Anaesthesia Associates and Physician Associates Order 2024
Lord Young of Cookham Excerpts(9 months, 3 weeks ago)
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Baroness Bennett of Manor Castle (GP)
My Lords, I rise to move what the Minister has correctly identified as a fatal amendment that the House do not approve this order. This is on two primary grounds: the lack of democratic oversight and the concerns of the medical profession.
Before I begin, I want to make it clear that I am not opposed to the existence of physician associates or assistants, or their anaesthetist colleagues. I am not opposed to their regulation—indeed, I am keen to see them regulated—and I respect the efforts of current and future PAs and AAs who complete their studies and have the student debt to prove it.
I also want to be clear that, unless I get an indication from the House that it wishes me to do so, it is not my intention to put this amendment to the vote. My intention in tabling it was to ensure that the many hundreds of voices of concern that have reached me personally and the more than 21,000 doctors and patients who wrote to their MPs opposing this order are heard, and that the Government consider—seriously, I hope—whether they should go forward to regulate PAs and AAs in this manner, with this order.
I will first address the second part of my fatal amendment, about the views of doctors and patients. Sir Robert Peel invented the concept of policing by consent. I want to adapt that for these circumstances by saying that we must have regulation by consent. I am sure that all noble Lords engaged tonight are aware that the British Medical Association, the Doctors’ Association UK and the EveryDoctor group are opposed to this statutory instrument, for reasons on which I am sure we will hear much more from the noble Baronesses, Lady Finlay and Lady Brinton, with their regret amendments.
One of the very serious concerns is about clarity for patients and the confusion introduced by the title “associate”. On that I turn to a report from the BBC, an interview with Marion Chesterton, the mother of Emily, who tragically died after being seen twice by a PA and misdiagnosed. Marion said that her daughter
“didn’t know she hadn’t seen a doctor”.
Marion added—and this is something that I think people should focus on:
“Physician associate sounds grander than a GP”.
I pick up a point made by the Minister about PAs and AAs having been around for 20 years, an often-cited statistic. If we look back to 2014 and 2015, there were fewer than 50 PA and AA graduates. There were literally handfuls in the system. It is only when you get to 2018 that you start to see the figures leaping up to 400 graduates, and the Government’s aim is to head towards the figures that the Minister cited. So we may not have seen much confusion, but there were few people to be confused about within the system. This is a situation that is arising now, and that demands a reconsideration.
However, I will largely leave the arguments about titles, and the General Medical Council as regulator, to the regret amendments. What I want to focus on is the word “consent” and the concerns of doctors and patients in the context of the state of our medical system.
We debate as junior doctors are in the middle of their 10th strike action. We debate as one in seven British-trained doctors is working overseas. We debate after a BMA poll found last year that around 40% of junior doctors plan to leave the NHS as soon as they can find another job.
We need to make changes to the system. That is something on which the Minister and I, and I think pretty well everyone, are agreed, but we can make changes to the system only with the consent of all those involved. There is a moral argument for that, but also a very powerful practical argument. The Government need to work co-operatively and sensitively, and to listen to our medical professionals rather than ride roughshod over their serious concerns—concerns that are shared by many patients and that have filled my social media feed in recent days.
The first part of my amendment is about democracy. The order got virtually no scrutiny or consideration in the other place. We, of course, have no opportunity to amend it to tackle the issues that the noble Baronesses will focus on in their regret amendments. We have only the extraordinarily rarely used option of rejecting it. I have not had any indication from the Labour Party that it would support that, and I assume that its silence on the Order Paper means that it supports the Government’s path, but I ask the Labour Front Bench to consider whether we have to take this back to the drawing board. That is a question I put to it directly.
The Minister raised the report of our hard-working and, I fear, underappreciated Secondary Legislation Scrutiny Committee, which makes it very clear that this is not just about PAs and AAs but is meant to be the model for broad and widespread changes to medical regulation in the future. The committee’s report says that this is
“the first use of powers inserted into the parent Act by the Health and Care Act 2022 to give the GMC direct powers to make and amend standards and procedures for these associates”,
while, as it says in bold,
“removing the process from Parliamentary oversight”.
It is interesting that the Committee says:
“The Explanatory Memorandum should have been more explicit on this point and on what safeguards remain”.
In testimony, under questioning from the committee of your Lordships’ House, the department confirmed that
“changes in registration processes etc will no longer be laid before Parliament in any form, they will just be posted on the GMC’s website … however members of either House can respond to consultations if they wish”.
I am glad about that.
This has really not been made clear through the process, as the committee highlights. I think it is worth focusing on the fact that had it not been for the amendments from the noble Baronesses and me we would not even be doing this in the main Chamber. We would be in the secondary Chamber, getting, as we all well know, very little attention at all.
