NHS: Nurses

Lord Kamall Excerpts

Tuesday 1st November 2022 Lords Chamber

[Lord Markham (Con)]

The Nuffield study was very interesting: of the reasons for people leaving, 43% said retirement, 22% said it was for personal reasons, and 18% said it was due to too much pressure. Again, in quoting those figures I accept that there is work we need to do on this. Clearly, 18% leaving due to too much pressure is something we rightly need to be concerned about. I know that is why we set up the 40 mental health and well-being hubs with a £45 million investment, to look at whether we can address some of those pressures. Most of all, though, I completely agree that we need to recruit as many nurses as we can so that we have as big a supply as possible to ensure that we continue to relieve any pressures that exist.

[Lord Kamall (Con)]

My Lords—

[Lord Lilley (Con)]

My Lords—

[Lord Kamall (Con)]

I apologise to the noble Lord but it is some time since I have spoken in this part of the House. Given that it was Black History Month last month, does my noble friend the Minister agree that we owe a great deal of gratitude to immigrants from the Commonwealth who helped to save our public services after the war? Now that we have left the EU, can he also assure us that we will no longer give priority to mostly white Europeans over mostly non-white non-Europeans, and treat all equally when we want to recruit health and care staff from abroad?

[Lord Markham (Con)]

I totally agree. My noble friend rightly states that we have had a fine tradition, right back to the beginning of the NHS, of recruiting people from all over the world, predominantly the Commonwealth. I am also delighted to say that, since we moved the cap on visas from people all round the world in 2019, the number of those who have joined has gone up from 25,000 a year to 48,000 a year. That is almost double the number and very much the result of what my noble friend said about making sure that we are welcoming people into the profession from all over the world.

NHS: End-of-life Care

Lord Kamall Excerpts

Thursday 8th September 2022 Lords Chamber

[Lord Balfe]

To ask Her Majesty’s Government what assessment they have made of the provision of end-of-life care by the NHS, particularly in respect of Archie Battersbee.

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

The Government are committed to providing high-quality end-of-life care, working closely with the NHS and other stakeholders. The Government are commissioning an independent review into the causes of disputes between those with parental responsibility and those responsible for the care or medical treatment of critically ill children such as Archie Battersbee. The requirement was specified in Section 177 of the Health and Care Act 2022 to lay a report before Parliament by 1 October 2023.

[Lord Balfe (Con)]

I thank the Minister for his Answer and for our meeting earlier this week. I stress that what I am looking for is a review, not an inquiry. We are not trying to pin blame and I hope that the review will have a wide range of disciplines and not be dominated by doctors and lawyers. Because although they say they acted in the best interests of the child—I am prepared to agree that—the parental grief will last for the next 50 years, for the rest of their lives, and we need to get this right. I hope the Minister will be able to reassure me that this will be a wide-ranging review that will involve all the disciplines involved in care.

[Lord Kamall (Con)]

I return the favour by thanking my noble friend for the meeting, but also for the frequent conversations we have had about mediation, for example. I know my noble friend is a qualified and experienced mediator. We are quite clear that the review has to attach no blame. We want to hear from as many people as possible. It will investigate the causes of disagreements in the cases of critically ill children between providers of care and persons with parental responsibility. It will look at whether and how these disagreements can be avoided, how we can sensitively handle their resolution, provide strong evidence and inform future recommendations to support end-of-life healthcare environments in the NHS. As much as possible, it will promote collaborative relationships between families, carers and healthcare. We can see it from both sides: as a parent, just put yourself in the shoes of someone who has to make these difficult decisions. Sometimes they feel that the medical profession acts like God; on the other side, there are medical professionals who believe that the parents do not really understand all the details. Let us make sure that we get this right.

[Baroness Finlay of Llandaff (CB)]

My Lords, I too thank the Minister for having met me earlier in the week to discuss this issue. When parents receive devastating news, they are in such a state of shock that communication with them, however sensitively undertaken, risks being misunderstood. Parents are unaware of the limitations on their ability to request interventions or transfer for their child, unlike when the child is at home. So will the Minister confirm that the review will take direct, in-person evidence from parents who have been in this terrible situation and who wish to contribute from their experience—not to apportion blame, but to improve care for others?

[Lord Kamall (Con)]

I thank the noble Baroness, Lady Finlay, for the conversations we have had since the passage of the Health and Care Bill. My officials have been incredibly appreciative of her bringing her expertise to this field and, in fact, for educating them—and me—on some of the sensitive issues that people have to deal with in these environments. We want the review to be as wide as possible; we do not want to cut it off; probably the only thing we want to avoid is blame. We want to do this in a sensitive way; we want to hear from the families; we want to make sure it is a balanced review, and we hope to take evidence for the review from as many people as have a view on this. That is why we are taking our time; we have to publish it by 1 October 2023.

[Baroness Butler-Sloss (CB)]

My Lords, as a family judge I tried a very considerable number of end-of-life cases, in relation to both children and vulnerable adults, so I hope this review will take into account that when the parents and the medical profession are locked in disagreement, there is a way out, where the judge who tries the case actually looks exclusively at the best interests of the child—taking into account, of course, what the parents think and what the doctors and the nurses think. It is crucial to have that ability to go to a family judge, who will deal with these cases sympathetically but firmly.

[Lord Kamall (Con)]

The noble and learned Baroness makes an incredibly important point about getting this right and getting the right balance. We know how difficult and sensitive these cases are when they have come to court. One issue that has been discussed by a number of parties is mediation: can we avoid it going to court in the first place, but also at what stage should mediation take place? It should not just be offered right at the end when everything has ended. We must make sure we really hear the voices of professionals as well as those affected, and families, to get the right balance. So far, we have relied heavily on the courts for some of these cases, sadly, but we just want to make sure we get this right.

[Baroness Brinton (LD)]

My Lords, over the last six years, the provision of palliative care for children and young people has become very patchy. CCGs across England have been closing down palliative care for children. Are the Government taking action to hold integrated care boards to account publicly on implementing their duty to commission palliative care for children and young people?

[Lord Kamall (Con)]

The noble Baroness will be aware that earlier in the week, when we had the debate on integrated care boards and their responsibilities, we added—thanks to the work, once again, of the noble Baroness, Lady Finlay—palliative care services to the list of services that integrated care boards must commission. Integrated care boards will be accountable to NHS England, but also the CQC will be doing a lot of evaluation and they will be measured against the list of services that they have to commission. Clearly, there will have to be accountability on palliative care services.

[Baroness Merron (Lab)]

My Lords, when a child is at the end of their life, quality palliative care should ensure, of course, both the child’s comfort and managing pain and symptoms, but also provide support and care for the entire family. These are clearly heartbreaking situations for everybody involved, so will the Minister assure your Lordships’ House that the review will take account of the support that is given to the whole staff team, including ancillary workers? They, of course, have a key role to play.

[Lord Kamall (Con)]

One thing that often happens at reviews is that we realise how complicated these issues are. One often cannot pinpoint one key issue, or one silver bullet, as it were. Therefore, quite often—and I was on a call on a different issue yesterday—we thought we had to tackle certain issues but realised there were wider systemic issues. Clearly, that is going to be the case here. NHS England’s palliative and end-of-life care programme is an all-age programme, but there are specific pieces of work focused on children and young people. We have also been working very sympathetically with charities such as Together for Short Lives. It has been commissioned to produce written guidance to provide ICBs and ICSs more detail, as the noble Baroness asked for, but also to make sure we make it a better environment and learn.

[Lord Alton of Liverpool (CB)]

My Lords, in my conversation with the family of Charlie Gard, they were emphatic that adding to the tragedy of the loss of a child, the thing they found hardest was having to go to court and go through an adversarial system. Anything the review can do to prevent the necessity of court action, notwithstanding wonderful judges such as my noble and learned friend, would be welcomed by such families.

[Lord Kamall (Con)]

I think many noble Lords will echo the sentiments of the noble Lord on that. That is why we want the review to be as wide-ranging as possible. People have suggested mediation, but should that be mandated or voluntary? There is also a difference between commercial mediation and family mediation. Commercial mediation is usually binding, whereas family mediation is not always binding. A further question is: at what stage do we offer mediation? One thing we are being told is not to offer it when everything else has failed: we should offer it as soon as possible, to encourage a collaborative approach.

[Baroness Stowell of Beeston (Con)]

My Lords, clearly it is important that the professionals are involved in this review, but I think it is also important—as this review begins and my noble friend considers the terms of reference—that emphasis really is given to families, because these tragic cases are symptomatic of a wider problem that a lot of people face when they engage with officialdom and professionals, which is feeling that they are not being taken seriously. It is even more acute when the situation is the one that these families find themselves in, when they are parents and have important status as parents, and the issue at hand is the life and death of their own child. My noble friend has been very good at reassuring this House, but I ask if he could just give greater emphasis again to the importance of the families in this review.

[Lord Kamall (Con)]

Once again, I thank my noble friend for joining the meeting this week on this issue. It is quite clear that we want to hear from all voices. We encouraged the families to come forward. We have heard a number of cases, including some raised by noble Lords personally, who have been in contact with the families, and raised their concerns. Quite often they felt that their voices were not heard and they did not really understand the issues; they were in a very emotionally difficult time to take some of those issues in and understand the choices that were available. Sometimes they felt rushed into it by medical professionals. I think sometimes medical professionals have to show a bit of humility and not act like God.

Care Homes: Energy Costs

Lord Kamall Excerpts

Thursday 8th September 2022 Lords Chamber

[Lord Harries of Pentregarth]

To ask Her Majesty’s Government what assessment they have made of the likely impact of increased energy costs on care homes; and what extra support they intend to provide in response.

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

The Government are committed to working with local authorities to help manage the pressures of inflation, for various reasons, on adult social care. We acknowledge the impact that challenges such as energy price rises will have on residential care providers and right across the system. As noble Lords will be aware, the Prime Minister has stated that a package of support for energy costs is her priority. Sadly, in terms of timing, we expect announcements shortly and will see how that feeds into the social care sector.

[Lord Harries of Pentregarth (CB)]

I thank the Minister for his reply. As he well knows, care homes are already under great financial pressure. In the six years up to 2020, more than 1,600 had to close—many of them rated good or very good—and the rise in energy costs is already absolutely staggering, from something like £660 per bed per year to over £5,000 per bed per year. Of course, some help will be offered this afternoon, but is the Minister confident that the Government have really taken on board the sheer scale and seriousness of this situation for care homes?

[Lord Kamall (Con)]

The noble and right reverend Lord makes a really important point about this issue and the impact on social care. What we are seeing right across government is the impact of this energy crisis: that is why the Prime Minister is making this announcement. We will then have to look into the details of how that affects the different sectors. We have heard from the social care sector, we have heard from care homes and we have heard from patients themselves about their concerns about the cost. I am afraid I cannot give more details at the moment. The Government are working very closely at the moment with local authorities and are in constant conversation about how we can help reduce the burden. Once we have more details of the package, we can look at that in more detail.

[Lord Scriven (LD)]

My Lords, heating costs are just the tip of the iceberg for care homes. What does the Minister have to say to people such as June, a care home worker in Sheffield of 24 years, who is now having to leave the sector that she loves, just to get enough money to be able to feed her family?

