NHS: Nurses

Baroness Brinton Excerpts

Tuesday 1st November 2022 Lords Chamber

[Lord Markham (Con)]

I totally agree. I am proud to say that we have 72,000 nurses and 9,000 midwives in training at the moment. There is no cap on the number of people who can join the programme, so that is very much the spirit of what we are trying to do. Key to that was a £5,000 grant each year for nurses to attract them into the profession. It is working.

[Baroness Brinton (LD)]

My Lords, the comment about the figures by the noble Lord, Lord Clark, was entirely accurate. The Minister gave us the truth, which is that the net increase is 9,000, whereas the manifesto promise of 2019 was for 50,000 extra. Does this explain why the Royal College of Nursing reported last week that 75% of shifts did not have the planned number of nurses? When will the NHS see 50,000 extra, on top of the 2019 figures?

[Lord Markham (Con)]

To be very clear, today, there are 29,000 extra, over the 2019 figures. That is more than half way towards the figure of 50,000. I will quite happily write to noble Lords so that they can see the figures clearly in black and white, but I can assure the House that we are talking about increases in nurse numbers. We have achieved a 29,000 increase on the 2019 levels.

Nursing: Recruitment

Baroness Brinton Excerpts

Wednesday 26th October 2022 Lords Chamber

[Lord Markham (Con)]

I would hope and trust that such a respected person would see this position as the vocation that it is and the support that they give. We accept that there are some agency workers being used in this space, because obviously, in terms of safety, we need to make sure we cover that number of people. The whole recruitment plan—which, again, we are on target to achieve—is all about making sure we have enough nurses so that we do not have to use agency workers.

[Baroness Brinton (LD)]

My Lords, following on from the question from the noble Baroness, Lady Harding, can I ask the Minister if there are plans to increase the number of student nursing places at universities and student apprenticeships over at least the next decade? While there is a short-term crisis, there is also a longer-term sustainability crisis, especially with current demographics.

[Lord Markham (Con)]

The noble Baroness is correct that this is a long-term pipeline. We have 72,000 nurses in training at the moment. To be clear, there is no cap at all on student places. We are seeking to increase them as much as possible, and we put a £5,000-a-year grant in so that trainee nurses could enjoy superior levels of financial support than other students. The fact that we have a pipeline of 72,000 shows that this is working, but that pipeline is not capped, so if we can get more people in, we definitely want to do that.

Maternity and Neonatal Services

Baroness Brinton Excerpts

Tuesday 25th October 2022 Lords Chamber

[Lord Markham (Con)]

I agree. We are putting the money into the training programmes. We have actually put £95 million on top of the £127 million investment into this area. As ever though, what is most important is outcomes not investment. Alongside the tragic instances we have seen, we have seen a reduction in stillbirth of 19% since 2010, a reduction in neonatal mortality over 24 weeks of 36%, and a reduction in maternal mortality of 17%. Alongside these tragic findings of individual trusts, we have an improving picture of maternity care overall.

[Baroness Brinton (LD)]

My Lords, in yesterday’s Statement on Dr Kirkup’s report, the Minister told us that 23 hospitals are in maternity safety support programmes—special measures—and that, while four are coming out, another 10 are due to go in. Can he assure the House that extra resources, including extra supervision, will be there to ensure that mothers and babies in those hospitals are absolutely safe?

[Lord Markham (Con)]

Yes. Resourcing the special measures programme—for want of a better name—is vital to all of us. I am pleased to see in the case of East Kent that, of the 67 special measures recommended, it has now passed 65 and the two remaining ones will be completed by the end of November.

Water Fluoridation (Consultation) (England) Regulations 2022

Baroness Brinton Excerpts

Tuesday 25th October 2022 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to follow the noble Lord, although I do not agree with him; we debated this during the passage of the Health and Care Act through your Lordships’ House only a few months ago. I must declare that I am president of the British Fluoridation Society.

I have form, because I remember when I was secretary of the Edgware/Hendon Community Health Council in the mid-1970s, taking part in an extensive consultation exercise in the London Borough of Barnet when the then Government were encouraging the introduction of fluoridation. We had two very well attended meetings in the borough where there was a clear view in favour of fluoridating water. Unfortunately, virtually no progress has been made since then. That is why I am very glad that the Government have brought forward primary legislation, and I was very glad to hear what the Minister had to say about the intention to move ahead in the north-east. That is very encouraging and I hope that that will be the first of many such schemes.

It seems that the consultation progress that the Government have set out is entirely reasonable. We must remember that the principle is decided—it has been decided by primary legislation. The local consultations that will take place are not a reason for reopening arguments about the effectiveness of fluoridation; they are about the detailed proposals, making sure that the areas are covered correctly and that individuals can have a say about that. However, I have to say that I noted in paragraph 7.3 that in the consultation a higher weight is to be given to individuals affected by the proposals

“who reside or work in the area.”

I am sure that that is right, but I ask the Minister to agree that the highest weight has to be given to the statement by the Chief Medical Officers of all four UK countries last year that water fluoridation is both safe and effective as well as being the most cost-effective way to reduce inequalities in dental caries prevalence. That must be the principle that lies behind any consultation process. I wish these regulations all speed ahead and very much hope that the foundations for a second wave of fluoridation schemes can now be laid in the north-east.

[Baroness Brinton (LD)]

My Lords, I welcome the Minister to consequential SIs from the passage of the Health and Care Act. Some of those present will remember the long debates we had during the passage of that legislation, some of which the noble Lord, Lord Reay, has returned us to today.