I particularly want to highlight, in case noble Lords did not receive it, the briefing from the Professional Standards Authority, which has responsibility for overseeing the GMC’s activities. It said, in what I think one would describe in bureaucratic terms as a carefully worded briefing, that we
“need to keep under review as the reforms are rolled out the accountability framework proposed to balance the increased autonomy for regulators with greater accountability”.
I wish to make a final point to address the fear and concerns of many patient groups and communities—which the Minister alluded to—that their communities and their families will lose ready or perhaps any access to doctors and be relegated to a second tier of NHS services, with PAs with two years of medical training versus GPs with 10. In the letter following up the very useful briefing that he arranged last week—and I think him very much for that and for the letter—the Minister makes reference, as he did in his speech, to the Government’s aim of doubling the number of medical places in England to 15,000 by 2031-32.
The Minister gave, I believe, the same figures as were reported in the Observer on Sunday. These were in a leaked letter from the Health Minister and the Minister for Skills, Apprenticeships and Higher Education to the independent regulator, the Office for Students. The figures in that letter have been interpreted as significant back-pedalling on the Government’s final aim and total. I ask the Minister whether he remains confident and can guarantee to the House that we are on target to achieve that final figure, given that we do not seem to be taking very strong steps in that direction.
The way those figures came out can only amplify the fears of many communities that those who can pay can go private, as increasing numbers of Britons feel they are forced to do. Patients at the centre of well-serviced areas where doctors can supplement their NHS pay with private work will keep access to a service like that now available, while other areas—the kinds of areas that are often talked about as being in need of levelling up—will get a second-class service.
We have to think about the context of this. Our NHS is battered by privatisation, with nearly 10% of services, including more than half of under-18 inpatient psychiatric services, now provided by for-profit providers. We have seen the disaster of PFI schemes, now set to cost £80 billion for the original £13 billion investment—the equivalent of £1,200 for everyone in the UK. We have seen this jewel in the British crown worn away by austerity—a decade in which investment in infrastructure and new technology collapsed and the pay of junior doctors and midwives in particular plummeted in real terms.
Please let us not deliver another blow. Please withdraw this order either tonight or afterwards. Take the path of consensus. Take the path of democratic oversight. Bring this forward as legislation that can be debated, amended and properly scrutinised. Please listen to the fear of communities. I ask everyone in this debate but particularly the Labour Front Bench to consider that approach and the wisdom of it. I beg to move.
The Deputy Speaker (Lord Young of Cookham) (Con)
I should inform the House that if this amendment is agreed to, I will be unable to call the amendments in the names of the noble Baronesses, Lady Finlay of Llandaff and Lady Brinton, by reason of pre-emption.
NHS Dentistry
Lord Young of Cookham Excerpts(10 months ago)
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Lord Young of Cookham
To ask His Majesty’s Government what assessment they have made of the availability of NHS dentistry.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
My Lords, since the pandemic this Government have taken decisive action to recover services. There are signs of recovery, with the amount of activity delivered and the number of patients seen increasing, but there is more to do. Our recently published plan to recover and reform NHS dentistry will make dental services faster, simpler and fairer for patients and will fund around 2.5 million additional appointments and more than 1.5 million additional courses of dental treatment.
Lord Young of Cookham (Con)
My Lords, I welcome the recent Statement but, with 80% of NHS dentists not accepting new patients and with 190 hospital operations every day removing rotten teeth from children, clearly a fresh initiative was needed. However, the dysfunctional, discredited 2006 dental contract, which is driving NHS dentists out of the business, and which was described by the Select Committee in another place as not fit for purpose, remains in place. When will it be reformed? Given that everyone has a right to register with a GP and if they cannot find one the ICB has to find one, why is there not an equivalent right to register with a dentist if dentistry is an integral part of the NHS?
Lord Markham (Con)
I thank my noble friend for raising this and declare my interest as my wife is a dentist, although she is not currently practising. It is accepted that we have made sensible improvements to the dental contract, but a fundamental longer-term overhaul is needed. In terms of the ability to get registered with a dentist, that is what the mobile trucks are all about. We realise that in certain areas it is difficult to get that registration. The idea is for mobile trucks to go into a neighbourhood where there is a particular shortage to resolve the problem.
NHS Dentistry: Recovery and Reform
Lord Young of Cookham Excerpts(10 months, 2 weeks ago)
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Lord Young of Cookham (Con)
My Lords, I felt that today’s Statement deserved a slightly warmer welcome than it has received so far, particularly from the noble Baroness. At a time of enormous pressure on public expenditure, more resources have been found to target the people in the areas who need dental treatment.
