Physician and Anaesthetist Associate Roles: Review

Lord Bishop of London Excerpts

Thursday 5th December 2024 Lords Chamber

[The Lord Bishop of London]

My Lords, it is good to participate in this important debate and I am grateful to the noble Baroness, Lady Bennett, for having secured it. I declare my entry in the register of interests, specifically that I was formerly the Government’s Chief Nursing Officer.

This is clearly a complex issue, and I join other noble Lords in welcoming the Government’s recently announced review of the physician associates and anaesthetist associates. In building an NHS fit for the future, it is right that the right people with the right training and the right competence undertake the right roles. Over the last 20 years, we have seen an expanding of roles to release medical staff to do what only they can do; for example, the development of nurse-led assessment, advanced nurse practitioners and nurse prescribing, and the expansion of the role of pharmacists. In some sense, the development of physician associates and anaesthetist associates is part of this change. However, any change in role and the healthcare workforce needs to be carefully implemented and regulated. Therefore, I welcome the regulation of physician associates and anaesthetist associates, but I too question whether their regulation should take into account the outcome of this review, rather than moving ahead at present.

The main points I will make are around clarity and trust. Noble Lords will often hear me speak in this place about the essential commodity of trust in healthcare and the health of the nation. Research carried out by Healthwatch found that the public awareness of physician associate roles is mixed, particularly among older people, who are less likely to know the difference between a PA and a GP. Clear information needs to be given to people about the healthcare worker they are seeing, and they need to be reassured that they are competent and working to clear standards.

I am encouraged to hear that both roles and standards will be examined in the review, but can the Minister tell us whether what and how information is given to the public will be part of the scope? I also wonder whether we can learn from past changes, such as the introduction of nurse prescribing, to help us understand how we bring about this type of change.

Giving clarity is a vital step towards ensuring trust, particularly in primary care. We must ensure that we are transparent and that we focus on building trust as a priority. I also speak from a London perspective, where the memory is fresh of the great losses during Covid that were disproportionate in some communities, especially those that still struggle to reach the health service—their trust in primary care is low. Will the Government assess the distribution of physician associates as part of the review and examine how patients might have greater clarity about who they are seeing at an appointment? This is especially important where communication might be difficult, such as when English is a second language. According to the Royal College of General Practitioners, GPs in more deprived areas are responsible for caring for more patients than those in affluent areas. It would be helpful to know how physician associates fit into that picture.

Looking more generally at the workforce and the long-term workforce plan, which accelerates the expansion of physician associate and anaesthetist associate roles, do the Government plan to change the projections of this expansion based on the outcome of the review? What impact will this have not just on the plan but on the wider workforce?

The issue of supervision has already been raised in the debate. While I welcome the diversification of roles in the multidisciplinary team to ease pressure where it is appropriate, it is absolutely clear that the supervision of those roles is important. Who is supervising them? Who are they accountable to? That is particularly the case when there is pressure already on our health service.

When the long-term workforce plan was first published, I am not sure that it answered the question related to supervision. On apprenticeship schemes for roles such as this, what progress has been made to ensure that in hospital settings and primary care, funding is given for backfilling? When apprentices are paid and have time for study, is the hospital or the primary care setting able to backfill with staff? If the Minister has any insight into how this has progressed since the plan was published, I would be grateful to know.

The role of the physician associate is a controversial topic, as has been highlighted in this debate. It is having a very clear impact on team dynamics. Within some of those teams, staff are reporting bullying. Staff morale is low, including that of the physician associates and anaesthetist associates. I wonder whether this should be a high priority for the Government and a dimension of the review.

Finally, I hope that the Government will learn from this review and that the learning they undertake will be transferred to other areas of health. As the Government shift from sickness to prevention, from hospital to community, as part of their 10-year plan, it is likely that diversification—in primary care but also elsewhere—will be required and will need to grow. Therefore, there is an opportunity to learn from this review and to roll that learning out. I look forward to hearing from other noble Lords on this important issue and from the Minister when she responds.

Fracture Liaison Services

Lord Bishop of London Excerpts

Wednesday 4th December 2024 Lords Chamber

[The Lord Bishop of London]

My Lords, it is very good to participate in this important debate on the fracture liaison service, especially since the issue of prevention in healthcare seems to be gathering pace. I thank the noble Lord, Lord Black, for having moved this debate.

