Ultra-processed Food

Lord Markham Excerpts

Thursday 26th October 2023 Lords Chamber

[Baroness Bennett of Manor Castle]

To ask His Majesty’s Government what is their assessment of the impact on public health of ultra processed food; and what steps if any they will take to reduce the amount of ultra processed food consumed.

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

Observed associations between ultra-processed food and health are concerning, but it is unclear whether these foods are inherently unhealthy due to processing or their nutritional content. A diet high in processed food is often high in calories, salt, saturated fat and sugar, which are associated with an increased risk of obesity and chronic diseases. This continues to be the basis of our dietary guidelines and policies to tackle obesity and poor diets.

[Baroness Bennett of Manor Castle (GP)]

I thank the Minister for his Answer, which reflects what he said yesterday in our debate, that the House did not agree on whether processed food per se is bad for you. Common sense has long suggested that food that, to quote the Washington Post, is

“refined, pounded, heated, melted, shaped, extruded and packed with additives”

is bad for you. These dreadful food-like substances do not just contain a terrible balance of nutrients; there is also a problem with the process. The science increasingly demonstrates that. Yesterday I referred to a study based on the French NutriNet-Santé study by Chantal Julia et al; I supplied the Minister with the link. Will he commit to asking the department to look closely at that study, which demonstrates that nutritional quality and ultra-processing are correlated but distinct issues in diet? Will the department provide a substantive response to the study?

[Lord Markham (Con)]

Obviously, I am always happy to look at all the research because this is a vital area. This is the fifth time we have discussed it in the last three and a half months, so I apologise for any repetition. We are ever vigilant on this area but, as the contributors to yesterday’s debate showed, the research is mixed. The key things to get behind are the bad features of ultra-processed foods that are high in sugar, salt and saturated fat.

[Lord Deben (Con)]

My Lords, I will ask a very simple question. Was it not true that, before we had the link between smoking and lung cancer, we did have evidence of an epidemiological connection? The problem here is that we have no direct link, but it does seem that there is a connection that we do not yet know is causal. Will the department be very careful not to ignore that evidence simply because it is very inconvenient for scientists if their whole history of understanding nutrition is undermined by it?

[Lord Markham (Con)]

Absolutely—we have to be understanding of the latest research in cause and effect. The evidence I have been shown so far is that it is about the features within those ultra-processed foods—are they high in fat, sugar or salt? Those are the things that are causing the harm. If we find links to the processing itself, we will act on that.

[Baroness Boycott (CB)]

My Lords, a few years ago the Government introduced very good obesity policies on stopping the sale of “two for the price of one” on junk food and limiting junk food advertising during children’s television. These have been delayed until 2025. What was the Government’s reasoning? Can the Minister assure the House that it was not based on any lobbying from the food industry?

[Lord Markham (Con)]

The rationale was very clear. The measures that we introduced by the modelling showed that in what we were trying to do we were attacking the things that cause 95% of the reduction in calories—namely, the product positioning, which has the support of 78% of people to reduce the so-called pester power. Early evidence shows that it is working, because foods that are not high in the bad stuff have gone up by 16% and those with high sugar, salt and fat content have gone down by 6%, all through the product positioning. It is working, but the most important thing is that we have gone after the big numbers, those that effect 95% reductions in calorific intake.

[Lord Allan of Hallam (LD)]

My Lords, to follow on from the questions asked by the noble Baroness, Lady Boycott, there is a public expectation that the delayed junk food advertising regulations will mean that children will be less likely to see ads for products from companies such as KFC and McDonald’s. But my understanding from the Minister’s previous comments is that the Government’s expectation now is that the advertising will carry on as before and children will continue to see just as many ads, albeit with the products reformulated to get around the ad ban. Is that correct?

[Lord Markham (Con)]

I have said many times that the prize is reformulation. I do not think that any of us should have a problem per se with the food if the bad stuff is taken out. Diet Coke is a perfect example. It is not particularly good for you but not bad for you either, so why should Coca-Cola not be able to advertise Diet Coke? If you take out the bad stuff, we should encourage industry because advertising works. It wants to advertise, so if it is encouraged to take out the bad stuff, that is a big incentive.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, as far as I recall, it was said that we should keep it simple and that the focus should be on sugar. When will the Government look at children’s school meals, review the regulations and reduce the sugar in children’s free school meals?

[Lord Markham (Con)]

The noble Lord makes a very good point. A healthy start to life is vital, which is why I am very pleased to say that we have the highest level of free school meals ever, with every infant school kid and a third of children overall having a free school meal. On the composition of those foods, I know that this was planned but was stopped due to Covid. The timing is now being reviewed again, because things move on in terms of the content and healthy foods.

[Lord Kirkhope of Harrogate (Con)]

My Lords, most people would be very concerned to know what ultra-processed food means. People who rely on staples such as bread, cereals, sausages, gravy, fruit juice, baked beans and biscuits would be very surprised to hear us talking about those as ultra-processed food and how bad it is for you. Some people say that five ingredients or more puts food into this category. While we should encourage vegetables, fruit and fresh food of various kinds being eaten, does my noble friend not agree that we are alarming the public too much if we deny them the staples that they are used to?

[Lord Markham (Con)]

That is absolutely correct. My understanding is that ultra-processed foods make up, on average, 60% of a person’s diet. If you were to try a blanket ban, it would have a massive impact. I think we all agree that it is important that we try to discourage things that are bad in ultra-processed food, not ultra-processed food per se. As I have said many times, there are many types of ultra-processed food that we encourage, such as wholemeal bread and many of the cereals.

[Lord Hannan of Kingsclere (Con)]

My Lords, ultra-processed food rests on the weirdly unscientific definition of containing stuff that we do not normally find in our kitchens. My noble friend the Minister has rightly said that the advice is to cut down on salt, sugar and fat. I suggest that almost all of us have plenty of salt, sugar and fat in our kitchens, so will my noble friend the Minister join me in urging people to stick to advice that is based on science and the empirical and reasoned method, rather than going for a basically primitive fear of things that we are unfamiliar with?

[Lord Markham (Con)]

That is absolutely right. We should always base this on the science. I thank my noble friend for that comment.

[Baroness Merron (Lab)]

My Lords, nearly half of baby snacks and up to three-quarters of baby biscuits and rusks are categorised as ultra-processed. Many of them are high in fat, sugar and salt and if overconsumed, reports suggest, can lead to weight gain, unhealthy eating habits and a wider negative impact on development. Have the Government made any consideration of measures to help parents to be more informed of these risks? What discussions have taken place with industry to address information and formulation?

[Lord Markham (Con)]

To take the second question first, the industry has worked with a lot of comments on reformulation across the board—for younger children and older ones. Noble Lords will remember me saying that foods such as Mars, Galaxy, Bounty and Snickers bars have all been reformulated, as have Mr Kipling’s “exceedingly good” cakes. Clearly, we need to look across the board at it all. I know that the industry is working in the area of young people. I am happy to follow that up in writing with the precise details.

[The Earl of Effingham (Con)]

My Lords, in yesterday’s QSD on ultra-processed foods, the Minister spoke of how he had recently made a sound choice due to calorie labelling. What will the Government do to help and encourage SMEs with fewer than 250 employees to show calorie labelling on food and drinks that are not pre-packed?

[Lord Markham (Con)]

My noble friend makes a good point. I gave an example of where it had affected my own behaviour. I am sure we all have examples of when we have looked at the menu and thought, “Oh, do I really want that choice? Is it worth the extra calories?”. We want to get it proportionate, so while we want to encourage as many companies as possible to take it up, we appreciate that for small companies it is quite a bit harder. We are working with them to introduce it voluntarily if they can.

Suicide Prevention Strategy

Lord Markham Excerpts

Thursday 26th October 2023 Lords Chamber

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

The actions in the new suicide prevention strategy for England are informed by the existing and emerging evidence, by engagement with people with expertise in suicide prevention, including people with lived experience, and by the mental health call for evidence. This strategy is population-wide and the actions within it aim to support as many people as possible, including those on out-of-work disability benefits.

