Cancer Research UK Report

Lord Allan of Hallam Excerpts

Tuesday 5th December 2023 Lords Chamber

[Lord Markham (Con)]

I agree that research funding is key. That is why I mentioned the £100 million that we spent in 2021-22. The Medical Research Council is also spending £125 million per annum on cancer research. That is allowing us to introduce vital things such as the point-of-care cancer treatments that our regulators that have brought in ahead of anyone else in Europe, showing the key flexibility that our regulators now have, meaning that people can have individualised cancer care. I agree that we need to invest in these sorts of activities.

[Lord Allan of Hallam (LD)]

My Lords, I recently had a meeting at one of our excellent specialist cancer hospitals. It explained that it had tens of millions of pounds in the bank that it would like to spend on facilities and equipment to support new cancer treatments, but it cannot. The only blocker is that it cannot get a certificate from the local integrated care board to authorise the capital expenditure. Frankly, I was astonished by that. I invite the Minister to explain, in terms that even I can understand, why the Government think it a good idea to prevent a world-leading hospital trust from spending money that it already has on much-needed cancer research facilities.

[Lord Markham (Con)]

I am not clear on the details of the case but will happily take it up with the noble Lord afterwards. I agree that, clearly, we want our leading institutions spending money where they can really impact change, and that is exactly what we are doing.

National Health Service: 75th Anniversary

Lord Allan of Hallam Excerpts

Thursday 30th November 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am not able to go back to the foundation of the NHS like the noble Lord, Lord Dubs, but I will start by going back half way, to 37 and a half years ago, when I was starting to travel the world, having just left school. I got into those conversations where you compare countries, and I was asked what was so special and interesting about the NHS. I could not say that it was all public, because it has always been mixed, and I could not say that it was all free, because there have always been charges for some elements of it. The best way I found of explaining why the NHS was special was that, in the UK, we can go to bed not worrying about getting help if we fall ill in the night, or if something happens to our parents or, God help us, to our children. That is certainly not true in all parts of the world. This reflects the promise that was in the newsreel that the noble Lord, Lord Lexden, cited at the beginning of our debate. It is a wonderful freedom that we enjoy, and it means that most of us can change jobs, move across the country, have children, and live far away from our families, all without worrying about whether those decisions will harm our healthcare and that of our families. These freedoms are underpinned by knowing that the NHS is there.

By contrast, a family member in the United States brings home to me what it is like not to have this freedom when he jokes that he has to stay with his spouse because of his health insurance—funny, but not funny. When I left my job with a US company in 2019, access to healthcare was irrelevant to my decision. It had a private health insurance policy, which meant it could get me back to work quickly because it needed me there, but I was much more interested in the free food; I did not see the private health insurance as essential because I had the NHS. I compare that with former colleagues who live in the United States or other countries, for whom the loss of their job vastly increases their health risks.

The NHS represents a significant form of freedom, but this applies only as long as it passes a key test: that we feel that it is sufficient and that we do not need something else. That proposition is holding up remarkably well, even though it has been under severe pressure many times. However, it is not certain that it will hold for the next 25 or 75 years without herculean efforts. In his introduction, the noble Lord, Lord Hunt, rightly talked about previous phases when there were herculean efforts. I was at the other end in the Parliament of 1997, and the work that Labour Ministers did then was remarkable and necessary. I feel that we are in that phase again and we need remarkable efforts to hold up.

The front-line staff have rightly been praised in this debate as critical, but I hope we also take a moment to recognise those who do the hard work of prioritisation. Administrative staff who manage waiting lists do not do fashionable or glamorous work, but it is essential to making sure that people feel that the service can deliver. Staff at the National Institute for Health and Care Excellence spend their time evaluating new forms of treatment and are often only in the headlines when they are being criticised, but their work prioritising new treatments means that that promise can be sustained. My noble friend Lady Walmsley mentioned IT staff, with whom I have a particular affinity, having been one for some years of my professional life; they keep the information flowing that allows patients to keep flowing and people to maintain confidence in the service.

There is no world in which some form of rationing of finite resources becomes unnecessary, but the key is the right allocation of those resources to where most people agree, most of the time, with the way the services are being prioritised. That is the key point I want to make in my contribution: that trust and confidence depend on not allowing the gap between people’s reasonable expectations and their actual experience of the service to grow too wide. Neither side of this equation is static, but will evolve over time.

Expectations are very different today, as we live longer and patterns of behaviour have changed, but we have also changed our expectations in wanting more information about and involvement in decisions. It is often said that the age of deference is dead. That is certainly true: we are in a very different world from 1948, when you were grateful for whatever the doctor gave you; now, people want to question and be involved in decision-making about prioritisation. My main ask of the Minister in this debate is for him to focus on that link between information and trust. It is about not data as an end in itself, but how we can turn data into useful information that feeds into a good process of deliberation, which means that we reach decisions about the allocation of NHS resources that win widespread trust and confidence.

