Medical Devices and Blood Safety and Quality (Fees Amendment) Regulations 2023

Lord Markham Excerpts

Wednesday 22nd March 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 6 February be approved.

Considered in Grand Committee on 20 March.

Motion agreed.

Health Education England (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Lord Markham Excerpts

Tuesday 21st March 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 20 February be approved.

Relevant document: 32nd Report from the Secondary Legislation Scrutiny Committee

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

My Lords, the noble Baroness, Lady Merron, has tabled a Motion to Regret, and I will first address her concerns in turn.

First, the noble Baroness noted that the regulations do not offer sufficient evidence to support the change, and that the information on the potential costs of and savings from this reorganisation are unspecified and vague. In response, I note that an amended version of the Explanatory Memorandum for these regulations has been laid, with additional information on the costs and benefits of, and evidence for, the transfer of functions from Health Education England to NHS England.

As the Explanatory Memorandum sets out, there are some smaller costs and savings relating to the transfer of Health Education England’s functions to NHS England, and more significant costs and savings related to the wider transformation programme that NHS England is currently undergoing, which would include the transferred Health Education England functions. As I will set out in more detail later, overall, the merger of HEE and NHS England will bring significant benefits to the delivery of workforce planning for the NHS.

Transition costs include the creation of the HEE transition programme office and short-term consultancy to deliver the overarching design and the new workforce function. Ongoing savings and efficiencies from the wider NHSE transformation programme are expected to include a reduction in the total size of the new NHSE, including Health Education England and NHS Digital, of up to 40%; savings from not having a Health Education Board; and removing the need for a range of duplicate processes currently in place.

These amendments to the Explanatory Memorandum are also intended to address comments on the regulations by the Secondary Legislation Scrutiny Committee in its 32nd report of Session 2022–23.

The noble Baroness’s second point was that the regulations have not been published alongside the Government’s NHS workforce plan. I will say more about the longer-term plan later, but I can confirm that the Government have committed to publishing the plan this spring and will include independently verified projections for the number of doctors, nurses and other professionals who will be needed in five, 10 and 15 years’ time, taking full account of improvements in retention and productivity.

The noble Baroness’s final point was that the regulations do not guarantee that NHS England will give long-term workforce issues sufficient priority. I can confirm that the Government are putting in place a range of measures to ensure that NHSE places sufficient priority on these vital issues. This includes setting objectives on workforce within the NHS England mandate, continuing to monitor and track expenditure on education and training, and establishing a ministerially chaired board to provide oversight and governance of workforce in the NHS.

--- Later in debate ---

[Lord Markham (Con)]

I thank noble Lords for their contributions to today’s debate. As ever, I will attempt to answer the questions as best I can, and I will come back in writing with the details.

First, on when the workforce plan will be published, forgive me for this answer but I cannot resist it. I looked on the HEE website and it will be delivered “at the right time and in the right place”. I could not resist that one. I think the term I am allowed to use is “shortly”, which is different from “soon”, but I will let noble Lords decide. Seriously, however, there is a very detailed plan. While I acknowledge that there are concerns about delays and this being “Treasury-fied”, at the same time, serious questions have been raised, as we would expect. This is leading to a lot more thinking, which is the right thing to happen, provided we come out with the right answer. I hope noble Lords understand that work is going on to ensure deliverability.

I will try to answer the many questions asked, particularly on what the measures of success will be, as raised by the noble Lord, Lord Scriven. From my point of view—it may be personal—we are publishing the workforce plan and the measure of success will be how well this body performs against that. It will not be down to that body alone; it is part of the newly merged entity. As the noble Lord, Lord Scriven, said, it is about recruitment, training and retention.

A key issue, as I know from being tangentially involved in some of the conversations with unions in the last few weeks, is a real recognition on our part that pay is a core issue, but so are things such as hot meals, rest areas for staff and parking. Some of those issues are important “health factors”, if you will excuse the pun, and we are very alive to them.

Turning to the questions raised by the noble Baroness, Lady Merron, and the noble Lords, Lord Allan and Lord Scriven, as I say, it is about looking at savings across the piece. As noble Lords will know, we are talking about quite a considerable structure. The average trust is run by 300 or 400 admin staff; an ICB has 700 staff; a region has 650 to 700 staff; the NHS itself, at the centre, has 4,000 staff; and the Department of Health and Social Care accounts for another 3,500 to 4,000 staff. I think we would all agree that layer upon layer of management is not good, from not only a cost and efficiency point of view but a management point of view. We all talk about our various backgrounds, and speaking from mine, the fewer layers you have between the so-called management and the front line, the better. That is the wider picture of what we are trying to do here.

[Lord Scriven (LD)]

I totally agree. I think Tesco, for example, has four levels of management between the customer and the chief executive. But I hope the Minister understands that, regardless of layers—this may not make me popular outside this place—the NHS is one of the most effective health services in western healthcare in terms of management costs. I hope the Minister does not take the populist view that having a go at the managers suddenly makes savings. We have to get the balance right. On comparators, the NHS is significantly well placed in the western world in terms of its cost ratio of managers to patient care. I hope the Minister will accept that.

[Lord Markham (Con)]

The noble Lord is right: it is about the effectiveness of the layers. I come at this from the view, “How do we make this most effective?” That is the major gain to be won from all this.

The noble Baroness is right to bring up the issue concerning the Secondary Legislation Scrutiny Committee. I have spoken to all the staff in the DHSC about it, and I have given assurances to the House on the importance we attach to it. I am meeting the Leaders of both Houses tomorrow to discuss how we are working to make improvements in this space. Hopefully, we are making progress.

I thank the noble Baroness, Lady Watkins, for her contribution. It is fantastic to have her on the board, given her experience. Several noble Lords asked about the social care element. As we know, the situation is slightly different because most people in the social care space are employed by third-party organisations. There will not be a direct read across, but the Minister will be announcing shortly the next version of People at the Heart of Care, which aims to address a number of issues. It is probably best to wait for that, and we can take it from there.

I have tried to cover as many of the issues raised as possible, and I am quite happy to follow up in writing any I have missed. Reassurance was sought regarding current training budgets, pointing out that, while we want to make savings where possible, we need to know they are being made in the right place. A separate board structure is being set up within the organisation to make sure that such matters are separately scrutinised and not lost within the overall picture, because it is understood how vital that is. These are all elements I will try to cover more completely in a written response.

[Lord Scriven (LD)]

That is a helpful answer. To be clear, you can have a separate board, but if the budget is not ring-fenced, all that they are scrutinising is a smaller budget. I think the question that was asked—although maybe not specifically—was, will the training budgets be ring-fenced and will the board therefore be looking after a ring-fenced budget?

[Lord Markham (Con)]

I think that is probably one element I need to come back to the noble Lord on in writing.

As I said, I will try to follow up the questions in detail. I welcome the contributions of various noble Lords and their understanding of what we are trying to do here. I understand the arguments, as an ex-management consultant, regarding centralisation versus decentralisation and how they go in and out of fashion. This is a slightly different case because it is about bringing a core function in house. To me, that is the key change and the key thing we will be seeking to measure. As well as setting out clinical needs, the key role of the NHS at its centre is making sure that it is recruiting, training and retaining talent to meet the workforce plan needs. On that note, I thank noble Lords for their contributions and hope that my follow-up answers any questions that I missed.

[Baroness Merron (Lab)]

My Lords, I am grateful to the Minister for his response, and to the noble Lords who have spoken in this debate: the noble Lords, Lord Scriven and Lord Allan, and the noble Baroness, Lady Watkins. I did smile when the noble Baroness gave us an update on the workforce plan, which I am sure was helpful to the Minister, and I also wish her well in her new role.

As the Minister and your Lordships’ House will have equally understood, this is not about the actual steps that are being taken. We have had a useful debate to pull out some aspects, but the regret Motion is about the workforce and, in particular, the failure to have produced a workforce plan. This is not something recent from the last year or so. We have to remind ourselves that this Government have been in government for 13 years, and still we wait. For every day we wait, we lose an opportunity—as noble Lords have said—to plan for the future, as well as to deal with the immediate, and that is what motivated me to put forward this amendment.

We are all in agreement today that a workforce plan has to be for health and social care, which are inextricably linked, and has to not sit on the fence—well, it may; we will see. The plan has to not sit on a shelf but be fully resourced and do the job it is intended to do. We will look forward to holding the Minister to account on that point, as I know he expects.