We have heard that the fracture liaison service identifies people at risk of osteoporosis and reduces the risk of long-term fractures. Treatment provided by the fracture liaison service is often excellent, and often nurse-led. But, as we have heard, there are just not enough of them. Like many aspects of healthcare that we discuss in your Lordships’ House, provision varies by region, and there are also other inequalities of access to these services. We know that bone density decline can be accelerated by other factors, including smoking, diet and other illness.

We often discuss the fact that those living in the most deprived areas have consistently worse health outcomes and are therefore likely to be most impacted by the lack of coverage of this service. We have already heard in the debate that another element of inequity is that osteoporosis impacts women more than men: 50% of all women over 50 are affected. Last month, a study showed that menopausal women of Chinese and black African backgrounds are almost 80% less likely to be prescribed hormone replacement therapy, and less likely to receive appropriate care during menopause. While this debate is not about hormone replacement therapy, it has a lot to do with equitable access and is therefore significant to this debate.

Fracture liaison services demonstrate genuine value for money, as we have heard, and the Government should be keen to recognise and promote this. It is through services such as these that the shift from sickness to prevention and from hospital to community will happen. Evidence shows that for every pound spent on a fracture liaison service, £3.26 is saved. Given that hip replacements take up 1 million acute bed days a year and are often preventable, rolling this out is an important decision in forwarding the Government’s agenda on the NHS.

We have heard already in this debate that many ICBs may well be ready to go with such services. However, the Royal Osteoporosis Society reported earlier this year the closing of the South Nottinghamshire Fracture Liaison Service, with the ICB citing serious financial pressures and the lack of a government mandate as reasons for stopping commissioning the service. Commissioning pressures on the part of ICBs is an issue that often comes up when we talk about prevention, particularly shifting from acute to preventive services. I know that ICBs face serious financial pressure and challenges from acute services that often override prevention; however, if the Government are going to prioritise prevention and reduce health inequalities, there must be a way for ICBs’ commissioning decisions to stand against that pressure.

I welcome the promise of 100% coverage by 2030, so I look forward to hearing from the Minister what actions the Government will take to make that happen. Will this be considered in the formation of the NHS 10-year plan, so that health inequalities can be prioritised?

NHS Plan: Consultation

Lord Bishop of London Excerpts

Monday 2nd December 2024 Lords Chamber

Asked by

[The Lord Bishop of London]

To ask His Majesty’s Government what steps they are taking to ensure the consultation for the NHS 10 Year Plan reaches all communities, including those who have least interaction with the health service.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, we want to ensure that the voices and experiences of patients are at the heart of our plans to make the NHS fit for the future, especially those voices that often go unheard. We are working with charities, faith groups, health and care providers, local government and others to ensure that we hear from those that national government often fails to reach. We will monitor this closely and target underrepresented groups before the engagement exercise concludes in spring 2025.

[The Lord Bishop of London]

I thank the Minister for her reply, and I am encouraged by the Government’s consultation on the NHS 10-year plan. However, does she agree with me that, if we are to move from sickness to prevention, any engagement ICBs have with their communities has to be long term and systematic? If so, what are the Government doing to resource ICBs to make sure that their engagement with communities is long term and systematic?

[Baroness Merron (Lab)]

I agree with the right reverend Prelate. Integrated care systems, which are responsible for reflecting the needs of the community and its spending, must follow guidance, and it is important that we identify the seldom-heard groups. We have built into the consultation plans a “workshop in a box”—a toolkit to support discussion in local communities, which ICBs are rolling out. It is a good way of encouraging ICBs to talk directly to local communities.

Mental Health Bill [HL]

Lord Bishop of London Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[The Lord Bishop of London]

My Lords, I am grateful to be able to participate in Second Reading of this important Bill. It is a privilege to follow the noble Baronesses, Lady Barker and Lady Watkins, who have a real breadth of experience in this field. I too welcome, along with many noble Lords, the reform of the Mental Health Act, which is long overdue.

The noble Earl, Lord Howe, highlighted the over-representation of minoritised communities detained under the Act but also placed on community treatment orders. Some groups are also more likely to be detained through contact with the criminal justice system or emergency departments. It is important to remember that we are speaking about these inequalities in the wider context of health inequalities; some groups present to health services far later, when their symptoms have worsened. The Royal College of Nursing notes in its briefing that mental health services are

“not seen as accessible to all communities”,

and that:

“Many black men have a first interaction with a service via the police during a crisis”.