I declare an interest in open data—I realise that I also spoke on this earlier in the week—as I am a non-executive director of the Centre for Public Data, which is a not-for-profit organisation campaigning to make more data public. I joined that organisation because of a long track record of believing in the value of open data, precisely because I think that transparency and not black boxes leads to trust in our much more inquisitive, non-deferential age.

We need to flesh out the narratives, as well, and not just get the raw data. It is interesting to know how many GPs there are—the Government just tell us that we have X number of GPs—and how many appointments they are serving but, for a complete picture, we need qualitative information, as my noble friend Lady Walmsley mentioned. We need to know how many of those GP appointments were useful, how many would have been better directed to other healthcare professionals, how many urgent consultations were stuck in a queue behind less urgent ones, and what could be done about improving the identification and prioritisation of those appointments.

I hope the Minister agrees that we need this kind of open, informed and above all honest discussion about how choices and prioritisation are done to maintain public confidence. This is not an alternative to providing additional resources, as many previous speakers have said, but is complementary to it, as people will feel that the additional resources they are putting in will really make a difference, according to their priorities for what they want to get out of the service.

On honesty and transparency, I note that the focus of the Government’s Autumn Statement on simply tax cuts, without telling us what impact they will have on public spending, was extraordinarily unhelpful. Certainly, the choices have been noted as a reflection of the Government’s priorities.

The prize here is that our children and grandchildren enjoy the same freedoms we have—freedom from worrying about getting help for their own health and about whether their elderly parents or young children will be cared for. This is a huge benefit in which it is worth investing, but it can easily slip away. Trust takes years to build, and the NHS still has bucketloads of it, despite the many challenges it has faced.

But if we as political leaders allow this trust to leak away, the drip may turn into a flood. Every detail matters in this debate, and in preventing the horrible outcome of a lack of trust in our National Health Service—and I know the Minister is a details man. I hope he will commit today to taking the measures needed to maintain trust, and that he is willing to agree with the proposition that a British Government, of any political colour, will have failed if the people of this country can no longer go to bed at night free from worries about where they will get healthcare when they need it.

Health Care Services (Provider Selection Regime) Regulations 2023

Lord Allan of Hallam Excerpts

Monday 27th November 2023 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, like the noble Lord, Lord Stevens, I very much welcome these regulations. As he put it—in a very kind way—in essence they withdraw the wretched health Act 2012, which enforced competitive tendering on clinical services and, as the noble Lord said, was not only bureaucratic and costly but got in the way of integration and collaboration. Of course, the Explanatory Notes that go with this SI are very explicit in saying so. I noticed, though, that the Minister failed to mention the 2012 Act. In fact, the Explanatory Memorandum was just the thing my noble friend Lady Thornton used at the Dispatch Box as we sought to scrutinise the wretched 2012 Bill, which cost so much money and staff time and achieved so little.

I want to pick up one or two points that the noble Lord, Lord Stevens, raised. The first is to acknowledge that there is a huge challenge for the procurement profession. I remind the House that I am patron of the Health Care Supply Association. I understand that the provider selection regime regulations come into effect in January, but these are ahead of the procurement regulations which come into effect in October next year. It is important that the Minister mentioned the guidance and I am very glad he mentioned the work that will be done by NHS England in supporting the service implement these regulations. However, I say to him that if you are trying to work out the relationship between the 2022 health Act, the 2023 Procurement Act, these regulations and the forthcoming procurement regulations, to a procurement manager sitting in an NHS trust this can be rather complex. The more help and guidance that can be given to those professionals, the better.

The Minister may well be aware that at the same time as procurement teams have been asked to implement this big change, they are having to generate short-term savings to meet the financial pressures in-year at the moment and actually cut their department operating costs. It is a short-term saving that may have long-term consequences, particularly as investing in procurement for the long-term value we wish to see enhanced in the health service makes economic sense. I point out to the Minister the recent announcement by NHS England that it is investing £600,000 in new commercial roles to unlock £1.5 billion of savings. That is very welcome, but we should be investing similarly in local and regional procurement teams as well. It is also important that the analysis behind the £1.5 billion savings is made available in order to guide the procurement function in the areas they need to be focusing on.

What is being done to support the skills, training and development of the NHS procurement and supply chain people? Will we invest in learning and development through organisations such as the HCSA and the NHS Skills Development Network to support upskilling and developing their functions? I commend the strategic framework for NHS Commercial, published only in September, and support the establishment of academies of commercial excellence—these are good initiatives—but you also need to support the people on the ground to do the job most effectively.