Regrettably, I do not believe that in this debate the Minister has addressed the shortcomings of the regulations before us. Those shortcomings are somewhat unnecessary, which is a great shame because overall the statutory instrument is one that will be beneficial. It is a shame that we have had to debate it in this fashion. With that, I beg leave to withdraw the amendment.

Medical Devices and Blood Safety and Quality (Fees Amendment) Regulations 2023

Lord Markham Excerpts

Monday 20th March 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Medical Devices and Blood Safety and Quality (Fees Amendment) Regulations 2023

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

I am grateful to be here today to debate these important regulations. Before I turn to the detail of the statutory instrument before us today, I would be grateful for the opportunity to highlight the vital role that the Medicines and Healthcare products Regulatory Agency—the MHRA—plays in safeguarding our public health. The MHRA’s work to regulate medicines, medical devices and blood components for transfusion ensures that the healthcare products used across the UK are safe and effective. It charges fees to recover the costs of providing a direct service for regulatory work; these fees are set in statute and, as such, legislative change is required to amend them.

We have seen throughout the Covid-19 pandemic and beyond the innovative and agile regulator that the MHRA can be. It must therefore have a sustainable financial footing; this is particularly vital as it strives to achieve its vision of being a world class regulator, embracing the opportunities of EU exit and keeping patient safety and access to healthcare products at the heart of regulation without adding additional burden on to the taxpayer or the Exchequer.

This instrument updates the fees that the MHRA charges in relation to its activities regulating medical devices and blood components for transfusion. Its fees have been updated several times in the past to ensure that they remain appropriate, as is standard practice for government bodies that charge fees. However, to provide certainty and stability to the sector throughout the EU exit transition period and the Covid-19 pandemic, the MHRA has not updated its fees since the financial year 2017-18 for medical devices and financial year 2010-11 for blood components for transfusion.

Additionally, a recent change in the legal status of the agency has made the need for full cost recovery more acute. The MHRA previously operated as a government trading fund, which gave it the ability to retain and rely on cash reserves to better manage areas of under-recovery, notwithstanding the fact that fees should fully cover costs. However, since April 2022, following the review by the Office for National Statistics, the MHRA was reclassified from a trading fund to a market regulatory agency. As a result, the MHRA is no longer able to retain cash reserves.

Full cost recovery for the MHRA’s services has become essential to ensure the future financial sustainability of the agency. The SI therefore introduces amendments which fall into three categories. First, there is a 10% indexation increase on all fees. The indexation is linked to staff costs, which have risen in line with the wider Civil Service pay award by 10% since the last substantial MHRA fee increases in 2016. Staff costs account for over half of the MHRA’s total expenditure and therefore have a substantial impact on cost of fees charged. Secondly, there is a further uplift for a specific number of activities that were identified as significantly under-recovering via their fees to ensure cost recovery. Thirdly, there is the introduction of some new fees for services that require cost recovery since the last fee changes in 2018 for medical devices. The SI also introduces two new optional services related to clinical investigation of medical devices which industry may wish to use. These new services relate to obtaining expert regulatory advice or statistical reviews from the MHRA in relation to clinical investigation of a medical device.

The MHRA is obliged to recover the costs of its regulatory activities in accordance with the Treasury’s managing public money guidelines. The amendments that this SI will introduce to the fees for the MHRA’s regulatory work on medical devices and blood components are necessary to ensure that the MHRA recovers its costs associated with delivering these services. It is appropriate that the regulated bear the cost of regulation and that the MHRA does not profit from fees at the expense of industry.

The full cost-recovery approach ensures that the MHRA does not make a loss which would fall on UK taxpayers and patients to subsidise. The MHRA is committed to regularly reviewing its fees and ensuring that these remain fair and reasonable and continue to reflect the true cost of providing regulatory services. The MHRA is also committed to delivering a reliable service and publishes performance targets that are reported against in its annual report and accounts, which are laid before Parliament.

The fees updates are important to ensure that the MHRA has the resources it needs to deliver reliable services. The fees updates will, in turn, contribute to operating modernised systems and processes, recruitment and retention of skilled staff and keeping pace with technological advancements.

To summarise, with this instrument, we have the opportunity to ensure that the MHRA has the financial security it needs to support the delivery of a responsive and efficient regulatory service for the protection of patients and improvement of public health across the UK.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I thank the Minister for introducing the SI and the important provisions within it. As my noble friend Lord Jones said, it is an important SI, and we acknowledge the role that the MHRA plays and the need to increase the fees that it charges for regulating medicines and related products.

I appreciate that the Minister said that the MHRA has not increased its fees to this extent since 2016-17, which was in an effort to provide the industry with certainty and stability through the EU exit period and the challenges of the pandemic.

The noble Lord, Lord Allan, asked some questions the responses to which I would also be interested to hear. The consultation process was important, and I am glad that it took place and has guided the SI and its provisions, because the views of relevant stakeholders are key in making sure that we get things in the right place.

There is a clear acknowledgement from noble Lords that the MHRA needs to be financially stable, because it needs to be able to deliver regulatory services that protect and improve patient safety with high-quality, safe, effective and innovative medical products. I certainly welcome the greater clarity that the SI provides on the increased costs of providing quality care in our health services. However, I have a question for the Minister specifically on the SI. Where the increased costs of the fee simply cannot be absorbed by the NHS, which is already facing the worst of crises, could the Minister outline how the Government will ensure that the increase will be accommodated without affecting the stability of NHS finances and without impacting patient care? In other words, how will it be done?

I will make some more general points about the work of the MHRA. Innovative companies in this field often say that a key block to their progress—a key block to getting their work through the MHRA—is the speed, or the lack of speed, with which it can be processed. Can the Minister indicate how he will ensure that the MHRA stays up to speed with the latest advances and is able to process them as quickly as possible?

It would also be helpful to know how the department scrutinises and assesses the work of the MHRA. For example, what is the formal matrix for success and the speed at which it processes new devices? How well does the MHRA communicate with other organisations in the sector? What engagement does the department have with the MHRA, both to hold it to account and to improve its practices?

In drawing my more general points to a close, I note and welcome the recent announcement of the extra £10 million of funding for the MHRA. Can the Minister outline the blocks to quick approval to which this money will be targeted? How will the impact of this additional money be measured, and is it sufficient to deliver the service we need to ensure that UK patients have faster access to the most cutting-edge medical products in the world? As part of the additional money, the Chancellor announced last week that treatments already approved by “trusted” regulators internationally would be nearly automatically approved. Which countries are counted as “trusted”? Has an impact assessment been carried out for this change and, if so, can it be published?

We are always looking forward and looking to make further strides in patient safety, it is certainly my opinion that this statutory instrument takes us further along this route, and we welcome it.

[Lord Markham (Con)]

I thank noble Lords for their contributions today and, as ever, will try to reply and follow up in writing where necessary. I shall try to take them in order, for ease. The noble Lord, Lord Jones, asked who is working on the bloods, for want of a better word. We have qualified professionals who are working to WHO standards, such as phlebotomists. Related to this was the question of who is in receipt of these fees. It is twofold. Obviously, a lot of fees go to fund MHRA itself, but a lot of the cost base is when it is hiring in subject-matter experts. In that case, they get the fees.

The general point raised by all noble Lords was the basis of this. As I said, it is a cost-recovery model. There are swings and roundabouts there, but it has tried to ensure that where there are bigger increases, it is only because that is the legitimate cost, but on average it comes to about 12% to 13%. I think that we would all accept that, for something that has not increased since 2016-17, that is reasonable. It is quite a bit behind inflation. That notwithstanding, I am very alive to the impact on SMEs, having been, as I said, in a similar space myself in the past. There are easements and waivers that can be applied, if that is the case.

To the general point about how we are trying to keep up with the speed of advances in the industry, it is very much the understanding that the industry is providing a service. Of course, safety must always be paramount, but it is a service to bring in innovation and attract new people into the sector. It has a transformation programme to ensure speedy replies—but I was pleased to hear that it is also looking to introduce a consulting service to help companies get into the field. That will be different from the regulatory side—obviously, we need a Chinese wall between the two. But it is recognised, especially for a small company, which does not have a regulatory team in place, that being guided and hand-held through the process, and having someone to tell them that this is what they need to do to get in, is very important. That is something that it is committed to doing.