[Lord Kamall (Con)]

The Government recognise that for a long time the social care sector has been treated like Cinderella: a poor relation of the health system. That is why we had the Health and Care Bill, to make sure that we have care right through people’s lives. One thing about social care is how disparate and fragmented it is. One reason we have the register is to understand who is out there—who is doing what, their qualifications and their levels of pay, but also how we can make sure that they feel it is a rewarding vocation and career.

[Lord Howell of Guildford (Con)]

My Lords, is my noble friend aware that many care homes and, indeed, even more retirement homes and retirement communities are serviced by what are called heat networks. These are combined systems; we used to call them combined heat and power, but heat networks are the modern description. These were not covered at all by the previous energy cap. Could the Minister be assured, and assure his friends, that in the coming arrangements they are properly covered as well?

[Lord Kamall (Con)]

As my noble friend will be aware, many care homes are privately owned and run. Quite often, we do not get into that level of detail but I will take the question back to my department once we are aware of the package that is announced.

[Baroness Pitkeathley (Lab)]

My Lords, to add to the problems of care homes to which noble Lords have referred is the report in today’s newspapers that the new Secretary of State for Health intends to use them as places to discharge people who cannot have a social care package in their own homes. Can the Minister assure the House that, if this happens, all attention will be paid to the huge problem that care homes already have in recruiting enough staff to carry out their existing functions?

[Lord Kamall (Con)]

All noble Lords will be aware of the challenges facing care homes and their owners, including recruiting sufficient staff. People have referred to a number of different issues; one is vocation and feeling valued—quite often they feel as if they are poor relations. Another issue is supply, which is one reason we have looked at a visa to try to encourage more workers from overseas. If we make it a proper vocation, people will want to train in it, get those qualifications and feel they have a valued career.

[The Lord Bishop of Durham]

My Lords, I was going to ask a very similar question; the Minister did not answer the specific question about the Secretary of State’s proposal that she may move people from hospitals into care homes and ensuring that that is joined up. Will he comment on that proposal?

[Lord Kamall (Con)]

I am afraid I was so busy swotting for these Questions and the three-hour debate afterwards that I missed the news, so I will have to take that back to the department and make sure that we give an answer. I will not avoid giving one.

[Baroness Brown of Cambridge (CB)]

My Lords, have the Government considered the impact of increased energy costs on our major scientific facilities, such as the Diamond Light Source? If increased energy costs eat up the increases in UKRI budgets, this will severely impact our ability to deliver the Government’s ambition of the UK becoming a science and technology superpower.

[Lord Kamall (Con)]

That is a really important angle that I had not considered, to be honest. We recognise that, across government, many Ministers in many departments will be waiting at the moment with bated breath for the Prime Minister’s announcement to work out the impact on those stakeholders who have been contacting Ministers and others about the impact of energy costs. Clearly, something has to be done. The Prime Minister will announce it and then we will have to work through its impact. If I am still in post, I can come back to say how that will impact the health and care sector.

[Baroness Altmann (Con)]

My Lords, will my noble friend look into the situation of care homes, whether they are in the private sector or not, that have not currently participated in the government handouts to help with energy costs? Second home owners have had discounts on their bills, but there has been no per-bed contribution from the Government to help care homes which are already struggling and for which many families are paying enormous sums.

[Lord Kamall (Con)]

My noble friend makes a point that I was not aware of, so I am afraid I will have to take it back to the department. However, it appears a very reasonable point.

[Baroness Wheeler (Lab)]

My Lords, what support will the Government specifically give those care homes whose pre-Covid Care Quality Commission ratings have been downgraded from good to inadequate as a result of staff shortages? This is on top of their deep concerns over energy costs. Recent press reports say that up to three-quarters of care homes in England have been reassessed in this way.

[Lord Kamall (Con)]

Clearly, one of the issues in the overall review of the social care sector is that, when the CQC and others report on care homes and other places, action is taken. One of the things we will do is talk to the right stakeholders and individuals, but we also have to work in partnership with local authorities—as quite often it is their responsibility—to try to make sure we raise the standard.

[Baroness Hussein-Ece (LD)]

My noble friend Lord Scriven asked a specific question on what the Government are doing about pay. The Minister will be aware that there is a crisis in the care sector in recruiting and retaining staff. I declare an interest as I have a family member in a residential care home and am acutely aware of the situation. What is being done to make sure that they are properly funded so that we can retain and recruit much-needed care staff in all residential homes?

[Lord Kamall (Con)]

When I speak to officials in the care part of my department about this issue, one of the things they say, in consultation with a number of individuals in the care sector—not only employees but owners—is that morale is clearly low, partly because of pay but also because they feel they do not have a proper vocation. It is very confusing to have all these qualifications; they are not recognised elsewhere and there is no clear career path. One reason we are putting together this register is that we want to understand the landscape out there—it is incredible that this has not yet been done—including the number of qualifications, the issues and what sort of career structure can be offered.

[Lord Whitty (Lab)]

My Lords, several noble Lords have referred to the terrible financial situation of the whole social care sector and its employees. I recall the last Prime Minister said he was going fix social care. Nothing happened. Does the current Government recognise that a step to help out the social care sector, over and above other businesses, would be at least a first step towards fixing the sector?

[Lord Kamall (Con)]

One reason we brought forward the Health and Care Bill was that we wanted to make sure that social care was given proper status. Social care has been seen as the poor relation to healthcare for far too long by successive Governments. What we want is a proper health and social care system, properly integrated. Sometimes social care workers leave the social care workforce and move to the health side because they feel it is more valued as a profession. We want to make sure the same is true of social care providers.

[Baroness Manzoor (Con)]

My Lords, the NHS has a great history of running great campaigns. I am thinking of “Clunk, click” and the campaigns against smoking and alcohol. Can the Minister say, because not only the cost but the supply of energy is very important, how the department is co-ordinating to ensure that there is a campaign to reduce the energy used in homes, particularly those in the higher income brackets?

[Lord Kamall (Con)]

I thank my noble friend for the question. The issue is much wider than just health. We are working with local authorities to understand the impact on the care sector, but there is also a huge cross-government approach on education and energy efficiency. We have to wait and see the package before we can look at this in detail with the sector, and at what measures can be offered.

Primary and Community Care: Improving Patient Outcomes

Lord Kamall Excerpts

Thursday 8th September 2022 Lords Chamber

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

My Lords, before I begin the response to the noble Lord, Lord Patel, and other noble Lords, I am sure that all noble Lords will be concerned by the news from Buckingham Palace about concerns over the health of Her Majesty. I am sure that the thoughts of all noble Lords are with Her Majesty and her family at this time.

I begin by thanking once again the noble Lord, Lord Patel, not only for introducing this debate but for our many conversations and his advice. In fact, he has given me so much advice, I sometimes think about calling him “uncle”. It has all been part of my learning—understanding the processes and the whole range of our health service, as well as some of the challenges. That was very well demonstrated in the noble Lord’s opening remarks and in some of the issues he has raised with me over time.

What has been interesting in this debate is that lots of people have different views on answers. We agree that there are problems and that they have to be fixed, and we want to see better integration. Some say that we need a revolution; others say that it should not be a revolution but evolution; and others would criticise evolution as piecemeal. We have to be very careful about that. Some say GPs are central to primary care; others say that it should be not only GPs but a range of workers. In fact, a number of GPs complain that they spend far too much time on things that could be done by other professionals in their practice.

The noble Baroness, Lady Watkins, rightly said that we should be careful about a one-size-fits-all approach and trying to suggest or impose one model that would work everywhere. It has to be community led, in many ways. In answering, it is really important to address these issues. I suppose the final debate we had was of some saying that we need a clear distinction between primary and secondary care, and others saying that we do not, as the lines are blurry and what is important is that patients are able to access the health and care services they need. All of that is part of this whole debate, which I found fascinating.

The noble Baroness, Lady Pitkeathley, reminded us that we are now talking about an integrated health and social care system. It is absolutely right that we look to make sure that its social care aspect has parity with the rest of health. I pay tribute to the noble Baroness for consistently reminding me and the Government about that.

We all agree that primary and community care are essential services. As a Government, we recognise that they are under significant pressure, as do noble Lords. My noble friend Lord Eccles asked why this is. There are a number of reasons. At the moment, we have more doctors and nurses than ever before but, as many noble Lords reminded me, demand is outstripping supply. Think about our awareness. During the passage of the Health and Care Bill, we spoke about the importance of mental health and about it having parity. Think about how seriously we took mental health only 30 years ago: many syndromes—post-traumatic stress disorder, for example, and others—were not even recognised until the 1980s. Before then, people were just told to pull themselves together or have a stiff upper lip. Now we recognise how important it is to tackle people’s mental well-being.

Some noble Lords will remember a debate I took part in recently on neurological disorders. When I asked my team for a briefing, I asked them to list all the neurological disorders so that I could understand this. They said, “Minister, do you realise that there are 600 of them?” Imagine that awareness of 600 disorders and how many people are needed right across the country. That shows the challenge we face in demand outstripping supply. It also highlights one of the points behind the question from the noble Lord, Lord Patel: given that all this demand is outstripping supply, is it really appropriate to continue with a model from 70-odd years ago, as the noble Lord, Lord Kakkar, rightly said? The debate we are having is on whether it should be revolution or evolution, and how we ensure it is patient centred.

Another important point mentioned by a number of noble Lords was prevention. It should not be about waiting for people to get ill and then, hopefully, curing them; it should be about prevention in the first place. Individuals, bodies and organisations can all play a key role in that. As the noble Baroness, Lady Brinton, said, it is right that the voice of patients is heard. No one should ever say again to the noble Baroness—I would not dare to—that patients know too much. We want patients to have a partnership with their health and care professionals, so that they understand the issues and so the patient feels valued and understood—a number of noble Lords mentioned this when it comes to named GPs, for example.

It is critical that we look at prevention. That shows that it does not always have to be the GP. I am sure that if the noble Lord, Lord Mawson, had been here, he would have talked about the Bromley by Bow Centre and how there are a range of skills and individuals there. It is not about only the GP but about making sure people have healthier lifestyles. I think the website of the Bromley by Bow Centre and others is about creating health. In his book, Turning the World Upside Down, the noble Lord, Lord Crisp, says that we have to shift away from cures to prevention, not just curing people but creating health. We have seen a lot of progress in the thinking about how we get that into the system.

I will respond to some of the general points that a number of noble Lords made. To draw again on the noble Lord, Lord Crisp, he said that we should also look to other countries. We have this view—not just the United Kingdom but the whole western world— that the rest of the world can learn from us. However, as he said, if you go to some of these countries which have challenges such as resource challenges, they have some very innovative solutions. Some of them have defined completely new roles which would not be recognised here. These people are trained for shorter times and are more specialised, and although the doctors’ lobbies in those countries have railed against them, he said that it gives you effective outcomes. Perhaps we have to look at some of the traditional roles, such as doctors and nurses—we are seeing physicians’ assistants, for example, and specialists. I hope that the rest of the medical profession will be open to completely new hybrid roles, which are not the same as those of 70 years ago.