The noble Lord, Lord Stevens, said that there is a good balance in the regulations, because, while we want to get rid of the bureaucracy of automatic competitive tendering, as there is clearly no point doing it, we do not want to lose the opportunity of inviting innovative companies to play a part in the health service in the future. There is an issue around conflict of interest in the new structures. He will be aware that, around the table at integrated care boards, the chief executives of the local trust will often be in membership. In these regulations, and more generally, there are rules about how you mitigate that in a competitive process, but the decisions that ICBs make will sometimes be not to go down a competitive process at all—decisions, as I understand it, that those trust CEOs can be part of. I have had a briefing from Specsavers, which says that there surely needs to be some kind of requirement for ICBs, particularly for community services, to consider proposals from non-commercial providers who can demonstrate that they can improve value, quality of care and clinical outcomes. It is there that the conflict of interest issue arises.

How will value-based procurement be driven forward? In the draft PSR statutory guidance, “value” and “social value” are two of the national criteria for procuring health services. As I understand it, value-based procurement is about looking at which product is not only cheapest per item but best for patient outcomes, quality of life and avoiding relapses or unintended side-effects. I have been championing value-based procurement because in the long term it provides better value for money and better quality of what is being procured. The Minister has kindly agreed to meet me—I am grateful for that—but a statement from the Government on the importance of value-based procurement would be helpful.

Finally, I will ask the Minister about health technology. How far does he think these regulations support our vital health technology sector? I have been in discussions with ABHI about the potential that health tech offers the UK—it is fast—but there are worries that, in the new world, there are issues limiting the ability of many of these companies to be competitive, some of which are clearly to do with regulatory uncertainty. He will know of the issues with the MHRA’s performance. I pay tribute to the MHRA, but there is no doubt that it has resource issues—both money and staff—when getting things approved where they need to be approved. Coming back to Brexit, surely one of the advantages of having an independent regulator is that we can be seen as a place that, for medicines or medical devices technology, has a first-rate regulator that takes these processes through as quickly as possible. The problem, as he will know, is that there has been a blockage inhibiting innovative companies, so we really need to do something about it.

Overall, I warmly welcome the regulations. I thought that the Minister could have acknowledged a little more the failings of the 2012 Act, but we will pass on that. I certainly very much support the general thrust, but the procurement function in the health service needs every support it can get in understanding the new architecture and implementing it fully.

[Lord Allan of Hallam (LD)]

My Lords, this is an altogether weightier statutory instrument than the previous one we discussed, running to many pages and with lots of interesting new acronyms. The noble Lords, Lord Stevens and Lord Hunt, have set out effectively the case for why the changes are necessary, in a kind of Birmingham pincer movement as I stand here in the middle. I also have ringing in my ears the comments of the noble Baroness, Lady Merron, on the previous statutory instrument, when she talked about a particular instance where procurement went wrong. We need to have that in mind.

It is worth putting a marker down now on the potential impact. We are talking about many billions of pounds of expenditure; how many billions is an interesting question that we will come to in a minute. The potential benefits are hundreds of millions of pounds of savings, as the noble Lord, Lord Stevens, pointed out, but we must acknowledge that there is a potential downside risk, which could be millions in fraud and legal fees. It is worth spending a moment as we debate the instrument to make sure that everything is being done to ensure that we get the upside but minimise the downside.

My first question is around the integrated care board members and conflicts of interest—something that was raised by the noble Lord, Lord Hunt—particularly where they are not in a competitive tender situation, where we are talking about direct awards and most suitable providers. Once that decision has been made, there are some valid questions around what that means. Candidly, we do not want to create 42 ICB VIP fast lanes where people can talk to the ICB and somehow get themselves out of the normal procurement process when they should not be out of it. Therefore, there are risks at that level; we must be conscious of that. Given the roles that ICB board members have, and since these are local entities, it is likely that an ICB board member will have relationships with people in the local community who deliver services that will be subject to the tender.

My next question is about the variability and the number. It is flagged in paragraph 4 of the impact assessment that the expenditure over a period was

“estimated to be between £75bn-£380bn”.

I am not great at maths but that is quite a significant variability. It talks about how the £75 billion concerned procurement processes that went through the EU process and were notified, while the long tail of the other £300-odd billion concerned other procurements that were not notified. However, we should be able to get better information than that. One of my requests for the Minister comes with a suggestion: there should be a machine-readable database somewhere where all health and care procurement can be analysed and studied. I know that the department intends to do that but, actually, the best way for us to understand that we are getting good value for money is this: if anyone, whether a researcher at one of our excellent universities such as the University of Birmingham or another interested party, wants to be able to look at NHS purchasing data and can analyse it, they should be able to do so.

This seems to me to be a reasonable request to make of government: that information about procurement—including the status and how the contract was awarded, whether it was competitive or elsewhere—is publicly available and analysed by any third party who chooses to do so. The Government would benefit from that, as would individual NHS procurers, as people will analyse those patterns of purchasing and perhaps suggest something that they had not thought of themselves where they may be able to make more savings.