I will start on water fluoridation. My points were actually about consultation, and I will return to those, but the noble Lord has a point: there are now scientific records to show that excess levels of fluoride do cause damage. There is a very good academic article entitled “Assessment of fluoride levels during pregnancy and its association with early adverse pregnancy outcomes”. It concludes that this happens mainly in developing countries where the level of fluoride is not managed. I echo the point that the noble Lord, Lord Hunt, just made, that if the four Chief Medical Officers for the four countries of the United Kingdom believe that it is safe, that should be enough for us.

Of course all care must be taken and monitoring must continue, but the other point I want to make is from a dentist in Australia, who was very supportive of Australia’s move to fluoridation a while ago. He said that the region where he lives was one of the last to add fluoride. He talks about the experience of having to give very small children repeated anaesthetics and pain relief, and the effect on them. He says:

“Since fluoridation was introduced to Geelong in 2009, my colleagues are much happier, as severe dental abscesses requiring tricky anaesthetic techniques are much less common, and tend to mainly come from areas in the region which still aren’t fluoridated.”


He goes on to say:

“The other anecdote … was that one of my colleagues who had worked in Europe for a few years went away with 3 children under the age of 6, who were the same age and social demographic as our own children. When they returned … 2 of his 3 children had needed dental treatment”


under general anaesthetic. The key point is that they went to unfluoridated places. Although I hear the concerns of the noble Lord, Lord Reay, I hope we can be reassured that everything we debated during the passage of the Health and Care Bill shows that this is being done very carefully.

During the passage of that Bill, my noble friend Lady Pinnock made a very important series of points about how to decide where to consult about fluoridation of water, given that we have so many reservoirs where water goes in lots of different directions. Often, you cannot identify each of those areas. Although it was good to hear the Minister talk about the way that consultation will happen, and it is good news that there has been broad consultation in the north-east and that there are some resources there, might the Minister comment on how it is possible for civil servants to identify the relevant areas for consultation? This was one of the reasons why we said during the passage of the Bill that there needed to be very broad consultation.

Moving on to the other statutory instrument on training on learning disabilities and autism, and on virginity testing and hymenoplasty, I signed both of those amendments during the Bill’s passage. Each time it came back I spoke to both of them. It was wonderful that the Government listened and accepted the amendments on training for health staff working with people with learning disabilities and autism. I know that this is only a technical amendment to remove the CQC, but this is a moment to thank the Government for listening to the concern of those of us who work with and know many in the learning disabled and the autistic communities, who have often found that they have been treated by people who do not understand their conditions, which makes it that much harder to communicate with them.

I will now move on to virginity testing and hymenoplasty—I welcome the Minister to the language that we have all had to learn. We were very pleased that the Government decided to support measures on this. I have one question for the Minister. He mentioned that this was about the suitability of foster parents or of their household. It is not clear how wide that household is regarded; is it literally the people who live in that house, or, as in other safeguarding issues, would it also include a member of the foster parents’ family who might be visiting that house on a regular basis and who, in any other safeguarding terms, would have to be notified? If the Minister cannot answer that today, I would completely understand, but I look forward to the answer because I have a particular interest in safeguarding. Apart from that, I support all three elements in front of us today.

[Baroness Merron (Lab)]

My Lords, I start by thanking the Minister for bringing these regulations forward today. They very much flow from the measures supported in the Health and Care Act, and we are very glad to support them.

I will first refer to the instrument dealing with fluoridation. My noble friend Lord Hunt and the noble Baroness, Lady Brinton, rightly made the point that this is not the time to reopen the whole matter as to whether fluoridation is a good thing. I feel that that has been exhausted in the debate. I am familiar with the concerns that the noble Lord, Lord Reay, has previously put before the House and which he referred to today. However, every independent review of fluoridation has confirmed its safety. As the noble Baroness, Lady Brinton, and my noble friend Lord Hunt said, the UK Chief Medical Officers back this measure, and I do not believe that they do so lightly. I hope that the noble Lord, Lord Reay, may come round to the way of thinking that explains why this measure is important in the Act and why we need the regulation today.

I have a few questions for the Minister. Regarding consultation, the necessity of taking responsibilities away from local authorities and to the Secretary of State reflects reality, because there are real difficulties when boundaries are different, yet fluoridation needs to be brought in. Also, it is important to take communities with us in this process, and the consultation measures in this regulation provide that opportunity.

Can the Minister comment on plans to extend fluoridation nationwide? What is the plan—the vision— bearing in mind that only 10% of people have fluoride in their water at present? What timeline might we be talking about? Do the Government have a target for the percentage of the UK that will benefit from fluoridation at the end of the process? I also wonder how the Government will spread awareness of the evidence of the benefits of fluoridation and gain buy-in for them, as that is extremely important.

In the course of evidence sessions in relation to the Health and Care Act we heard from experts that many families do not habitually drink water, and that many people who suffer tooth decay are now too far down the line to stave off tooth loss. It would be helpful to hear whether the department has any plans for a wraparound strategy on dental health generally.

I note from the Explanatory Memorandum that a separate impact assessment, beyond that of the Health and Care Act, has not been done for this regulation. Can the Minister comment on that? It is important to have an analysis of how the movement of powers in respect of consultation beyond local authority boundaries will play out.

East Kent Maternity Services: Independent Investigation

Baroness Brinton Excerpts

Monday 24th October 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I start by thanking Dr Bill Kirkup and his team for bringing together a report of harrowing events. This litany of failures makes for very difficult reading, and it marks another landmark for a further group of families fighting for justice who should not have had to do so. Forty-five babies could have survived had they received care at the nationally recognised standards. I am sure that the thoughts of the whole House are with the bereaved families at this extremely painful time.