My noble friends Lady Hodgson and Lord Eccles talked about the right to see a named GP. We understand that, but not every patient will want a named GP. We have to get the balance, because the technology gives us a better service but it is not just about that; it is about people’s first interface. They want to speak to someone who understands their condition. Clearly, however, in other cases it will be important to see a named GP. At the moment, all practices are required to assign their registered patients to an accountable GP but, as my noble friend Lady Hodgson reminded us when we debated the Health and Care Act, that does not mean that the individual always responds. In theory, they should be responding, so one thing we want to look at in more detail is why that is not happening in many places.

A number of noble Lords, including the noble Baroness, Lady Finlay, talked about how we are growing the GP workforce. There are concerns. One of the things I promised in previous debates—I have not had the answer yet; I hope I get it before I leave office, whether that is this week or whenever—is on this cap on training numbers. Yes, we are training more GPs, but at the same time we are losing an awful number of them. Programmes on retention are in place, and the issue of pensions is clearly important. Sadly, I am not able to update the noble Baroness, Lady Meacher, on this; I have asked the question but, let us put it this way: discussions are taking place with another government department. When I worked in other areas of commerce and elsewhere, quite often people reminded me that the price of acquisition is often more expensive than the cost of retention., so we should be investing in the retention of people who still want to work. However, we do not want any of these artificial retirement dates; people are all living healthier lives. We are increasing the number of trainees but we also have to look at morale and retention. A number of proposals are there, but how do we make sure that they get out?

The GP business model is changing—it should not be one size fits all. I talked about the Bromley by Bow Centre; I speak to some GPs who are concerned that their practice is seen as too small. They say, “I am under pressure to go into a practice, but I give a personalised service and I worry about the service we are getting.” At the other end, you get these large health centres that are taking on some functions which were previously secondary care. I understand that challenge, therefore we agree that the primary care entry point should be about multidisciplinary teams. It should be making use of the best capacity we have and looking at alternative sources of expertise, such as dieticians, a physiotherapist or social prescribing, which a number of noble Lords mentioned during the passage of the Health and Care Act.

We made an announcement in July about reforms to dentistry. These are not the complete reforms; there are still conversations around the UDA, for example, and what is felt to be fair remuneration, but we have at least made some progress in those conversations and now have a collaborative discussion. For some people, that is not enough and we have to speed up; I completely understand that, but at least we are making some progress. Up to now they have just been at loggerheads, and we have had others saying, “You’ve got to look at the UDA, which is the source of all these problems.” We are now looking at that, and I pay tribute to the BDA and others for those collaborative conversations.

My noble friend Lady McIntosh of Pickering always raises the issue of rural practices—and rightly so; it is critical that we are reminded of it. We recognise that there are issues with retention in certain areas, and one thing we have been doing with the new medical schools is understanding that people are more likely to stay where, or close to where, they are trained. That is why we have been looking to open some schools in those areas. That will not solve everything. My noble friend also talked about rural connectivity. That issue is widely recognised at the top of the NHS, which is looking at connectivity to be managed locally and the availability of networks. I had a meeting earlier this week with a number of different suppliers on telecare. The meeting was about the switch from analogue to digital, but an issue that came up was the poor provision in many rural communities. One conversation we must have is with the broadband suppliers. Fortunately, technology will fill in a lot of this—we are seeing the cost of satellite coverage dropping and more support for fill-in systems—so I hope we will be able to improve on that. We want to recruit more people in rural areas.

Let me just make sure that I have tackled all the points raised. The noble Baroness, Lady Masham, talked about the steps to discharge patients. It is the Government’s priority to make sure that people are safely discharged. The moment the previous Secretary of State came into office just before the summer, he got together the heads of the various parts of the NHS and spoke to particular trusts and said, “What can we do to clear the pipeline to make sure that people can leave quickly to the community, and what challenges are there?” I know that my new boss, my right honourable friend the Secretary of State for Health, will look at that.

A number of noble Lords raised the issue of seeing a GP in person, and technology. One challenge we have had is that sometimes there is too much technology. We want the NHS app to be the gateway. The noble Lord, Lord Patel, referred to the recent report by Policy Exchange, and I thank Policy Exchange and the other experts who sent us all notes to help us with this debate. When you go on the NHS app, you can, in theory, book an appointment—but you cannot. Then I go to my GP’s website, which says, “You can book an appointment”, but when I go to book one, it says, “You can’t book that appointment; you have to phone us up.” Then we get back to the problem of 8 o’clock in the morning—and not just Monday, but all the way through the week.

One very sensible question is why you have to phone that day for the appointment. Can we look at a way to ensure that you can book today for up to, say, seven days in advance? We have gone backwards. When I was ill as a child, my mother could pick up the phone, phone the local GP and if they could not see you that day, if it was not that urgent, they would say, “How about next Tuesday?” How do we get back to that situation? We are still trying to understand those challenges and why that cannot be done. It says on the website that you can book an appointment, but when you press it, you cannot do so.

We are trying to make the NHS app the gateway. If I get an appointment at my local hospital, I think, “Oh great, I will just look at the appointment on my NHS app.” It does not appear there. I then get a text from that hospital that says, “Please go on to our portal.” So I have the NHS app, my GP website and my hospital website. This is the challenge. They have all said, “Yes, we want technology”, but it is about the processes behind that. On top of that, we all have to know how to make sure it works and to plug the gaps. I was asked to go to have an ECG at a primary care centre. I thought, “That’s very clever. Good, that works much better”, and was told that the consultant would phone me a week later for a conversation. I am quite relaxed about having a phone consultation, but when the consultant phoned me a week later and started talking, I asked, “Sorry, did you see my ECG from last week?” He said, “What ECG?” Then I said, “I tell you what, I can tell you the exact time and date, you can get it and then we can have the conversation.” He said, “Oh, don’t worry about that, I will make a new appointment for you.” We can have all the technology in place, but how do we ensure that the people processes are in place too?

This shows that we all have a role to play in this. The noble Baroness, Lady Merron, often brings up, rightly, the amendment on workforce planning. We talked about this during the debate. There is local-level workforce planning in the ICS. Individual practices and centres have their workforce planning. Many noble Lords will know that regarding the long-term, the department commissioned Health Education England to look at and report on those drivers. We have also commissioned NHS England to develop the long-term workforce plan for the next 15 years, including long-term supply projections. Also, under the Health and Care Act 2022, the Secretary of State has a duty to report every five years at minimum describing the NHS workforce planning and supply system. A lot is being done on workforce planning. One reason we did not accept the amendment at the time was the timeframes, and whether they would change between one report and another. We wanted to look at it in the long term, and for it to come from the NHS and to be from the bottom up.

I have gone on for far too long, but I really hope that this debate has shown everyone not only that all political parties are committed to reform but that at the same time, we must ask ourselves some very big questions. In some ways, it is a valid criticism that we are tinkering with a system that was designed 70 years ago. We must evolve a system rather than tinker with a system. We must tackle the supply of workforce, and we must look at the roles as defined today and whether there are newer roles. Can we learn from overseas, from some of the new roles that are defined elsewhere? Is everyone ready for change? Sometimes, I am not entirely convinced that every player in this system is ready for change. I have had GPs say, “I can take on more patients in my area, but the problem is that the system does not incentivise me to take on a patient elsewhere. They must deregister then re-register with me.” I hope that some of the primary care network initiatives we have will help that, but we all must accept that the current system has just been tinkered with for the last 70 years.

I am not necessarily concerned about the distinction between primary and secondary. It is important that the patient speaks to the right person when they need to, whether in person or remotely, and that they get the right follow-up care. I have had conversations about the model with the noble Lord, Lord Patel. As it is, if you can see a GP, you get five to 10 minutes. Noble Lords rightly expressed the pressures of that. You then hope for a referral. There must be a better way. Some patients are voting with their feet and getting direct referrals to consultants, and others are not. We do not want that two-tier service. We want everyone to have the same access.

The Government must do more. We clearly understand that. Maybe we are not doing it quickly enough, but we must look at the whole system and the roles as defined, while ensuring that it is not “one size fits all”. What is appropriate for one area and one population is not the same as what is appropriate for others. One of the really interesting things that the noble Lord, Lord Crisp, said, when talking about community workers, was that these are people who know about 120 people in their location. They know the families, they are trusted, they go out and knock on the doors of families to ensure that they are all right and help them with their diets and lifestyle. That is being tried in a couple of wards in London. We look forward to the results, but it might be revolutionary in terms of prevention.

I thank the noble Lord, Lord Patel, and all noble Lords. There were more specific questions that I did not answer. I will read the Official Report and write to noble Lords in response to those questions that I have been unable to answer today.

NHS: Access to Treatments

Lord Kamall Excerpts

Wednesday 7th September 2022 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what steps they are taking to improve access to treatments for NHS patients.

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

To improve access to treatment, the Government have committed to spend over £8 billion from 2022 to 2025, and this in addition to the £2 billion elective recovery fund and £700 million targeted investment fund made available last year. This funding is increasing capacity through community diagnostic centres and surgical hubs, supporting hospitals to prioritise treating the patients waiting longest, as well as accessing capacity via the independent sector. We are also making it easier for patients to choose treatment at different providers with shorter waiting times.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord will be aware that access to the NHS, whether in primary care, the ambulance service, A&E or discharge, has become worse and worse. All the organisations that submitted evidence this week said that the core issue is workforce. I declare my interest as a member of the GMC. Can the Minister explain why has the number of medical training places this year been drastically reduced to 7,500 compared to 10,500 for last two years, and 9,500 in the pre-Covid year? The Medical Schools Council has said that we should have 14,500 medical places. How can the Minister justify 7,500?

[Lord Kamall (Con)]

We are looking at a number of different things when it comes to doctors across the service. One is clearly opening new medical schools in areas which are underserved: sometimes we have doctors, but not in the right areas. We are also looking at overseas recruitment but, on the specific issues, we are having discussions—let us put it that way—on the cap. That is constantly being debated and I will take that back to the department.

[Baroness Blackwood of North Oxford (Con)]

My Lords, NHS leaders have warned of a life-threatening situation in which clinically vulnerable people are being admitted to hospital after having their energy supplies cut off. This is obviously horrendous for the patients involved, but also risks putting tremendous pressure on NHS systems, which cannot bear that pressure at the moment. I urge the Minister to advise the incoming Health Secretary to take action to prevent the cost of living crisis becoming a health crisis when we can least afford it.

--- Later in debate ---

[Lord Kamall (Con)]

My noble friend raises a very important point. It is not just in my department; across government a number of different departments are looking at the impact of the cost of living crisis and higher energy bills. Clearly the NHS, but also individual practitioners and centres within the NHS, will be affected by rising costs. Discussions are going on at the moment. One of the things that my right honourable friend the incoming Secretary of State has said is that she is very clear on the priorities—ABCDD: ambulances, backlog, care, dentists and doctors—but also understands the energy crisis.

[Lord Winston (Lab)]

My Lords, the Minister’s Answer to the noble Lord, Lord Hunt, does not seem to address the question. What we are seeing, of course, is a reduction in the number of doctors, whether from retirement and not being replaced or for whatever reason, or from a lack of training. Are the Government intending to reduce the number of doctors, as they have been doing, and how do they intend to substitute for proper medical care by a doctor, which is what patients want to see?

