Care Workers: Foreign Worker Visas
Lord Bishop of London Excerpts(4 days, 8 hours ago)
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Baroness Merron (Lab)
While I absolutely agree about the value of volunteering, as we have discussed before, I should make clear that volunteering is not a substitute for employment on the right pay, the right terms and conditions and with the right status. I also absolutely agree with the noble Lord about the contribution that has been made by those from overseas to supporting our care services, and indeed by all care workers.
As we have discussed in this Chamber, the scheme was not simply closed. It was something that was appropriate for when we were in a pandemic but not for now. In fact, we have introduced a whole range of measures which I will be very pleased to remind the noble Lord of, to ensure that we can have more volunteers who are better used and more highly regarded. They are a complement to our workforce, and very valuable they are too.
Captain of the Honourable Corps of Gentlemen-at-Arms and Chief Whip (Lord Kennedy of Southwark) (Lab Co-op)
We will hear from the Bishop next and then the Cross Benches.
The Lord Bishop of London
My Lords, as we have heard, concerns around low pay and insecure contracts are long-standing in the social care sector. The Minister made mention of the fair pay agreement; can she explain how this will ensure that a living wage, living hours and living pensions will be paid to staff among the private social care providers?
Baroness Merron (Lab)
As noble Lords will be aware, the Employment Rights Bill establishes a framework for fair pay agreements. That will mean an agreement through which adult social care sector pay, as well as other terms and conditions, will be established through negotiating bodies. The negotiations will be reached by employers, workers’ representatives and others, in partnership. That will provide the opportunity to negotiate this in a responsible manner and help address the recruitment and retention crisis in the sector and support the delivery of high-quality care.
Learning Disabilities Nursing
Lord Bishop of London Excerpts(5 days, 8 hours ago)
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Baroness Merron (Lab)
I agree. We have many excellent staff from countries around the globe who are very committed, professional and hard-working. I presume my noble friend is referring to changes in international recruitment. I can assure him that that is why, certainly in respect of care staff, there is a transition period until 2028 to make sure that we have the recruitment in the right place.
The Lord Bishop of London
My Lords, the NHS England 2025 best practice guide has a number of suggestions for growing the learning disability nursing workforce, including requiring CQC-registered providers to provide staff with training for learning disabilities and autism. Can the Minister say what the Government are doing to ensure that this is implemented equitably across the integrated care systems?
Baroness Merron (Lab)
We are very focused on that, and NHS England is working with all areas of the country and local services to ensure that that is the case. There is a national plan for learning disability nursing that has been developed with key partners and focuses on four priorities: attracting, retaining, developing and celebrating the workforce. It is very important that we elevate the standing of learning disability nurses, to whom we are all grateful.
Adult Social Care
Lord Bishop of London Excerpts(6 days, 8 hours ago)
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Baroness Merron (Lab)
As the noble Lord rightly outlines, this is a move, over a number of years, to reduce the reliance on international recruitment. I am really glad that just a couple of weeks ago the Department for Education announced the launch of a health and social care foundation apprenticeship, set to begin in August this year. This is focused on young people and will give them a paid route into the sector so that they can earn as well as gain skills and experience. It will be a wonderful foundation for young people, ensuring that they are encouraged into what is an extremely valuable sector and will have the right skills, including technical skills, and the ability to carry out the job. That is just one of the measures but it is an extremely positive initiative, as the noble Lord calls for.
The Lord Bishop of London
My Lords, given the well-documented regional and social economic disparities in access to adult social care, in what way are the Government, in focusing on the shortages in the workforce, focusing their efforts on tackling this inequality in access?
Baroness Merron (Lab)
In general terms, of course, the independent commission into adult social care will be part of our critical first steps towards delivering a national care service. The commission, as the right reverend Prelate is well aware, will be chaired by the noble Baroness, Lady Casey. I agree with the right reverend Prelate that there are particular demands in certain local areas, and the strategy will take account of that, including the fact that, based on the growth of the population aged 65 and above, the sector may need 540,000 extra new posts by 2040. That is a big challenge, but by setting up the professionalisation, the training, the skilling and the fair pay for people, it is one that we will be in a much better place, across the country, to be able to deliver on.