This is, regrettably, yet another example of women’s voices being ignored and silenced, to the extent that some were told that they were to blame for the deaths of their babies. At a time when women are at their most vulnerable, they were let down by the very people who they were relying on to keep them safe. However, this is not a one-off: East Kent is the latest in a long line of maternity scandals, including at Shrewsbury and Telford Hospital NHS Trust and Morecambe Bay, while the upcoming review of services in Nottingham is expected to be highly critical. Dr Kirkup said that avoidable deaths happened because recommendations that had been made following reports into other scandals had not been implemented. I would be grateful if the Minister could respond to this.

We know that no woman should ever have to face going into hospital to give birth, not knowing whether she and her baby will come out alive. Those who allowed this culture of neglect and what was referred to in the report as a disturbing

“lack of kindness and compassion”

to take root must be held accountable. Can the Minister tell your Lordships’ House how this may happen?

It is shocking that there is a pattern of avoidable harm in maternity units across the country. Half the maternity units in England are failing to meet safety standards. Pregnant women were turned away from maternity wards more than 400 times last year. One in four women are unable to get the help that they need when in labour. The Government need to fully accept all the recommendations in Dr Kirkup’s review without delay. I hope the Minister will today confirm that this is the case.

In the wake of the Ockenden review, the former Health Secretary announced additional funding for maternity services to help deliver the reform that is clearly needed. Can the Minister tell your Lordships’ House how that funding has been spent and how its impact will be measured? Indeed, it would be very helpful if the Minister could bring a further report to this House on progress in the improvement of maternity services.

Underpinning the issues in maternity care and across the NHS is, of course, the workforce. But more midwives are leaving the profession than are joining it and there is now a shortage of some 2,000 midwives in England alone. Can the Minister indicate where we can find the workforce plan to get the staff needed to provide good and safe care in the short, medium and long term? It is evident that the Government must provide the staff that maternity services desperately need to provide safe care across the health service.

I am sure we were all concerned to read the Care Quality Commission’s report published just two days after Dr Kirkup’s report. It also makes sobering reading. It says that maternity services in England have deteriorated to their lowest level, services are worsening and, time and again, there are issues with the leadership and culture in maternity units.

The CQC’s chief executive said that the failings were systemic in the NHS, with two in five maternity services now ranked as requiring improvement or inadequate. This is a wholly unacceptable situation. Does the Minister share the view of the regulator that the issues in maternity services are a “national challenge”?

This CQC report shows that there has been a deterioration in maternity services overall and in relation to their safety, describing progress on improvement as “slow”. The proportion of maternity services ranked as inadequate or requiring improvement is, we see, the worst it has ever been. What actions will the Government take? Will the Minister be meeting the CQC urgently to discuss its findings? How will a major change in maternity services be brought about?

All that women and their loved ones ask for is to have confidence that they and their babies will be safe. This really is not much to ask. I hope the Government will provide the means to deliver this.

[Baroness Brinton (LD)]

My Lords, I want to start from these Benches by sending my deepest sympathies to the bereaved families and to say that we admire the parents for their campaigns over many years against the dreadful treatment by the east Kent hospitals trust for more than a decade. I echo the thanks and gratitude from the noble Baroness, Lady Merron, to Dr Kirkup and his team. Once again, he has risen to the challenge of providing a very clear picture of what has gone wrong at a hospital trust.

The trust failed to read the signals over an 11-year period. The Kirkup report puts this very bluntly and is exceptional in the way it uses evidence. Yes, there is the evidence of the voices of mothers and their families and the evidence from staff, but equally important is the use of data, especially the CESDI data from the Confidential Enquiry into Stillbirths and Deaths in Infancy. In the section headed “What happened to women and babies”, paragraph 1.16 says that

“we have not found that a single clinical shortcoming explains the outcomes. Nor should the pattern of repeated poor outcomes be attributed to individual clinical error, although clearly a failure to learn in the aftermath of obvious safety incidents has contributed to this repetition.”

This short paragraph encapsulates how failings have become cultural in the trust. Paragraph 1.19 says that

“we have found that the origins of the harm we have identified and set out in this Report lie in failures of teamworking, professionalism, compassion and listening.”

It is really worrying to have the report from the CQC of a few days ago, which echoed these exact points but more broadly across maternity services in England.

As has been mentioned, there is a wider problem. We know that. The reports on Morecambe Bay, Shrewsbury, Telford and now Nottingham, where Ms Ockenden is now working, show that systemic and cultural failures, especially with the complexity of regulators, are creating real problems. There is the idea that clinical staff will allow favouritism and the opposite of growing and supporting staff, while letting things fester and not caring to drag patients into their concerns.

Can the Minister outline the timescale for the independent working group report referred to in the Statement? The creation of the group is welcome; its main remit is to advise the maternity transformation programme in England—but by when? Is the work of the group revealing that other maternity services have problems, even if we do not know how severe they are or if they are as severe as East Kent?

In the section on the actions of the regulators on page 9, at paragraph 1.50, Dr Kirkup identified that

“the Trust was faced with a bewildering array of regulatory and supervisory bodies, but the system as a whole failed to identify the shortcomings”.

It is good that it is reported that NHS England and Innovation sought to bring about improvements, but every other trust is also facing that same complexity of different regulators. Are the Government looking at the roles of regulators and how their competing demands can be streamlined to avoid this problem?

The Commons Minister said that she would review all the recommendations and provide a full response once she has had time to consider it. I think we all appreciate that the NHS has a very large workload at the moment, but can the Minister say roughly what timescale we are looking at?

One key problem in many maternity services is with the workforce, especially midwives. Although NHS England made an exceptional grant in March of £127 million as a boost for

“safer and more personalised care”,

can the Minister say—I echo the point made by the noble Baroness, Lady Merron, which he will not be surprised to hear—where the workforce plan is for the next decade for maternity services? A year’s extra money is not going to help with training the midwives of the future and ensuring that maternity units are professionally and adequately staffed.