[Lord Kamall (Con)]

The noble Lord raised a number of different points, which I will try to respond to. One issue is that, although we are recruiting more doctors, at the same time clearly there are doctors who are looking to leave. There is a demographic of people reaching a certain age, and one of the issues is pensions and whether they hit the limit. Those discussions are going on. There are also lots of discussions going on about how we can improve retention of those staff who feel overworked and have had enough.

In addition, at certain levels, for example primary care, it does not always have to be a doctor that the patient sees. It could be a practice nurse or a physiotherapist. There is also more emphasis on the Pharmacy First programme, whereby people can get advice from pharmacies, unless they actually need to see a doctor.

[Baroness Brinton (LD)]

My Lords, for elective surgery, it does need to be a doctor that the patient sees. On Monday, a patient waiting for a long-delayed hip operation was told by his doctor about the delay. He thought he heard “18 months’ delay”: the doctor corrected him. It is 80 months’ delay in that particular area. This is the workforce problem that other Peers have already raised. What are the Government going to do? Setting up emergency elective places does not solve the problem when there are not enough doctors to go around at the moment.

[Lord Kamall (Con)]

If we look at elective care, we have seen a record number of referrals. We are also seeing more people receiving treatment. Of those on the waiting list, 16% are waiting for in-patient surgery. A lot of those on the waiting list are waiting for diagnostics. We have the surgical hubs and community diagnostic centres. On top of that, the two-year waiting list has been virtually eliminated, except difficult cases and those who need complex treatment. The next target is to eliminate the 18-month waiting list by 2023. It is a concerted effort right across the system, looking at a number of innovative solutions.

[Lord Laming (CB)]

My Lords, some of the conversations that we have had show that the availability of services in the NHS depends to a large degree on efficient access to social care provision. Could the Minister tell the House what the Government are doing to sort out the social care problem in this country, which is getting worse?

[Lord Kamall (Con)]

The noble Lord is absolutely right. There are a number of issues to do with social care. One of the reasons, frankly, is that it has been treated for far too long as a Cinderella service. One of the things we are doing is registration—there is a debate in the care community about whether it should be a voluntary or compulsory register; it is voluntary to start—to make sure that we really understand the sector. No one really has an overall picture of the care sector, and there is a range of different qualifications, which are quite often inconsistent. If we can get all that together, understand what is out there and understand the qualifications, we can make it a proper vocation and career for people. That is what we are doing at the moment.

[Baroness Morgan of Huyton (Lab)]

My Lords, I urge the Minister to talk to the new Secretary of State and urge her, after 12 years, to actually start governing rather than campaigning. As we have just heard, a series of headlines—ABCD and all the rest—may tick some boxes for the media but does not change the system. The fundamental issue is social care and there is still no plan to change that.

[Lord Kamall (Con)]

I am afraid I shall have to disagree. I ask noble Lords to think about what we have been doing with the Health and Care Act: for the first time, we are talking about properly integrating health and care together. They will be completely connected from the beginning of life and all the way through life. We also had the paper on integration and we are taking a number of different steps to make sure that social care is no longer the Cinderella service, but properly joined up all the way through people’s lives.

[Lord Bellingham (Con)]

My Lords, the Minister will be aware that access for NHS patients depends on hospitals that are fit for purpose and structurally sound. Is he aware a number of hospitals around the country, built in the 1970s, have leaking roofs and ceilings that are being propped up, including the Queen Elizabeth Hospital in King’s Lynn in my old constituency? Can he tell the House about plans to announce the new phase of rebuilt and new hospitals?

[Lord Kamall (Con)]

This is something that the previous Secretary of State, who had a very short term in office, considered. When he was looking at the priorities, one of the issues for him was the hospital programme—how we make it more streamlined and modular, and how we simplify the whole process of building new hospitals. Sometimes, these will be hospitals based on old models; at other times, this will mean things such as surgical hubs, which, whatever is happening elsewhere, will focus specifically on the conditions that need to be treated.

[Baroness Merron (Lab)]

My Lords, the QualityWatch report by the Nuffield Trust and the Health Foundation found that the record waiting lists we now see cannot be attributed to the pandemic, as has so often been suggested in this House. What is the Minister’s response to this report’s findings?

[Lord Kamall (Con)]

The Government are well aware of the waiting list problem. In fact, we have virtually eliminated two-year waiting lists, except for some of those difficult cases. The targets, working with various partners across the system, is to make sure that we eliminate 18-month waits by April 2023. When we look at this, those waiting 18 months or longer will be reviewed every three months at a minimum. Diagnosis and treatment of patients will be prioritised according to clinical urgency, then length of wait. NHS England has introduced six categories of prioritisation and is regularly reviewing those to make sure that patients are treated appropriately.

[Baroness Butler-Sloss (CB)]

Why have the Government reduced the number of doctors being trained and when will this be changed?

[Lord Kamall (Con)]

A number of noble Lords have already asked that question. I will take it back to department and get an answer.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, could I ask the Minister to read and circulate an article from Saturday’s Guardian by Merope Mills, a devastating account of the preventable death of the journalist’s 14 year-old daughter, Martha? Would the Minister note that Ms Mills, an erstwhile, uncritical NHS cheerleader, stressed that this

“had nothing to do with insufficient resources or overstretched doctors and nurses … austerity or cuts, or a health service under strain”?

Can the Government recognise that this crisis goes far deeper than simply listing numbers, money or technical solutions?

[Lord Kamall (Con)]

The noble Baroness is absolutely right that it is not just about money, although money does play an important role; it is also about processes and efficiency. In my conversations with people who have been in the NHS or medical services for years, many have commented that we still have the same old model: you go to see a GP, you hope to see them for five or 10 minutes and then you are referred to someone in secondary care. There is a much more efficient way of doing that in this day and age. We have to look at the whole model of both health and social care and modernise it.

Disabled People: Personal Assistants

Lord Kamall Excerpts

Wednesday 7th September 2022 Lords Chamber

[Baroness Thornton]

To ask Her Majesty’s Government what steps they will take to address the reported shortage of working age disabled people’s personal assistants, needed to enable them to work and live independently.

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

Personal assistants are invaluable in supporting people to live independently. The Government have in place a range of measures to support recruitment and retention, including delivering a national recruitment campaign, providing a £462.5 million boost for recruitment last winter and ongoing work with the Department for Work and Pensions to promote carers in adult social care. We are also investing £500 million to support and develop the social care workforce, including personal assistants, to address long-term barriers to recruitment and retention.

[Baroness Thornton (Lab)]

I thank the Minister for that Answer. The lack of PAs is a serious emergency and is creating huge anxiety for the working-age disabled, who need and have a legal right to be economically and social active. What seems to have happened is that the market for and availability of people who want and value this kind of job have vanished. Welcome as they were, none of the measures that the Minister mentioned address that emergency. For example, one no-cost action that would help—it would not solve the problem, but it would help—would be for PAs to be recognised as skilled workers and be made eligible for work in the UK, since more than 32% of them vanished as a result of Brexit. Are the Minister and his colleagues meeting the disabled groups that are very concerned about this matter?

[Lord Kamall (Con)]

I thank the noble Baroness for raising those issues. As she will recognise, some of them fall between DWP and the Department of Health, so I can take the second question back to DWP on her behalf. We recognise this issue as part of the wider social care sector but one issue with bringing people in from overseas—as many noble Lords will know, I am in favour of recruiting from overseas—is that personal assistants are often employed by individuals and, sadly, under the Home Office rules, they are not considered sponsors. When this was raised with me yesterday, I asked for it to be looked into in more detail and was assured that more conversations will be going on. It is a reasonable suggestion; we just need to have those conversations with the relevant department.

[The Lord Speaker (Lord McFall of Alcluith)]

My Lords, we have a remote contribution from the noble Baroness, Lady Campbell of Surbiton.

[Baroness Campbell of Surbiton (CB) [V]]

My Lords, I have contributed to your Lordships’ House for 15 years because I am supported by PAs. Without them, thousands of disabled people could not work. Can the Minister explain how the Government are honouring their commitment to support disabled people’s UN convention rights to live independently, given the current PA employment crisis? Does he agree that fixing social care must include many different ways of attracting motivated PAs? Will he meet me and disabled experts to discuss solutions to this crisis?

[Lord Kamall (Con)]

The noble Baroness makes a welcome point and clearly demonstrates the usefulness of and real need for personal assistants; indeed, I have met and had conversations with her and her personal assistant. This is part of the wider issues around employing and getting more people into social care, as well as professionalisation. At the moment, some of the initiatives to professionalise a service do not extend to personal assistants, partly because of the way they are employed. When I asked why we cannot harmonise between personal assistants and other people in the care sector, I was told that conversations are going on. I will have to take this back to the department and DWP to get an answer for the noble Baroness.

[The Lord Speaker (Lord McFall of Alcluith)]

My Lords, we now have a virtual contribution from the noble Baroness, Lady Thomas of Winchester.

--- Later in debate ---

[Baroness Thomas of Winchester (LD) [V]]

My Lords, the Minister has partly replied, but can he say a bit more about Home Office bureaucracy which is holding up the recruitment of care workers from overseas?

[Lord Kamall (Con)]

One issue that I think noble Lords across the House agree on is a suggestion made by the noble Baroness, Lady Thornton. If we want to make sure that we have the right number of workers, we should improve training over here, but there will clearly be a skills gap in this country and therefore we need to look overseas. Sadly, as I said earlier, under the Home Office rules at the moment, individual employers do not count as sponsors. Officials in the department are having conversations with DWP to look at whether that can be rectified, or whether there is a way to find a trusted sponsor.

[Baroness Donaghy (Lab)]

My Lords, working-age people with disabilities are virtually prisoners in their own homes. We are not talking about improving skills or having conversations. When disability is supposed to be a subject where people are treated as normal citizens who want and can go out to work with sufficient support, we are looking for some answers from the Government about how they can do so. Why are the Government only having conversations, after 12 years?

[Lord Kamall (Con)]

The Government have been committed to ensuring that there is equality for disabled people, including plenty of initiatives in other sectors—transport, building new homes and offices, and retrofitting—but the issue of personal assistance is a particularly difficult one in the context of social care having been treated as a Cinderella service for years. Some of the initiatives that we are putting in place, such as the proper qualifications and recruitment from overseas, sadly do not yet apply to personal assistants because of the rules. We are looking at those barriers and hopefully will be able to tackle them.

[Lord Polak (Con)]

My Lords, I am a member of the Adult Social Care Committee in your Lordships’ House, chaired by the noble Baroness, Lady Andrews. We are looking at the invisibility of the unpaid carer, but it was timely that yesterday we went to Real, a charity in Tower Hamlets. It was a humbling and educational experience in which the difficulties and issues within the social care system for disabled people were brought to us. The difficulty of accessing PAs was very clear. My noble friend the Minister highlighted the problem in one of his answers. He said that maybe we need go to DWP or maybe we need it to be here. It needs to be coherent. To help those people, it needs to be one person, one Minister, one department dealing with this matter.

[Lord Kamall (Con)]

My noble friend makes a very important point. I have found this to be the case with a number of initiatives that I have been working on in my department. Quite often, I will have a joint meeting on an issue—with someone from BEIS, for example—and I then realise that they have to go and talk to someone else outside of the room. When I have been involved in such initiatives, I have always insisted that whoever else across government has a role or interest in them is in the room with us. This is clearly another example of what should be happening. It should be jointly DHSC and DWP. Rather than thinking about whose responsibility it is, we should work together to find a common solution.