The final area that I want to cover is one that the noble Lord, Lord Hunt, touched on: skills in procurement. I suspect that all of us who follow healthcare have seen the Health Service Journal article in October that talked about integrated care boards in the south-west of England paying £1.7 million in compensation for a procurement failure. Obviously, that is happening under the existing regime, but it is a strong warning sign that we need to heed what happens when we get this wrong. Again, the impact assessment helpfully talks about the litigation process and the different costs that may be assigned to each area. I think that we tend to underestimate these things. If anything, once you get into a litigation process, the pressure to settle and resolve it means that money is often thrown at the problem. This could mean a significant cost to the NHS if we get it wrong. The fact that we have a new process means that new risk is being introduced. What is being done around training? That comes in two aspects. The first is general awareness raising, which applies to everyone. Certainly, I have had experience in business of working for an American company where you are subject to the Foreign Corrupt Practices Act, meaning that you go to prison if you try to bribe a member of a foreign legislature.

Health Protection (Coronavirus, Testing Requirements and Standards) (England) (Amendment and Transitional Provision) Regulations 2023

Lord Allan of Hallam Excerpts

Monday 27th November 2023 Lords Chamber

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

My Lords, I draw the House’s attention to my declaration of interest in the company that I founded, which was accredited under these rules. The fact that it is accredited means I have some experience, which always helps in an area. It is not affected by these regulations, but I was keen to state that for the record.

The 2023 regulations update the legislation introduced in 2020 to impose requirements on private providers of Covid-19 diagnostic testing. Once they are implemented, private providers will need to be accredited by a signatory of the International Laboratory Accreditation Cooperation mutual recognition arrangement before they can supply testing. These measures replace the current three-stage UK Accreditation Service process with a simplified and streamlined one. They also remove requirements that are no longer necessary due to legislative developments that have taken place since 2020. The changes will empower consumers to choose a private testing service with confidence, continuing to improve safety and quality. During the Covid-19 pandemic, the Health Protection (Coronavirus, Testing Requirements and Standards) (England) Regulations 2020 focused on enabling providers who met appropriate quality standards to be able to rapidly enter the private testing market. This struck the appropriate balance at the time between protecting public health and growing the market quickly.

I am pleased that the worst of the pandemic is behind us, so the urgent need to grow the Covid-19 testing market quickly no longer applies. The department has therefore reviewed the 2020 regulations and proposes that all private providers must be fully accredited before providing testing services. This amendment will bring in requirements and standards that help to strengthen consistency, safety and high-quality Covid testing services.

I am pleased to be debating the statutory instrument that is necessary to implement our proposed updates to the existing legislation. The 2020 regulations introduced a three-stage accreditation process for organisations providing Covid testing commercially. The three-stage accreditation process requires providers to satisfy the UK Accreditation Service that they meet the relevant ISO standards within a set timeframe. Stage 1 requires the private provider to make an application to UKAS for accreditation and make a declaration to DHSC that they meet and will continue to meet certain minimum standards. Stage 2 requires the applicant to demonstrate, within four weeks of applying for accreditation, that they meet requirements published by UKAS. From January until June 2021, stage 3 required providers to complete their application within four months.

We wanted to ensure that a greater number of high-quality applicants were given sufficient opportunity to complete the process and reduce resourcing constraints on UKAS while maintaining quality control. In June 2021, we passed legislation to update stage 3. Applicants were now required to achieve a “positive recommendation” from UKAS within four months of completing stage 2. Provided they received this, they then had a further two months to achieve accreditation. Providers who fail to meet any of these deadlines, or fail to satisfy UKAS that they meet the relevant standards within this timetable, have to stop supplying testing. The purpose of this approach was to ensure that enough providers were able to enter the market soon enough to meet the public demand for testing. It ensured that we were not as a country left with insufficient testing capacity while still putting providers through an appropriate process.

Now I move to the substance of the regulations. The 2023 regulations implement several policies coming into force from 1 January 2024. First, private providers—diagnostic laboratories, sample collection and point-of-care testing—must be accredited against the appropriate ISO standard by a signatory to the International Laboratory Accreditation Cooperation mutual recognition arrangement before they can start supplying their service. This replaces the three-stage accreditation process. Since setting up this process, the Medical Devices Regulations 2002 were updated to prescribe a specific process for the validation of Covid-19 test devices. We therefore no longer need test validation measures in these regulations as well, so we are removing those. Secondly, the amendments reflect the publication of the updated ISO Standards 15189:2022. The amendments are forward-looking and do not affect private providers who applied under the previous ISO standards—ISO/IEC 17025:2017—before this instrument came into force. Lastly, this instrument removes the requirements to make a declaration to DHSC at the start of the application process and shifts the legal responsibilities for the clinical service to the private providers providing the clinical service, rather than the customer-facing part of the testing service.