As for holding the MHRA to account, to be candid, I see that very much as my job. That is obviously for officials as well, but I have the brief for the ALBs, and I set up regular meetings with them. As I said, I am very much alive to the fact that that is needed to make sure that it really is serving the industry properly. Part of holding it to account is about making sure that it is providing a decent service level. That is something that I will look for it to carry on doing. Consultation is useful as a formal process, but it should always talk to its customers and get that sort of feedback.

I have to fess up that I probably cannot answer some of the nerdy questions right now, particularly on the reclassification of the agency. I will have to phone a friend or get my colleagues to reply on that point. Likewise, I think we would all agree that the extra £10 million is welcome in this space. How the MHRA will go about that distribution and how it will measure that effectiveness is something I will follow up in the detailed letter that I will send.

Similarly, on which countries are counted as “trusted”, my understanding is that often the MHRA looks at the processes that are in place—again, I will come back in detail on this. Rather than a country being trusted, per se, it is more about the scrutiny process that it undertook. Obviously a regulator would be accepted as good in a place, but again, I have some personal experience. If you can see that the CDC or the FDA has gone through a very similar process, does it really make sense to do that all again? Clearly, it is felt that I have not quite answered the question—but I mentioned the waivers.

At this point, I hope I have covered most of the questions that I can right now, but I will follow up in detail. I appreciate that noble Lords are generally supportive of what we are trying to do here, and that we all agree that the MHRA has an important part to play and that the cost recovery is a reasonable approach, particularly with some of the price increases in recent years. As I said, I will happily follow up in writing. On that, I commend the regulations to the Committee.

Motion agreed.

Patient Deaths: Ambulance Waiting Times

Lord Markham Excerpts

Tuesday 14th March 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what assessment they have made of reports that over 500 seriously ill patients died in England last year after long waits for an ambulance; and what steps they are taking in response.

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

We recognise the pressures facing the NHS and the need to recover performance following the impact of the pandemic. We are working hard to make sure that no one waits longer than necessary, given how important response times are for patient care and outcomes. We are backing the NHS to meet these challenges and our emergency care plan will deliver one of the fastest and longest-sustained improvements in waiting times in history, backed by £1 billion in funding and up to 800 new ambulances.

[Baroness Merron (Lab)]

My Lords, it is alarming that last year, the number of deaths of patients waiting for an ambulance for up to 15 hours more than doubled from the previous year. What action will the Government urgently take, co-ordinated across the whole of health and social care services, to reverse this tragic tide? Can the Minister also explain the lack of a government plan over the years for getting to hospital in time those who have had a stroke or a heart attack, whose breathing has stopped, or who have been in an accident?

[Lord Markham (Con)]

I thank the noble Baroness for that question. As I said, we are providing 800 new ambulances, but there is a flow issue, as she rightly points out. To resolve the issue at the back end, so to speak, £500 million will be provided for new adult social care places, which is a vital part of unblocking 13% of the beds that are blocked and creating space throughout the system. At the same time, providing ambulance hubs will create offloading space so that ambulances can quickly get back on the road again. These are all key aspects. Fortunately, we are starting to see an improvement but there is a lot more that needs to be done.

[Lord Sherbourne of Didsbury (Con)]

My Lords, talking of patient care, is it not a matter of shame that the strike by junior doctors is leading to patients with heart problems and cancer problems and those needing hip operations having their operations postponed for more than six months, because the doctors have walked out of hospitals and operating theatres? How does that help patient care?

[Lord Markham (Con)]

Clearly, we regret any circumstances where capacity is taken out of the system, and this is a clear example. Patient care is primary, and we hope to sit down and resolve the differences. I am glad to say that we are now having good conversations with the nurses’ unions and other unions, and I hope we can have similar productive conversations with the doctors.

[Lord Allan of Hallam (LD)]

My Lords, NHS data shows that there are significant variations in ambulance response times in different areas of England, and we see especially long response times in areas like the east of England, where some category 4 patients were waiting for over eight hours in February. Can the Minister explain how we got into this situation with what are supposed to be national targets? What are the Government doing specifically to help areas that are currently missing the targets by a country mile?

[Lord Markham (Con)]

Local ICBs—integrated care boards—are integral to this, understanding the need for ambulances in each of their areas. As noble Lords have heard me say before, often, having a fall does not require an ambulance response at all, but it is much better to have a full service. Now, it is the responsibility of every ICB to set up a full service so it can respond more appropriately. Additionally, we are tasking each ICB with getting on top of ambulance wait times.

[Baroness Finlay of Llandaff (CB)]

My Lords, the Royal College of Emergency Medicine’s February report says:

“The crisis in emergency care is relentless and staff are burned out and exhausted. The significant shortfall of beds and staff is driving this crisis.”


In February there were 1.2 million A&E attendances. More than 126,000 patients waited more than four hours from the decision to admit them—these are trolley waits —and nearly 35,000 of those were delayed by more than 12 hours. What are the Government doing in their workforce plan to look at projected workload and figures and ensure that the plan has minimum staffing levels and staff numbers overall?

[Lord Markham (Con)]

The noble Baroness is correct that capacity is key to this, as are the workforce and the workforce plan. I am pleased to say that a more advanced version of that will be published shortly, hopefully showing that we are getting on top of it. At the same time, we have put 7,000 extra beds into the system, which is starting to have an impact. Category 2 wait times are down by an hour compared with last month, but clearly there is more that we need to do.

[Lord Sahota (Lab)]

My Lords, I declare that I am a councillor in Telford and Wrekin. Shrewsbury and Telford hospitals are under one health trust. The Government plan to close 24/7 A&E services at Telford hospital, which means that people will have to travel 15 miles to Shrewsbury in ambulances. This will put further pressure on our already overstretched ambulance services. Does the Minister agree that this will have a negative impact on the people of Telford and Wrekin?

[Lord Markham (Con)]

I am convinced that the ICS will make the best decisions for that area. I am very familiar with Sir Jim Mackey’s plans, which advocate setting up so-called hot and cold sites. It is often better to specialise in A&E in one area and “cold” elective treatments in another, in order to have more efficient treatment in both. I imagine that is very much part of the plan, which will see improvements in both A&E and elective services.

[Baroness Walmsley (LD)]

My Lords, may I ask about dissemination of good practice? Some trusts are improving ambulance response times but others are not. I accept that they are working in different geographies with different demographics, and have different A&E capacity in each area, but how are the Government making sure that proven best practice is being disseminated across the country?

[Lord Markham (Con)]

The noble Baroness is absolutely correct. Some 50% of all wait times—I have used this statistic before and I will correct it if I have not got it exactly right—come from I think 20 trusts. Clearly, there is a focus on working on those areas. That is starting to bear fruit, with each of those trusts having specific plans to ensure that they use best practice. We have tried to pick the best practitioners in an area— I have done this on two occasions recently—and bring them into the centre to help us advise across the board. That really is making a difference.

[Baroness Manzoor (Con)]

My Lords, as well as disseminating good practice, there is the issue of accountability. The Government have put significant sums of money into the NHS, so what are the regulators —NHS England and others—doing to ensure that good practice is disseminated and, more importantly, that the chief executives and the boards are delivering on the commitments they have made?

[Lord Markham (Con)]

My noble friend is absolutely correct: with responsibility for these things comes accountability, and it is the job of us all to hold people to account where performance is not where it should be. I know each Minister has their own set of ICBs— I have a particularly close relationship with seven; other Ministers have the same—so that we can bear down on exactly these sorts of differences and hold people to account.

[Lord Patel (CB)]

My Lords, does the Minister agree that the junior doctors’ representative at the BMA and the Department of Health should get round the table and negotiate the end of the doctors strike before more harm is done to the patients? To express a personal view, as a doctor, I would never withdraw my services from patients.

[Lord Markham (Con)]

I thank the noble Lord for his contribution, as ever. Yes, absolutely; these things always have to be resolved around the table. As I say, I am pleased that we are making good progress with nurses and ambulance workers, and I hope we can get around the table and make more good progress with GPs as well.

[Lord Watts (Lab)]

My Lords, there is a shortage of nurses, a shortage of doctors and a shortage of ambulances. What have the Government been doing for 13 years to let this crisis happen?