Dr Kirkup also criticised NHS England for firing chairs and chief execs too frequently, indulging in a blame game that reinforced the culture happening inside East Kent. It is no longer good enough to say, once again, that this must never happen again. This is the third devastating report in under seven years, and another is now being prepared in Nottingham. What will the Government do in the next three months to ensure that further appalling practice will be uncovered and dealt with immediately?

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

Dr Kirkup’s report, published last week, contains some stark and upsetting findings. As mentioned, the report examined more than 200 births in east Kent between 2009 and 2020 and found that, had care been given at nationally recognised standards, 45 babies might not have lost their lives and many more families might not have experienced such distress at what should have been a time of joy. He also found a toxic culture in the trust, with a disturbing lack of kindness and compassion, and victims’ families even blamed for their devastating losses. The report underlines that the NHS needs to be better at identifying poorly performing units and at giving care with compassion and kindness, as well as team working with a common purpose and responding to challenge with honesty. I take all the findings and areas of concern extremely seriously.

I want to thank Dr Kirkup and his team; his experience has been invaluable and I know that his approach to putting families first has been welcomed. I also know that hearing the accounts of families has been a harrowing experience at times, yet, as he said, it is difficult to imagine just how hard it was for the families as they relived some of their darkest days. I am profoundly sorry to all the families who have suffered and continue to suffer from these tragedies. I pay tribute to the families who have come forward to assist the review; it is thanks to the tireless efforts, courage and determination of families in east Kent that we have been able to shine a light on maternity failings in East Kent Hospitals University NHS Foundation Trust.

Before directly addressing the recommendations, I want to put the tragic findings in the context of an improving service overall. Since 2010, stillbirths have declined by 19%, neonatal mortality over 24 weeks by 36% and maternal mortality by 17%. That is not to undermine the seriousness of the circumstances.

On the recommendations, I echo the comments already made. I know that it is top of Minister Johnson’s agenda in making sure that there are speedy, but also measured, responses. As part of that, I want to touch on some of the points made, particularly by the noble Baroness, Lady Brinton, about the use of data as part of the early warning indicators. I think we all agree that that is key to this area. This is exactly the work that the national maternity safety surveillance and concerns group was set up for: to make sure that there is methodical oversight in this area. It is in its power to recommend that people are put into the maternity safety support programme; 23 hospitals are currently in it and it is recommended that four have progressed enough to come out again, but another 10 have been identified that may need to be put into it.

It depends on how you look at it, and whether you take solace in these trusts being identified, or whether you are concerned about the number out there. Personally—I hope I echo the comments of all of us in the House—I believe it is much better that we identify them and deal with it, however uncomfortable that might be in the meantime. The lesson we have learned from these unfortunate cases, as recognised by the noble Baroness, Lady Merron, is that we have seen a failure of leadership and accountability here.

I am glad to see that, in responding, the trusts have been unequivocal in accepting unreservedly the failings on their part and have apologised wholeheartedly. As we know in these times, when dealing with these situations the first thing that has to happen is recognising that the problem exists.

I will need to write to the noble Baroness about the extra investment and how that spend is being allocated. It is very much on the agenda of Minister Johnson to look at that and at the improvements that have been made.

On the shortage of midwives, the picture as I understand it right now is that we have had a stable number of midwives—around 21,500—over the last four years. Within that, we do have the target, as mentioned, to increase it by 1,200, and that is part of the £95 million investment towards this. I accept that doing that is more than a one-year plan and needs to be part of a much larger picture.

I welcome the CQC focus on this area. It is something that we all agree needs to be an area of focus; if that makes for some uncomfortable findings then so be it. It is only when we understand those areas that we can really get on and make sure that we deal with them. I hope that we are looking to move on in these areas.

The Maternity Safety Support Programme is a force for good, and I am glad to say that, in East Kent, they have been working on the improvement plan as part of the support programme, and 65 of the 67 actions have now been completed, with the final two to be completed by the end of November. That is not to be complacent: that work should have been done a lot earlier, but I am glad to see it is being worked on now.

I have tried in these answers to respond to the questions, but I will follow up in any areas where I have not. In summary, I again thank and pay tribute to those families whose tireless determination to find the trust in telling their stories has brought us to this important point. The Government will be reviewing and considering all the recommendations from the report. We will listen, learn and act to ensure that no other family has to ever experience the same pain in the future.

Menopause

Baroness Brinton Excerpts

Tuesday 18th October 2022 Lords Chamber

[Lord Markham (Con)]

I agree that we want to make sure that there is national access. I understand that, whereas we had 30% take-up as long ago as the 1990s, with the incorrect scare around some of the causes since then, that rate is only about 15% today. There is clearly a need to increase awareness and the ability for people to receive treatment.

I am aware of the issue around formularies; I have heard that they believe that it can be resolved. I will take it away and write to the noble Lord to make sure that it is properly dealt with.

[Baroness Brinton (LD)]

My Lords, in the initial Answer that he gave to the noble Baroness, Lady Thornton, the Minister said that access to support during the menopause is vital. Does he therefore agree that, for health and economic reasons, the menopause should be added to the quality and outcomes framework to encourage doctors to investigate and treat patients who present with symptoms associated with the menopause?

[Lord Markham (Con)]

Yes. The noble Baroness will be aware that only 55% of women showing symptoms felt able to talk to GPs about it and another 30% felt that there were delays in diagnosis. Clearly, more work needs to be done. I know that it is part of the core curriculum—that is not the proper phrasing; please excuse me. The whole point of appointing a women’s health ambassador is to make sure that every avenue and channel is used to maximise access, whether at the level of GPs or as part of the education or formularies.