The amendments will hold providers to high standards, by requiring them to be accredited before they can join the market. This will give confidence to individuals choosing Covid-19 testing services. The amendments also remove the additional requirements and administrative steps that were necessary in the early stages of the pandemic. Those who have already achieved accreditation will be unaffected by the change; that is, they will not need to reapply for accreditation under the new regulations. All private providers will be required, as normal, to transition to the new ISO standard by 6 December 2025 at the latest.

The amendments allow private providers who are accredited by a signatory of the International Laboratory Accreditation Cooperation mutual recognition arrangement to enter the market. The UK Accreditation Service is one of 90 accreditation bodies that have signed the arrangement. It enhances the acceptance of products and services across national borders. By accepting accreditation from these signatories, we help to remove barriers to trade such as the retesting or inspection of products.

Private providers must be accredited to the relevant ISO standards for clinical testing services. These standards were reviewed and updated in 2022 and transition proceedings have begun: the old standards will be revoked in 2025. The existing 2020 regulations do not reflect the updated ISO standard. So, if we did not make these amendments, providers who transition to the new ISO standards—as they are required to do—would not under our own rules be able to provide testing services. This is a clear lacuna that we need to address.

I am happy to be bringing forward this legislation today. These regulations will reduce bureaucracy whilst still delivering rigorous accreditation requirements, important for public health. I commend these regulations to the House.

[Lord Allan of Hallam (LD)]

My Lords, it is good to be able to debate a piece of legislation that is quite technical but still quite important. The regulations themselves are entirely sensible as tidying-up legislation after the coronavirus pandemic, but they trigger a few points that are worth putting on the record and seeking a response from the Minister on.

The first is just to note that it is good that we are following the international standards on this. I am sure all noble Lords experienced that period during the pandemic when there was confusion around which countries accepted whose tests and it became blindingly obvious that we needed international recognition. It is pleasing that we are following a standard that, as the Minister said, 90 bodies are now signed up to. It is good to have the confidence that when we pay for tests here in the United Kingdom, there is a good chance that they will have that international recognition. Does the Minister have a sense of whether other countries are following a similar path, where they implemented a special regime during the pandemic that they are now transitioning into a normal regime, just as we are doing today? Is the United Kingdom in step with other countries or are we ahead of or behind them? It would be interesting to know that; I assume the department has done some work around it.

Mental Health: Children and Young People

Lord Allan of Hallam Excerpts

Thursday 23rd November 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to my noble friend Lord Russell for securing this debate. Like many others, I am impressed by how quickly he has brought value to the work of this House and by the combination of passion and reasoned argument that he brought to today’s debate.

I congratulate the noble and learned Baroness, Lady Hale, on her maiden speech. I had not realised that she is from Yorkshire but, based on the comments of the noble Baroness, Lady Hollins, I can say, as a Sheffielder, that we are now on a Yorkshire hat trick as a group of three speakers. In my household, it is not often that we talk about the law as a cool and attractive profession, but the activities of the noble and learned Baroness in her previous role triggered such comments. Based on her contribution today, I am sure that, in future, she will provide examples of how our words here can be both impactful and entertaining. I hope that she does not let her natural diffidence get the better of her too often.

Turning to the subject of the debate, I start with a question: what do we call a family with experience of child mental health issues? The answer is “a normal family”. That has been reflected in the debate, as well as in my noble friend’s contribution as he related his own experience, but I suspect that every person sitting here today has their own direct personal experience of a young person suffering from mental health issues during their childhood, whether through their children, their nieces and nephews, their grandchildren or those children’s cousins. This understanding is necessary not to trivialise the matter—quite the opposite. If we normalise it, we may get to a position where we understand that child mental health issues need to be treated as seriously as other child health conditions, with an infrastructure and an understanding that, as my noble friend said, it is unacceptable to ignore them or somehow treat them as less serious.

The tools that we need to help people are common to all kinds of healthcare. First, we need early and accurate identification of problems. Secondly, we need good availability of the right treatment options; that is the case whether it is a physical issue or a mental health one. There are also four settings that need to work for young people in order to achieve these goals of the identification and treatment of the issues with which they present. The first is families themselves; the noble Baroness, Lady Hollins, referred to the importance of family as the primary setting. The second is the educational institutions in which children find themselves; the third is primary healthcare; and then there are the acute services to which children may need to turn. I will not go into the issues around family support in any depth today other than to flag the fact that families and the care they provide must be recognised and supported. There is an important objective for government in supporting families who provide care for somebody, whether they have a physical condition or a mental health one; that care provides enormous value to the individual but also to society. There are questions around the extent to which, today, government provides the support that those families need.