[Baroness Thornton (Lab)]

I thank the Minister for that Answer, but I am not sure that clarifies this issue. This issue concerns one bit of government not heeding the research of another bit. NHS Digital’s Adult Psychiatric Morbidity Survey clearly shows that more than 43% of ESA claimants—that is employment and support allowance out-of-work disability benefit claimants—have considered suicide, compared with 7% of non-ESA claimants. The argument that this group should be included in the NHS suicide prevention strategy was made five years ago, and it was not included with no explanation. We now have the new suicide prevention strategy, and they are omitted again. I would like the Minister to clarify whether this group will be included in the Government’s—actually rather good—suicide prevention strategy or not, and if not, why not?

[Lord Markham (Con)]

What the strategy is trying to do is to look at those high risk groups and the risk factors behind them. One of the biggest risk factors causing suicidal thoughts are financial difficulties, which of course out-of-work disability benefits come into. One of the highest groups in terms of priority are middle-aged men, who are often the people suffering in this space. There are other groups as well, such as children and young people, pregnant women, new mothers and autistic people. There is a range, and what we are trying to do in this strategy is hit those areas of highest risk. To put this into context, those people on all DWP benefits in the reviews done on suicide make up less than 1% of the population of suicides. What we are trying to do is hit the major risk groups.

[Lord Allan of Hallam (LD)]

My Lords, the suicide prevention strategy says that DWP staff will be trained to identify benefit claimants who express suicidal thoughts and escalate these appropriately. Can the Minister confirm that the DWP will collect data on out-of-work disability benefit claimants who are caught or flagged by the system, so that we can understand whether or not this new policy is as effective as we would all want it to be?

[Lord Markham (Con)]

Yes, and I had the opportunity, because I used to be the lead NED at DWP, to go along to a number of jobcentres and see the sorts of work that they do. They have two things. They have an independent review of each of these, and those are the stats I was using: they get about 50 cases a year in these categories. Where there is a serious case they have a serious case review, independently chaired with a Permanent Secretary on it as well.

[Baroness Browning (Con)]

I remind the House of my personal interest: I have family members claiming ESA. I advise my noble friend the Minister that I am awaiting an appointment with DWP Ministers following Questions that I tabled before the Summer Recess about the suicide rate among disabled benefits claimants—in fact, among all benefits claimants. My concern is not only around the way the DWP collects data but around the way it sometimes does not disseminates the information that it has. Will my noble friend pause in relying totally on the way in which the DWP produces data at present? For example, I am particularly concerned about how it collects information from coroners’ courts. This is something that I think is ongoing; I hope that my noble friend regards it in that way as well.

[Lord Markham (Con)]

We are definitely always looking to improve, get access to better data and learn lessons from that. I will make sure that that is understood and follow up with DWP Ministers accordingly.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests in medicine. The new suicide prevention strategy is most welcome, but do the Government recognise that the ONS data shows that the time of diagnosis and first treatment of those with severe health conditions can be a high-risk time when they feel devastated and often do not have adequate support? The way in which news is communicated and bad news is given to them alters their risk of suicide, particularly in those who have been bereaved by suicide previously. Will the Government therefore put pressure on NHS England and the GMC to ensure that communication skills are included in revalidation and appraisal processes so that patients get better support and are steered towards the new SR1 benefit, which is designed specifically for people with poor prognoses and can play a really important role in relieving financial pressures?

[Lord Markham (Con)]

I thank the noble Baroness for her support for the suicide prevention strategy. It tries to look at the themes behind this issue, of which working to give effective support, communication and training is absolutely key—as is making sure that that is followed up on. The other thing that I want to pull out from the report is the real feeling, in terms of the seven key themes, that suicide prevention is everyone’s business and is something that we all need to be aware of and could learn more about.

[Baroness Brinton (LD)]

My Lords, the Minister has outlined how important it is to learn from the experience of people who have considered suicide. Last week, an Information Rights Tribunal asked the DWP to publish its secret report on suicide rates among vulnerable claimants; it has not yet been published despite the fact that it was written in 2019. Can the Minister explain why it still has not been published? If not—I appreciate that this falls under the DWP—can he write to me, because it is clear that we need to learn the lessons of what went wrong?

[Lord Markham (Con)]

Absolutely. I would be happy to write to the noble Baroness.

[Lord Davies of Brixton (Lab)]

My Lords, on the suicide prevention strategy more generally, does the Minister share my concern at the figures published today by the ONS showing that the suicide rate among offenders in the community is six times that of the general population and the suicide rate among female offenders in the community is 11 times that of the general population? Surely this points to the need for priority action.

[Lord Markham (Con)]

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

[The Lord Bishop of London]

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

[Lord Markham (Con)]

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

[Lord Kamall (Con)]

My noble friend the Minister rightly said earlier that suicide prevention is all our responsibility—or something like that—and that we need more awareness. Can he enlighten us on some programmes to increase awareness of suicide prevention so that we recognise that it is the responsibility of someone’s wider family, wider community and others and so that they are aware of the signs to look for?

[Lord Markham (Con)]

Yes. Effective bereavement support comes into this in a similar way. There are a number of communication methods, which I will happily share in writing so that noble Lords can see them, but there is also a full marketing and support plan around them.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister assure us that DWP staff are being trained properly in recognising the suicide risk of such claimants? One of the most important things is that people largely want to work and getting rejected following job interviews is a huge risk for that particular population.

[Lord Markham (Con)]

Absolutely. It is my understanding that all front-line DWP staff have two days of mental health training in precisely this area. Also, their stated objective is to support people in what they can do and support them into work based on their abilities. We all know that work gives people a big feeling of self-worth and confidence and is a key to both physical and mental health.

Children’s Health: Ultra-processed Foods

Lord Markham Excerpts

Wednesday 25th October 2023 Lords Chamber

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

I too add my thanks to my noble friend Lady Jenkin for bringing this debate forward, and I thank all noble Lords who have contributed to what I feel has been a very interesting debate. We have seen a wide range of different views, which shows that this is a highly complex area. I know we all agree that there are many bad things about ultra-processed foods, but there are many things we do not agree on, such as whether ultra-processed food per se is bad. As brought up by the noble Lord, Lord Krebs, there is plenty of evidence that it is not the ultra-processed element that is bad; it is the fact that many of the things inside the foods are bad, namely high levels of fat, sugar and salt. At the same time, some of the things we are putting forward in the Eatwell Guide, such as some breakfast cereals and wholemeal bread, would also be caught under the definition of ultra-processed food.

The real problem is that I have not yet heard—and I am very happy to discuss this—how we could find a workable definition here so we can take the sort of action that we take in other places. What do you try to do when something is bad? You try to tax it, as we did with the sugary drinks levy. You try to restrict product placement and advertising and you try to educate and label—but you can do that only if you have a definition that everyone understands.

The problem is that if on the one hand there are some ultra-processed foods that you are saying you are going to tax so people will eat less of them but on the other hand there are some that you are trying to promote in the Eatwell Guide, I do not see how that is a manageable system or something that people can understand. What we all totally agree on is the need for education, so that people understand what we are trying to encourage and discourage. What I would like to concentrate on, which is something that we all agree on and that my noble friend Lord Dundee said we need action on, is those foods that are high in fat, sugar and salt, many of which are ultra-processed.

As my noble friend Lord Effingham said, this starts with education. We have got some good examples there. I hope this will answer some of the points made by the noble Lord, Lord Bird, on our schools. Our free school meals are at the highest levels ever, which we know not only addresses food poverty but makes sure that those children are receiving a balanced diet. The fact that all infant school children now receive this is a huge step forward and, as I say, the level of roughly a third of all children receiving free school meals is huge as well.

The other initiatives, such as Healthy Start, helping kids get their five-a-day, are very important to this. Equally, in terms of education, I remember being taught years and years ago at school how to make shepherd’s pie and apple crumble. The advice on teaching children to cook six healthy meals is far more useful than a lot of things we receive in our education; it was definitely far more useful than my very poor efforts at woodwork and metalwork at the time. So I totally back those.

I would also like to talk about the action that we have taken on the bad elements of foods, such as those high in salt, sugar and fat, which really is working. Noble Lords will have heard me mention the sugary drinks levy, which has reduced average sugar levels in these drinks by 46%. Just this weekend, going out to eat Sunday lunch, I swapped from eating a chicken pie, which looked pretty tasty and had more than 2,000 calories in it, and saw that the roast beef had only 1,400—and I did not eat the Yorkshire pudding, so I had even less than that. So, again, these are useful ways forward that help to educate people.