[Lord Markham (Con)]

Noble Lords will be aware that this is a situation facing people all around the world. Just today I was being grilled by a Select Committee talking about the problems in Stanford in California, where people were having to wait 48 hours to go from A&E to get to a bed. It is a worldwide issue.

[Noble Lords]

Oh!

[Lord Markham (Con)]

It absolutely is; just look at Wales, at Scotland and at the whole country: it is a systemwide issue and we are implementing a systemwide solution. We have recruited 29,000 additional nurses, with still more to come and more in training than before. There are more doctors. We are targeting 50 million additional GP appointments and we have increased them by 30 million to date. That is solid action. Is there more to do? Yes. Are there plans to address that? Yes. Will I report on them very regularly? Absolutely.

Covid Pandemic: Testing of Care Home Residents

Lord Markham Excerpts

Monday 6th March 2023 Lords Chamber

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

My Lords, for the record, noble Lords are aware of the Covid testing business that I set up at the beginning of the pandemic. We offered testing to the Department of Health and Social Care on a not-for-profit basis. That offer was not taken up and the business never had any government contracts. I wanted to make that clear at the beginning of my answer.

To answer the noble Baroness’s question on the Covid inquiry, the team is staffed to make sure that all the information that is needed is provided. Everyone agrees that we need to learn any lessons from what happened and that all the information that is available is brought to bear.

[Baroness Brinton (LD)]

Mr Hancock denies that he rejected Chris Whitty’s advice in April 2020 that everybody going into a care home should be tested. On 19 May, I said to the then Minister in the Lords:

“The Secretary of State has repeated his claim that he has prioritised testing in care homes, yet he still repeats that testing for everyone in care homes … will be only ‘offered’ by 6 June.”


My noble friend Lord Rennard asked whether the Minister had heard the programme “More or Less” and the

“total demolition of the claim that 100,000 tests were being conducted each day”.—[Official Report, 19/5/20; cols. 1086-94.]

The following day, I said that

“Dame Angela McLean said testing had been prioritised in the NHS over care homes. Today, Justice Secretary Robert Buckland said the Government had prioritised the NHS over care homes as well.”

The Minister said that

“we rolled out outbreak testing for all symptomatic care home staff and residents.”—[Official Report, 20/5/20; col. 1177.]

Two weeks later, I said that

“a number of CCGs are still pushing care homes to take block-bookings of patients coming out of hospital without having had Covid tests.”—[Official Report, 3/6/20; col. 1417.]

We all knew what was going on at the time because we were being told by care homes and by the families of residents. Will the Government now apologise to the many families who lost loved ones as a result of the delay in getting full testing into care homes?

[Lord Markham (Con)]

It is to the regret of everyone that so many deaths were caused in care homes. That is something that I know everyone feels very deeply about. At the same time, the testing capacity was expanded very rapidly. As we know, at the beginning of the pandemic in mid-March, there was capacity for only 3,000 tests a day. At that point, the decision was made that they should go to NHS front-line staff. However, it was then rapidly expanded: on 15 April there were 39,000 tests, and by May there were about 100,000 tests a day. Obviously, at that point, the Government were able to expand the tests more fully to care homes.

Was that prioritisation right? That was the subject of the Gardner review but, clearly, the body that can decide best on whether the right decisions were made at the right time is the inquiry, with which everyone will co-operate fully.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, what is so devastating in reading the Telegraph’s WhatsApp lockdown file is that it has confirmed that the most susceptible to Covid were victims of a lack of targeted testing in care homes, while the least at risk were hectored and frightened into getting tested to reach one government Minister’s self-set arbitrary targets. Will the Minister take back that we urgently need this public inquiry? Will it scrutinise the process of target-setting that lost sight of its original aim? Also, after the revelations that Minister Helen Whately raised concerns about the inhumane policies of separating people in care from their families—so lonely and distraught that they gave up—will the Minister support the Rights for Residents campaign to enshrine in law the right to maintain family contact in all care settings? It was not just the lack of testing that killed people but some of the policies too.

[Lord Markham (Con)]

We all agree that visiting should be allowed as much as possible. I know that the policy is that people can receive at least one visitor, but I know that there are also examples where that is not happening enough. It is very clear, from our side, that it is a priority that everyone should have visitation rights, because they are vital. Can we say that that will always be the case in every circumstance in the future? Well, clearly no one foresaw the pandemic, so this is one of those situations where we can never say so definitively, but we all firmly agree that visitation is a key part of people’s care and well-being.

[Lord Naseby (Con)]

Is my noble friend aware that I should declare an interest, in that my wife is a retired GP? In the period February-March 2020, it was very clear to those of us who were in contact with the medical services that things were not right in care homes. On 21 April 2020, I put down a Question—and I have a copy for my noble friend—which read:

“To ask Her Majesty’s Government what has been the COVID-19 testing policy for hospital patients that have been discharged to nursing and care homes over the last four weeks.”


That took us back to 23 March 2020. I got an Answer some three weeks later, which read:

“As outlined in the Adult Social Care Plan, published on 15 April 2020, any patient who moves from the National Health Service to social care will be discharged in line with the current NHS COVID-19 Discharge Requirements. NHS England and NHS Improvement published a letter on 16 April addressed to all accountable officers of all hospitals (public and private sector) working for the NHS and discharge teams outlining the new requirement to test patients being discharged from hospital to a care home.”


This did not answer the Question that I had asked about what had happened between the latter end of March and early April.

I recognise that my noble friend has only recently joined the Front Bench but, as far as I am concerned—I have taken a detailed interest in this—it is fundamental that we are honest. If things went wrong, as I am sure they did, they must come out in the public inquiry. I am happy to give a copy of my Question to the opposition parties, so that they do not have to scratch around to find it.

[Lord Markham (Con)]

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

[The Lord Bishop of London]

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

[Lord Markham (Con)]

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

[Lord Allan of Hallam (LD)]

My Lords, the Government’s defence of their entire testing strategy has been that we should trust them but, based on all that we have seen of the former Health Secretary over recent months—far too much, would be many people’s reaction—can the Minister say whether he is a person who displays consistent good judgment or is he capable of making some quite serious mistakes?

[Lord Markham (Con)]

I do not know the said ex-Minister, so cannot comment on that. If we cast our minds back, it was a very pressurised environment in which lots of decisions had to be made very quickly. Mistakes were undoubtedly made as part of that. As to how we did overall, it is best for the inquiry to make findings rather than for me to give my opinion.

[Baroness Browning (Con)]

Can my noble friend confirm that, when the results are published, the contingency plan brought forward by the Government will include, quite clearly, what will happen with care homes in future situations? We are all concerned that this was very last-minute.

Can I ask my noble friend to reflect on my own circumstances? My aunt Vicky, aged 99 years and nine months, died in April 2020 in a care home that she had been in for some time. The death certificate said “Covid”. She was symptomless and not tested. When the family challenged it, it was changed to “died of old age”. I ask my noble friend to reflect on that.

[Lord Markham (Con)]

I am sorry for my noble friend’s loss, albeit one of too many losses in those circumstances. Yes, we absolutely need to learn the lessons around social care settings. Most people would accept that, of the many things that were done well during Covid, that was probably one that we would have done differently, in the early stages, if we had our time again. The Covid inquiry is all about making sure that we learn those lessons, going forward.

[Baroness Bennett of Manor Castle (GP)]

Following the question asked by the right reverend Prelate about what is happening today, I actually agree with part of the Government’s response, which referred to selective snippets of WhatsApp conversations. That is what we are hearing today. While we are waiting for the official inquiry, which will give us a clear, independent view of what happened, it is clear that there were big problems in our care homes. What are the Government doing today to look at the problems that continue in our care homes, particularly those associated with excessive profit taking and privatisation, particularly in homes under the management of hedge funds?

[Lord Markham (Con)]

I know that that is something in which Minister Whately is very engaged. The House has already seen some of the plans around social care and there is further work on discharge going on as we speak. I have spoken many times in the House about the need to resolve this, not just to make sure that the right care is in place for those involved but to free up hospital beds to improve the performance of the whole system.

Communications Act 2003 (Restrictions on the Advertising of Less Healthy Food) (Effective Date) (Amendment) Regulations 2022

Lord Markham Excerpts

Monday 27th February 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, the Children’s Minister recently admitted that the nation had a problem with childhood obesity that should not be ignored. I am sure that noble Lords who have spoken today, and I am grateful to them, will share that view, not least because children with obesity are five times more likely to become adults with obesity, increasing the risk of developing conditions including type 2 diabetes, cancer and heart and liver disease. This is an extremely serious and pressing matter, as the Minister has been reminded yet again.