I turn to educational settings. These are generally schools for younger children but we should not forget the significant role of universities and colleges. That is important because we are talking today about children and young people; to me, that extends through into those university years. It is another period of transition. For many of the young people who reach the age of 18 or 19 and transition to university, that is when the crisis hits. Again, universities have a critical role to play in this.

Major shifts are needed to improve staff training. Staff across all these different kinds of establishment need to be trained in such a way that they can help identify problems, because problems may first present themselves in an interaction between a young person and a professional in an institution. We also need to make sure that counsellors are available when they represent an appropriate form of treatment; they are frequently the first line. The Minister has made commitments around both those aspects previously—the training of all staff in educational establishments where that may be useful in identifying problems; and the provision of counselling services to the right degree so that, when issues have presented themselves, that first line of treatment is available—so I hope that he will be able to demonstrate progress.

I am interested to understand from the Minister how budgets will operate in this space given that it sits between different government departments. The young person does not care that one thing sits with DHSC and another sits with DfE, or whatever acronyms we are using now; they care about whether treatment is available. I hope that the Minister can indicate how we will ensure that budgets follow need rather than being stuck in departmental silos.

I want to touch on bullying, which can be both a cause and an exacerbating factor for somebody with mental health issues: it can trigger the mental health issue but, sadly, the start of bullying can also sometimes be the response of young people to someone in their school who has a mental health issue. It then compounds the crisis that a young person is suffering. The challenge is to have an effective response because these issues are often labour intensive, requiring engagement—often over a long period—with the children and families involved.

As noble Lords may be aware, I have professional experience of the online component of this as I spent many years working at a large online platform. It seems obvious that the nature of bullying has changed with ubiquitous connectivity. However, sometimes, there is also the risk of us seeing the solutions as entirely within the domain of technology. People report bullying to a platform, which can result in the removal of the content and sometimes the closure of the bullying account, but it rarely solves the underlying problem.

In some cases, the bullying is entirely within an online community, but much more typically the online activity is an extension of something that is happening offline in the real world. The intervention that resolves the problem is one that brings young people, parents and others together to discuss the offline and online activity. I understand the challenges for school staff in resourcing this, but some option will have to be found or we will simply be playing whack-a-mole on the online platforms, knocking down individual instances while the young person’s mental health continues to deteriorate because the bullying is moving from place to place and never being addressed at its root causes.

Some of the best work that I have seen on this involves civil society organisations working with schools. I cite one young person, Alex Holmes, an individual who experienced online bullying in large part because of a racial dimension. He came to me when I worked at an online platform to try to turn his experience into something positive. He went on to work for the Diana Award and he now works for the BBC Children in Need foundation. I saw the work that he did, and that similar organisations do, complementing the work that is being done in schools, running effective anti-bullying programmes and getting the kind of intervention that we need to deal with those root causes. I hope that the Minister will agree that this kind of approach, bringing together schools, platforms, online platforms, which do have their responsibilities, and also civil society organisations with anti-bullying expertise, is a smart way to reduce the risk of bullying affecting young people’s mental health.

The other natural choice for people who are seeking help is to look to primary care, particularly their GP. The response is likely to vary considerably, as not all general practices have the skills to offer specialist mental health support. This is not to criticise or blame GPs but is a simple recognition of the limitation in capacities in most practices and that the support needed may go beyond that which the GP contract was designed to deliver. GPs are bound within a particular framework. This may result in the GP referring someone to a mental health service, but it is worth asking whether more could be done in the primary care setting itself. This might be better for the patient, it might involve shorter waiting times and, from the Minister’s point of view, it may well be more cost effective, which the department would see as a positive take.

Recently, I met with a group of mental health nurses working in primary care at the Royal College of Nursing who made a very strong case for developing their profession. At the moment, there are not mental health nurses in all practices, but some of the best practices do have them. This could happen on a group basis—for example, where a primary care network contracts together to ensure that there is a mental health nurse available so that, whichever GP you go to, you get the benefit of that mental health nurse; it does not necessarily require every practice to have one. The noble Baroness, Lady Hollins, referred to the need for public health support. Understanding the pattern of need and ensuring that you resource appropriately is critical and something that public health professionals really can help with. This could also be delivered through specialist centres. We propose that there should be youth mental health drop-in centres. This is something that we need to ask young people about. It may be that they would prefer a different setting from the general practice setting if they want to talk about something as sensitive as this. In either case, the critical thing is that there is some trained professional available to that individual if they present within the primary care system. Today, we must recognise that support is very patchy.

The acute sector will be necessary for some young people as other interventions have proved insufficient. I think that we will come back to one aspect of this in our next debate, but I have some questions for the Government now. The first is whether there is sufficient investment in community-based treatment for people with serious mental health that allows them not to be moved into in-patient settings except where this is strictly necessary. Some of the stories that are reported to us suggest that people are being taken to an in-patient setting not because that is the best treatment option but simply because their complex needs cannot be treated in a community setting due to resources, not due to the fact there is no treatment available. It is a shame if we are moving people to in-patient settings where it is not necessary. I would be interested in the Minister’s view on whether the test is being met or whether too many young people are still being treated as in-patients only because of that lack of appropriate out-patient support.