[Lord Addington (LD)]

My Lords, does the Minister agree that if we are dealing with this, it will need every department involved, as has already happened? Will he also ensure that the Treasury leads, because if you are denying that person the chance to work, you are also denying yourself their taxation? Can he go to the heart of government and say, “Get your act together and bring your friends along as well”?

[Lord Kamall (Con)]

The noble Lord makes an important point about who should be in that room when we are talking about all these issues. Generally, across government, there are a number of joint initiatives in terms of ensuring that we hit our target of equality for disabled people, but as other noble Lords have pointed out, this issue falls between DWP and DHSC. I was surprised when I was briefed on this about where it fell. It clearly must be people in the same room.

[Baroness Watkins of Tavistock (CB)]

My Lords, it was a pleasure earlier to hear the new Health Secretary say that this is the kind of example that she would want to resolve—she did not use a particular one. Could the new integrated care boards not be the trusted sponsor for such personal assistance in each area? It would be straightforward and simple to introduce.

[Lord Kamall (Con)]

On the face of it, that sounds a very sensible suggestion, so let me take it back to the department, and if I am still here, I will respond.

[Baroness Uddin (Non-Afl)]

My Lords, I very much welcome this Question, at a time when my family has just started experiencing the hard stuff of social care. It is completely absent from many people’s lives because they are stuck in hospitals and not able to leave. People who are already in employment will be suffering exactly the same problems and issues with personal assistance. The Minister has been in his post for a long time, and we have all been requesting that he listen to what many of us with long-standing experience have said. What will he do now?

[Lord Kamall (Con)]

I first pay tribute to the long-standing experience of the noble Baroness and to the many conversations we have had on this. That this Question has been asked will raise and highlight the issue. It also allows me to go back to the department, kick a few desks, as it were—without being accused of harassment or violence—and make sure that government can look at this in a joined-up way.

Urgent and Emergency Care

Lord Kamall Excerpts

Tuesday 6th September 2022 Lords Chamber

[Noble Lords]

Oh!

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

I thank both noble Baronesses for their welcome that I am still in post; let us see for how long.

I pay tribute to my right honourable friend the former Secretary of State for Health, Stephen Barclay. When he came into office, he was quite clear that he saw the headlines, the issues about access to GPs and primary care and the ambulance waiting times. He said, “Look, I don’t know how long I’m going to be in office, but I’m determined to work on this over the summer”. This Statement is the result of that. Had he stayed in post, no doubt some of the questions that the noble Baronesses, Lady Brinton and Lady Merron, raised would have been answered with other Statements. Hopefully he has set in place the process to enable his successor to deal with some of these issues.

When he came into position, he was quite clear. In fact, he was so clear that he said, “I want the latest numbers on my wall”. He also asked, “Who do I need to talk to?”. He got the NHS England leadership in, contacted the most challenged trusts and the ambulance services and asked, “What can we do to help and how do we understand about discharge?” As the noble Baronesses rightly said, it is about not just ambulances but the whole system of discharge, making sure that there is somewhere in the community for patients to go from hospital. Are there sufficient beds? He has tried to work on this. Clearly, some of this will take time to work through.

Both noble Baronesses referred to the fact that we have contracted St John Ambulance to deliver auxiliary ambulance services. My understanding from when I checked is that this is immediate, but I will have to clarify that to make sure I have given an accurate answer to the question. Because ambulance trusts receive central monitoring and support from the NHS England-funded ambulance co-ordination centre, the Secretary of State worked closely with NHS leadership to look at how to put money into the system and to make sure it gets spent and gets through the system. It is all very well talking about inputs, but how about that? We have provided £150 million extra to improve response times, additional call handler recruitment and investment in the workforce. We have seen an increase of about 12% in ambulance staff and support staff since 2019.

On the handling numbers, it is really important that it is not just about signposting individuals. There are health professionals on the line who can deal with the patients when they ring up for advice. When I had to call 111 just before the summer break, I spoke to the call handler, who then arranged for a GP to ring me back to have a further, detailed conversation. As a result, the GP then made an appointment for me at the local A&E, so I just had to turn up at an allotted slot. That is what they are looking to do to ease pressure on A&E. Can they deal with it without having to go to A&E in the first place? For the less urgent but immediate cases, can they allocate a time slot?

So we are boosting the 999 and 111 call handler numbers and providing targeted support to some of the hospitals facing the greatest delays. The former Secretary of State was quite clear about looking at the areas where we have the most trouble, seeing what we can do about it and getting all the system leaders together. I am afraid it will not be resolved overnight—I am sure that noble Lords recognise that—but trusts are now closing 12.5% of incidents over the phone, which is nearly twice the pre-pandemic rate. We are also providing investment to upgrade the accident and emergency facilities at more than 120 separate trusts.

There is also the national discharge task force, which is focusing on how we address the discharge problems in particular areas and work with local system leaders to understand those problems. The former Secretary of State has been having those conversations and diving into real detail, either convening people or bashing heads together to make sure that we tackle this. He has put in a place a number of processes, which my right honourable friend the new Secretary of State for Health, Thérèse Coffey, will have to deal with. He has at least put that process in place so she can hit the ground running. As I said, he has taken a close interest in the most difficult and challenged areas.

I will try to deal with some of the specific issues. First, the former Secretary of State was quite clear that we need to think about the winter plan now and not wait until we hit winter. That means preparing for variants of Covid-19, and increasing capacity outside of acute trusts and resilience in 111 and 999 services, as we have mentioned; it means looking at target category 2 response times and ambulance handover delays, at how we reduce crowding in particular A&E departments, and at how we reduce hospital occupancy.

In response to the question from the noble Baroness, Lady Brinton, about the breakdown between virtual beds and hospital beds, I cannot give that data at this point; it might be a dynamic situation, as and when, and will depend on whether individual patients’ homes are suitable to accommodate a virtual bed. They will have to meet certain standards; it is not just a word but a proper virtual bed. We also need to look at how we can ensure timely discharge and provide better support for people at home.

On mortality rates, we see the headlines and, clearly, we have conversations with our officials within the NHS. They do not believe that it is correct to link those performance figures directly to current excess mortality rates but they recognise that there are, sadly, far too many cases of people who should have been seen. There have been deaths but I do not have exact numbers. I will try to get more details for the noble Baroness.

On the overall workforce, as I have said a number of times, I would disagree with noble Lords who say that there is no plan; that is not correct. We have already commissioned Health Education England to work with partners. The department has also commissioned NHS England on long-term workforce planning. As noble Lords will know, the Health and Care Act makes it incumbent on the Secretary of State to publish a report on the workforce and the challenges ahead.

I will stop there for now. I apologise to the noble Baronesses; I will try to answer in writing the questions that I have not answered here this evening.

[Viscount Hailsham (Con)]

My Lords, would my noble friend agree that the problems in the ambulance service are essentially reflective of the problems in the National Health Service more generally? Would he also agree that there is a widespread feeling that the National Health Service as presently constituted is no longer fit for purpose? Given that, and bearing in mind that proposals coming from individual parties or Governments are unlikely to command general consent, has the time not come for the Government to appoint a royal commission to consider how best health services in this country should be provided and funded? Such a way forward might provide the basis for a proper, agreed change.

[Lord Kamall (Con)]

I thank my noble friend for his question. We have a debate this week tabled by the noble Lord, Lord Patel, on reform of the health system. One thing the noble Lord believes, as do a number of other practitioners and noble Lords who have worked in the health service, is that it is time to reform the old model of seeing your GP, getting five or 10 minutes if you are lucky, and then being referred to secondary care elsewhere. In this day and age, we need such reform. We need to take advantage of data and new technology but also to look at work processes. Some of the stuff that was being done in secondary care until recently can now be done at primary care level. Even in primary care, it does not always have to be the doctor who sees the patient; it can be a practice nurse, a physiotherapist or a local civil society group.

Clearly, there is a need to look at the model of the NHS and how services are provided; all parties recognise that there are areas for reform. It would be great if we could get consensus but, sadly, this issue is too much of a political football. When I speak with my friends from other parties, we say candidly that something has to change and that there has to be reform, but it is clearly too tempting to bash any Government. I know that, when we were in opposition, we would have bashed the Government of the day on health. It is, sadly, too tempting a political football.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I follow on from a point raised by the noble Baroness, Lady Merron. The Statement refers to the new contract with St John Ambulance—I join others in welcoming that—and to recruiting call handlers, paramedics and social carers. There is no reference to the acute crisis we have regarding doctors, nurses, midwives and associated health professionals.

To pick up on the question of whether we need a royal commission and systems change, the underlying situation is that the UK has 2.8 doctors per 1,000 people and 7.9 nurses, which is the second lowest in the OECD. Our number of hospital beds per head of population is on average lower than everywhere in the OECD but Denmark and Sweden. We simply have an acute lack of resources, which is independent of systems and is putting enormous pressure on services. We are now seeing huge pressure being put on medical professionals. Being a specialist in A&E is an acutely difficult and challenging task. The issues of ambulance response times and the queues of ambulances outside A&E are clearly putting huge pressure on people.

The Minister referred to the fact that, as we speak, we have a new Secretary of State. Surely it is time to acknowledge the contribution that those doctors, nurses and other medical professionals are making, through some kind of new, big gesture from the new Secretary of State to say, “We have to keep you. We really value you.” We are recruiting new people but others are walking out of the door as quickly or more so. This has to change. Surely a recognition of the care and service that has been given and continues to be given would help.

[Lord Kamall (Con)]

The noble Baroness makes a very important point which noble Lords across the House will agree. We should pay tribute to the hard work of medical staff in our system of care; there is no doubt about that. I take the point that this is about not just the ambulance service but other parts of the health service. In fact, had my right honourable friend the former Secretary of State stayed in post, he would have issued subsequent Statements on what we are doing about the GP workforce and some of the other issues that noble Lords have raised.

It is clear that one of the issues is retention. The NHS has its people plan, published in July 2020. We understand that people are leaving and, yes, there are newspaper headlines, but what are the issues behind those headlines? There is a very difficult issue around pensions and, particularly for some of the wealthier GPs, whether it is worth their while, having built up a massive pension over the years. There has been a bit of discussion and to and fro with the Treasury over that. However, it is quite clear at trust and workplace level that we have to make sure there are well-being courses and that we are looking after staff. We also have to look at the individual decisions as to why people may want to leave.

No doubt many staff are exhausted after the last couple of years. An amazing amount of pressure has been put on them and, as the noble Baroness says, it is right that we find ways to send a strong message that we value them and want to keep them as well as recruit new staff. We also have to look at this against the wider picture. We have more doctors and nurses than ever before. The question is: why, despite that, do we have this pressure? It is because the demand is outstripping supply.

We are now aware of far more health conditions than we were, say, five, 10 or 20 years ago. When preparing for a debate on neurological conditions the other day, I asked my officials to list them all. They said, “We can’t do that, Minister—there are 600.” Let us think about that. We were not even aware before of all those conditions. How many staff does that require? Or let us think about mental health: 30 or 40 years ago, it was not taken seriously; it was all about a stiff upper lip and pulling yourself together. Now we take it all seriously, and have mental health parity in the health Bill, which will need more staff. We will have more staff—more doctors and nurses—but the demand will outstrip supply. That is why a proper debate is needed across parties.