Two in five children in England are above healthy weight when they leave primary school and we now see the fastest increase in childhood obesity on record, as my noble friend Lord Brooke highlighted in his remarks. But it gets worse. Children starting school in the most deprived areas are three times as likely to be severely obese as those in the wealthiest, while NHS data shows that almost half of boys in England’s poorest areas are overweight or obese when they leave primary school. Last year, there were 3,400 severely obese children aged four or five in the most deprived parts of the country, as compared with 630 in the richest. So will the Minister give some indication as to what account is being taken of this great disparity between those who have more and those who have less in the Levelling-up and Regeneration Bill currently being considered in your Lordships’ House?

As we have heard today, it is absolutely right that we make informed choices about what we eat and drink, but choice can only really be choice if there is no distortion, and if those who are making the decisions have all the information they need and are able to interpret it. As the noble Baroness, Lady Bull, said, we actually need an integrated health approach to tackle the complexities of achieving a healthy weight. So the question for the Minister that has run throughout this debate is: how will the statutory instrument support this integrated health approach to tackle the complexities we know we have?

In the Government’s original analysis, they suggested a watershed on advertising, saying that introducing restrictions to prevent adverts for products high in salt, fat and sugar being shown before 9 pm could lead to 20,000 fewer obese children. I took it that this was, as others have said in the debate today, about shifting the environment, shifting the power of influences, in order to manage the challenges that we all face in supporting our wish to secure good health. So, will the Minister tell your Lordships’ House what will be the change in opportunity to tackle children’s obesity because of this regulation and the change it brings about? I refer in particular to page 33 of the Secondary Legislation Scrutiny Committee report. The noble Baroness, Lady Walmsley, referred to the figures. The report states:

“Analysis conducted to inform the Government’s Impact Assessment of the advertising restrictions found that under current restrictions children were exposed to 2.9 billion less healthy food and drink TV impacts and 11 billion less healthy food and drink impressions online in 2019”.


The committee observes that the effect of the delays means that, presumably, this level of advertising will continue and asks for an explanation as to why this is acceptable given the harms stated. Perhaps the Minister could refer to an answer on this point. The committee also asks for an explanation as to how the Government anticipate that they will still achieve the target of halving childhood obesity by 2030 if various elements of the strategy are delayed. Again, perhaps the Minister can tell your Lordships’ House his view on this.

Of course, there is a difficult balance to strike when seeking to improve public health and also when working with broadcast and online and the advertising industries. The Government have produced a regulation that has been drawn to the attention of the Secondary Legislation Scrutiny Committee once again, and this clearly does not assist the striking of that balance. It is not acceptable that the Explanatory Memorandum is described as “poor”, and that it fails to evaluate the effects on public health and the NHS from this delay. Nor is it acceptable that it fails to explain the use of a different definition from previous legislation. This refers to the unexplained shift from “high-fat, sugar and salt” to “less healthy foods”. The committee rightly asks whether the Government’s intended scope of products that they want to regulations to cover have been changed. Perhaps the Minister could respond on this point.

The SLSC also says that it

“provides insufficient information to gain a clear understanding about the instrument’s policy objective and intended implementation.”

It also says that, worryingly:

“The views of the NHS are not addressed or explained.”


This, I believe, is quite remarkable and suggests a breath-taking lack of engagement with those who should be engaged with. Once again, poor policy-making and poor administration have come together to leave your Lordships’ House unable to properly scrutinise what the Government are doing and why, even though it is the job of your Lordships’ House to do this. Perhaps the Minister could address these points of concern.

The Minister will recall that I have raised many times before the point about his department’s approach to legislation and the criticism that it has attracted. He kindly gave an undertaking that he would look into this with a view of doing better in future. Can the Minister could update the House of progress in this regard? Finally, I hope that the Government will not be diverted from measures that will have an impact on the health and weight of the nation.

[Lord Markham (Con)]

My Lords, I congratulate the noble Lord, Lord Allan—despite his wish to invite people to kick our balls—and the noble Baroness, Lady Merron, for securing the debate to discuss these regulations. I also thank the Secondary Legislation Scrutiny Committee for its report on this, and I thank all noble Lords for their constructive discussion on how to tackle the pressing challenge on obesity. I thank the noble Baroness, Lady Bull, in particular, for her thoughtful contribution showing the complexities of the subject with regard to the impact on eating disorders, as well as obesity.

I like to think that we are all agreed on the scale and the gravity of the issue at hand. Data from the latest child measurement programme, as mentioned by others, shows that 38% of children leaving primary school were either overweight or living with obesity. One in four were living with obesity. This, as we know, is fuelled by the regular overconsumption of food and drink that is high in calories, sugar and fat—or HFSS food and drink for short. As the noble Baroness, Lady Merron, mentioned, we know that being overweight or living with obesity at a young age increases the risk of being overweight as an adult which, in turn, significantly increases the risk of diabetes, coronary heart disease, musculoskeletal issues and certain cancers. This impacts on both the individual’s well-being and wider society. As we all know, it comes at a very high cost. Not only does it cost the NHS £6.5 billion a year in the latest estimates—there is an economic cost estimated to be as much as £58 billion. For all those reasons, this Government are committed to tackling obesity: it is the morally and fiscally responsible thing to do.

Physiotherapy: Rehabilitation Services

Lord Markham Excerpts

Thursday 23rd February 2023 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government what assessment they have made of the survey by the Chartered Society of Physiotherapy, published on 1 December 2022, which found that there was a shortage of rehabilitation services, that rehabilitation spaces had not been returned to use for physiotherapy care following the COVID-19 pandemic, and that stroke survivors were being “imprisoned at home with a bed and commode” while waiting for care.

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

We welcome the Chartered Society of Physiotherapy survey and the valuable insights it gives us regarding rehabilitation services. Integrated care systems are responsible for commissioning appropriate services for their local populations. Decisions on the use of physical estates are rightly for local organisations. Rehabilitation and physiotherapy are critical to many patients’ care and recovery. For stroke survivors, the NHS aims to deliver personalised, needs-based, goal-oriented rehabilitation to every stroke survivor in their home environment.

[Baroness Wheeler (Lab)]

My Lords, the CSP survey paints a dismal picture of the state of rehabilitation services: overstretched and underresourced prior to the pandemic and still struggling to re-establish physio rehab services that had their staff, space and facilities diverted to deal with the crisis and with chronic staff shortages. The recent stroke audit showed that only 10% of the UK’s stroke survivors were able to access the recommended amount of rehabilitation they need. What actions are the Government taking to address this unmet demand for the vital services that will help prevent patients deteriorating and becoming more frail and vulnerable?

[Lord Markham (Con)]

I thank the noble Baroness for bringing this to our attention; again, I believe that the advantage of these Questions is that they shine the spotlight on particular areas. As the survey pointed out, there are a lot of places which, for very understandable reasons, were swapped over to Covid uses during the pandemic and which now need to be brought back into physio use. That was one of the main recommendations from the society, and we will now write to all the NHS chief executives on the back of that. As the House will be aware, I am doing some work anyway to make more space available as part of the capital programme, so this is very much on my list to make sure that we expand that space and provision.

[Lord Addington (LD)]

My Lords, does the Minister agree that physiotherapists do very little of their work in the actual appointment, and that it is the supervised exercise patterns they give patients afterwards that are probably the most important for all forms of rehabilitative structure? Bearing that in mind, what is the Department of Health doing to make sure that local government has facilities such as swimming pools and gyms that remain open under the financial squeeze?

[Lord Markham (Con)]

I agree with the noble Lord’s point; our estimate is that over half of all physiotherapy takes place outside the hospital environment. Clearly, all sorts of settings, including swimming pools and gyms, are vital for that. The work we have done with the Energy Bill and the caps has been a vital help to those leisure centres, and, thankfully, we are now starting to see bills come done and so these places are on a better financial footing.