The product placement and positioning steps that we are taking are really tackling 94% of the estimated reduction in calorific intake, and 78% of people are in favour of them. It is early days, because the measures have not been in for long, but what we have seen in early data is that foods that are not high in fat, sugar and salt have gone up by 16% and foods that are high in sugar, salt and fat have gone down by 5.7%. These are early signs, but those product placement steps are working. Those are the things that are impacting 94% of the data. The noble Baroness, Lady Merron, asked about what we were doing about other things such as “buy one get one free”. We all talk about evidence and data: the modelling showed that this would account for less than 5% of our estimated reduction in calorific intake. And there is more to boot, because we are working with industry on this and Sainsbury’s and Tesco have already agreed to do that voluntarily. That means that it accounts for even less. Surely that shows that what we are about is trying to tackle the big things that make a difference.

Mostly importantly of all, as some noble Lords have said, the real prize of course is the reformulation of food. We know that companies are starting to change this. I apologise because I have mentioned this before, and noble Lords will probably hear me say it again in answer to tomorrow’s Question on ultra-processed food, but Mars, Galaxy and Snickers have all changed their formulation. Mr Kipling’s “exceedingly good” cakes are now compliant in their formulation. All these things are making a difference at the industry level.

However, I agree with the helpful suggestion from the noble Lord, Lord Allan, that we need to be data driven. I hope that, by sharing some of the statistics, I have shown that we are focusing on the 94% of things that really hit the reduction and that we are data driven. I definitely want to take his suggestion further; perhaps we could meet after the debate. Many people know that Steve Rowe, a former CEO of M&S, has been giving the department some advice. I hope he will help us to convene a round table with relevant CEOs so that we can talk about what might be manageable, because we should be data driven.

I also agree with the noble Lord, Lord Bird: we need to look at this holistically and bring all the elements together. The best example I have seen through my work in different departments was the troubled families work I saw early on when I was a non-exec director at what is now DLUHC. It looked at what really had an impact on troubled families—be it something they could do or something in the social, education, health or police space—and tried to look at things across the board. We have to consider some of those ways. So, although I am not quite sure and need to understand more about the work of the Minister with responsibility for poverty, I agree that we need to work in a joined-up fashion.

As ever, if there are any questions I did not manage to answer, I will try to follow up on them in a more detailed letter. I look forward to seeing tomorrow most of the noble Lords who are here today—probably asking me similar questions on ultra-processed food. We are all violently in agreement on the objective: stopping the consumption of unhealthy food. We need to do a bit more work between us on making sure that we really know what we are trying to stop, and the definitions, so that we ensure that any action is evidence-based and makes a difference. At this point, I thank everyone for their input.

Domestic Violence and Brain Injury

Lord Markham Excerpts

Monday 23rd October 2023 Lords Chamber

[Lord Hunt of Kings Heath]

To ask His Majesty’s Government what analysis they have undertaken into the links between domestic violence and brain injury.

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

In June this year, the Government, through the Medical Research Council, announced the £9.5 million traumatic brain injury platform, which will facilitate research and analysis of victims of brain injury following domestic violence. The platform is being led by the University of Cambridge, with the aim of revolutionising data collection and curation for TBI research. This will include data linkages between the underlying causes of head trauma, such as domestic violence, and health outcomes.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for his Answer. The death of Sir Bobby Charlton, that great footballer, has brought attention to the impact on sportspeople of head impacts in relation to an increased incidence of dementia. Professor William Stewart from Glasgow University, who has undertaken much of the work in the sports arena, is doing parallel work in relation to domestic violence. The scale of intimate partner violence, with between 20% to 30% of women affected, is huge, and 90% of those women may suffer brain injury impact. In addition to the welcome news about research, could I ask that the Minister’s department looks very closely at stepping up the research but also at increasing knowledge and awareness throughout the health system, in terms of prevention and treatment as well as research?

[Lord Markham (Con)]

I add my condolences following the passing of Sir Bobby Charlton—a true great. I thank the noble Lord, Lord Hunt, for the work he has done in this space; it is another example of where being asked a Question forces us to look at the situation. The noble Lord made the point very well. Sport is in the news, and we have all seen the head injury assessment protocols, especially in rugby, but you are 11 times more likely to suffer a traumatic brain injury from domestic violence than you are from sport. When we get the findings from the research, early in the new year, I invite the noble Lord, Lord Hunt, to join me in ensuring that we have an action-oriented approach to make sure that the awareness and research supports a good action plan.

[Baroness Verma (Con)]

My Lords, can my noble friend assure me and the House that, when he is collecting data, he will also be looking at people from minority communities, particularly those who cannot report domestic violence issues for language reasons? Would my noble friend also talk to his colleagues in education, to ensure that everyone living in this country has access to learning English?

[Lord Markham (Con)]

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

[Baroness Walmsley (LD)]

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

[Lord Markham (Con)]

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

[Lord Patel (CB)]

My Lords, data collection and research is very good news. However, under normal circumstances, any person who suffers a head injury, for whatever reason, would be subjected to immediate testing for a brain injury. Why would that not be the case for someone who suffers a head injury from domestic violence?

[Lord Markham (Con)]

It is a very good point. As all noble Lords are aware, often the challenge is getting people to come forward when they have suffered domestic violence. Some of this research shows that there are tools, such as a spit test, to understand whether someone has suffered from a traumatic brain injury. Bringing some of those things into play, so that people are identified and encouraged to come forward, is vital.

[Lord Winston (Lab)]

My Lords, the Minister is to be congratulated on his call for more research. Would he care to comment on the use of organoids—clumps of generative stem cells—which act as an artificial brain in culture and show clear evidence of certain injuries, such as whether the brain may be easily propagated? That kind of research is important but is often condemned in the press. Can the Minister make sure that the Government will allow that kind of research to continue? It is completely harmless ethically.

[Lord Markham (Con)]

Yes. The main thing is that £9.5 million is being invested into research on traumatic brain injury, but this is a platform to allow spin-off research from there. When speaking to people on this, I am clear that this is not a cap: if we get good research proposals put forward in areas such as the one the noble Lord mentioned, the money is there to pursue that.

[Baroness Manzoor (Con)]

My Lords, it is good news that research is going to happen in this area. We all know that women suffer through domestic violence much more greatly. However, there is also research that shows that young girls in sports suffer more from concussion. Can we look at the preventative elements to ensure that girls are safe in sport, and by working closely with DCMS?

[Lord Markham (Con)]

The hope from this research is understanding all the different causes and some of the protocols. I know it is controversial sometimes, because, speaking as a centre half myself, heading the ball is a key part of the game. However, making sure that children under a certain age are not heading the ball a lot is one of the things that we should be looking at as prevention.

[Baroness Merron (Lab)]

My Lords, as not all brain injury from domestic violence is immediately apparent, will the Minister raise with his colleagues in the relevant departments the consideration of a reappraisal in policing and the criminal justice system? Will the Government also work with those supporting victims of intimate partner violence to actually give a name to the brain trauma that victims may be suffering? If victims know that traumatic brain injury is part of their trauma, it can give a source of strength and guidance to those who are suffering, enabling them to seek the right medical support.

[Lord Markham (Con)]

The noble Baroness makes a very good point; it is often the hidden side of domestic violence. The problem is that there is not much information on this, but a US study shows that as many as between 30% and 74% of women who suffered domestic violence had suffered from traumatic brain injury. It is about making people aware that this is not an edge case; this is something that unfortunately is all too familiar. As the noble Baroness mentions, every strand of society needs to be aware of this and to act on it.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Minister reflected that many victims of intimate partner abuse sometimes do not report until weeks, months or years later. Will the Minister ensure that there are services available that recognise this medical issue when they may not present primarily as a medical case, making sure that all the support that is available to victims of domestic violence is aware of this issue? In responding to the noble Lord, Lord Hunt, the Minister said that we will wait for the research. I think there is already clearly enough evidence in what we have heard today, and the fact that 3% of dementia in the community is attributed to traumatic brain injury. We need to act now, not wait for research.

[Lord Markham (Con)]

It is a good point, and there are already some very good examples, such as in Cambridge, where the ICB has a single front door to make sure that all facilities, whether it is neurologists, psychologists, physios or speech therapists, are there and available. The noble Baroness is correct: there are lessons we can learn and roll out straight away, and we are looking to do that.

[Baroness Bull (CB)]

My Lords, research projects in Glasgow and at Drake Hall prison in Staffordshire have shown a very high percentage of female prisoners to have traumatic brain injuries that have been sustained as a result of domestic violence. Is it now routine to screen female prisoners for brain injuries as they enter the Prison Service?