Edenfield Centre: Treatment of Patients

Baroness Brinton Excerpts

Thursday 13th October 2022 Lords Chamber

[Lord Markham (Con)]

My Lords, I completely agree with the question in making sure that this does not happen or is not happening elsewhere. We have been in touch with the CQC, as one would expect, which has made significant changes to protect people in specialist services, people with learning difficulties and autistic people in mental health patient settings. These include making it mandatory for all staff to undertake specialist training before inspecting these settings and introducing a new single assessment framework, which would allow more frequent inspections of the worst-performing providers. The CQC is doing a number of things around that framework, including six key evidence categories, which set out the type of evidence that will be collected. These categories are: people’s experiences; feedback from staff and leaders; observation of care; feedback from partners; processes; and outcome of care. The new assessment means that more targeted time can be spent on site, taking longer to talk to people using services and making every minute count.

Those are some of the standing replies. On a personal level, there clearly need to be questions about how the CQC can go in on an ad hoc basis because, when an investigation or inspection has been announced, a place has an opportunity to put things right. One area of my interest—and I do not claim to be an expert on this—is how we can pick up those ad hoc cases quickly. Clearly, we should not be expecting people such as “Panorama” to be doing that; we want to pick those up ourselves.

[Baroness Brinton (LD)]

My Lords, despite the Minister just commenting on the way it is possible for some organisations to game-play inspections, it is noticeable that the CQC inspection of 2019, published in 2020, was “Good”, despite the finding that,

“In acute wards … records did not show that supervision of staff in the service was effective”,


which was a “breach of regulation”. This is really concerning.

Reform of the Mental Health Act is long overdue. It was created over 40 years ago, and many noble Lords have been fighting for that to happen. It was good to hear in the Queen’s Speech that there will be a draft mental health Bill, but there are real concerns that it is about to be shelved. My honourable friend Munira Wilson MP asked the Minister responding to this Urgent Question whether it was going to come forward. She did not get a straight answer. I ask the Minister whether Parliament, and this House in particular, will see the mental health Bill this Session.

[Lord Markham (Con)]

My Lords, like the noble Baroness, I am aware that the White Paper is in draft, but I have not seen its latest status. I know it will address some of the issues that we all agree are not to our satisfaction. At the moment, I can undertake only to understand the position of the White Paper and come back to her, if I may.

Skills for Care Report

Baroness Brinton Excerpts

Thursday 13th October 2022 Lords Chamber

[Lord Markham (Con)]

The noble Baroness is correct that a number of people are on zero-hours contracts. As I am sure she is aware, their employment is through a number of agencies and local authorities, but it is an issue in a number of places and goes to the wider conversation about how we make this sector an attractive place to work. Earlier, my colleague mentioned the Skills for Care working group, which found that a significant proportion of all employers—around 20%—have a turnover rate of only around 10% versus the 29% average. So, clearly there are areas where certain employers do a fantastic job of not only recruiting but retaining, and making the sector an attractive place to work. I believe that the whole emphasis of the conversation we are having now is exactly about how to make this sector an attractive place to work because, as we all know, it is a vital part of our care and health system.

[Baroness Brinton (LD)]

My Lords, the Minister referred to the £500 million investment in social care but this is only his fourth day in the job. Many people in your Lordships’ House know that that money is for winter pressures and was omitted from the budget for the NHS and social care at the beginning of the year. Without it, social care would be in even deeper trouble than it is now. The noble Baroness, Lady Chakrabarti, made an extremely important point about zero-hours contracts. The problem of staff working in domiciliary care is that there is not enough money even to allow them to be paid for travelling between clients. There is a real shortage of money. This is a group of dedicated workers who are being treated very badly. Will the Minister undertake to look at this particular problem?

[Lord Markham (Con)]

Any industry with the sort of turnover rate that was mentioned earlier demonstrates that there is a need to look further into it, so I absolutely accept the premise of the question and, as I mentioned before, the importance of this area. As I have said before, this is also about looking at areas of best practice because we can always look to spend more money but we know that there are limitations on the public purse. I would not be doing my job if I did not try to see where we can learn from good employers, employ those practices and see whether we can spread them wider so that everyone has the same level.

The other point that I made previously was about opening this up. We know that our healthcare system is founded on good workers from all around the world. They can be a bedrock. I am delighted that we are looking into that area now. We are starting to see good numbers of people coming in from abroad. It is an excellent level of entry into our country. There are a number of things we can do to improve the situation but I completely agree with the noble Baroness on the importance of tackling it.

Pharmaceutical Research and Development Spending

Baroness Brinton Excerpts

Thursday 13th October 2022 Grand Committee

[Baroness Brinton (LD)]

My Lords, I too congratulate the noble Lord, Lord Hunt, on securing this debate and thank the noble Baroness, Lady Wheeler, for stepping in at such short notice and giving us such a comprehensive introduction. I also thank the ABPI, Roche, STOPAIDS, dementia awareness and the Lords Library for their very helpful briefing.

Four decades ago, I was a manager at Newmarket Venture Capital in the City. We funded the first wave of spinning out monoclonal antibodies. I remember one of the senior managers involved with it saying, “This will transform pharmaceutical treatments over the next few years”. She was right. A hundred years ago, my great-grandmother, who also had rheumatoid arthritis, had been told there was no treatment other than gold injections. She was in a wheelchair and unable to use her hands because they were so badly deformed.

Twenty years ago, I started on disease-modifying drugs and these days, along with many other people with my condition, I use a JAK inhibitor, which is a tablet that I take once in the morning and once at night. I used to have to spend a whole day in hospital having my infusion of a monoclonal antibody. We need to recognise the enormous advance in pharmaceutical work that has transformed the work of the NHS. It has reduced the number of beds needed and addressed a large number of other issues. But only one in 10,000 compounds and only 7.9% of medicines that get to clinical development actually make it to approval. It takes around eight to 12 years from initial discovery to launch, although I really hope that we have learned some lessons from the Covid pandemic and are able to start speeding things up somewhat.