I shall raise an issue that has not been raised in exchanges so far. The single most effective public health measure that the Government could take to reduce tooth decay, particularly among children, is to add fluoride to the water supply in those parts of the country where it does not occur naturally. The Health and Care Act 2022 transferred the responsibility from local authorities to my noble friend’s department. Since then, until today, nothing has happened. I welcome the announcement that there will be consultation on extending fluoride to the areas in the north-east where tooth decay happens to be at its highest. Can my noble friend give some idea of the timescale of that consultation and whether there are any plans to extend fluoride to other parts of the country where it is urgently needed as a public health measure?
Lord Markham (Con)
I thank my noble friend. He is absolutely correct that the benefits of water fluoridation are well proven. The consultation for the north-east of England, which will bring in 1.6 million people to this, is starting very shortly. The idea behind that is that we can really try to get moving quite quickly on that. I was surprised to learn that the level of water fluoridation in England today is only at about 6 million people. I know that a lot of people think that their water supply has fluoridation, but there is obviously a long way to go on that. The 1.6 million in the north-east is a good extension to that, but there is a lot more that we plan to do in this space.
Smoking
Lord Young of Cookham Excerpts(10 months, 3 weeks ago)
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Lord Markham (Con)
I thank the noble Lord. Actually, Khan recommended four major things to achieve that in his report Smokefree 2030. The first was to increase the anti-smoking spend that the noble Lord refers to. As part of this, we propose to increase that spend from £70 million to £140 million—so we are doing absolutely what the noble Lord suggests. The second was to increase the age of sale, which of course this legislation is all about. The third was to promote vaping to help quit smoking. Again, the legislation will do that. The fourth was to increase NHS prevention methods which, again, we will do from here. So it is very much a range of measures to stop people ever smoking but also to stop many who are currently smoking by helping them to quit.
The Earl of Courtown (Con)
My Lords, I think the House would like to hear from my noble friend Lord Young.
Noble Lords
Lord Young of Cookham (Con)
Further to the Question from the noble Lord, Lord Rennard, the Government commissioned the independent Khan review, which concluded that the Government would miss their smoke-free target for England by several years unless an additional £125 million a year was spent on prevention. Given the pressure on public expenditure, the Khan review instead suggested a levy on the profits of the tobacco industry, based on the polluter pays principle. Does that proposal not commend itself to my noble friend?
Lord Markham (Con)
As I say, we have tried to answer the four major points that Khan put forward, including doubling the spend from £70 million a year to £140 million. The levy was the one thing that was not so much favoured; there was a lot of modelling done on it and the thought was that the net increase would be only about £25 million or so. That is why it was thought better to look at taxes on tobacco itself as a way of raising revenue, and generally introducing the four major methods that Khan recommended.
Adult Social Care
Lord Young of Cookham Excerpts(1 year ago)
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Lord Markham (Con)
I do not have the figures for those 12 years, but I will happily send them to the noble Lord.
Lord Young of Cookham (Con)
My Lords, further to the original Question from the right reverend Prelate, is not the real problem facing the care sector that of recruiting and retaining care workers, who can often earn much more in a local supermarket than in a nursing or residential home? What action are the Government taking to make this a more attractive profession for people to go into?
Lord Markham (Con)
My noble friend is correct; they are the bedrock and are valued, and it is important that we make them feel valued. As I said, we are reforming the process in order to give them a qualification, which means that that work in the social care setting will be transferable between positions. In addition, if they want to go further into the medical service, be it nursing or other areas, a modular qualification system will enable them to build towards that, so that they not only feel valued but are in a long-term career structure.
King’s Speech
Lord Young of Cookham Excerpts(1 year, 1 month ago)
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Lord Young of Cookham (Con)
My Lords, it is a pleasure to follow the noble Lord, Lord Best. A wise political party would cut and paste his speech and put it in its next election manifesto under housing.
I warmly welcome three of the Bills relevant to today: the leasehold and freehold Bill, the Renters (Reform) Bill, and the tobacco and vapes Bill. The leasehold Bill will make progress towards phasing out a feudal system of tenure that exists nowhere else in the world and crystallises the tension between freeholder and leaseholder. But the Bill bans new leasehold only for houses, of which hardly any are built. Most of the new leaseholds are in blocks of flats. If we are to achieve the Secretary of State’s ambition of abolishing leasehold, we need to make commonhold the default tenure for all new developments of flats. I hope the Government will consider an amendment to that effect, which I might conceivably table.