[Lord Markham (Con)]

My understanding is that it is not routine at the moment. I know there is some conflicting research as to how much screening should be used as a regular tool. I must admit that I do not fully understand the reasons behind some of that, so I was not quite persuaded as to why that was. It is something on which I want to do more research to understand. I will happily write to the noble Baroness to give her more information.

General Medical Council: Internal Guidance

Lord Markham Excerpts

Tuesday 17th October 2023 Lords Chamber

[Baroness Hayter of Kentish Town]

To ask His Majesty’s Government what discussion they have held with the General Medical Council on its removal of the words “mother” and “women” from its internal guidance for pregnant or menopausal staff, and whether this reflects advice to doctors as to how to treat and describe patients.

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

The Government have not had any discussions with the General Medical Council on its internal guidance for pregnant or menopausal staff. The GMC is independent from the Government and its internal guidance is produced for its staff. It is not for doctors registered with the GMC. The Government are clear that biological sex matters and that there are different health needs between the sexes. Removing language around biological sex has the potential for unintended and adverse health consequences.

[Baroness Hayter of Kentish Town (Lab)]

I do not think that Answer is quite satisfactory and I am sorry that the Minister used the words “pregnant staff” rather than “pregnant women”. Maybe the GMC lost out on medical lessons, where they would have learned that men produce sperm. We produce eggs and when they are fertilised in our wombs, we give birth and become mothers. When that is over, it is us who go through the menopause. The GMC has a statutory duty; it is the register of all the doctors who work in the NHS and it has a duty to maintain public confidence. I wonder how many mothers would have confidence in a doctor who thinks that men can have babies. The Minister should engage with the GMC and I ask him to do so, because although its internal guidance may have upset some of us, it regulates doctors and the language it uses matters in how it oversees, trains and interviews them. I hope the Government will take this a little more seriously.

[Lord Markham (Con)]

I can definitely confirm that we are taking it very seriously. The Secretary of State was clear in his speech at the recent party conference that it is vital that we recognise the importance of the different biological health needs. That means being clear about describing a woman as a woman. I apologise: the noble Baroness was quite right to pick me up on that point, but we are very clear that biological sex is absolutely vital in addressing people’s health needs. It is clear that we are addressing women as women and men as men.

[Baroness Gohir (CB)]

My Lords, under the Government’s watch there have been attempts to erase the word “woman” in various government departments and public bodies. One example is the NHS Race & Health Observatory, which the Government fund. I wrote to it last year and it said that it would address my concerns. What assurances can the Government give that all incidents anywhere where they have oversight have been addressed? Are there any central mechanisms where the public and staff can share concerns, because it is not feasible to report concerns to a line manager when it could result in bullying? Us women will not be erased.

[Lord Markham (Con)]

I absolutely agree. That is why, as I say, we could not be firmer in saying we want to make sure it is very clear in the NHS Constitution that we are referring to women as women—that has to be the absolute primary descriptor—and men as men. We could not be clearer on that, and I am very happy to take that up across government as well.

[Lord Cormack (Con)]

My Lords—

--- Later in debate ---

[Lord Cormack (Con)]

I am most grateful. Would my noble friend on the Front Bench take the opportunity to pay tribute to the heroism—I use the word deliberately —of JK Rowling and those like her who have spoken out so passionately and so often? What the noble Baroness, Lady Hayter, said, we should all echo to the rafters.

[Lord Markham (Con)]

I completely agree. I believe that, more than anything in society, we have to be tolerant of people and their ability to have free speech and express their views freely. I think we have all seen circumstances where people feel intimidated in expressing what they feel is right, particularly in this circumstance of stating clearly when a woman is a woman and when a man is a man.

[Baroness Butler-Sloss (CB)]

My Lords, I am very proud to be a grandmother as well as a mother. Will the Minister in fact talk to the GMC?

[Lord Markham (Con)]

Yes, I am very happy to do that and to make clear the feelings of this House.

[Baroness Burt of Solihull (LD)]

My Lords, I welcome the Minister’s comments on the GMC and endorse its independent role. I commend its wish to treat all patients with dignity and respect. Even though there are only a relatively tiny number of trans men giving birth each year, they all matter and they all deserve to be treated with respect and dignity. If he can, will the Minister tell the House how both women born as women and trans men are to be treated with equal respect, without offending either group?

--- Later in debate ---

[Lord Markham (Con)]

People should always be treated with respect. That is why we are quite clear that the primary descriptor in this circumstance should be “woman”. However, in a few cases it has also been clear that a secondary descriptor is “people with a cervix”. It is quite clear that we are talking about a woman as a woman. By the way, that is very important for people with English as second language, so they understand very clearly that a woman is a woman. For completeness, in those cases where there might be a change of sex, we are being very clear that it is for everyone with a cervix.

[Lord Winston (Lab)]

My Lords, I intend no disrespect to anybody, but in view of the fact that the GMC has a really important role in regulating language, particularly for overseas graduates who come to Britain, can the Minister tell me how many male members of the GMC have given birth to a child? If he cannot tell me, maybe he would be good enough to send me a letter.

[Lord Markham (Con)]

I am very willing to hazard a guess that it is zero, but I will happily follow that up in writing with the exact number.

[Lord Patel (CB)]

My Lords, I do not intend to be frivolous. I have looked after thousands of mothers during their pregnancies; it has been a great privilege to do so. Terms like “mother” and “women” should not be removed from any guidance, GMC or not. I have spoken to the GMC and expressed my discomfort at its removal of the words “mother” and “women”. Of course, I recognise the transgender issues. I also recognise therefore that those who may not consider themselves women could have children, but that does not remove the importance of motherhood. Being a mother is more than that; it is about motherhood and the responsibilities and what mothers contribute to children. I regret that the GMC has decided to remove these words.

[Lord Markham (Con)]

I think the noble Lord makes the point very well. I do not think I have anything to add, apart from basic agreement.

[Lord Sandhurst (Con)]

My Lords, the GMC may be independent but it is a creature of statute and should remember that. Parliament can change its statutes at any time. Are we to anticipate that, if the doctors’ regulator —this creature of statute—refers to its female staff, by which I mean women, as chest feeders or people with cervixes, the Minister will make it plain that this language from the medical regulator is unacceptable?

[Lord Markham (Con)]

I am quite happy, as mentioned previously, to talk to the GMC about its use of language, the importance of the use of correct language and the clear feelings of all of us in the House today about women who are women and mothers, and men who are male and fathers. I will leave it to the GMC as to how it deals with staff matters, but I will be very clear on medical issues and the belief of all of us here in this House.

[Baroness Symons of Vernham Dean (Lab)]

My Lords, can the Minister tell the House how many men there are on the GMC and how many women?

--- Later in debate ---

[Lord Markham (Con)]

I will need to reply in writing on that.

[Baroness Hussein-Ece (LD)]

My Lords, clear, unambiguous language in healthcare messaging saves lives. I was disturbed to read that one-third of women who are eligible for cervical screening are not coming forward. Can the Minister explain why NHS UK has not used the word “women” when it comes to cervical screening, yet for men’s conditions, the word “men” is used?

[Lord Markham (Con)]

The noble Baroness is absolutely correct, which is why we have made sure that that language is made clear. The most important thing about the whole debate is people’s health needs. Absolutely as the noble Baroness said, the vital thing is that every woman understands that it is important that she has cervical screening from time to time. In all of the communications, it is clear that we mean “her” in that instance. Obviously, in circumstances for men, we are clear where we mean “men”. So I completely agree with the noble Baroness: the health needs are paramount, and that requires clear language.

Paediatric Care: Wating Times

Lord Markham Excerpts

Monday 16th October 2023 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government what recent assessment they have made of the impact of the length of waiting times for paediatric care on children’s developmental outcomes.

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

Cutting waiting lists is one of the PM’s top five priorities, and we are aware that waiting times impact more developmentally on a younger person’s life. Given this, we are committed to ensuring that babies, children and young people are prioritised in integrated care systems, and that the reforms in the Health and Care Act 2022 to improve child health and well-being outcomes are delivered on the ground.