Between 2015 and 2019, 43% of NICE recommendations were optimised for access to new medicines. This meant that they were recommended for a smaller patient population than the medicine had originally been approved for by either the European Medicines Agency or the MHRA. Of those optimised recommendations, around two-thirds recommended treatment in less than half the approved population. So, from a patient perspective, in the UK, a large number of patients are not getting access to the treatments that have been approved. The uptake of new medicines is a major concern. For more than 75 medicines recommended by NICE and launched between 2013 and 2019, the per capita utilisation in the first three years was around 64%, which was around the average in 15 comparator countries.

I want to focus on advanced therapy medicine products, the use of data and the voluntary pricing system, also known as VPAS. Advanced therapy medicine products are new, revolutionary medicines based on genes, tissues or cells and have the potential to save, lengthen and improve patients’ lives by treating the root cause of diseases. But they present challenges to health systems because they are so different from traditional medicines. Because they are used as a one-time-only treatment, they have a very high up-front cost, particularly if it takes 10 to 12 years to develop them and possibly up to £1 billion in research costs.

Currently, only a very small number of ATMP treatments are on the market and the NHS is managing to provide access despite these challenges. But, looking at monoclonal antibodies and the way that they are used now, it is likely that ATMPs will become the go-to drug for the future. Unfortunately, already we are behind other countries such as France, which is taking a very forward-facing example. France introduced a measure in its 2023 social security financing bill to allow innovative payment models to be used for ATMPs to share the risk between the manufacturer and the healthcare system.

We must not forget the transformative use of global pharma R&D, especially that which has been developed in the UK, in the spend on the wider world. It is one of the big lessons that we learned from the Covid pandemic. Oxford’s early R&D for the vaccine platform became the AstraZeneca vaccine, but unfortunately those technologies were unobtainable and inaccessible to most of the globe. Many noble Lords present spoke about that in your Lordships’ House during the Covid pandemic. We must make sure that that does not happen again, so I ask the Minister, what lessons have been learned from developing these drugs and how can we share that technology, probably through TRIPS waivers and other systems. in the future?

On data, during the passage of the Health and Care Bill, many Members across the House discussed the use of patient data and the safety net that we needed, but there is absolutely no doubt that the NHS has unique potential, given its large and diverse patient pool, to be one of the most effective engines for research. The Data Saves Lives strategy, announced earlier this year, is a good vehicle to overcome these barriers, and it was very much welcomed by the pharma sector. In implementing the strategy, I hope that the Government and the NHS will work to ensure that the national trusted research environment is fit for purpose, and has the necessary functionality to enable safe, high-quality research and the use of advanced analytical tools to derive insights. I am particularly concerned about this after the patient data—the care.data—and the GP data débâcles of this year and five years ago. It is really important that patients’ data can be protected.

Briefly, on VPAS, the Voluntary Scheme for Branded Medicines Pricing and Access between the UK Government and the pharmaceutical industry has historically been very useful, but Roche says that fluctuations of spend are now causing a rapid increase in VPAS payment rates, undermining the industry’s ability to sustain and invest in the UK. There has been a 10% jump from 5% to 15% over the last year and, worryingly, there is a projection that this may increase to over 30% next year. The worry is that this will impact the whole of the sector. Can the Minister say whether the Government are discussing VPAS with the extended life sciences sector?

Health and Social Care Update

Baroness Brinton Excerpts

Monday 10th October 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, it may have been some weeks since this Statement was made in the other place, but its subject matter is as relevant today as it was when it first saw the light of day. The big questions remain: among them, where are the costings and how will it be funded?

The NHS is facing the worst crisis it has ever seen, with patients waiting longer than ever in A&E, stroke and heart attack victims waiting an hour for an ambulance and some 378,000 patients waiting more than a year for an operation. Those figures date back to the summer—before we even get to the winter and the challenges winter always brings.

At the time of the Statement, the NHS Confederation’s verdict was that

“these measures will not come close to ensuring patients who need to be seen can be within the timescales set out … they will have minimal impact on fixing the current problems that general practice is facing over the winter”.

But has not the situation got even worse since this Statement was first heard? The scale of the challenge faced by our health and social care services, the people who work in them and the public who rely on them has worsened as the state of the economy worsens. The country is now experiencing spiralling inflation which far exceeds the assumptions on which budgets were set, while those who work in the health and care services are struggling with the cost of living. What will be the response to this? How and where will the so-called efficiency savings demanded by the Treasury be found?

What we do know is that the impact will not be equal. As the right reverend Prelate the Bishop of London addressed at the weekend, it has been reported that the Government’s long-promised White Paper on health disparities has been dropped. Can the Minister confirm this? If that is not the case, can he advise on when can we expect this crucial plan to narrow the widening inequalities in health outcomes between the poorest and the wealthiest, between white and black, Asian and minority-ethnic people and between those in the north and south?

The Statement says that patients will be able to get a GP appointment within two weeks, but let us remind ourselves that, prior to 2010, the guarantee of an appointment was within two days, not merely an expectation of two weeks. Can the Minister provide more detail as to how the two-week expectation will be met? I ask this in the context of the record numbers of GPs indicating that they will be retiring or leaving the profession, where burnout and low morale are at an all-time high. How will the numbers stack up when 4,700 GPs have been cut over the past decade, and the long-promised 6,000 GPs are not on course to be delivered? With 330 practices having closed in just the last three years, where will these appointments take place? Are there plans to open new practices?