There is also unfinished business on the Building Safety Act, which protects leaseholders against remediation costs for which they are wholly innocent. As the noble Earl, Lord Lytton, and I have consistently pointed out, that Act has crucial omissions. The leasehold Bill offers an opportunity to provide the protection that Ministers originally promised, but never delivered, to groups of people such as those living in buildings under 11 metres, those who have enfranchised and those who have invested in buy to let. All those—thousands of them—live in buildings that they cannot mortgage or sell, and they are exposed to high service charges. There is an opportunity to build on the BSA and make it a more comprehensive piece of legislation.
On housing, I welcome the Renters (Reform) Bill, but we need clarity on the timetable for implementation. I read the Secretary of State’s speech on Second Reading and he was pressed on this. This is what he said:
“The sooner the Bill is on the statute book, the sooner we can proceed. Alongside that, we of course need to ensure that the justice system … is in a position to implement it effectively”.—[Official Report, Commons, 23/10/23; col. 638.]
Does this mean Section 21 will not be abolished until the court backlog has been cleared? In June, the mean time from claim to repossession in London was 40 weeks, and the backlog also disadvantages tenants who want to take action against their landlord. Can my noble friend put some timeframe on Section 21 abolition and also give an assurance that the MoJ has the necessary resources to tackle the backlog?
On the rental market, which the noble Lord, Lord Best, referred to, we need to reduce our overreliance on the small private landlord and replace it with what happens nearly everywhere else, where rented accommodation is funded by long-term institutional finance with professional management, and where tenancies are not terminated simply because the owner wants to sell.
Finally on housing, we need to increase the local housing allowances, which have been frozen in cash terms since 2020, while rents have risen by up to a fifth. Low-income households are being forced to find, on average, £1,900 for a two-bedroom flat, out of the resources not covered by the LHA. These shortfalls are nearly double what they were a year ago. Many tenants cannot pay, leading to evictions for non-payment. Data published in July shows that more than 104,000 households were in temporary accommodation at the end of March 2023—the highest figures since records began in 1998. The Autumn Statement should increase the local housing allowances, along with the discretionary housing payments, as more and more local authorities have exhausted their budgets.
Along with others, I regret the Home Secretary’s remarks about rough sleepers. I launched the original rough sleepers initiative in 1990 as Housing Minister, and met many rough sleepers, along with the noble Baroness, Lady Casey, whose work in this area I applaud. I never met anyone who was sleeping rough as a lifestyle choice, and I commend the letter which the noble Lord, Lord Bird, wrote in Tuesday’s Times.
If I may say a quick word on education, I welcome the commitment in the Speech to
“strengthen education for the long term”,
with steps to be taken to ensure young people have the necessary knowledge. But young people will only get this if they actually go to school—a point made by the noble Baroness, Lady Watkins. One of the adverse consequences of the pandemic was to weaken that contract between children and parents, on the one hand, and schools, on the other, with a quantum leap in non-attendance. Persistent absenteeism has more than doubled in the last four years to 22.5%. A recent report by the Children’s Commissioner found that just over a third of all pupils were either persistently or severely absent in either Year 10 or 11, with correspondingly poor GCSE results. So we do need to reset that relationship between families and schools, and build on the extension of attendance hubs, with perhaps more national training for national attendance officers.
I commend the commitment to introduce the tobacco and vapes Bill, as would the noble Baroness, Lady Finlay, had she been able to be here. I hope that this short measure might be introduced very early in the Session. Its key recommendation of progressively raising the age at which it is legal to sell cigarettes was a recommendation in last year’s Khan report. It puts England, along with New Zealand, ahead of the pack in the campaign to phase out smoking over time and re-establishes our reputation as a pioneer in this particular field of public health. But its impact is essentially long-term. In the short term, if we are to hit the Government’s target of a smoke-free England by 2030, we need additional measures. As the noble Baroness, Lady Jay, has just said, the public health budget has been hit hard. Khan proposed a levy on tobacco company profits, ring-fenced for public health to give it the boost it needs. I hope the Treasury will reflect on that for the Autumn Statement.
Finally, I turn to social care. The gracious Speech said the
“priority is to make the difficult but necessary long-term decisions to change this country for the better”,
but there was no mention of social care. We need reform of how social care is funded and a workforce plan for social care to complement that for the NHS workforce. If this is now not going to happen in this Parliament, then the Autumn Statement should ensure that local authorities have the necessary resources to fund the current system adequately, while work goes on for fundamental reform in the next Parliament, ideally on an all-party basis.
To conclude, I welcome the measures I have spoken about, but I will seek to make them even better by tabling some amendments.