Secondly, and somewhat related, there is the question of where young people go when they need a place in a hospital. It is usually beneficial for all patients, but especially for young people, to be near to their home area, for the family visits and support and, crucially, because of their reintegration into the community on discharge. Being taken far away and then moved back is clearly more disruptive, particularly if you are going through a process of phased discharge from an institution, when it is much more helpful to be in your home community normally. There are exceptions, but typically we would want to see that. I am keen to understand the Minister’s views on out-of-area placements and how these can be minimised where they are not helpful from a treatment point of view.

Once again, I thank my noble friend Lord Russell for securing this debate, and I congratulate the noble and learned Baroness, Lady Hale, on her maiden speech. I close with a ready reckoner reminding the Minister of the issues which I hope that he can address in his response. Are the Government committed to building a culture where we treat mental health on a par with other forms of childhood illness? How are the Government ensuring that educational institutions can provide the support that their students need, especially around anti-bullying where that is a significant component in mental health problems? What is the department doing to provide more specialist support in primary care settings, whether that is by GPs or dedicated centres? What is the NHS doing to minimise the need for in-patient treatment where there are out-patient alternatives available but it is simply a question of resourcing? Finally, what are the Government doing to ensure that placements are not out-of-area where in-patient treatment is unavoidable?

Learning Disabilities and Autism: Solitary Confinement in Hospital

Lord Allan of Hallam Excerpts

Thursday 23rd November 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, on a good day we learn in and through debates in this place, as we bring a mix of different experiences. I was struck by the suggestion of the noble Baroness, Lady Hollins, that there should be Secretary of State approval for certain forms of solitary confinement. That made me think of debates that we have had in a different context around warrants for the interception of communications, where critics will say, “What is the point of the Secretary of State warrant? They will just approve it, rubber-stamp it”. Of course, it is true that the Secretary of State is not sitting there thinking, “Does this particular drug dealer deserve to have their phone tapped?”

However, crucially, the instrumental part of it, the key functionality, is that the approval process then requires a group of officials to dig into the case, look at all the details and understand whether the warrant is justified. They do not want to send up to the Minister for approval something that is deficient. It made me think that if an official is willing to send to the Secretary of State a request to approve a confinement for 450 days in a windowless room on a mattress on the floor, then good luck to them, but if nobody is willing to put that forward, it should not be happening. This is a process that is well worth considering. Who ultimately signs off and takes ownership of this? Also, the process by which it is approved is critical. It should not be left to the decision of, as the noble Baroness said, a private provider somewhere who just has a problem to resolve and feels empowered, with no further external approval, to make such a fundamental decision that will have such an impact on an individual. That was interesting. I hope that the Minister will respond on it.

The other part of the report that I found helpful was the four-stage failure that is described in annexe B, which appeals to my analytical brain. There is a notion that the first failure is the community-based failure that leads to someone going into hospital, then the failure of the treatment in hospital, which then leads to solitary confinement being considered, the failure of the solitary confinement, then the failure properly to assign responsibility and ownership, which is wrapped around all this. This was really helpful from an analytical point of view.

I hope that the Minister can confirm that there will be published data on all those stages. There are certainly recommendations for there to be reporting on the use of the solitary confinement mechanism, but it is really important to understand how many people are being treated in the community and how many failures there are of that treatment which then lead to hospital treatment and how many failures there then are in the hospital, so that at each stage we understand the number and types of failures that are occurring. That will inform our ability to hold the right bodies to account and resolve that fourth failure, that of accountability. It is only through that relentless scrutiny that we can address the issue of accountability—and that relentless scrutiny depends on the data.

I want to ask the Minister about the federated data platform in this context, although today is not the day to talk about this. For noble Lords who are not following this closely, this is the new all-singing, all-dancing thing that will pull together all NHS data. It seems to me that is very much acute focused—which is a good thing—as it is very much about ensuring that we get the flow-through in in hospitals, but it seems to me that the same kinds of tools and disciplines are needed for what we are talking about here, for understanding where people are in the system including, crucially, across different providers. However, it is not clear whether the hundreds of millions of pounds that are being spent and all that effort will yield any benefits in this area where, as the noble Baroness, Lady Watkins, pointed out, you are dealing with multiple providers of services and multiple commissioners, and it seems that a lot of them have very un-joined-up systems. It may be that the federated data platform is not the answer, but the tools, practices and data models that are developed could potentially all read across very effectively to the world that we are describing today, in which we face similar challenges about understanding where people are, how they are moving through and, critically, whether those failures occurred at any point when they moved from setting A to setting B either between or within institutions.