Many of the organisations that have helpfully sent briefings ahead of the debate have acknowledged that the legislative actions available to address this issue are limited. The Minister highlighted the advanced choice directives, which are a welcome step towards this. As the Joint Committee on the Draft Mental Health Bill notes, this is important for those who have experienced trauma, disempowerment and discrimination.

Data collection has also been discussed during scrutiny of the Bill. Although data collection is improving, capturing more complex data on ethnicity is important when looking at health inequalities in this way. In much of the work I have done on health inequalities with the NHS and faith groups, ethno-religious identity is significant if communities are to be better understand at an ICB level or higher how to reduce inequalities.

It is also important that, in evaluating the changes to the Act, the Secretary of State has the appropriate data to do so. What steps are the Government are taking in the Bill or in other ways to mandate this kind of data collection, so that racial inequalities are monitored?

The Royal College of Speech and Language Therapists also emphasises that communication considerations are important to the Bill. In my experience, some faith communities find it very hard to discuss mental health, and that is made worse by the biases and discrimination they meet when they seek help. The patient and carer race equality framework is to be welcomed as the first ever anti-racism framework for mental health trusts and service providers. In order to assist in this, the Royal College of Nursing has recommended that mandatory training on equalities be given to all working under the Mental Health Act. As I often say in this place, faith literacy is an essential component of that.

Much of this is still about trust and culturally competent care. It is critical that services be accessible and effective for people with different traditions, cultures and faiths. Empowering patients to offer their data is as important as mandating that it be collected.

Many briefings note that the Bill will be effective in reducing racial discrimination and health inequalities only if there is investment in community services and other actions. Not everything we can and should do is medical; the involvement of the voluntary and community sector is also crucial.

I welcome the provisions in the Bill to restrict the long-term detention of autistic people and those with learning disabilities. I support the Joint Committee on the draft Bill’s recommendation of clearer duties for ICBs and local authorities to develop robust community services and social support.

I pay tribute to the work of the work of the noble Baroness, Lady Hollins, and the independent care and treatment review programme to expose the serious harm and trauma inflicted by the use of solitary confinement, detention and long-term segregation in mental health and specialist learning disability hospitals. I too support the comments made by the noble Earl, Lord Howe, with regard to young people.

The right reverent Prelate the Bishop of Gloucester is the lead Bishop on prisons for the Church of England, and she apologises for not being in her place. She and I commend the Government on bringing forward the long-overdue provisions to end the use of prisons and police cells as places of safety. The right reverend Prelate has told me that last year more than 300 people suffering mental health crises were taken not to a hospital but to a police station. According to the recent report from the Chief Inspector of Prisons, the average time to wait to transfer mentally ill patients from prisons to hospitals is 85 days—almost three months. We welcome the statutory time limit of 28 days, but I highlight, as other noble Lords have, that if this is actually to happen, it needs to be resourced. As the noble Baroness, Lady Watkins, highlighted, there is a question of resource not just on this point but for much of the Bill.

Shortages of mental health nurses and doctors impact on those detained under the Mental Health Act and in the community. The learning disability nursing workforce in the NHS has dropped by 44% since records began in 2009. Investment in the workforce will be key to the success of the Bill. Community services can be developed and resourced only as far as the NHS, local authorities and directors of adult social care are supported to do so. I welcome the Bill and look forward to following its passage and working on what is an extremely important reform.

Type 2 Diabetes: Continuous Glucose Monitors

Lord Bishop of London Excerpts

Tuesday 19th November 2024 Lords Chamber

[Baroness Merron (Lab)]

It is probably important to say at the outset that type 1 diabetes, as the noble Lord knows, is not related to lifestyle issues, and at this point cannot be prevented, so it is a case of management. The technology that is available now is quite remarkable— not just the CGMs that the noble Lord, Lord Rennard, inquired about, but also hybrid closed loop systems, where the CGM is paired with an insulin pump, so it is administered automatically without the person having to calculate. I think that is incredibly helpful. It is only available to those eligible, with type 1 diabetes, but the rollout began in April 2024. The noble Lord makes a good point, as did the noble Lord, Lord Rennard, about access and inequality in access. That is something we continue to work on, ensuring that everybody can fairly access these wonderful technology advancements.