[Baroness Wheeler (Lab)]

My Lords, the Academy of Medical Royal Colleges has described sick children as the

“forgotten casualties of the NHS’s waiting list crisis”

across hospital and community health. NHS data shows that over 220,000 are waiting for children’s and young people’s services, including paediatrics, autism spectrum disorder diagnosis, health visiting, and speech and language therapy. Even worse, almost 20,000 have been waiting over a year—that is 8% up on the previous month. What action are the Government taking specifically to address this appalling situation, and what cross-government measures are in place to try to mitigate the huge knock-on impact on children’s education, health and well-being, and on their families?

[Lord Markham (Con)]

I thank the noble Baroness for bringing this question up; this is an important area, and we all know that a year in the life of a child aged 10 is a lot more impactful than it is to a 60 or 70 year-old. It is a question very well put. Since receiving this Question, I have been working on it with the department and talking to the relevant Ministers about what we can do specifically. We are expanding capacity generally through the CDCs and the 95 surgical hubs designed around this space, but we are putting in measures with ICSs and tiering to make sure we are specifically addressing children’s wait times as well.

[Lord Allan of Hallam (LD)]

My Lords, it is naturally very stressful for any parent when they face a long wait for their child’s paediatric referral. That stress is often compounded by the fact that it is left to the parents themselves to chase things up through confusing referral systems and systems that are still far too manual and depend on paper letters that get lost. Will the Minister make a priority of improving the information flow to parents about a child’s referral, so that they can quickly and easily see what is happening and know what to expect?

[Lord Markham (Con)]

That is a point very well made. as the noble Lord knows, that is one of my priorities and what we are trying to do with the app. There will be a number of launches, but already we are seeing hundreds of thousands of messages going out via the app to make sure that people are getting them on time. That has become the backbone of our communication system and will expand across the piece to try to cover exactly the points the noble Lord raises.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in addition to the list raised by my noble friend, I would also mention hearing assessments for children who do not initially get the newborn hearing assessment. Does the Minister consider that one of the problems is that, around the table at the ICBs and integrated care systems, no one really has the responsibility of representing the interests of young people and children, and that this is reflected in the discussions they have on prioritisation? If he would agree to look at this, does he not think we need a way of ensuring that, around that table, experts in issues relating to children, infants and young people are brought to the fore?

[Lord Markham (Con)]

It is now the legal responsibility of the ICBs to appoint an executive lead in this area, but I think the point generally is a good one. As I said, as a result of this Question I have managed to spend some time looking into this and we clearly need to make sure it is a priority. One of the other things I have been talking about with the executive team of the NHS is how we can introduce this to the tiering measures so that hospitals are given special help in making sure that children’s wait time is one of the key priority areas, and we can put more resources and support towards that and more support where hospitals are not performing well in that area. I agree with the noble Lord.

[Lord Laming (CB)]

My Lords, does the Minister agree that all staff in the front line of these services need to be aware of the dangers of child abuse or child neglect, because the developmental needs of very young children can also be indicators of serious neglect in the home?

[Lord Markham (Con)]

Yes. That is where our colleagues in the Department for Education have a key part to play. Start for Life is a joint initiative with DfE which is trying to look at early diagnosis. At the same time, often some of those issues can manifest themselves in anxieties and mental health issues. That is why we have done a lot of work to expand the number of mental health-aware teachers and assessors in schools, so that we can have early detection.

[Lord McLoughlin (Con)]

Have the Government made any assessment of the impact of strikes on waiting times?

[Lord Markham (Con)]

Unfortunately, industrial action is impacting on waiting times; we estimate that about a million appointments have been lost to date. Clearly, that is a matter of regret and not good news for anyone.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, I take the Minister back to the question from the noble Lord, Lord Allan, who referred to the necessity for parents to do a lot of running around and following up for themselves. Does he agree that this is a particular problem with the management of long-term conditions in young people—for example, ADHD and other things relating to autism—where the challenge is not just to get the diagnosis but to then get a consistent level of treatment over the long term? Can he comment on what steps have been taken to improve that? Can he also comment on the reported limited availability of appropriate drugs for treating young people with ADHD?

[Lord Markham (Con)]

I am aware from personal experience that, when you have a child with neurodiversity or developmental needs, it is a long journey. We are seeing this manifest itself much more in recent years; I was talking to Minister Caulfield about this just this morning. One-to-one is always preferable but, where capacity is constrained, group education and help can sometimes lend themselves to this space. It is a long-term condition, and clearly it will not be solved by treatment over a few months but needs many years.

[Lord Winston (Lab)]

The Minister quite rightly referred to the brain development of a child being very rapid and resulting from experience, and to various experiences having a profound effect on children’s development. However, he did not mention the place of primary care and, particularly, general practitioners in this. Does he feel that general practitioners are getting enough resources to be able to assess children on a more routine basis? The app will certainly be useful, but it does not get them clearly involved with medical practice; we need some standard way of doing this. Can he give us some information about the role of the GP?

[Lord Markham (Con)]

The role of the GP is clearly vital. That is what I was trying to get behind in the Start for Life initiative and clear early warning indicators. Clearly, that needs to go right through the development of a child at different key stages along the way. On digital treatments, I was at Boston children’s hospital last week, and it has early indicators for dyslexia—for example, looking at pattern recognition via an app, as it is not until children are older that they can see letters. Similarly, early signs of neurodiversity can be seen in the way that children play online on certain apps. I think we can add some of these digital support tools, but clearly the GP has a primary role.

[Lord Addington (LD)]

My Lords, following on from his last comment, can the Minister give us some idea of what contact there has been on this with the Department for Education? We are supposed to talk to each other, but it becomes increasingly apparent that we do not do so.

[Lord Markham (Con)]

I like to think that we have good contact on this, centred around, as I said, Start for Life, which is a £300 million joint programme between ourselves and the Department for Education. There are also other things; for example, noble Lords might remember me mentioning the Bradford pilot previously, where we are looking at children’s scores in test environments and using those where there may be early indicators of ADHD or other neurodiverse needs. There is quite a bit of work going on in this space. No doubt we could always work more closely, but there is some promising work being done.

[Lord Kamall (Con)]

My Lords, looking at the waiting lists, there is clearly an issue of different needs and levels of seriousness in the conditions that people are suffering. Can my noble friend the Minister tell us what sort of prioritisation process has been put in place to make sure that those who need care immediately are prioritised over those who could possibly wait a little longer?

[Lord Markham (Con)]

Probably the best example of that is in the whole area of cancer, which we all agree has to be the absolute priority. We have set up children’s cancer networks precisely around that. They are also set up so we can do whole genome sequencing for all children with cancer and start to introduce specific point-of-care medicines especially for them. These are examples of where we are saying that this really is the priority and that it is what we will devote all our resources to.

Adult Social Care (Adult Social Care Committee Report)

Lord Markham Excerpts

Monday 16th October 2023 Lords Chamber

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

I add my thanks to the noble Baroness, Lady Andrews, and all the participants involved in putting together the reports of both the Lords committee and the Archbishops’ committee. I thank Members for an expansive and extensive debate today. We also had a good debate on this in the spring and a good round table on all this, where we were able to take to heart the point made by the noble Lord, Lord Polak, about taking the politics out of the debate. I commend all those speaking in the House on this today for having taken that approach. I know that in all our dealings, the noble Baroness, Lady Wheeler, takes that approach, and it is much appreciated.

I also say that the thrust of what we are trying to do is taking to heart the Archbishops’ report, where care is everyone’s business, whether that is citizens, families, neighbours or carers, and based very much, as the noble Lord, Lord Weir, said, on the concept of co-design, working with the local partners, the local authorities and integrated care system. I will also try to tackle head-on the challenge of the noble Baroness, Lady Bennett, about the policies we feel that, as well as implementing today, we plan to take into the next election as a whole-systemwide approach.

Of course, as mentioned by many noble Lords, this has to start with funding. We have made up to £8.1 billion more available over the next two years. To answer the point of the noble Lord, Lord Allan, I say that funding in recent years represents a real-terms increase of about 2.5% per annum. This will allow local authorities to buy more care packages, help people to leave hospital on time, improve workforce recruitment and retention and reduce waiting times for care. We are also trying to use the money to transform the adult care system, for which we have a £700 million targeted spend on improving care workers’ skills, supporting career progression and investing in technology in digitisation and adapting people’s homes to allow them to live more independently. I will give details on each of those as we go through it all. As mentioned by many speakers, key to that is our £2 billion market sustainability and improvement fund, which is designed to impact and work on reform and improvement of the whole workforce recruitment and retention. I will write to the noble Baroness, Lady Finlay, on how the funding is specifically distributed so that that detail is understood.