[Lord Colgrain (Con)]

My Lords, I apologise for leaping rather prematurely to my feet before my noble friend the Minister just now.

It is often the case that you read things in the newspaper and either you doubt the veracity of the information or you feel it is apocryphal, and you have to wait until such time as something occurs to you personally before you understand how vital it is. Last week I visited my 97 year-old mother, and I was there when she suffered a fall as a result of which she broke her hip. I rang the emergency service at 5.30 pm on Wednesday afternoon and at 4.30 am on Thursday morning the ambulance arrived—so she had been disabled on the floor for 11 hours at that stage. I said to the ambulance people that I thought it was appropriate that I follow them to the hospital, but they said, “I wouldn’t do that if I were you. It’s an hour’s journey to the hospital and there’ll be a waiting time of two hours before she’s admitted because we’ve just come from a queue there”. So that took it up to 14 hours.

I have to say that the good cheer and good manners of the people on the 999 line when I was calling them every two hours was exemplary, as were the good humour and good treatment that my mother subsequently received at the hospital, but I had difficulty answering her rather acerbic comment at 3 am that she wondered why she had fought so vigorously in the last war if she was going to be left lying on the floor for that length of time before being taken to hospital. I myself really felt the comment about the darkest moment of the night coming before the dawn, being completely helpless and not knowing what to do with someone in considerable pain, with no one able to tell me whether or not to administer painkilling pills and whether or not to give her something to eat or drink. It made me realise how helpless other people feel in similar circumstances.

So I ask the Minister to do whatever he possibly can all the way down the chain to make sure that this sort of situation does not occur to too many people. We have had noble Lords in this debate talk about the length of hours that people are now waiting to be admitted to hospital, but it is perfectly clear, on the strength of my mother’s experience, that in many cases those hours are extended. It really is a third-world situation in which we find ourselves, so anything that the Minister can do to help with that, I, she and the public in general would be extremely grateful for.

[Lord Kamall (Con)]

I start by thanking my noble friend for sharing that very personal experience with us. One of the reasons why my right honourable friend the former Secretary of State wanted to issue this Statement was that when he came in he saw that they were sadly far too many such stories—my noble friend will not be the only one with such a story; undoubtedly, there will be other noble Lords with similar stories—and it was important for him to say, “Look, this has gone on long enough. Let’s get all the people together in the room”. That is why he made this a priority. He wanted to put the numbers on the wall but was told he should not do so for various reasons—but at the same time he wanted to make sure that he spoke to the leadership of trusts as well as NHS England to make sure that they were really focused on this.

Some of the measures announced in the Statement will take time to filter through while others, hopefully, will be immediate, such as the St John Ambulance. All I can say is that I will continue to push and, if I stay in post, I will encourage my right honourable friend the current Secretary of State to continue the work that their predecessor put in place to really make sure that we get a grasp of this issue and try to pull as many levers as we can to tackle it.

[Lord Scriven (LD)]

My Lords, I declare my interest as a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust and as a vice-president of the Local Government Association.

It is not hubris when I say that the Minister needs to understand that this is a crisis and the health service is at the point of breaking, when you see what is happening to patients and to staff trying to deal with the total number of procedures and patients coming into the health service. An absolutely breathtaking statistic from analysis shows that in July only 40% of patients who were ready for discharge were discharged on the day that they were medically fit. That meant that 60% of beds were blocked in England by people who could not get social care or go home.

It is anticipated that at a bare minimum £7 billion per year is required to deal with the social care issue. The Government have a vision but no road map, no timetable, no milestones and no measures of success for social care. What is happening with social care? It is one of the key issues that are leading to ambulances being held at A&E and potential deaths before people can get into hospital for the medical care that they need.

[Lord Kamall (Con)]

I assure the noble Lord that we are aware of the situation; it is one of the reasons why this Statement was made in the first place. We know there are problems with delayed hospital discharges. That is why we have the national hospital discharge task force, which has been set the 100-day discharge challenge, focused on improving the processes but also on digging deep—not just the Secretary of State issuing an edict from afar and saying “Get on with it” but following up with NHS leadership to make sure that we are looking at this issue.

We are selecting these national discharge frontrunners from among ICSs and places to look at new ideas but also to see what has worked in a particular place. A number of noble Lords often give me an example of a hospital that they believe is doing very well. When we take it back to the NHS and say, “Can we replicate this elsewhere?”, they talk about the specific circumstances of that local area and the way that system is set up and why it could work. The ICBs and the integrated care partnerships have committees to look at this, and they know it has to be done as quickly as possible. So first there is the 100-day challenge between DHSC, the NHS and the local government discharge task force.

Adult care capacity is a problem that has been brewing for a long time. One of the things that we have been trying to do with social care, particularly through the integration White Paper but also with the Health and Care Bill, is finally to put it on an equal footing with health so that it is no longer the poor Cinderella service, and indeed to professionalise it. One of the reasons why we have the voluntary register is to make sure that we understand what is out there, who is out there, who is working and what qualifications they have so that we can build a proper career structure for people in social care to make sure that it is an attractive vocation for life and not just something that they do rather than working in Asda or elsewhere, and also that they have parity with the health service.

We are also looking in the medium to long term at some of the discharge frontrunners and at streamlining the intermediate care service, which could reduce delays by about 2,500 by winter 2023-24. Some of this stuff is to tackle the crisis now but some of it is long term to make sure that if we resolve it and get the numbers down we still do not forget about it, and that we build resilience into the system.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I phoned 999 two weeks ago after my wife had a nasty fall at home. The good news for the Minister is that the ambulance and paramedics turned up within half an hour, they were extraordinarily good and she was admitted to a major hospital—it was St George’s Hospital; I may as well name it. Unfortunately, it was just before the bank holiday. She had problems with her spine and she waited five days in a brace before they could do an MRI because, apart from the most acute emergencies, MRI scanning had closed down. In 2014, the Government were attacked for failing to provide proper services over bank holidays. They said they would look at it and change it, but here we are eight years later, and it is no different. Had it been done quickly, she could have been out, the bed would have been freed and the waiting list would have been shortened. I actually offered to pay for an MRI to be done if they would do it quickly to relieve her of the pain and torture she was going through, but they said, “Sorry, we can’t do that.” This is the problem we have with the NHS.

The real elephant in the room is that much, much more money has to go in. Those who can pay more must pay more and be willing to pay more. That will shorten the lists and produce more money to make conditions for staff even better so that they work in a different way. It would reduce the lists for everybody, but we are not radical enough and not prepared to do it. With the change that has taken place, nothing fundamental is going to happen in the next two years and this problem is, regrettably, going to continue. My question is: can the Minister please do something to make sure we use the equipment available to the maximum, which is not happening at present?

[Lord Kamall (Con)]

I thank the noble Lord for sharing that personal story—the good and bad side of it. I was on a visit to a hospital a few months ago where they showed us a nice, new scanner, which they were very proud of. The question was: how much is that used? Does it sit empty at weekends? With more networks and being more connected, we can find out where there is capacity in the system. If there is equipment, why are there not staff available? It could be for staff absence reasons. If it is not there, where can people go? With more community diagnostic centres, you will find lots more diagnosis facilities and scanners, so if the acute place does not have it, there should be availability in the community.

On the wider question about being “radical”, the noble Lord will know that, while we may have candid conversations as friends from different parties, sadly, health is too tempting to use as a political football. There are some issues that people feel very strongly about. Some of the points about charging that the noble Lord mentioned would be seen as too radical by some, or as undermining the very ethos of the NHS. I think we have to be prepared to be radical and think the unthinkable, but, sadly, this is the formal, political debate that we have got, and we have to work within the remit of that debate. Why should it be, for example, that millionaires could not pay a little bit more to help—not through taxation, but maybe direct?

Some local trusts have tackled this issue. For example, my local trust has set up a private arm, but the money paid for private diagnosis or surgery is reinvested into the hospital to help NHS patients. I know that more than one trust has done that. That might be an interesting way of raising more money and making sure that people value the service and care they get.

On the specific issues, one of the reasons we are having this discussion is because the former Secretary of State was looking at all the issues that need to be tackled now, both in the short term and the long term.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the noble Baroness, Lady Brinton, referred to overseas recruitment of doctors and nurses. The Statement refers to the “international recruitment task force” for social care. I am not sure if the Minister is aware of the report prepared by the Rights Lab at the University of Nottingham, The Vulnerability of Paid Migrant Live-in Care Workers in London to Modern Slavery. If not, I ask him to assure me that the department will be looking at this. The report highlights real issues about the treatment of migrant care workers, particularly in live-in situations. It is a cross-departmental issue, looking also at immigration issues like being tied to one employer where migration status is a real problem. It also looks at the need for a registration system for recruitment agencies. Can the Minister assure me that the department will look at that?

[Lord Kamall (Con)]

I thank the noble Baroness for the question. I am not aware of that report. If the noble Baroness would be happy to send a copy to my parliamentary email, I will happily forward it to officials in my department and see if we can get an answer to that.

House adjourned at 8.03 pm.

Integrated Care Boards

Lord Kamall Excerpts

Monday 5th September 2022 Lords Chamber

[Baroness Merron]

To ask Her Majesty’s Government how they are monitoring and assessing the transition of Clinical Commissioning Groups to Integrated Care Boards; and how the success and impact of the new structure will be evaluated and reported to Parliament.

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

Integrated care boards took over the role of commission and secondary care services from clinical commissioning groups on 1 July 2022. NHS England formally oversees these ICBs, and it has a legal duty to assess annually the performance of each ICB and to publish its findings. CQC system assessments will also provide an independent assurance to the public and Parliament. The success and impact of these new arrangements will be measured by a DHSC-commissioned evaluation completed by academics.

[Baroness Merron (Lab)]

My Lords, there are key factors to providing successful health and social care services that are outside the control of integrated care boards but very much within the control of the Government, including workforce supply and investment in social care capacity. Could the Minister tell the House how the impact of government provision will be measured and, where necessary, what action will be taken to put this right so that ICBs are actually able to deliver quality joined-up services for local people?

[Lord Kamall (Con)]

As the noble Baroness will be aware, a lot of the work at the local level will be done by the ICBs, in partnership with others, under the ICS system. On the Government’s role on workforce, the department commissioned Health Education England to produce a report to look at the long-term strategic drivers to support long-term workforce planning. This work is nearing its final stages. We have also commissioned NHS England and NHS Improvement to develop a long-term workforce plan for the next 15 years. In addition, as the noble Baroness will know, Section 41 of the Health and Care Act 2022 gives the Secretary of State a duty to publish a report at least every five years.

[Baroness Chisholm of Owlpen (Con)]

My Lords, can my noble friend the Minister say whether the importance of civil society to these care boards is realised? It is often local charities that really know what is going on in a community, and it is really important that they are involved going forward.

[Lord Kamall (Con)]

My noble friend makes a really important point on this: if you look at the structure at the local level, you will see the ICBs, but they are in partnership with civil society organisations and others to form the ICP. The integrated care boards and integrated care partnerships together comprise the integrated care system locally. When looking at local health needs and the health of populations, particularly in deprived areas, it is really important that we work with local charities and civil society organisations; they are quite often trusted more by local people than professionals.