[Lord Patel (CB)]

My Lords, I was previously a trustee of the Stroke Association and the chair of Chest Heart & Stroke Scotland. Every five minutes, a person suffers a stroke. Their outcome depends on two crucial factors: first, the so-called golden hour during which they should receive treatment—if they do not, their outcome is poor—and, secondly, the rehabilitation they get over the next three to six months, including training on speech, mobility and dealing with daily life. Sending these patients to care homes or their own homes without that kind of support decreases their outcomes considerably. Currently, 10% of these patients end up in nursing homes for ever; if these services are not available, that number rises to 30% to 40%. So, despite the positive response from the Minister, there is a degree of urgency for integrated care boards to address the issue of rehabilitation for stroke patients.

--- Later in debate ---

[Lord Markham (Con)]

Absolutely. That is why, as part of my research, I was pleased to read up on the national integrated community stroke service, which is designed to give personalised stroke rehabilitation in every person’s home. Its work is vital in achieving this. The House has heard me talk many times about the 13,000 beds that are blocked in our hospitals, and a lot of the way to free them is by having rehabilitation and getting people back into their home environment. I absolutely agree on the importance of this issue, and that is why noble Lords will see it as an important part of the workforce plan.

[Baroness Manzoor (Con)]

My Lords, I welcome the Answer my noble friend the Minister gave, but I will give him a real-life example, and declare my interest in doing so: somebody had two strokes, then had a third while waiting over an hour for an ambulance to arrive, has had no physiotherapy rehabilitation at home, and is still waiting a year on for that. This is a real example of people on the ground. Does the Minister agree that we must connect our policies with very clear outcomes?

[Lord Markham (Con)]

Totally. I am sorry to hear that case, and I think that we would all agree that that is not the sort of service we would want to see. As I said, we have put increases in staff in place—there have been 3,300 extra staff since 2017—but, clearly, we need to do more. That is why I was very pleased to read that this area is an important part of the workforce plan, which noble Lords will be happy to hear we are now seeing drafts of.

[Baroness Pitkeathley (Lab)]

My Lords, if stroke survivors are imprisoned at home with a bed and a commode, as my noble friend’s Question suggests, does the Minister agree that their unpaid carers are similarly imprisoned? Is the lack of rehabilitation services part of the reason why the numbers of people giving more than 50 hours a week unpaid care is increasing rapidly, as the latest census figures suggest?

[Lord Markham (Con)]

As I said, physio is key to rehabilitation, whether for strokes, as we have discussed, or for any one of the number of reasons that people are in hospital and trying to come out. As I mentioned, we have seen increases: there are about 7% more people now in training each year, and that figure increases each year. We now have about 50,000 physios in the public and private sectors who are providing those types of services. Clearly, there are examples where we need to do more, but we are also making progress.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interest as the president of the Chartered Society of Physiotherapy. Do the Government recognise that almost three-quarters of physiotherapists feel that they cannot do their job properly now, and that, as well as a workforce plan, there needs to be a workplace plan for adequate rehabilitation that goes way beyond cancer and stroke services? All orthopaedic operations, and many other interventions, will not be successful without adequate, immediate physiotherapy in the post-op period, so, by failing to provide physiotherapy, we are stacking up problems for the future with long-term physical dependency and not maximising the benefit of interventions provided early.

--- Later in debate ---

[Lord Markham (Con)]

I start by wishing the noble Baroness a happy birthday. I was pleased to read the three recommendations from the Chartered Society of Physiotherapy: return the rehab space to use; include physios in the long-term workforce plan; and give staff and space to the physio service. As I have said in my earlier responses, we are working on all three: we are working with the NHS trusts to return the rehabilitation space; we are putting physiotherapy in a very important part of the workforce plan; and we are providing the services. So we are making a lot of progress, but I welcome the involvement of the Chartered Society of Physiotherapy in that.

[Lord Allan of Hallam (LD)]

My Lords, it is pleasing to hear that physiotherapists are included in the proposed and long-awaited workforce strategies; there is clearly a shortage in this area. Can the Minister comment on today’s press reports that, while his department is persuaded that there needs to be a dramatic increase in training places across the medical professions, his friends in the Treasury are declining to support that essential expansion?

[Lord Markham (Con)]

As we are all aware, the Chancellor was very keen to kick this off in the first place. We have been participating in this by working very closely with the Treasury, and I am heartened by the work we are seeing on it all. There are some early reports, and, while they do not yet know the full picture, I am looking forward to being able to talk to the whole House about it in the not-too-distant future.

GP Appointments

Lord Markham Excerpts

Thursday 23rd February 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what assessment they have made of (1) the impact that the logistical difficulties of getting a GP appointment has on patient outcomes, and (2) the extent to which the needs and choice of individual patients are being met in making healthcare appointments.

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

We recognise that some people have struggled to access timely care from their general practice. We are taking action to expand general practice times to increase the availability of appointments, upgrade practice telephone systems, and publish data about how practices are performing so that patients can make informed choices when registering and commissioners can help the service to improve. In 2022, nine out 10 patients felt that their needs were met at their last general practice appointment.

[Baroness Merron (Lab)]

My Lords, the latest GP Patient Survey shows that more than one in four of those needing an appointment actually avoid making one because it is just too difficult. So does the Minister accept that practices such as being made to ring at 8 am, long phone queues, waiting hours for a call back and no online booking, all stack up more serious problems for the patient and the National Health Service? What are the Government doing to tackle these very basic practices, so that people can get to their GP in a way that suits them?

[Lord Markham (Con)]

Absolutely. One of the things I am very proud to be leading on the NHS side is our whole digital way of addressing access to the health service. This will be fundamental to how people make their hospital appointments and take control of their own health, so it will be the main thing that will help with the 8 am appointments, alongside the increased telephony services and everything else. Just as every walk of life is coming down to being able, at your fingertips, to make appointments and bookings and get your own records, this will also be the case with GP surgeries and I think it will fundamentally change the way that we address our whole health.

[Baroness Jolly (LD)]

My Lords, part of the problem is where there is no mobile phone signal. People who live or who have homes in Cornwall will identify with that. Does the Minister have any idea what proportion of patients find accessing their GP difficult? What advice has been given to practitioners on resolving the issue? In rural areas such as Cornwall and Northumberland, there are poor bus services, if any. Getting home can mean a really long wait—sometimes half a day if there are only two buses a day. What advice would the Minister give to the GP and to the patient?

[Lord Markham (Con)]

First, my understanding is that the vast majority of homes in Cornwall have broadband, to which your mobile phone will of course connect. That is where people will be making appointments from. They can use digital to do that. Secondly, we are rapidly increasing the number of doctors’ appointments. We made a pledge to increase the number of appointments by 50 million. To date, we have increased them by 36 million—11% up since 2019. So we are making more appointments available. Do we want to do more? Absolutely. Are we going to publish a primary care plan shortly to show how we will address those additional needs? Yes.

[Lord Kakkar (CB)]

My Lords, I draw attention to my registered interests. Deprived communities often have the most acute shortages of general practitioners, yet it is among those populations that there is the greatest burden of chronic comorbidity that requires integrated care, with a particular focus on communities where outcomes are the poorest and the healthy life years are the shortest. What do His Majesty’s Government propose to do about addressing the specific issue of GP shortages in deprived communities?

[Lord Markham (Con)]

As mentioned, we are increasing the number of doctors. We have 2,000 more versus 2019. The House will be pleased to know that that is a key part of the workforce plan for recruiting and retaining more doctors. As to comorbidities and deprived areas, clearly that is the role of the integrated care boards. They are set up very much to understand the needs of their areas and to make sure that they are looked after properly. In a lot of cases that means investing in primary care. We all know that a lot of the reason why we have a lot of people in A&E is that they cannot get GP-type services, so getting upstream of that issue and investing in primary care is the direction in which we need to go.

[Lord Sandhurst (Con)]

My Lords, it is often forgotten that general practitioners, unlike salaried NHS doctors, are self-employed contractors under contract to provide services. What plans, if any, do the Government have to review the existing GP contract to ensure that new terms are imposed to require better delivery of services by general practitioners?

[Lord Markham (Con)]

My understanding is that the new GP contract is part of live conversations with the BMA that we are about to get into—I think it is over the summer that those negotiations will start to take place. Within all of that, we will be looking at all those sorts of things in terms of how we want to see the GP service evolve. At the same time, we will be talking openly to the BMA about what it wants for its doctors, so that we get an outcome that works well for both sides.