We really believe in this vision to transform social care in England. It is a long-term vision which puts people at the centre of adult social care, to make sure that we can draw on the care support and include the absolute necessity of unpaid carers’ role in all that. I say that as someone who was an unpaid carer to good, dear friends of mine for many years.

We want to make sure that people can access outstanding quality in tailored care and support and find adult social care in a fair and accessible way, try to make it joined up in how we do it all and, I think for the first time, really try to involve the CQC in making assessments and ratings to guide where local authorities and local ICBs are doing a good job and where there are areas of improvement. I know that there are many concerns about the burdens that sometimes puts on a system which is always stretched, but I think noble Lords would also agree that inspections are typically a force for good in analysing those areas that are good and those that really need more work and improvement.

Of course, all this would be backed by much better data provision. Therefore, we are investing about £50 million into this area. I will begin by talking more about career progression, to answer some of the staffing points raised by the noble Baroness, Lady Andrews. Key to improving workforce retention is better training, recognition and career progression. The £250 million spend that was mentioned by my noble friend Lady Fraser goes very much to the heart of the training and retention of these people.

As many noble Lords mentioned, fundamental to all that is a career structure that staff feel goes beyond the particular care home that they are in and which they can take forward. Key to that is the creation of a new care certificate qualification, allowing them to move from place to place without needing to retrain each time. It is a modular system, so if they want to they can build that into an overall nursing qualification. Alongside that, we are ensuring that we are providing subsidised training programmes to decrease the turnover. We have modelled that to show that we can improve this by about nine percentage points.

Many comments have been made about how we are going to fill these workforce vacancies. The current run rate in terms of international recruitment is about 150,000 a year. I know that many comments have been made about how good it is that these are filled largely by international people, but that is a function of having a successful economy with full employment—you look to fulfil that. This has been the background to the whole health and social care system, right back to its foundations and a substantial part of the recruitment in the 1950s and 1960s. It brought people to the UK who have been an asset to the life and society that we have today. I had better say that, being married to one of these people, but I feel and hope that this should be the backbone of it and a successful way forward.

Also, it is important to understand the key role that unpaid carers play in this all. We are trying to help in this space. I perfectly understand that whatever we do here will not take the place of a full-time wage. I accept that but I hope that noble Lords will see that we are trying to make steps in the right direction. To answer the question raised by the noble Baroness, Lady Wolf, about the ability to offer respite care, we have earmarked £327 million of the better care fund towards providing those breaks. It is £76 plus the ability to claim benefits on top of that. I will not pretend that this completely compensates for a national wage, but it is not £76 alone. On the point raised by the noble Lord, Lord Davies, about pension flexibilities, I hope that we showed in the case of the doctors that we could be quite creative in that space. I will take that back and ask people who are more knowledgeable in this space than I am to take a proper look at it.

Of course, in all of this, there is the importance of supporting all these people in terms of the digital side. We have invested almost £50 million in the last year to improve the level of digitisation. It now stands at about 55%. I freely admit that 55% is not 100% but it is a big move in that direction and, to answer the points raised by the noble Lords, Lord Dubs and Lord Allan, it is something that we see as critical to the planning and provision of care, where it really can provide that information so you can plan around it.

It can also provide information to make smarter planning decisions. Again, I have seen excellent examples of putting all this data together; places such as Redhill have used it as part of its preventive screening programmes. There is a tremendous opportunity, as we build these bigger databases and include social care, to use that as the key to the prevention programme in which I know noble Lords believe.

The point made by both the noble Baroness, Lady Goudie, and the noble Lord, Lord Polak, was how we can use that to allow people to stay in the place where they most want to be, their home environment. The answer comes from not just using the data and AI to look at prevention tools; the latest funding bid launches technologies that we want to use to help people stay in their home environments. One particularly good example I have seen is a very simple tool that looks at people’s electricity usage each day. They know from people’s patterns that there is a normally a big spike at 8 am, when they turn the kettle on. If they see that that is not the case one day, they know to make a call to that person and check whether it is not because they have had a fall; it could be because they have visited a relative. This can be done on a mass-produced scale, which would give people support and early warnings, when people are at the lighter end of the scale and do not need substantial support. Relatives, local authorities and local bodies would feel that there are those extra guard-rails around this.

I will address the point made by the noble Lords, Lord Bradley and Lord Dubs, about the champion role. This was considered as it was a large part of the report. We have a champion in place in the roles of the chief nurse and the Chief Social Worker for Adults. That is a key part of their roles. I am sure noble Lords will join me in thanking Lyn Romeo for the role she has played in the last 10 years. She retires towards the end of this year.

As ever, because of the brief time we have had, I plan to write in detail to answer all the points I was not able to cover. I have tried to set out what we see as the four pillars: stable funding, a stable workforce, digital enablement and the principle of coproduction in which everyone has a role, as was outlined in the most reverend Primates’ report—because care is everyone’s business.

Nursing Courses: Reduction in Applications

Lord Markham Excerpts

Tuesday 19th September 2023 Lords Chamber

[Lord Hunt of Kings Heath]

To ask His Majesty’s Government what assessment they have made of the causes of a reduction of 16 per cent in applications to nursing courses in England compared to last year, according to UCAS data for the 2023 application cycle.

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

The drop in nursing applicants reflects an expected rebalancing following unprecedented demand for healthcare courses during the Covid-19 pandemic. Nursing is still a popular career choice. Applicant numbers remain 15% higher than pre-pandemic levels. We also continue to see growth in the number of people pursuing nursing apprenticeships. This is not final data; figures are accurate as at the end of June application deadline, but the application cycle remains open through clearing until mid-October.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister, but I think he would accept that any drop-off in applications is something to worry about, alongside the current drop-out rate for student nurses in the UK of around 24%. On that basis, surely the NHS workforce plan in relation to nursing is simply not sustainable. If the Minister does accept that, is there not a case for looking at writing off debt run up by student nurses through tuition fees if they commit to working in the NHS for a length of time?

[Lord Markham (Con)]

We are delivering on a number of routes to recruit nurses. Obviously, the graduate route is one route, which, as mentioned, is above pre-pandemic levels; apprenticeships is another route, which is proving very successful; and associates is another route again. So there are many routes in, and the result is that our applications are 20% up on pre-pandemic levels. We set ourselves a target of recruiting 50,000 more nurses by the end of this Parliament and we are currently on 45,000, so we are going to hit it.

[Baroness Manzoor (Con)]

My Lords, I welcome what my noble friend the Minister said regarding the number of nurses joining; nevertheless, the number of nurses leaving the NHS is higher than we would expect. Would my noble friend say exactly whether we are collating this information and understanding why those people are leaving, because they have a very valued skill?

[Lord Markham (Con)]

Yes, absolutely. Clearly, we want to recruit, but we also want to retain our workforce and again that is what the long-term workforce plan is all about—trying to look at a clear professional development path and other things we can help with, such as childcare support and the culture and leadership, and really make nursing a very successful and rewarding career structure. There is a lot to do on it, but I think there has been a lot of good progress as well.

[Lord Allan of Hallam (LD)]

My Lords, the NHS Long Term Workforce Plan will make funding available for an increased number of nurse training places, which is of course welcome, but the increase in capacity for the NHS will happen only if there are sufficiently qualified candidates applying for those places and completing the training. Would the Minister be willing to share the assumptions his department made about application and attrition rates when setting the targets in the workforce plan, so that we can compare those assumptions with reality as revealed by the numbers in the Question today?

[Lord Markham (Con)]

Yes, my understanding is that all the workings behind the long-term workforce plan are currently being analysed by another body— I am not quite sure whether it is the NAO, the ONS or whoever. The point is that all the modelling and the underlying assumptions are being analysed, and I believe there will then be a report on them so that everyone can see what we are trying to do and how reasonable those assumptions are.

[Lord Bradley (Lab)]

My Lords, the University of Salford, where I am chair of council, has seen applications for adult nursing down by 28%, children’s nursing down by 27% and mental health nursing down by 6%, with an overall drop of 23%. From the feedback the university is receiving, the main barrier is that the financial support needed to undertake a highly intensive course, which leaves little time for part-time working, is insufficient to meet the current cost of living. Does the Minister accept that this is a factor in the drop in applications, and will the Government review the financial package of support available to nursing applicants to ensure, as we have heard, that the NHS workforce plan is deliverable?

