that abuse of power in this way must be prevented.

What underpins everything I say today and will say in the coming Session is that people are made in the image of God and are immeasurably valued. Recognising that value, we must do more to pursue health equality and provide adequate resources. As Nye Bevan famously said in 1948:

“Illness is neither an indulgence for which people have to pay nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community”.

Suicide Prevention Strategy

Lord Bishop of London Excerpts

Thursday 26th October 2023 Lords Chamber

[Lord Markham (Con)]

The noble Lord is absolutely correct. The priority groups identified include people in the justice system for exactly that reason; likewise, as I mentioned, middle-aged men, who are three times more likely to commit suicide. There is a strategy behind each priority group—people with poor mental health, people on the autistic spectrum, pregnant women, people who self-harm, children and young people, as well as people in the justice system—in terms of how we help and support them.

[The Lord Bishop of London]

My Lords, as we have heard, our financial situation has a serious impact on our health and mental well-being. This is supported by recent polling commissioned by Christians Against Poverty. This issue is not just about more disease; it also includes malnutrition, mental health and failing to take time off when sick due to financial insecurity. What assessment have the Government made of the impact of the cost of living crisis on people’s mental health, particularly in our most deprived and vulnerable communities? What steps are the Government taking to reduce health inequalities, specifically those related to suicide?

[Lord Markham (Con)]

It is understood that people’s financial well-being—or lack thereof—is one of the key causes here. Interestingly, as I looked at the statistics, there was a big jump up in the suicide rate from 2008 onwards, following the financial crisis. It is about making the point that, when people feel under more stress, they are, unfortunately, more likely to commit suicide. However, if you look at the statistics over the past five years, the rate has been pretty flat; so far, there is no evidence to show that, in the past year or so, the cost of living crisis has caused more suicides. None the less, it is something that we absolutely need to stay on top of and ensure that we are monitoring closely, as the right reverend Prelate the Bishop of London mentioned.

Reinforced Autoclaved Aerated Concrete: Hospitals

Lord Bishop of London Excerpts

Wednesday 13th September 2023 Lords Chamber

Asked by

[The Lord Bishop of London]

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

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

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

[The Lord Bishop of London]

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

[Lord Markham (Con)]

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

Countess of Chester Hospital Inquiry

Lord Bishop of London Excerpts

Tuesday 5th September 2023 Lords Chamber

[Lord Markham (Con)]

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

[The Lord Bishop of London]

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

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

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

[Lord Markham (Con)]

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

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

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


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

Long Covid

Lord Bishop of London Excerpts

Tuesday 25th April 2023 Lords Chamber

[Lord Markham (Con)]

As I say, the data that I have been working with indicate that 80% are seen within eight weeks, which I think most noble Lords would agree is a pretty good statistic. My understanding is that GPs are fully briefed on referrals and disability types. It is clearly important that people who are suffering in the long term make sure that they get treatment.

[The Lord Bishop of London]

My Lords, the advice of the DWP and DHSC is that, if those impacted by long Covid are unable to work, they will be able to access financial assistance through schemes such as PIP. However, in practice, as the noble Baroness said, there is a lack of recognition of long Covid among GPs and PIP assessors. What steps are the Government taking to make sure that more long Covid sufferers are identified and able to access financial support?

[Lord Markham (Con)]

They are absolutely part of the prescribed path. I know from my DWP colleagues that it is part of the training that those people should be supported with personal independence payments. As of January, more than 4,000 people were being treated and receiving payments in this way. It is fundamental that they get access to those payments going forward.

Covid Pandemic: Testing of Care Home Residents

Lord Bishop of London Excerpts

Monday 6th March 2023 Lords Chamber

[Lord Markham (Con)]

Yes, it is vital that we understand exactly what happened when and that we learn lessons. I am sure we will see that some mistakes were made, and we need to learn from those. From our side, that was the whole point of setting up the Covid inquiry. We will ensure full co-operation.

[The Lord Bishop of London]

In advance of the outcome of the UK Covid-19 inquiry, which will take some time if it is going to be thorough, can the Minister tell us what attempt the Government have made to learn from how decisions were made during that period and to ensure that better decisions are made today?

[Lord Markham (Con)]

The first major finding was setting up the UK Health Security Agency, because of a feeling that the bodies that were there at the time were not best placed. That was the first learning. From that, things such as the 100-day vaccine challenge were set up to make sure that we are well placed should another pandemic occur. We have tried to learn lessons all the way through and have made sure that testing capacity is still in place, so that we are able to react quickly, and stocks are there. I like to think that sensible measures are being taken and that we are not waiting for the inquiry, but I am sure we will learn more as the inquiry is fully engaged and when it makes its own findings.

Hospital Beds: Social Care

Lord Bishop of London Excerpts

Monday 19th December 2022 Lords Chamber

[Lord Markham (Con)]

The number of care workers is key to all this and I delighted to say that the latest data shows that we are back to the levels of April 2021. Too many people have left, but we have managed to fill the gaps with the international recruitment fund and other measures. We all agree that we need to progress that further, but we are now making the increases that are needed in this space.

[The Lord Bishop of London]

My Lords, we have heard how important a sustainable workforce is, both in social care and healthcare. Can the Minister tell us what the Government are doing to listen to the concerns of health and social care workers about patient safety and their own working conditions at this time?

[Lord Markham (Con)]

Clearly, if we are going to retain and recruit the key staff in this area, it has got to be a good career, and that means that we must listen to their concerns. I know that Minister Whately is talking to and visiting them all, so it is a key part of the plan. As I say, the fact that we are managing to grow the workforce again shows, I think, that we getting on top of it—but absolutely we need to keep close and make sure it is a good place to work.