[Lord Foulkes of Cumnock (Lab Co-op)]

My Lords, has the Minister seen the report produced today by the Auditor-General for Scotland? It is devastating about every aspect of the NHS in Scotland, including access to GPs. How much of this is because of underfunding by the UK Tory Government and how much because of the devastating administration of the Scottish Government?

[A noble Lord]

Go on.

[Lord Markham (Con)]

Are you going to dare me?

Sorry, I think a diplomatic response is probably wise at this stage. I note that, under the Barnett formula, per person funding for the NHS is Scotland is higher than it is in England. So there is significant funding in place. How well it is administered north of the border is probably a matter for the Scottish Government.

[Lord Bellingham (Con)]

My Lords, is it not the case that many European countries charge patients who fail to turn up for appointments without due cause? Is this something we are going to look at in this country?

[Lord Markham (Con)]

I am clearly aware of that. At the same time, I am very aware that we want to make sure that people are able to see a doctor when they need to and are not deterred from that. So we would have to tread very carefully and it is definitely not in our plans at the moment.

[Baroness Bull (CB)]

My Lords, given that a dual system of online and in-person GP interaction is inevitably the future and that virtual appointments are clinically appropriate in some circumstances, what are the Government doing to increase public confidence in virtual interactions with their GP? How will they ensure that all triage systems do not disadvantage those groups who are less likely to vocalise their preference or to advocate for the urgency of their own needs?

[Lord Markham (Con)]

Absolutely. One of the key benefits of the digital approach is the triage system. We all know that a lot of people who call at 8 am for an appointment could probably be well served by a pharmacy, a physio service or nursing. So proper triage through a digital-type system is a big step forward. It will end up with them being able to make an appointment with the pharmacy, physio—or the GP in this case. It will also free up resources so that those people who are not able to access digital services are able to get through at 8 am and speak to a person. So I really believe there is a win-win for both sides and personally I am very excited to take this through the House later in the year and see all the services that will be launched.

[Lord Allan of Hallam (LD)]

My Lords, following on from the Minister’s previous answer, what steps are the Government taking to develop the profession of care navigator? They are skilled staff who can make sure that people are directed to the right resource, whether a GP, nurse or pharmacist. Some people can use digital, but others need a personal contact for that direction process.

[Lord Markham (Con)]

Absolutely. I know that a lot of the best trusts that I have seen and visited have that right at their front door. It applies to A&E as well. One of the first comments I made when I joined the department was about expanding pharmacy services. That is brilliant and is part of the increase we are seeing but, if we are not telling people when they should go and under what circumstances, how is this going to help? So, yes, there will be both digital and analogue navigation.

[Lord Wigley (PC)]

My Lords, the Minister referred to the generous provision of finance to Scotland through the Barnett formula. In that case, does he accept the underfunding of Wales through that formula? This has been recognised by a committee of this House. Does he therefore recognise that the pressures on the health service in Wales faced by the Government in Cardiff are a direct consequence of this underfunding?

[Lord Markham (Con)]

Again, my understanding is that Wales receives more health funding per person under the Barnett formula than England. I am pretty sure I am right on that—I will confirm if I am wrong, but I am pretty sure I am correct. So both the Welsh and Scottish Governments have more funding than England. Do they get better outcomes? Well, I would rather be living in England, let me put it that way.

Adult Social Care

Lord Markham Excerpts

Monday 20th February 2023 Lords Chamber

[Lord Laming]

To ask His Majesty’s Government what steps they are taking to meet the needs of the 10 million people in England affected by the adult social care system.

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

My Lords, 10 million people in England are affected by the adult social care system, including those drawing on care and support, unpaid carers and the workforce. We have made up to £7.5 billion available over two years to put the sector on a stronger financial footing, improve access to social care and address workforce pressures. We will publish further details this spring, setting out how we intend to make improvements to the system.

[Lord Laming (CB)]

My Lords, I am grateful to the Minister. He will know that, at any time, any one of us could suddenly become responsible for the care of another person who has experienced a life-changing condition—indeed, any one of us might need to be cared for in those circumstances. The evidence to the Adult Social Care Committee was extremely compelling, indicating that unpaid carers feel that they carry a huge burden but are largely unappreciated and ignored. One wrote only last week, saying that, “after years and years of nursing experience, I now feel completely worn out and very lonely”. Could the Minister assure the House that the Government will take note of the recommendations of the report?

[Lord Markham (Con)]

I thank the noble Lord for his Question and for the work he has done around this report. As an unpaid carer for a number of years myself, I am familiar with the circumstances and the fact that unpaid carers are the backbone of the social care sector. I like to think that we are making moves in the right direction. The weekly allowance, the ability to have a one-week break and the ability to go to your local authority for extra support where needed are all steps in the right direction. But there is definitely more we will be announcing that we are doing in this space.

--- Later in debate ---

[Lord Forsyth of Drumlean (Con)]

Answer.

[Lord Markham (Con)]

It is lovely to have noble friends.

Given the conversations I am sure we will come to shortly about improving hospital flow and the 13% of beds that are blocked, we felt that the focus needed to be very much on providing beds for short-term care. That is where we wanted to put the £7.5 billion of extra funding. We thought that was the immediate priority because we knew the flow issues were impacting A&E, ambulance wait times and everything else. That is not to say that we do not intend to implement all the Dilnot reforms, but the priorities were very much around improving flow and discharge.

[Baroness Barker (LD)]

My Lords, when Sajid Javid was Minister for Health and Social Care, he stated publicly what some of us had long suspected: namely, that we have a health and social care system that is predicated on the assumption that people will be looked after primarily by their families. One million people are ageing without children; they do not have close family to look after them. When will his department acknowledge the existence of this group of people, and when will it be a requirement for planners of health and social care to take them into consideration?

[Lord Markham (Con)]

Again, I would like to say that the big increases in funding—the 20% increase that we are talking about in two years’ time—are very much an acknowledgement that there is a demographic issue here, where more and more people are going to be coming into this situation. That is why we are putting those plans in place and working on the workforce; we are already seeing thousands of people being recruited every month to assist with capacity in the system. So we are putting in place the plans to address that.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, one of the issues identified in the report of the Adult Social Care Committee, on which I had the privilege to serve with the noble Lord, Lord Laming, was the invisibility of unpaid carers. What are the Government doing to support services to identify unpaid carers, and what more targeted support can we give this vital population—more than just one week of carer’s leave?

[Lord Markham (Con)]

Again, as I said before, they are the backbone of the system; some of my personal experience attests to that. So I hope that what we were talking about will be seen as the start, rather than the end, of what we are trying to do. But we recognise that it is a decent start, because this issue has been out there for many years and we are starting to address it. Obviously, forums such as these make sure that it is something that more people are aware of. I accept at the same time that a week a year is a start in terms of a break; it is not the end of the situation.

[Baroness Meacher (CB)]

My Lords, I recognise that the Government are understandably very concerned about public expenditure, but I wonder whether they have recently undertaken a cost-benefit analysis of spending on social care. For £1 million of additional spending on social care, what would be the savings to the health budget? I have a feeling that it could be at least £1 million, and possibly rather more.

[Lord Markham (Con)]

Absolutely, and that is the whole intention behind the ICSs: the ability in their areas to know local needs and invest in the right places—that is, in social care rather than having people in beds in hospitals, because it is a much more effective use of resources, and also in primary care. We all know that a lot of people go to A&E because they have not got primary care services, so the whole point of the ICSs is that they start to invest where demand is in the area, rather than using hospitals as the place of last resort to go to.

[Lord Bradley (Lab)]

My Lords—

--- Later in debate ---

[Lord Bradley (Lab)]

My Lords, I too was a member of the Select Committee. One of the other key recommendations of our report was the establishment of a commissioner for care and support, to act as a champion for older adults, disabled people and, crucially, for unpaid carers, and that we should prioritise to ensure a review, update and implementation of the Care Act. Do the Government support these proposals?

[Lord Markham (Con)]

Again, we welcome the report and many aspects of it. What I and my ministerial colleagues care most about is having the results and the impact. I think—and hope that noble Lords will agree when they see the work that she is doing in this space—that Minister Whately is gripping it and providing results. Let us see how that progresses first, because I think that that will have the impact that we need.

[Lord Forsyth of Drumlean (Con)]

My Lords, given that the Government promised that they would fix social care, and given that in the Answer to this Question the Minister said that there were 10 million people affected, is it wise to go into a general election without having done so?