I ask the Minister specifically: is there a group somewhere in NHS England that is working on this, looking at the data flows in mental health care, so that we can understand and benefit from all the investment that is going in, rather than potentially facing a scenario where acute medical healthcare gets the investment and mental health care is the also-ran, poor service which will only benefit at a later stage?

I am extraordinarily grateful to the noble Baroness, Lady Hollins, for the report and for analysing the problem so well and so effectively. It is a short report, which is great: there is no excuse for anybody not to understand the problem with a report that size. I am also grateful to her for providing this very clear set of recommendations, and I look forward to the Minister explaining how he will be accepting all of them without reservation.

Adult Social Care

Lord Allan of Hallam Excerpts

Wednesday 22nd November 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I know the Minister is keen to ensure that people who are fit to leave hospital can do so quickly, but is he concerned that local government spending restrictions, imposed because of the state of the finances highlighted in the Question from the right reverend Prelate, may lead to more delayed discharges this coming winter? What steps are the Government taking to ensure that that does not happen—a hospital saying that a patient should leave, but the local authority saying that there is nowhere to go?

[Lord Markham (Con)]

The noble Lord is absolutely correct that the flow through the hospital is vital to A&E and other wait times. That is why we have announced things such as the virtual ward: the 10,000 beds are designed to get people out of the hospital and into a care environment where they still feel supported, thereby using technology to help take the strain. The point about this year, and the whole reason why we announced the £600 million extra investment over the summer, is that we learned the lessons of the previous year, recognising that the earlier we can get this money to the local authorities, the better they can spend it to put the provision in place.

Mental Health Act 1983

Lord Allan of Hallam Excerpts

Tuesday 21st November 2023 Lords Chamber

[Lord Markham (Con)]

The noble Baroness is absolutely correct. With the mental health units to detect problems early, we are now at around 35%; last year it was only 25% but in the next 18 months or so we should be at 50%, which is higher than ever before. I freely accept that 50% is not 100% but it is clearly a step in the right direction. The £2.3 billion investment we are putting in means 350,000 extra places for young people as well.

[Lord Allan of Hallam (LD)]

The Government keep telling us that they plan to take other measures to improve mental health outcomes in the absence of the legislation. I hope the Minister will understand why, having been let down on the promised Bill, we want to see the colour of the Government’s money. Can he go back to his department and ask it to produce a list, with details and dates, of all the measures it intends to take to improve mental health practices via statutory instrument and new guidance in this parliamentary Session?

[Lord Markham (Con)]

Yes. I am happy for the noble Lord to come to the round table and put those points himself as well.

Black and Minority Ethnic Babies: Mortality Rates

Lord Allan of Hallam Excerpts

Wednesday 15th November 2023 Lords Chamber

[Lord Markham (Con)]

The database from which all the evidence and data have come has just been published. That is exactly why we are publishing the database: so that we can understand the reasons behind it. We are also tying that to the NIHR to see what research is needed in those areas.

[Lord Allan of Hallam (LD)]

My Lords, behind every figure in the national child mortality database lies a personal family tragedy, which we all need to try to understand and reduce as far as we can, as the Minister said. The regional breakdown of the figures shows that there is much less variation between different ethnicities in London than in other English regions. Will the Minister look into that to see whether there are things we can learn from London—perhaps there the staff follow procedures where they are more responsive to people from varied cultural and ethnic backgrounds —so that those lessons can be applied in the rest of England?

[Lord Markham (Con)]

Yes, absolutely. One main reason for that is that in London there is generally a more ethnically representative mix of staff, who are better placed to understand and work in that way. Clearly, we need to increase training as well as recruitment across the rest of the country to make sure that they achieve the same levels.

Children’s Hospices: Funding

Lord Allan of Hallam Excerpts

Tuesday 14th November 2023 Lords Chamber

[Lord Markham (Con)]

My noble friend is correct; it is a long-term part of the statutory requirements of all ICBs to provide palliative care, so it is written into that NHSE mandate. It has to review all 42 ICB arrangements, and we make sure that in each setting they have the 24/7 care set-up required of them.

[Lord Allan of Hallam (LD)]

My Lords, following on from the Minister’s answer to the noble Lord’s supplementary question, most integrated care boards will have only a very small number of residents who need services from local children’s hospices. Given that, it raises concerns that spending on those services will not be prioritised at that very local level. Does the Minister accept that there is a case for integrated care boards to band together at the regional level and fund hospice services that way?

[Lord Markham (Con)]

Yes, absolutely. Again, there is a balance we are trying to get over here, because we are all agreed on the importance of what they are trying to do. At the same time, we believe that ICBs, generally, are the right people make provision at a local level, because they know best what is required in their area. Clearly, where it makes sense for them to band together, that has to be sensible.