[Lord Markham (Con)]

Clearly, as the largest employer in the UK—if not most of the world—the NHS always has to be looking at the whole package that it is offering its staff to make it an attractive place to recruit good talent and retain it. The point that the noble Lord makes is absolutely correct, and those are all things that need to go into the mix. As I say, recent data is encouraging. We have increased the numbers by 45,000 and are on course to hit the 50,000 target, but, as ever, we need to be vigilant because we want to recruit a lot more.

[The Lord Bishop of Chichester]

My Lords, following on from the noble Lord who spoke about his university, the University of Chichester—in the diocese where I serve—is now developing practice-focused nursing courses, including a new nursing associate apprenticeship scheme, even though the cost of living in the south-east is a disincentive to seeking to work in the healthcare sector. However, the university is finding that the current funding and availability of external placements are restricting the growth of these courses, despite the university’s capacity to take more students. What measures are the Government taking to support education and placement expansion at the pace requested by the NHS Long Term Workforce Plan?

[Lord Markham (Con)]

The whole long-term workforce plan is supported by a £2.4 billion investment to make sure that we hit our ambitious targets. It takes into account things like apprenticeships: we want to see the proportion of people coming through the apprenticeship route increase from 9% to 28%. On nursing associates—noble Lords will remember that this is a subject close to my heart, because for my mother, who had children when she was very young, nursing was a route for her to get back into the workforce, so this is something that I am glad to see us now picking up again—we have seen nursing associates increase from 1,000 to 10,000 over the last few years. These are all key routes, which we are backing up with investment behind them.

[Lord Hampton (CB)]

My Lords, it appears that the reduction in student nurses was most prominent among mature students. Applications from those aged 30 to 34 dropped by 25%. Out of nearly 49,000 qualified entrants to teaching last year, fewer than 12,000 were over the age of 39. As someone who retrained as a teacher at the age of 50, can I ask what the Government are doing to attract more mature students to both professions—a group of people who might be under less financial pressure and are able to see these professions as the incredibly important and rewarding careers that they are?

[Lord Markham (Con)]

As I just mentioned, the whole point around nursing associates is to try to attract those more mature recruits as well. As I was trying to show with the example of my mother, there are lots of people who have a lot of value that they can give later on in their life. That is definitely the sense of direction that we are trying to achieve. I repeat that, while people are talking as if numbers are going down, across the field of graduates, apprenticeships and associates we are looking at a 20% increase since pre-pandemic levels.

[Lord Lucas (Con)]

My Lords, would my noble friend consider making it much easier for young people to get work experience in the NHS, so that they can see what a wonderful career it is, rather than having to rely on the chance of someone they know working in that industry?

[Lord Markham (Con)]

Absolutely. We are trying to adopt a modular approach so that you can have units that can build towards getting in there. For people who go into social care, for instance, there is a modular unit that can add towards going into nursing later on. That is a means of attracting people to nursing by having more routes in and making a career such as social care attractive in terms of career progression.

[Baroness Walmsley (LD)]

My Lords, the noble Lord, Lord Hunt, mentioned the attrition rate among student nurses, but I understand that the attrition rate among student mental health nurses is even greater. That is a particularly challenging specialist course, and one of the problems is that very often the clinical placements are a long way from where the student nurse lives. Is there any programme of support available to make sure that we do not lose the student nurses who undertake this very challenging route to nursing?

[Lord Markham (Con)]

The noble Baroness is quite correct that mental health is a particular case in point. When we introduced the £5,000 grant for all nurses each year, we gave additional add-ons, and mental health nurses get an add-on in addition to that £5,000 a year. We also increased the travel and accommodation costs allowance by 50% to cater for those who have to travel far and wide.

[Baroness Wheeler (Lab)]

My Lords, the figures on overall declining numbers are concerning, particularly since this is the second successive steep fall, with, as the Minister said, the Department of Health relying on the UCAS clearing system and future nurse apprenticeships to try to make up the numbers. What changes does the Minister consider need to be made to the NHS workforce plan in the light of escalating problems with both the recruitment and retention of key staff?

[Lord Markham (Con)]

I am sorry to keep coming back to the data, but it suggests a 45,000 increase, which shows that we are doing pretty well. A 20% increase across all the different fields since the pandemic also shows that we are doing a good job on recruitment. Clearly, we cannot rest on our laurels, so we need to look at all those routes in, but I do not understand why people characterise the numbers as dropping when in fact the data shows the overall increase is far greater.

National Health Service: Major Conditions Strategy

Lord Markham Excerpts

Monday 18th September 2023 Lords Chamber

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

My Lords, the Government are providing additional funding of £3.3 billion in 2023-24 and £3.3 billion in 2024-25 to support the NHS in England. The Government have not committed further additional funding specific to the major conditions strategy. However, as part of the strategy, we will be identifying innovative actions to help alleviate pressure on the NHS and support improvement within the current settlement, such as maximising the use of new technology to screen individuals for conditions.

[Baroness Wheeler (Lab)]

My Lords, the major conditions strategy has been well received in both approach and content, particularly the focus on primary and secondary prevention as part of a life-course approach, and bringing together a strategic framework for the six major conditions that drive over 60% of morbidity in England, including cancer, heart disease and stroke. However, key stakeholders have warned that, without adequate resources, NHS trusts and other bodies will struggle to deliver, especially given their current and future focus on trying to cope with ever-escalating waiting lists. Do the Government acknowledge this and how will January’s future strategy address it?

[Lord Markham (Con)]

We are investing about 11% of the economy—£160 billion—in the NHS, and the conditions in the major conditions strategy account for 60% of all the causes of death and long-term illness. What we are really talking about is prioritising spend around prevention and personalised care, as the noble Baroness said, and channelling the money we are already investing towards those aims, on which I think the whole House agrees.

[Lord Allan of Hallam (LD)]

My Lords, in June, the Government announced a ring-fenced AI diagnostic fund of £21 million to support the major conditions strategy. Will the Minister update the House on progress with the rollout of that fund? What other steps are the Government taking to ensure that NHS patients in all parts of the country can benefit from the latest developments in artificial intelligence?

[Lord Markham (Con)]

AI is a key point. Take stroke, which is one of these conditions. I saw a very good example in the Royal Berkshire the other day of what we all know as the golden hour, and the results from it. The Royal Berkshire has AI scans that go straight to the responsible physician, who can say straightaway whether a thrombectomy, for instance, is needed, the timing of which is critical. That is now being used in that cluster of hospitals and will be one of the six key technologies, the roll out of which we will encourage across the board to others.

[Lord Black of Brentwood (Con)]

My Lords, osteoporosis must surely be included in the major conditions strategy, as fractures are the fourth-worst cause of premature death and disability in the UK, with as many people dying of fracture-related causes as lung cancer and diabetes. Does my noble friend agree that the inclusion of osteoporosis in the strategy would need to be backed up by investment in fracture liaison services to make it effective? Would not a two-year transformation budget of just £54 million to pump-prime universal coverage of FLS in England, which would quickly pay for itself, be a game-changer for patients, the NHS and the taxpayer?

[Lord Markham (Con)]

I thank my noble friend. I think that is covered by musculoskeletal conditions, which is one of the six major conditions we are looking at. Key to pathways is moving treatment away from individual silos to patient-based treatment that looks across the board. We know that 55 year-olds have, on average, at least one condition, and that 80% of those over 85 will have one, two or three of these conditions. We need to ensure that we look at this across the board, rather than in silos.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I understand the rationale for identifying these areas, but how will the Government ensure that integrated care boards do not deprioritise services for other clinical conditions, such as eye health or kidney disease, for which there is huge demand in the NHS, involving many patients?

[Lord Markham (Con)]

The strategy tries to provide a road map for how we want to do this. It starts with prevention, which I think we are all agreed on, then early diagnosis, quality treatment and then living or dying well with that condition. It is a philosophy: the idea is that we get it right in these six major areas with 60% morbidity, and then we roll it out across the board in all other areas. It is a way of treatment, really—a way of looking at the whole problem, centred around whole patient needs, that we will roll out to other conditions as well.

[Baroness Barker (LD)]

My Lords, if this is to become a reality rather than an aspiration it will require a huge increase in the number of community nurses. How do the Government think that will happen when the main incentives and career development for nurses lie within the acute sector?