[Lord Markham (Con)]

As ever, I thank my noble friend for his friendly questions. No; we know that this is an area that needs to be addressed, and I think that it is an area that we are addressing. I have been up here for about five months now, and in the time that I have been here, we have announced a £7.5 billion increase in spending over two years, a £700 million discharge fund over this year, and the recruitment of thousands of people every month from overseas. Yes, there is a lot more to be done, but there have been some very solid results in the meantime.

[Baroness Wheeler (Lab)]

My Lords, on that theme, the Minister makes much of the Government’s historic £7.5 billion social care funding settlement, but he knows that it has been and remains seriously underfunded—the Health Foundation’s estimate is a £12 billion a year shortfall. As the excellent Lords committee underlines, it is no good attempting to resolve the social care crisis by providing short-term funding for more care packages while still depending on local authority council tax flexibility to raise the extra funds. Is the Minister concerned that three-quarters of the largest councils in England with responsibility for social care have been left with no choice but to raise their council tax by the full 4.99% increase, just to keep current inadequate levels of service going?

[Lord Markham (Con)]

I am aware of some of the challenges raised by funding through the local authority system—and I say that as a former deputy leader of a local authority, so I am very familiar with the situations at play there. At the same time, we have put a lot of the central funding in place to make sure the security is there. As I said, we will see more measures as Minister Whately announces them in the spring, not far from here; there will be further progress in this area.

[Baroness Butler-Sloss (CB)]

My Lords, one group of carers is made up of children. What are the Government doing to help local authorities to identify and to give extra help to children?

[Lord Markham (Con)]

I am aware of the many circumstances where it suddenly falls to children, who obviously have their own demanding situation with education and are suddenly expected to provide a lot of care. We have tried putting steps in place with the local authorities so they can provide further support to children. We know that childhood is a critical part of their own development, so expecting them to look after a parent is not the right way around, if I can put it that way. So we have done work there, but there is more to be done.

Maternity Services

Lord Markham Excerpts

Thursday 9th February 2023 Lords Chamber

[Lord Patel]

To ask His Majesty’s Government what steps they intend to take in response to the Care Quality Commission’s Maternity Survey 2022, published on 11 January.

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

My Lords, we are committed to continuing our work to ensure that all maternity services provide safe and compassionate care. We will continue to closely monitor progress in improving the standard of maternity care across the country. We have made significant investment into maternity and neonatal services, with £127 million announced in 2022 to go into the maternity system to help to increase the NHS maternity workforce and improve neonatal care.

[Lord Patel (CB)]

My Lords, I thank the Minister for his Answer. The Ockenden report on Shrewsbury and Telford, the Kirkup reports on East Kent and Morecambe Bay, the current report of the CQC, the fact that the CQC fined a Nottingham hospital the maximum amount—£800,000—for a baby death, and the fact that we are now paying out in maternity litigation costs over £1 billion per year all point to one thing: a question of safety in our maternity units. Mothers and babies should not die in our maternity units without care and compassion, but that is what is happening. I am glad that the Minister, the honourable Maria Caulfield, met Dr Kirkup last week, which is a great improvement and progress. I hope the Government will now take seriously the need for zero tolerance of mothers dying in our maternity units and zero tolerance of normally formed babies dying or being damaged in childbirth. I shall keep pursuing this until we get that.

[Lord Markham (Con)]

I welcome the noble Lord’s pursuit because that is absolutely the right thing to do. I think we all agree with that, and we would all say that what happened in East Kent and the other examples from the Ockenden report are clearly not something that we are happy with or that we should put up with. The Kirkup and Ockenden reports gave us a north star, a way forward. I am pleased to see that we are making progress on that, but I expect the noble Lord to hold us fully to account because I am holding the department to account on this.

[Baroness Manzoor (Con)]

My Lords, building on what the noble Lord, Lord Patel, has said, my noble friend will know that continuity of care is really important and has been recommended by the Better Births maternity review. That builds up with better medical understanding of the woman, the pregnancy and the issues related to it. However, only 37% of women are afforded this, and that drops down to 27% in antenatal care. What are the Government doing to take steps to address this so that the terrible examples that we have seen recently are averted?

[Lord Markham (Con)]

I agree with the work by my noble friends, including the noble Baroness, Lady Cumberlege, to put the importance of midwifery continuity of care at the centre of everything. The survey to which my noble friend’s question refers shows that that is coming through in terms of a consistent message that having that confidence in the person in treating them is vital to all of this. That remains important. Key to this is the workforce, so this is one of the things that is being built into the workforce plan. That is starting with ensuring that we have new people coming in. The 1,200 graduates that we now have going into training each year are a vital part of making sure that we can deliver.

[Baroness Barker (LD)]

My Lords, report after report shows that the current system of treating maternity and reproductive health services on an episodic basis is costly and inefficient. Will the Government undertake to review that so that we can begin to go back to the system where staff were trained in both maternity and general nursing? We could therefore treat women on the basis of the whole of their lifestyle and get back to doing the most important jobs, such as making postpartum contraception available, which in the end would not only enable women to be treated more safely but save the NHS money.

[Lord Markham (Con)]

That question probably deserves a more detailed reply then I can give here in 30 seconds. In terms of the direction of travel, continuity of care, not just in the maternity service but in understanding that person and their needs, has to be the right thing to do to make sure that we have cradle-to-grave treatment with people who know your case. So I agree with that direction of travel and I will follow up with a more detailed response.

[Baroness McIntosh of Pickering (Con)]

My Lords, will my noble friend update the House on the number of midwives available? I understand that there is concern among expectant mothers about the availability of midwives.

[Lord Markham (Con)]

The figure for the number of midwives has been roughly constant over the last few years at about 23,000. We want to increase that, which is why we have made a commitment to increase the number of graduate places to more than 1,000 each year. This year, as I say, we have 1,200 places, so we are making good progress.

[Baroness Merron (Lab)]

My Lords, there is an almost twofold difference in maternity mortality rates between women from Asian ethnic groups and white women, while black women are now 40% more likely to experience a miscarriage than white women. When will there be a report from the Maternity Disparities Taskforce? Could the Minister confirm that Parliament will have a full opportunity to examine its findings and review the progress that has been made?

[Lord Markham (Con)]

The noble Baroness is quite right to point out those figures, and they are something that none of us is happy with. That is exactly what the Maternity Disparities Taskforce was set up to deal with, so I am happy to make a commitment to talk through with the noble Baroness the progress of that.

[Baroness Finlay of Llandaff (CB)]

My Lords, running through the reports that my noble friend Lord Patel referred to are two strands: one is workforce, which relates to numbers and qualifications, but the other is dysfunctional teams and a failure of teamwork across the different disciplines, both within maternity services and relating to general medical services, for providing support to women, particularly those with multiple comorbidities who are then going through pregnancy and delivery. I wonder whether the Government are commissioning a specific piece of work to look at ways in which these teams can alter their behaviours internally and be supported to improve on this dysfunctional behaviour within them, which is having an adverse knock-on effect on the experience of mothers and on the clinical outcomes which, as has been said, are sometimes fatal.

[Lord Markham (Con)]

Yes, one of the Kirkup recommendations—recommendation 3, I believe—was about an improvement in teamwork, and that is what will be done under the guidance of national and regional maternity safety champions. I should say that while there is much improvement that we want to do, the overall context is a 19% decrease in stillbirth since 2010 and a 36% decrease in neonatal mortality over 24 weeks since 2010. So it is an improving picture, but it is something that we want to improve further.

[Lord Allan of Hallam (LD)]

My Lords, another day, another area of the NHS that is suffering from serious staff shortages, and these shortages are having a real impact on the willingness of midwives to stay in the profession, more than half of whom are considering leaving the NHS, according to surveys by the Royal College of Midwives. What is the Minister’s view on the proposals that have come from various groups that there should be nationally agreed minimum staffing levels for maternity and neonatal staff?

[Lord Markham (Con)]

Again, I think there are certain things that we are saying we want to see in place. Continuity of care is part of that, and the workforce plan is how we put teams around to do that. It will always be a feature that we then expect the local health trusts and ICBs to work out how best to do that in their own situations. I also say in this context that we are increasing our numbers but this is not like other demographics where we have an ageing population. The birth rate, as we all know, is actually constant/declining, so it is not like those other areas where we are talking about that. Notwithstanding that, as I mentioned before, we are increasing the number of graduate places.