Covid-19: Day of Reflection
Lord Bishop of London Excerpts(3 months ago)
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The Lord Bishop of London
To ask His Majesty’s Government, following the COVID-19 Day of Reflection, what steps they are taking to improve support offered to people bereaved as a result of COVID-19.
The Lord Bishop of London
My Lords, I declare my interest as the former chair of the UK Commission on Bereavement and other interests as set out in the register. Though we are small in number, I am grateful for the opportunity to hold this debate. I am aware that reflection on the impact of Covid-19 is no longer a particularly attractive subject, but I feel strongly that the impact of this world-changing event will continue to be felt in the years to come.
In our nation’s living memory, there has not been a moment in which so many of us have experienced bereavement at the same time. Over the course of 2020 and 2021 alone, there were an additional 750,000 deaths over what would ordinarily be expected based on the previous five-year period. By the end of 2022, an estimated 16,700 children and young people in the UK had been bereaved of their parent or a primary caregiver through the deaths associated with the pandemic.
On Sunday 9 March, we marked five years since the start of the pandemic with a day of reflection, on which communities up and down the country remembered our national and personal loss. Many of these wounds are still raw, and the BBC reported that sobbing could be heard at the National Covid Memorial Wall. This afternoon, I will discuss the particular disruption to bereavement during the pandemic and the long-term impacts of restricted bereavement.
The UK Commission on Bereavement was launched in June 2021 and, in October 2022, we produced our report, Bereavement Is Everyone’s Business. The report identified a number of key ways that the pandemic disrupted the grieving process of those bereaved. The first, and perhaps the most obvious, is funerals. Restrictions meant that there were delays, restrictions in numbers, social distancing of attendees and changes to collective end-of-life rituals: wakes, shivahs, collective recitation at home, nine nights, and the viewing and embalming of bodies at home were not possible.
As with many aspects of the pandemic, not everyone’s experience was the same. Many religious and ethnic-minority groups faced more significant barriers to organising funerals. Many people reported that finding funeral directors or bereavement organisations with culturally appropriate funeral services was difficult, and that not being able to participate in usual rituals prevented them grieving properly.
Being able to access a meaningful and affordable funeral was already a challenge before the pandemic, and it remained so afterwards. According to SunLife’s Cost of Dying report 2025, the average cost of a simple funeral was £4,285, which is a rise of 134% since data collection began in 2004. It also found that a third of people said that the cost of living crisis had impacted on how they organised a funeral. Almost half said that paying for a funeral had impacted on their mental health. The funeral support service Down to Earth, which is run by Quaker Social Action, notes that a complex relationship exists between somebody’s grief and their paying for a funeral. If somebody gets into debt doing so, that debt can last for years and has a profound impact on their feelings around their bereavement. I have serious concern that people’s ability to access the funeral that they may like is financially determined.
A second way in which the grieving process was disrupted was in the most common experience of social isolation and loneliness. A significant part of the bereavement process for many is being with family and friends to support one another in grief, but 74% of adults who were bereaved during the pandemic said that they experienced social isolation and loneliness after the death of a loved one.
Thirdly, having contact with the dying person at the end of life was heavily restricted, as so many people died in hospital. Some said to the commission that knowing that their loved one was alone in hospital before they died was the hardest part of the bereavement process at the time. Those were the impacts that we saw in our work in 2022, but further work has been undertaken since then and there is more to learn.
New research published in 2023 examined the longer-term impact of grief among those who had lost loved ones during the pandemic. It found that, two years after their bereavement, 29% of people studied met the criteria for prolonged grief disorder. In particular, the social isolation and loneliness in early bereavement contributed to higher levels of prolonged grief symptoms.
According to another study on prolonged grief disorder during Covid 19, there may be a detrimental, long-term psychological outcome for those bereaved individuals regardless of the cause of death of their loved one. We do not yet fully understand all this, but there is a growing body of evidence detailing the ongoing impacts of the pandemic on bereaved people and the difference that accessible, timely and effective bereavement support can have on their bereavement symptoms. In addition, we should not forget those with long Covid who grieve the loss of who they were before they contracted the virus. It is important that we support the ongoing impacts in this area as well.