The gaping hole at the heart of the Statement is, as we know, the lack of a workforce strategy. In the ABCD plan presented by the Health Secretary, the only reference is under D, which refers to doctors and dentists. They are important—there is no doubt about that—but what about the nurses, paramedics, technicians, care workers, cleaners and caterers? Without a plan to tackle the whole staffing crisis, there is not a plan for the NHS.

What are the Government going to do about the staff shortages of 132,000 in the NHS today? This cannot be overlooked. Earlier today, the Minister told your Lordships’ House that there were 200,000 more staff in the NHS than 12 years ago. Perhaps he could elaborate further. Are these full-time equivalents? Where are they and what roles do they perform? Crucially, does the Minister accept that there still needs to be a fully costed plan to deliver the workforce that we so desperately need?

The Statement refers to some £500 million to speed up delayed discharges. Can the Minister help with some more detail on this? Is it a new investment or a re-announcement? How will it be funded? It is indeed right to say that if patients cannot get out through the back door of the hospital because care is not there in the community, we get more patients at the front door and more ambulances queuing at the front. That is exactly the situation we see today. The crucial point is that unless the Government act on care workers’ pay and conditions, employers will not be able to recruit and retain the staff they need. What is the plan to address this?

Finally, can the Minister reassure the House and patients across the country that the response to the crisis in the NHS will not be to lower standards for patients but to raise performance instead? I am sorry to say that this Statement misses the target. I hope the Minister will reflect on the points that I have raised, and other noble Lords will undoubtedly raise, and take the opportunity to use his new and important position to make proper change and improvement.

[Baroness Brinton (LD)]

My Lords, I echo the comments of the noble Baroness, Lady Merron, about the nature of the plan. It is full of warm words and aspiration, light on detail, especially on funding, and seems to disregard the reality on the ground at the moment. I also echo her concern about the rumours of the White Paper on inequalities being shelved. That is really important. Many of us spent a lot of time in your Lordships’ House during Covid hearing about the problems of people with Covid, particularly those from ethnic minorities and deprived backgrounds. There is a lot of data to say that those people have really struggled.

The workforce plan is something else that from these Benches we asked for consistently long before work started on the Health and Care Act, but absolutely consistently since then. Turning to the plan itself, on ambulances, the announcement in July was welcome but three months on—and this was an emergency announcement—it feels as if nothing has changed. The number of delayed discharges remains stubbornly high, and we know that there is a new wave of Covid rising: the ZOE study figures today suggest around 230,000 new daily cases and 2.2 million active cases. That is going to continue to rise: all the medical experts in this area say we are now definitely at the beginning of this wave.

B stands for backlogs, and I am afraid that that is not really improving either. Although it is good to see that the two-year waiting list is reducing, the under-two year list continues to grow: 6.8 million at the end of last month. The plan talks about patients being redirected from hospitals, but our primary care system—GPs, community nurses, physios, speech and language therapists in the community, and especially social care—is already at breaking point. It is good to be offering Covid boosters, but why are under-12s excluded unless they are immunocompromised? Children at schools without proper ventilation were drivers of the last two waves of Covid, and it just seems ridiculous that they have not been included, because that would be an easy win.

In my question earlier today, I asked the Minister about care and particularly about virtual hospitals. It is good that the plan is picking up on some excellence in the NHS, and I am very proud of my local hospital for doing it, but the Minister did not actually answer my question, which was: given that this work of virtual hospitals creates more work for GPs, community nurses, physiotherapists in the community that in the past would have been done in hospitals, will there be extra resources for primary care? Without it, primary care is already at breaking point; they cannot just magic extra time and energy to do it.

The section about GPs is admirable in spirit, but doctors have repeatedly said that their main problem is a lack of doctors. We also know from the BMA survey back in the spring that GPs’ workload has increased by 30% on clinical administration alone. It is not Covid; it is mainly to do with digitisation and complex systems. It is all very well talking about getting administrators in to do it, but these are administrative tasks that doctors have to do themselves. Unfortunately, it is causing a problem, and I do not see any solution in the plan.

Whenever Ministers talk about doctors, they talk about the highest number ever—indeed, the Minister did so earlier—but there are two problems with that. There are more patients than ever, and that is never reflected in any comments by Ministers. Government funding for doctor training has not been sustained. This year, far too many—hundreds, just under 1,000—newly qualified doctors, fresh out of university, could not get training places because there was no funding for hospitals to be able to do it. The exodus of NHS staff was reported in the Times just last Saturday. The net change is not positive now; it is negative.

On dentists, it is very good news about the simplification of government rules regarding overseas dentists qualifying to work, and we look forward to seeing the regulation shortly, but the main problem is the drastic need to overhaul the government contract. While the Statement says first steps are being taken, I ask the Minister when the major work funding for it will be concluded. Will he also tell your Lordships’ House what provision there will be for the 3 million people who are either immunosuppressed or immunocompromised—for example, because of blood cancer or because of strong medication which has to suppress their immune systems? The government advice on the web page still says that people in this group should not mix with people who are not fully vaccinated or may possibly be brewing Covid, but a year ago all support to this group was ended. Along with other people in this group, because I am one of them, I am about to have my sixth Covid jab, but I have no idea how long I am going to be protected for—that is why I wear a mask a lot of the time in the Chamber. Half a million of the most severely immunocompromised people cannot make any antibodies in response to the vaccine. They were promised antiviral medication or Evusheld. Five million doses of antivirals were ordered, but only 50,000 were handed out, and the Government have just refused to allow Evusheld to be used. What will the Minister do to ensure that this group of people will be protected?

Finally, the Health Service Journal has said that two out of three integrated care systems have fallen off track on their financial plans because of the impact of inflation, Covid cases not being funded this financial year and higher spending on agency staff. This plan will not work if the new integrated care systems cannot work. It is vital that the Minister tells us what plans there are to make sure that ICSs will be supported properly.