[The Lord Bishop of London]

My Lords, women with type 2 diabetes face a higher risk of miscarriage, stillbirth, neonatal deaths and birth defects. As we have heard, women who live in areas of high deprivation as well as women who come from black and minority ethnic groups are more likely to be impacted by type 2 diabetes. This compounds the existing inequalities in the maternal mortality rate. What steps are the Government taking to support integrated care boards to build relationships with these women who are most likely to experience these impacts, to ensure that they have the best maternity care and diabetic care, including ensuring they have access to continuous glucose monitoring where necessary?

[Baroness Merron (Lab)]

The right reverend Prelate is quite right in what she says, including that responsibility for CGM implementation rests with integrated care boards. It is their responsibility to ensure that the technologies we are talking about can be accessed by all eligible patients regardless of their ethnicity or their indices of multiple deprivation. I assure the right reverend Prelate that achieving that equality of access in all diabetes technology is an absolute priority. We will continue to monitor progress and encourage ICBs to do that by the NDA quarterly dashboard in 2025-26. In other words, we will give ICBs the tools to do the job they need to do.

Hospices: Funding

Lord Bishop of London Excerpts

Thursday 24th October 2024 Lords Chamber

[The Lord Bishop of London]

My Lords, I too thank the noble Lord, Lord Farmer, for introducing this debate. I declare my interests as outlined in register, particularly that I am patron of Hospiscare in Exeter.

I suspect there has never been a more important moment in time to discuss the funding of the hospice sector, which is facing extreme challenges. It is also important to remember that hospices deliver excellent care to a significant number of people who are dying well. However, according to Hospice UK, the sector is facing the worst financial crisis in more than 20 years.

The state provides on average only a third of hospice funding. A large proportion is found by fundraising. Those who live in affluent areas are more likely to financially support their hospices than those in deprived areas. That will have a direct impact on not only access but quality of care to those in the deprived areas.

It also entrenches the worsening inequalities in health, as highlighted by the noble Lord, Lord Farmer, not just between regions but also within them. In addition, the funding given to ICBs for palliative and end-of-life care is highly variable, and sometimes disproportionate for the demographics of their population. In the absence of any long-term plan, I echo the request of the noble Lord, Lord Farmer, and ask the Minister what support the Government are giving to ICBs as they make their commissioning decisions in this area.

As already indicated by the contributions made, noble Lords are aware of the introduction of the Private Member’s Bill in the other place which seeks to change the law for those who are terminally ill. How can we consider this if we do not give enough funding to hospices, palliative care and palliative care research, so that people dying receive the best care—the care that they need to make life worth living and, in the words of Dame Cicely Saunders, to live life until they die?

I hope that we are not prioritising the care of those who need it based on their contribution to our economy. This is contrary to how God values each one of us, contrary to the principles on which the NHS is founded, and contrary to human dignity. How the Government choose to prioritise palliative care matters very much. I look forward to hearing from the Minister about the Government’s plan to secure a sustainable future for hospices, palliative care and palliative care research.

Palliative and End-of-life Care: Funding

Lord Bishop of London Excerpts

Wednesday 4th September 2024 Lords Chamber

Asked by

[The Lord Bishop of London]

To ask His Majesty’s Government what assessment they have made of the adequacy of funding arrangements for accessible and equitable palliative and end of life care.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, we want a society where every person receives high-quality, compassionate care, including at the end of their life. Integrated care boards are responsible for the commissioning of palliative and end-of-life care services to meet the needs of their local populations. This is to promote a more consistent national approach and supports commissioners in prioritising palliative and end-of-life care. We will be considering the next steps, including funding, more widely in the coming months.

[The Lord Bishop of London]

I thank the Minister for her reply. We know that the hospice sector depends on charitable giving because of the low level of statutory funding at present. This means that the wealth and resilience of a community define the level of hospice services. This entrenches inequalities of place and means that access to hospice services is extremely unequal. Can the Minister outline what the Government are doing to look at the funding settlement, and particularly the wider hospice funding model, to ensure that this is not just another service that has poorer access for those in more deprived areas?

[Baroness Merron (Lab)]

I certainly take on board the point that the right reverend Prelate makes. It is the case that the amount of funding that charitable hospices receive varies by ICB area. That, in part, is dependent on the breadth of a range of palliative and end-of-life care provision within the ICB area. I can assure your Lordships’ House that my colleague, Minister Kinnock, the Minister of State for Care, has recently met with NHS England, and discussions have started on how to reduce inequalities and variation in access to services and their quality.