NHS Long-term Workforce Plan
Lord Young of Cookham Excerpts(1 year, 5 months ago)
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Lord Young of Cookham (Con)
My Lords, in welcoming the report, I press my noble friend on a very interesting suggestion on page 79, where the Government propose a “tie-in period” to
“encourage dentists to spend a minimum proportion of their time delivering NHS care”.
There are a number of professions trained at public expense that are in short supply, including police, doctors and teachers. Why have dentists been selected? Is it proposed to broaden this policy to other areas trained at public expense that are in short supply?
NHS Dental Contract
Lord Young of Cookham Excerpts(2 years ago)
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Lord Young of Cookham
To ask His Majesty’s Government what plans they have to review the NHS dental contract.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
In July, the department announced a package of improvements to the NHS dental system, which included reform of the 2006 contract to ensure that dentists are remunerated more fairly and patient access is improved, especially for those with higher oral health needs. Implementation of these changes is under way, and we recently laid legislation in Parliament to deliver them. We continue to work with NHS England and the dental sector on further reform, which we plan to announce in 2023.
Lord Young of Cookham (Con)
I am grateful to my noble friend for that reply and for the recent modifications to the contract. But does he agree that much more radical reform is needed to that contract, which was described as “not fit for purpose” by a Select Committee in another place, if we are to address the exodus of NHS dentists, encourage more to join, address the 91% of dental practices that no longer admit new adult patients and help areas of the country with no NHS dentists at all? When will we have the longer-term radical reform referred to the last time I asked this Question, in May?
Lord Markham (Con)
I thank my noble friend, and I declare an interest: my wife is a dentist, although she is not practising at the moment. This is one of those rare occasions when it is a case not of announcing new spend but of making sure that the £3 billion we spend is fully utilised. To answer the question directly, it is absolutely right that we need a radical package to make sure that dentists are contracting against their UDAs and finding working in this space worth while and profitable, so that we get the full use of that. I will happily come forward with further proposals, planned for 2023, on what we are going to do in this space.
NHS Dental Services
Lord Young of Cookham Excerpts(2 years, 6 months ago)
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Lord Young of Cookham
To ask Her Majesty’s Government what plans they have to improve access to NHS dental services.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
The Government are working with NHS England and the British Dental Association to reform the current NHS dental system and to improve access for patients, tackling the challenges of the pandemic. We have also provided an extra £50 million for additional activity and patient appointments. We are working to return quickly to pre-pandemic levels of activity. For this quarter, a new activity threshold for NHS dentists has been set at 95% to increase patient access.
Lord Young of Cookham (Con)
I am grateful to my noble friend, but with 86% of NHS dentists closed to new patients, do we still have a national dental service? The current dental contract was deemed unfit for purpose 14 years ago by the Health Select Committee in another place. Will my noble friend, as a matter of urgency, introduce a new dental contract which reverses the decline in NHS dentistry? As his fellow Minister has said,
“there is a shortage … not of dentists but of dentists taking on NHS work.”—[Official Report, Commons, 19/4/22; col. 7.]
Will my noble friend negotiate a contract with private dentists in the meantime to address the NHS backlog?
Lord Kamall (Con)
I half-thank my noble friend for giving me advance notice of one of his questions. I will try to answer that one. Many dentists who provide NHS treatment also already work in a private care capacity, and all dentists who provide NHS care must be registered on the performers list. The NHS uses the list to ensure high quality and safety standards in NHS dentistry.
On the UDA and negotiations, NHS England is in conversations with the BDA concerning both short-term changes and longer-term changes given the concerns that have existed since they were introduced in 2006.
NHS Mental Health Patients in Private Hospitals
Lord Young of Cookham Excerpts(2 years, 7 months ago)
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Lord Kamall (Con)
I thank the noble Baroness for the question and for repeating the fact that you can find problems in the independent sector and in NHS providers. What is really important is that we are looking at the HEE workforce plan as well as the NHS workforce plan, while working with trusts at the local level and other providers of care to ensure that we have the most appropriate staff levels to meet local conditions.
Lord Young of Cookham (Con)
My Lords, if the £2 billion which the NHS is paying to the private sector is enabling vulnerable mental health patients to get high-quality care, is this not to be welcomed as it takes pressure off the NHS?
Lord Kamall (Con)
I should remind noble Lords that the noble Baroness said that she was not against private provision out of principle. Private provision can be very helpful and has always worked with the NHS, ever since it was founded. If we think about responders—for example, the impact of lockdown on many people—we have seen an increase in mental health needs. What do you do to increase the provision of mental health services? Do you wait for a new NHS hospital to be built? No—if there is a private provider out there, or an independent provider that can provide those services, you engage them. That is why the NHS and the independent sector, working together, is a really important partnership.