[Lord Markham (Con)]

My Lords, the noble Baroness is absolutely correct. That is set out in the long-term workforce plan: a move much more upstream to prevention and primary care, of which community nurses will be a key part. The recruitment is in place for it all. Yes, a lot of people might see the action as being in the acute sector, but a lot of people really enjoy working in the community as part of their lifestyle. The hope and expectation is that it will appeal to a lot of people in those areas as well.

[Lord Aberdare (CB)]

My Lords, less survivable cancers such as pancreatic cancer are often characterised by vague, non-specific symptoms, making them hard to diagnose. Will the major conditions plan include making funds available for symptoms awareness campaigns to ensure that these signs of deadly cancers are not missed? Will it also cover increased funding for research aimed at increasing survival rates for pancreatic cancer, which is the deadliest common cancer? Survival rates have hardly changed in the past 50 years, whereas for leukaemia there has been a surge in survival rates following an increase in funding for research.

--- Later in debate ---

[Lord Markham (Con)]

This is all about prevention—letting people understand when there is something not right within themselves and trusting them to know that. That is why the self-referral part of this is so important, rather than always having a GP as a kind of gateway to it all. Most people know their bodies better than anyone else does. If we can arm them with awareness and give them the ability to self-refer to these centres, we can get them diagnosed that much quicker.

[Viscount Stansgate (Lab)]

Does the Minister agree that in the broadest sense, this strategy would be aided by the Powers of Attorney Bill that passed in this House last week and will shortly reach the statute book? With the indulgence of the House, I pay tribute to my friend and colleague Stephen Metcalfe, the Member for South Basildon and East Thurrock, who steered the Bill through the other place, my noble friend Lord Ponsonby of Shulbrede and the noble and learned Lord, Lord Bellamy, both of whom are in their places, for getting government and opposition support. I thank the officials at the Ministry of Justice who worked for years to make it possible. Does the Minister agree that lasting powers of attorney as applied to health will make a difference to the better?

[Lord Markham (Con)]

Absolutely. The Government, and in particular my noble and learned friend Lord Bellamy on behalf of the whole MoJ team, fully support the noble Viscount’s remarks on the Powers of Attorney Bill and warmly thank him, Stephen Metcalfe MP and all the others for their efforts on the Bill.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, I congratulate the Minister on concentrating on the importance of person-centred care, particularly for people with long-term conditions. I declare an interest as chief executive of Cerebral Palsy Scotland. Cerebral palsy is a good example of this, because we actually have very good NICE guidelines for the treatment of adults with CP but there seems to be nothing we can do to ensure that integrated care boards around the country follow those guidelines. Can the Minister explain why?

[Lord Markham (Con)]

My noble friend is absolutely correct, in that we are setting out the whole emphasis of what we are trying to do here. It is really ingrained in those pathways. It is about culture and behaviour as a whole, rather than a silo-based scheme, looking at the whole patient. Once we have got those pathways set up properly, it is Ministers’ job—I have mentioned before that we each look after six or seven ICBs—to hold them to account and make sure they are following those pathways.

[Baroness Bennett of Manor Castle (GP)]

My Lords, on that whole- patient approach, in 2021 when the Office for Health Improvement and Disparities was launched, the then Secretary of State said that the Department of Health would be co-ordinating activity across government, looking at the wider drivers of good health—employment, housing, education and environment—lack of which often drives many major conditions. Can the Minister tell me how that co-ordination is going?

--- Later in debate ---

[Lord Markham (Con)]

As mentioned, this is about looking at the whole patient, and that is why the ICB role in this, working with local authorities, is key. The environment in which people live is also key, as is tailoring our part of the jigsaw puzzle—health—towards this. One of the major elements that noble Lords have heard me talk about before is mobile lung cancer screening, which goes into neighbourhoods where it is known to be a problem, often the old mining communities or places where there are high levels of smoking and deprivation. That mobile screening technology has meant that instead of reaching only 60% of people by stage four of cancer, we are capturing 75% at stages one and two. This is about working with local authorities on whole health needs to ensure that our efforts are targeted in the right places.

Reinforced Autoclaved Aerated Concrete: Hospitals

Lord Markham Excerpts

Wednesday 13th September 2023 Lords Chamber

[The Lord Bishop of London]

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

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

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

[The Lord Bishop of London]

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

[Lord Markham (Con)]

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

[Lord Allan of Hallam (LD)]

My Lords, to give credit where it is due, the DHSC has produced a very good fact sheet on RAAC in the NHS. I draw the Minister’s attention to the last line of it—the place where the bad news is usually buried. It says:

“Privately owned primary care estate is not part of the national programme. NHSE has issued RAAC guidance to private landlords who hold the responsibility for surveying and maintaining their own property”.


That reads a bit like “not our problem”. Can the Minister assure the House that the department will ensure that those smaller primary care settings get surveys done quickly? How will the department be staying on top of that?

--- Later in debate ---

[Lord Markham (Con)]

We have given guidance and are making sure that everyone understands exactly what they should be doing across the estate, whether we are the landlord or not. Clearly, there is a difference where we are the landlord because then it is our responsibility to do it. The prime example of this is that in the NHS Property Services GP estate—which is quite extensive—we are dealing with three RAAC GP surgeries. Where they are owned by other landlords, we need to make sure that they are on top of it and do the work without taking responsibility for it ourselves.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Lord mentioned 40 new hospitals by 2030, but he will be aware of the NAO report in July which made it clear that the original 40 target will not be met because of the substitution of the eight RAAC hospitals. Can the Minister tell us what is going to happen to the eight hospitals that were in the original programme and have now been delayed?

[Lord Markham (Con)]

I hope and trust that most of us would think that it was sensible to prioritise the RAAC hospitals. That meant that we had to move some others to the right-hand side of the budget envelope, so to speak. It is not publicised very much, but we now have an agreement with the Treasury to move to five-year capital cycles, like the Department for Transport, which I think is a real positive because we need long-term planning cycles. We are busy developing a 2030-35 programme now, which those hospitals that the noble Lord mentioned will be placed in.

[Baroness Brinton (LD)]

My Lords, I want to follow on from the question from the noble Lord, Lord Hunt. My local hospital, Watford General Hospital, has been top of the rebuild list for 20 years. The town was delighted with the news on 23 May that it would be part of that group and is not part of the eight. Last week, the council was informed that there is still no confirmation of when funding will be approved by the Treasury. The town knows that it will run out of the chance to rebuild Watford General by 2030 unless that funding is confirmed very soon. Can the Minister say when it will be confirmed?

[Lord Markham (Con)]

In every hospital—and Watford was one of the first ones I visited—there is a programme on which the draw-down of the funding depends; there is already a new car park there, for instance. I can assure the noble Baroness that the plans are in place to make sure that the draw-down is in time. I have also said on all the hospitals I have visited over the summer—I have seen about 20 or so—that I have a quarterback role where I have to project manage across them all and, where there are issues, they can approach me directly. I will raise today’s question with the Treasury and make sure that Watford is well in order.

[Baroness Merron (Lab)]

My Lords, as the Minister said in answer to an earlier question, the Government will replace only seven of the 27 NHS sites confirmed to have RAAC in their construction, while the other 20 are set to be monitored and mitigated until it can be removed. How long will it take to complete the removal on these 20 sites? What assessment has been made of the risk to patients?

[Lord Markham (Con)]

Three of those have already had the RAAC eliminated from them. The remaining ones are part of the programme and the commitment to have their RAAC eradicated by 2035, but in the meantime the remedial measures are there and that is what the £698 million is all about. I visited them first hand to see the work, and all credit to the team—they have become real experts on the subject. At every hospital I visited, you could see that the team were right on their game and understood very well what work they needed to do there, always using expert advice from the Institution of Structural Engineers and others.

[Lord Lexden (Con)]

My Lords, do the details that my noble friend gave in answer to the noble Lord, Lord Hunt, represent the current position in implementing the clear commitments given by Mr Johnson in the 2019 manifesto, which I do not think have advanced quite as swiftly as had been hoped?

[Lord Markham (Con)]

The commitment to 40 hospitals is absolutely there, but, as noble Lords have mentioned, we have prioritised the seven RAAC ones—in fact five of those were new, while two were already in the programme—which clearly have to be done by 2030. So, just as we moved those in, we moved the others into the cycle of 2030-35, but we will still be delivering 40 hospitals by 2030, albeit, because of the RAAC hospitals, of a slightly different complexion.