The plan for patients has many warm words for delivery. I know this is something the Minister cares greatly for, and we will support him, but the words on their own will not do it. Our NHS and care sector are on their knees already. The Nuffield Trust report says that data shows that even without the pandemic, the backlog would have been well over 5 million. It says the NHS was already stretched. I look forward to hearing the Minister explain how the NHS and care sector will be able to deliver on this plan in their current state.

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

I thank noble Lords again for the warm welcome they have all given me today. I feel like an old hand already—I wish. Before I begin, I draw attention to my declaration of interests in the register as a new boy here, so to speak.

I am grateful to noble Lords for the interest they have shown in our plan for patients and will try to address the questions raised. As my right honourable friend the Secretary of State said in the other place, these measures across a number of important areas are the start, not the end, of our ambitions for health and care. They will help us to manage the pressures that health and care will face this winter and next, and they will improve these vital services for the long term.

First, I want to set down that there is record investment going into this area. In fact, we are spending about 12% of our GDP, which is the highest level ever. To answer the noble Baroness’s question directly, the 200,000 figure I gave was for FTEs since 2010. That means 200,000 more full-time equivalent employees in the health services than in 2010, so the investment is there, and we have a plan, set out in the plan for patients, to increase supply by 30% in terms of electives. I have seen some excellent examples of that already in Chase Farm Hospital, one of the new hospitals.

As I think I mentioned earlier, the new hospital build programme is one of the areas for which I am responsible; a £10 billion investment per year will go into capital programmes such as this and other initiatives. It is all about increasing supply by 30%, because we will be able to get on top of these issues only if we increase supply.

At the same time, as has been drawn out, I appreciate that we face an unprecedented challenge in the levels of Covid we are seeing and in flu respiratory issues; we have had less warning about that than ever before, because normally we can see what happens in Australia and use that as a warning. I am aware that we are likely to face more challenges there than ever. At the same time, we are putting forward the beginnings of a long-term plan to tackle this. I will talk about that and, I hope, answer the questions raised—my own ABCD, if I may.

I will start with care, because not only is it important in its own right to make sure that people are cared for in the correct place—it is much better and more cost effective for people to be in a care home than in a hospital—but freeing that up will free up the whole system. We all know the problem is often that A&E is full because it cannot put patients into hospital beds and therefore the ambulances cannot release their patients into A&E, backing up all the way through the system. That is why one of my priorities is the care side.

I will need to get back to the noble Baroness, Lady Brinton, on virtual wards in terms of support for GPs. I have seen the excellence at first hand, and the incredible reduction in figures that it can make, so to my mind we should focus on that and make sure that GPs and their surgeries have the right focus and support to help them. I will follow up with the noble Baroness with more detail on that, if I may.

I see this as key to care and the £500 million spend—again, I will give the noble Baroness, Lady Merron, details of how that is being used, because we want to make sure that we work with the integrated care boards, as she said, to ensure that it works to best effect. With that, I think we will start to see improvements come in for A&E and ambulances. As I mentioned before, we have seen a 10% increase in staff there versus 2019-20; that is what the 7,000 new beds are all about.

However, in terms of performance, we have seen great disparities. I am sure noble Lords have heard before the statistic that 15 of the hospital trusts account for 45% of all waits. I want to understand why that is. It is fair enough to trot out that statistic—I expect noble Lords to challenge me in a couple of months’ time to ask what was happening in those 15 trusts and what I have done to put it right and make sure they are performing well. My task is very much to put them under the spotlight and try to understand how we can perform much better in some areas and take those learnings to help them in others. I am under no illusions that it is tough out there. My wife is a dentist, so I have some knowledge of this; also, my mother was a practice nurse, so I understand how important and tough the role is.

Working through the backlogs and getting on top of the waiting lists will be key. There is an £8 billion programme, as we are all aware, to increase supply by 30%. I have seen fantastic examples at Chase Farm, as I have mentioned, and Watford of robotic surgery—I had the pleasure of playing with it myself, though not on a real patient—that I am sure will be revolutionary and transformative. It is about doctors, dentists and all care workers—all of them. As I say, I have a particular interest in the nursing profession.

It is all about releasing the 50 million more appointments, which I am glad to say we are making progress on. A lot of that is about making sure that you see the person best suited to meet your needs. We must make sure that we use GPs where they will best meet those needs. They are our most skilled specialist resource, so I want to make sure that they are focused on the cases that are best for them. As I say, I have experience through my mother’s role as a practice nurse of how much she could do and how much we can use them to meet a lot of the appointments targets—and make it a better job for them, because they have the skills and can be very valuable. The same is true of community pharmacies. Funnily enough, I worked at one in my first job—many years ago—so I have a little experience of that. It is all about trying to expand capacity.

I apologise, I cannot answer the noble Baroness, Lady Brinton, right now on the 3 million immunosuppressed so I will need to get back to her on that.

As the noble Baroness, Lady Merron, said, it is about trying to raise performance across all areas. The brilliant thing is that we have seen very good areas—I am sure we have all seen them when we visit hospitals—which have excellent performance, but my feeling, coming in as a bit of an outsider from business, is that it is patchy. There is an opportunity to spread that performance, really understand what good looks like and do more work to make sure that it is spread across the system. Part of my remit will very much be the performance agenda and working with the NHS executive team to make sure we see those improvements across the board.

I hope that gives noble Lords a flavour of how I hope to address what we see as our plan for patients. It is our commitment to what our patients can expect. I hope we can see that it is proactive, not prescriptive; ambitious but also achievable. We hope that, by empowering patients, they can start to challenge and drive performance as part of that, as a first step. Through that, we will be able to help, as part of the long-term plan, both the NHS and health and social care deliver for them. As such, I commend this Statement to your Lordships’ House.