[Lord Laming (CB)]

My Lords, I know the Minister agrees that the NHS depends very heavily on efficient and effective social care services being available to it. Could the Minister tell the House whether he is satisfied that, throughout the country, local social care services will be involved in these new arrangements from the outset and as equal partners?

[Lord Kamall (Con)]

During the debate on the Health and Care Bill, which became the Health and Care Act, one of the things on which we agreed across the House was that each integrated care board should have the appropriate mix of skills. I think that was thanks to an amendment by the Liberal Democrats. This particular issue shows that we need to ensure that we are considering all the important aspects of health. One of the things that will be very important is the parity of mental health with physical health. All these issues will be considered at the local partnership level.

[Baroness Brinton (LD)]

My Lords, one of the key elements of ensuring there is a good transition is the procurement process. Last month, three CCGs were fined for using considerable organisational bias to ensure that their contracts went to a preferred company. The fine must be paid by the ICB, and the staff from the CCG are now in the ICB. What are the Government going to do to ensure that this sort of practice is monitored and ruled out by the new bodies as they get under way?

[Lord Kamall (Con)]

I hope the noble Baroness will remember that, during the debate on the Health and Care Bill, there were concerns about private sector bias, as it were, in giving contracts. We agreed to an amendment suggesting that there should be no conflict of interest. I am afraid I am not aware of the specific cases that the noble Baroness raises, but I will look into them and write to her.

[Lord Turnberg (Lab)]

Does the Minister agree that yet another reorganisation of the management structure of the NHS is irrelevant to the latest problem facing the NHS, which is the dramatic loss of staff? We are losing thousands every month. That is where we should be focusing our efforts—does he not agree?

[Lord Kamall (Con)]

One of the challenges that we all face, and that the system as a whole faces, is that, even though we have more doctors and nurses than ever before, demand is outstripping the supply of healthcare workers. One reason for that is that there are far more conditions that would not have been considered years ago. Therefore, the Government, in partnership with the NHS, are looking at particular issues—for example, retention of the workforce, where they are worried about their pensions, and making social care an attractive vocation, with training and skills, as well as looking to recruit people, as we did after the war. As I often remind noble Lords, it was people from the Commonwealth who saved our health service after the war, and when we do not have the skills locally we will look to recruit people from abroad.

[Baroness Meacher (CB)]

I understand from a senior ICB medical member that doctors expect general practice to be in the position that dentistry is in today in a bit of time. In other words, access to a GP will depend on the ability to pay. That is incredibly serious—it is the end of the NHS as we have known it, free at the point of delivery and need. Will the Minister take back to his colleagues the absolutely essential point that the Government must ask the ICBs to prioritise the assessment of general practice in their areas and to develop a strategy to ensure that general practice continues to be free at the point of need?

[Lord Kamall (Con)]

The noble Baroness makes the point about general practice. One thing that we are looking at, which will probably come up in the debate later in the week on the future of primary care, is the whole issue of what GPs do. There are many things they do that they do not have to do—these could be done by local partners, practice nurses, physiotherapists or social prescribing, and so on. In addition, Ministers and the NHS have been in conversation with GPs’ representatives, looking at these particular issues.

[Baroness Altmann (Con)]

My Lords, could my noble friend update the House on the scheme for bringing in overseas workers to fill the gaps in social care that have opened up so seriously over the last year or two? There have been suggestions that the salary level—which currently does not allow sufficient numbers of care workers to come into the UK, when they are desperately needed—might be lowered. Is there any update for the House on that?

[Lord Kamall (Con)]

I thank my noble friend for the question. The last I was aware of—and I shall look at it and write to my noble friend—was that, under the visa scheme, we were looking to bring in people from overseas to fill those vacancies. We have historically done that; as I said, after the war we looked to people from the Commonwealth, who came and saved our public services. Clearly, when we are unable to recruit enough people locally, we have to look at those issues and at whether it is something to do with the education system, and whether we can encourage them to come forward. But where there are gaps we will have to look more widely to our partners around the world.

[Lord Hunt of Kings Heath (Lab)]

My Lords, when the Minister took the Bill through the House, he argued that a restructuring was necessary to integrate services, yet outside every acute hospital dozens of ambulances are stacked up every day, often waiting for hours with patients inside, because we have a disintegrated system. Can he show me what the integrated care boards are doing today to end that dreadful practice?

[Lord Kamall (Con)]

One priority of my right honourable friend the Secretary of State—I think he is still the Secretary of State—has been to look at the ambulance system. On a wall in his office, he has all the various things; he has talked to various partners and he has brought people together to see what the problems are, why we are unable to unload patients into hospitals, what the blockages are and how we can address this from a systemic view.

[Lord Patel (CB)]

My Lords, the recent Civitas report put the UK second from bottom in patient outcomes in key areas of cardiovascular disease, cancer and a reduction in life expectancy. Can the Minister say what role commissioning should play in improving patient outcomes?

[Lord Kamall (Con)]

On patient outcomes, the noble Lord is quite right: we need to look at the statistics—where we are doing well and where we are not doing so well—and then focus efforts at not only the national level but the local ICB level, to make sure there is the appropriate commissioning. Indeed, one responsibility of the local integrated care board is to look at what services are needed in the local area and make sure that they are commissioned.

Cannabis: Medicinal Use

Lord Kamall Excerpts

Tuesday 12th July 2022 Lords Chamber

[Baroness Meacher]

To ask Her Majesty’s Government what plans they have to amend the Misuse of Drugs (Amendments) (Cannabis and Licence Fees) (England, Wales and Scotland) Regulations 2018 to enable general practitioners to prescribe cannabis medicines to patients whose symptoms are being substantially alleviated by such medicines currently purchased privately.

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

The Government share the aim of NHS funding for licensed medicines that have proved safe and effective, rather than patients paying private subscriptions for unlicensed products that are not assured by our medicines regulator. Broadening who can prescribe these products will not achieve this. For this to happen, we need the cannabis industry to invest in clinical trials. Our medicines regulator—and the National Institute for Health and Care Research—has asked it to do so and is ready to support it when it does.

[Baroness Meacher (CB)]

My Lords, the Minister will be aware of Bailey Williams, aged 20, who has very severe epilepsy and was hospitalised every week throughout his childhood, until the last four years, when he has been on medical cannabis—these have been his best years. His parents are struggling financially and asked Bailey’s consultant to prescribe medical cannabis under the NHS; after all, NICE has approved this in its guidance. The answer was no, but palliative care was an option—palliative care but not a proven medicine that has done so well for this child for four years. The Minister cannot accept that situation. Will he meet MHRA, with me, to discuss the way forward? There has to be a way forward.

[Lord Kamall (Con)]

First, I thank the noble Baroness for meeting with my colleague, my noble friend Lady Penn, yesterday. When I became a Minister, the Permanent Sec recognised a potential conflict of interest, which I have been told means that I cannot meet with people about this particular issue, but I can answer this Question if I declare my interest. So I better quickly declare it: I used to work for a think tank that received some funding from the medicinal cannabis industry, and I shared a round table. That immediately ruled me out as having a conflict of interest. None the less, I am very happy to facilitate meetings with my ministerial colleagues. As the noble Baroness will be aware, there is a new ministerial colleague in place at the moment. The point remains that we have asked the industry, which makes lots of money in this area, to come forward and fund trials, but it has preferred not to do so.

[Baroness Walmsley (LD)]

My Lords, I understand that the MHRA is considering extending its compassionate access scheme, particularly regarding the import of Celixir20 from Israel. A number of children with rare forms of drug-resistant epilepsy rely on this medicine. Given the severity of the crisis of access to NHS prescriptions for medicinal cannabis, can the Minister ensure that there are no barriers to the MHRA acting now to extend this scheme?

[Lord Kamall (Con)]

The noble Baroness raises an important point about working with the importer of those medicines. The MHRA is exceptionally continuing to allow those medicines and is hoping to work with the importer and the Israeli company itself to see whether they will go through the MHRA approval process. In Israel, there are two ways of supplying the product: one is medicinal and the another is for non-medicinal cannabis uses. It has advised us that this is not a licensed medicine in Israel, and therefore we are asking the company to come forward. In the meantime, we are looking at an interim solution.

[Lord Dubs (Lab)]

My Lords, will the Minister confirm that, for certain very severe forms of epilepsy that affect children, medical cannabis is absolutely appropriate? Can he explain why only three such prescriptions have been issued?

[Lord Kamall (Con)]

Yes, but I should start by saying that I have been warned a number of times that it is inappropriate for Ministers to tell doctors and clinicians what they can prescribe. In certain cases, given that it has not been regulated as a medicine in this country, doctors can make an exception and ask for it to be prescribed on the NHS. They will go to their CCG—and now to their ICS—and ask for that. However, that has been agreed to in only a few cases.

[Lord Farmer (Con)]

My Lords, will the Government heed warnings from respected addiction psychiatrists in US states where cannabis has been legalised that medical marijuana acted as a Trojan horse to get recreational use in, that the upward trend in medical potency means that people get addicted, and that super-strength products are associated with a significant rise in cannabis-related psychosis? Are they aware that states are now tightening restrictions on cannabis prescribing, having previously liberalised it, not least given sharp increases in teenage suicides with marijuana in their systems post-mortem?

[Lord Kamall (Con)]

I thank my noble friend for his question and note his concerns. However, I think we should look at this in two ways: there is medicinal cannabis and there is recreational cannabis, and we must be quite clear on that. Some people clearly want to liberalise both. I cannot comment on my own particular views because I am conflicted on this, but what is really important here is that we take a cautious approach and look at the particular issue of medicinal cannabis. The MHRA is ready to regulate medicinal cannabis; it just needs companies to come forward and spend money on the trials.

[Lord Winston (Lab)]

My Lords, the Science and Technology Select Committee, which I had the honour to chair some 15 or 18 years ago, looked at the medicinal uses of cannabis. One of the things we clearly showed was that the statement we just heard is not true; in fact, there was no evidence then that the medicinal use of cannabis led to addiction in patients. Indeed, patients who were having medicinal cannabis were trying very hard not to become high and trying to use the doses in very limited amounts so that they could cure their symptoms.

[Lord Kamall (Con)]

The noble Lord makes a very important point: whatever our personal views, we must distinguish between recreational and medicinal uses of cannabis. We know from observations and many stories that many people believe that they benefit from medicinal cannabis. We know that there is a barrier because companies have not come forward to have it regulated or go through the clinical trials, but we are trying to work with those companies and encourage them to come forward. In fact, we have also found some NIHR research money available to help with those trials. My request to the industry is: “You make a lot of money out of this—please come forward and go through those trials with the MHRA”.

[Baroness Jones of Moulsecoomb (GP)]

My Lords, there is a suspicion among those of us who think that the Government are being very slow about this that they are arguing it from a medical point of view, just as the Minister has today, but that in fact this is a political decision because the Government’s right wing does not like the idea of cannabis use in this way.