Covid-19 Inquiry

Lord Bishop of London Excerpts

Tuesday 3rd September 2024 Lords Chamber

[The Lord Bishop of London]

My Lords, I declare my interest as set out in the register. It is good to have this opportunity to speak in this debate and to acknowledge the important recommendations of this first report from the Covid inquiry. The pandemic was a seismic event for us all, and a great tragedy for many. My thoughts and prayers go to those who have lost individuals because of the pandemic. My thanks and gratitude go to those who stepped up and beyond to care for and protect us.

I want to highlight a couple of points from the report. The first is that the clearest flaw identified in the risk assessment was the underlying health of the UK population prior to 2020, as mentioned by the noble Baroness, Lady Tyler. We are all aware of the entrenching and exposing effect that the pandemic had on health inequalities. We are all aware of the impact that non-clinical factors such as housing have on our health. We are all aware of the vast difference in healthy life expectancy depending on where we live. We are all aware that those living in more deprived areas are more clinically vulnerable on average, but spend much more time in front-line jobs.

We are an interconnected people whose health and well-being are bound up in one another’s. It is the weighty responsibility of all of us, especially in this place, to take on such an injustice with priority and focus. In the section on data, the inquiry recommends that:

“The UK government should … commission a wider range of research projects ready to commence in the event of a future pandemic,”


including to

“identify which groups of vulnerable people are hardest hit by the pandemic and why”.

The Covid-19 Bereaved Families for Justice spokesman responded to the publication of this report by saying that we must

“challenge, address and improve inequalities”

and not just understand

“the effects of these failures”.

In fact, I wonder whether we have really and completely understood the impact. We were all affected, but we were not equally affected. At the height of the virus, the Bangladeshi population had a death rate around five times higher than the white British population. The rate in the Pakistani population was around three times higher and in the black African population it was twice as high. But even these statistics do not communicate the extent of the damage that the virus caused to specific communities. Between March 2020 and February 2021, the Church End area in Brent lost 48 people. The damage done to individual communities was, in some cases, very severe. What action are the Government taking to address the widening health inequalities in our communities, not just for future pandemics but for now?

There are questions I believe we need to ask about how these devastating events have impacted the trust that those communities have in the health service, local government services and the Government. In 2021, I did a piece of work examining the role that faith communities played during the pandemic and heard their stories and experiences. Many shared stories of loss and resourcefulness, but they also shared stories of culturally incompetent care. This included the story of a Sikh man in Southall, who had had a stroke and was unable to speak, who had his moustache and beard cut without obtaining the permission or seeking the consent of his family. This was deeply offensive and after investigation it was found there was no medical reason for it to have occurred. We heard stories of distrust of the health service and a lack of understanding from statutory bodies of the provision for their communities that faith groups had held for generations. They said:

“There was a lack of cultural knowledge about how a burial for the Muslim community happens so we did it ourselves. We raised money so people could die with dignity”.


During the pandemic, faith leaders were rightly identified as important partners, and there are fantastic accounts of successful vaccination rollouts and health campaigns supported by them. However, that engagement has not been sustained. Forming relationships in a moment of crisis is not the way that resilient and interconnected communities are built. I have said many times in this place that, if we are to make a serious and sustained effort to tackle health inequalities, faith groups must be involved. I was encouraged to hear the words of the noble Lord, Lord Evans, about including diverse views, which I would see as also including faith groups.

Areas of high deprivation often have a higher level of faith observance. A person’s faith is also significant to their healthcare needs. Because of these things, systematic engagement with faith communities at a local, regional and strategic level is vital. This both ensures that the PLUS target populations are prioritised and makes sure that appropriate healthcare is offered to those with faith-based requirements. In addition, the extraordinary effort that faith groups gave to supporting their communities during the pandemic and continue to give should be recognised for the benefit not just to their communities but to us all. What progress are the Government making to engage with faith groups not just in the moment of crisis but over the long term?

This report should inform not just the earmarked actions that we take to prepare for the next pandemic but our approach to other areas of life and health. Our collective health will be undermined if these entrenched inequalities persist and will make us all the more vulnerable to future health threats. I urge the Government to consider carefully how they respond to this report to improve the health of those communities which bore the brunt of the Covid-19 pandemic and to undertake a serious reform of social care. This has never been more urgent.