[Lord Kamall (Con)]

I do not know how to respond to that. All I will say to the noble Baroness is that nothing could be further from the truth. This is clearly an issue based on medicinal cannabis. The noble Baroness will know that my party is a coalition; there are quite a number of libertarians in my party who would take a very different view on banning these issues. What is really important is that, to be licensed as a medicine, it has to be approved by the MHRA; to be approved by the MHRA, except in very exceptional circumstances, you have to go through trials. These companies make a lot of money; they can afford to go through the trials; they are just choosing not to.

[Baroness Watkins of Tavistock (CB)]

My Lords, NICE has actually supported the limited use of medical cannabis. It has, over many years, supported the limited use of novel drugs in cancer and heart disease, which have been readily available. Does the Minister agree that it is a national scandal that we are discriminating against some of the most vulnerable people with severe epilepsy in our country by not providing this in limited forms on the NHS pre further clinical trials?

[Lord Kamall (Con)]

What I would say is that it is left up to the doctors, who are able to ask for it to be prescribed on the NHS. In some cases, that has clearly not been accepted and that is why people have to go privately, but the best way to solve this problem is for the industry to come forward and go through trials. The offer is open, the NIHR has money available, but for some reason the companies prefer to sell it unlicensed.

[Baroness Butler-Sloss (CB)]

My Lords, is there not a way around this? It seems to me extraordinary that we cannot cut through this.

[Lord Kamall (Con)]

In simple terms, I completely agree. There should be a way around this and I will take this back to the department. In fact, I was quite provocative when I was getting advice on this, but I have also been warned that I am conflicted on this issue, so I will try to push it as long as I am not seen as being in conflict. It is very difficult, but I want to do the right thing.

[Baroness Merron (Lab)]

My Lords, we look forward to the Minister returning on this point, but to build on the points made by other noble Lords, despite the change in the law, many families are experiencing great anguish in getting treatment for young epilepsy sufferers and are left with little option but to pay thousands of pounds each month. What is the Government’s view on implementing all the recommendations of the recent NHS review of the barriers to accessing prescription cannabis products for medicinal use? If they are not planning to implement all the recommendations, which ones are the Government looking at?

--- Later in debate ---

[Lord Kamall (Con)]

The department has been reviewing the Hodges review and has been looking at the method of data collection. At the moment, I cannot comment on the significance of the statistics in the report, but the important thing here, I think, is that once again we are asking the industry to come forward. It can fund the trials—it can afford this—but for some reason it prefers to sell it unlicensed.

[Lord Watts (Lab)]

My Lords, just to clarify the point that the Minister made, that it is not for him to tell doctors what medicines to prescribe, is he really saying that if doctors are failing to give their patients the proper and adequate medicines—the only medicines that work—there is nothing he can do?

[Lord Kamall (Con)]

These are left to clinical decisions, and it is up to individual doctors. Some doctors believe that the evidence is not there to prescribe it; other doctors believe that it is there and they would like to prescribe but they go to their local CCG or elsewhere and they are not given permission or access. What we are trying to do is make sure that there is sufficient evidence, but we really need the companies to come forward. If I can make one appeal to noble Lords, if anyone contacts them from the industry, ask them to come forward and go through the trials.

General Practitioners: Shortage

Lord Kamall Excerpts

Tuesday 12th July 2022 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

I beg leave to ask the Question standing in my name on the Order Paper and declare my interest with the Dispensing Doctors’ Association.

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

The Government recognise that growing the GP workforce is challenging, particularly in light of pressures from the pandemic. There are over 1,400 more full-time equivalent doctors in general practice in March this year compared with March 2019, showing that there is some movement in the right direction. However, we need to go further, and we are working with NHS England and NHS Improvement, Health Education England and the profession to boost recruitment, address the reasons why doctors leave and encourage them to stay or return to practice.

[Baroness McIntosh of Pickering (Con)]

I am grateful for that Answer, but my noble friend will be aware that by 2030, we will be facing an acute shortage of GPs as more doctors leave the profession than join. There are 9 million people living in remote rural, coastal and island communities, which is more than live in London. Will my noble friend ensure that all health policy is rural-proofed, and that those living in rural areas have equal access to healthcare to those living in urban areas?

[Lord Kamall (Con)]

My noble friend makes a very important point, and she referred continually throughout the passage of the Health and Care Act to practices in rural areas. We have looked at the challenges and have asked GPs about this in surveys, and we know that there are problems about the reduction of working hours, administrative burdens, some stress and burnout, and some issues about equitable distribution. One thing we do have is the Targeted Enhanced Recruitment Scheme launched in 2016, which has attracted hundreds of doctors to train in hard-to-recruit areas by providing a one-off financial incentive.

[Lord Patel (CB)]

My Lords, in 2017, a House of Lords report recommended that the current small business model of primary care is not fit for purpose. The same has been said by the Royal College of General Practitioners, which produced a report; the British Medical Association; two think tanks, the Nuffield Trust and the King’s Fund; and, more recently, Policy Exchange, which produced a report on the model being fit for the future. Is it not time that the Government had plans to look at future models of delivering primary care? If they do not have such an intention, does the Minister agree that the House of Lords should set up a Select Committee to follow on from the excellent report produced on the NHS in 2017?

[Lord Kamall (Con)]

I thank the noble Lord for that question, but I should explain to him that I have been warned for exceeding my powers, as it were, in the past. I think setting up a Select Committee is a bit beyond my powers. The noble Lord and I, and many noble Lords across the House, including previous Health Ministers of all parties, have had this conversation, and we know that the old-fashioned model of a five to 10-minute appointment with your GP, only to be referred elsewhere and into secondary care, is broken in many ways. We need a much more modern model. We have seen primary care take on some of the functions of secondary care, but we have also seen, at the GP level, that the GP does not have to do everything, and that there are other workers such as nurses, physio- therapists and pharmacists who can do more of what the GP has done in the past.

[Lord Winston (Lab)]

My Lords, the figures show that more than half of GPs are considering retirement or are retiring before the age of 60. As the noble Lord has pointed out, there are lots of reasons for this, but he has not told us what he is doing about them. What is he doing constructively to change the attitudes and experience of GPs, which lead to this disillusionment among men who are at the highest point of their career, when they are the most useful to patients in primary care?

[Lord Kamall (Con)]

I assure the noble Lord that the Government are doing lots of things. Not only are we listening but we are looking at potential solutions and discussing them with the relevant bodies. For example, one of the pressures mentioned was the impact of the number of phone calls. There has been investment in handling them and getting them redirected appropriately, and GP practices have been offered money for that. The other issue is pensions: some GPs are worried about taking a hit on their pension if they come back to service. There are discussions about whether they are really worse off and how we can retain staff. Also, having other staff at the GP level who can take on some of those functions that GPs do not necessarily need to do could ease their workload. The administrative burden has added to this, but the digitisation of services should solve a lot of those problems.

[The Lord Speaker (Lord McFall of Alcluith)]

I call the noble Baroness, Lady Brinton, to make a virtual contribution.

[Baroness Brinton (LD) [V]]

My Lords, the Royal College of GPs reports that since 2019, GP clinical administration tasks have risen by a shocking 28%. GPs say that it would make a significant difference if hospital consultants could refer patients directly to other consultants, rather than patients having to come back to GPs and then be redirected. The back-office functions for repeat prescriptions take an ever-increasing amount of their time, and GPs are not in control of either of these processes. As a matter of urgency, will the Minister investigate how to reduce some of this bureaucracy so that GPs have more time to see their patients?

[Lord Kamall (Con)]

As part of the joint NHS England and NHS Improvement and DHSC bureaucracy review—there is such a thing—we have been working across government to reduce unnecessary bureaucratic burdens. There have been a number of key work streams, including a new appraisal process and digitisation of the signing of some notes, along with work to reform who can provide medical evidence and certificates and who can provide notes—nurses, occupational therapists, pharmacists and others. We are continuing to look through the process to engage with GPs to see how we can remove more such administrative burdens.

[Lord Patel of Bradford (Non-Afl)]

My Lords, looking at wider health workforce issues, I understand that we need another 2,000 radiologists in the next five years and that it is highly unlikely that we will be able to produce them. That is the pessimistic note. On an optimistic note, I heard recently that Apollo, the large healthcare provider in India, in partnership with the royal college and the GMC, has been training up 150 high-quality radiologists every year, some of whom are coming to this country. Does the Minister approve of such schemes, and is the department doing more work in places such as India where we can recruit high-quality medical staff?

[Lord Kamall (Con)]

I thank the noble Lord for his question, but also pay tribute to his commitment to tackling racism in our society.

We know that there are countries that train more people than they have places for in their country. They do that, first, to help those people get a better life elsewhere, but also because remittances are much better than foreign aid for many of those countries. I frequently mention the fact that it was immigrants from the Commonwealth who saved public services in this country after the war. We should remember that and continue to encourage people from the Commonwealth to come to this country. Sadly, for some reason, noble Lords quite often do not want them and make up all sorts of excuses for trying to block non-white people from outside Europe.

[Lord Young of Norwood Green (Lab)]

My Lords, one of the disincentives for both men and women GPs is the quality of accommodation. They are in overcrowded buildings. There is a good example from a care commissioning group in my area which spent £1 million planning a new centralised health centre, which would have provided top-of-the-range facilities and would have encouraged general practitioners to remain in practice. Will the Minister look at the quality of accommodation? What plans are there to introduce new buildings? That is a really important factor in dealing with the shortage of GPs.

[Lord Kamall (Con)]

The noble Lord makes the very important point that GP practices are evolving. Some are moving premises; some are merging in larger premises; some are moving into primary care centres, where they are able to offer not just traditional GP services but some of the services that secondary care currently offers. I am not entirely sure of the specific point that the noble Lord makes. He would be welcome to have a conversation so that I can follow it up with my department.

[Lord Moylan (Con)]

My Lords, does my noble friend agree that an increasing number of GPs prefer to work part-time because they face a marginal tax rate of 62% on earnings over £100,000? Will he consider discussions with his friends at Her Majesty’s Treasury to address those anomalies in the tax system?

--- Later in debate ---

[Lord Kamall (Con)]

There are a number of reasons why some GPs and other health professionals prefer to work part-time as opposed to full-time. Many people, especially given the stresses of the pandemic, want a better work/life balance. Some people have suggested in the past that we should focus on full-time equivalents. We should make sure that current staff who want to go from full-time to part-time can do so within the system, so that we can retain them, while tackling all the barriers to retention as well as recruiting more GPs.

[Baroness Merron (Lab)]

My Lords, the appointments system is not working well for GPs or patients. Healthwatch England reports that complaints about GP services are rising, the main problems being difficulties getting an appointment, exorbitant waits on the phone, about which we all know, and an end to online facilities to book slots. What assessment has been made of the detrimental impact on people struggling to access GP services, particularly those who are more vulnerable, and what is the plan to put this right?

[Lord Kamall (Con)]

The noble Baroness is absolutely right. We know that, for many people, their first entry into the system—their portal, if you like—is trying to get an appointment with their GP. As the noble Lord, Lord Patel, mentioned earlier, we have to look at how we can modernise this service. In the short term, we have made money available to help improve triage for people who phone up for services; this includes how to manage incoming and outgoing calls. In future, we are looking at more digitisation and extending the functionality of the NHS app so that people can book appointments for all sorts of services; if they are waiting for an appointment or secondary care, they will also be able to see how long they will have to wait and where they are in the queue.