Following the recommendations of the bereavement commission, there has been much progress which we can commend. This has been and is being worked on by different Governments, including the previous Minister, the noble Lord, Lord Markham. We are glad to see the introduction in the Employment Rights Bill of a new right to bereavement leave for people who have lost a close relative. The Government are also introducing the facility for people to register a death online. The Department for Education in England has consulted on proposals to include grief education in the curriculum. On the housing front, the Ministry of Housing, Communities and Local Government has an amendment to the Renters’ Rights Bill to prevent the use of ground 7 as a ground for eviction—that is, death of a tenant. This increases housing security for bereaved tenants in the private rented sector. It is very welcome.
However, there is more that can be done to support bereaved people. One of the initial recommendations from the UKCB report was for the Government to establish and deliver a cross-departmental strategy for bereavement. It is clear that bereavement and its surrounding issues are multifaceted and in need of cross-government working. A strategy could be a useful way to give this issue the attention it deserves.
The cross-governmental working group was established in 2021 and is a useful space to discuss bereavement-related issues, but there must be much more of a focus if we really are to support bereaved people. There is also the need for wider investment in bereavement services, especially for black, Asian and minority-ethnic communities and others who have been demonstrated as being poorly served. This is particularly significant given that some communities experienced much heavier loss than others during the pandemic, especially in London. If the findings I mentioned earlier prove true, this may mean that some communities are more adversely affected by symptoms of prolonged grief than others, which, of course, leads to poor mental health.
Finally, it seems that everyone, when asked, agrees that it is healthy and good for us as a society to talk about death. However, we are still poor at doing it. I am not going to talk about the substance of the assisted dying debate here, but it has prompted us as a nation to talk about death and dying, though this is still far from a normalised topic for many of us. That is reflected in our planning for and focus on bereavement, both nationally and perhaps personally.
My own experiences as a cancer nurse and as a priest mean that I have sat with people in the final hours of their lives and with people coming to terms with the loss of a loved one. To grieve is a universal experience and part of what it is to be human. My faith prompts me to believe that our feelings and relationships and the grief that comes when we lose somebody important to us are important. These experiences and emotions must be tended to. It is the role of us all, including the state, to do so.
I am grateful to your Lordships’ House for providing the time for this very important debate. Will the Minister agree to meet me and perhaps some of my key colleagues in the bereavement policy space to discuss this further? I hope that the national day of reflection will not confine our thinking on supporting bereaved people to a future crisis or as a thing of the past but that we will take this opportunity to cast a renewed focus on bereavement, because it remains everyone’s business.
Safe Housing and Hospital Discharge
Lord Bishop of London Excerpts(3 months ago)
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Baroness Merron (Lab)
I am glad that the noble Lord shares my enthusiasm for virtual wards. I shall expand on what they are: they allow people to be not in hospital but in their own home, whether it is their personal home or whether their home happens to be in a care home or some other setting, by the use of technology that allows them to be monitored. I recently saw an excellent example of that, and the liberation that it provides for individuals who would much rather not be in hospital is key. The noble Lord will know that, in the 10-year plan, the move from hospital to community is a key pillar, and we will soon be reporting on that. I certainly share his enthusiasm.
The Lord Bishop of London
My Lords, the VCSE sector plays a critical role in discharge planning. The Minister may know of a project in Warrington, where a social prescribing link worker and the VCSE team are integrated into the discharge team, and are therefore able to support people on discharge. The pilot has been positive, not least in that it has reduced readmission into hospital. Could the Minister say what support the Government are giving to integrated care boards so that they can enable this type of innovative provision? Can she reassure us that the aspiration to cut the ICBs by 50% will not impact on that potential?
Baroness Merron (Lab)
I very much commend the innovation and the commitment of people locally in the way that the right reverend Prelate describes. ICBs would be wise to work closely with the third sector in order to provide support and to tackle the very real challenges. With regard to decisions on how they use their funding, it is for ICBs to take into account the needs of the population and provide accordingly. As I say, it would be a wise ICB that took advantage of the innovation and the commitment in its local area.
NHS England Update
Lord Bishop of London Excerpts(3 months ago)
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Baroness Merron (Lab)
The noble Lord is right to talk about NHS England in all its functions. Bringing it together with the department will not diminish those functions but will allow them to be delivered rather more effectively than they are currently. At the head of the transformation team is Sir James Mackey, the new chief executive of NHS England, working with Dr Penny Dash as chair. Both individuals are well respected across the sector for their outstanding track records, not least on turning round NHS organisations, in Jim’s case, but also on balancing the books, driving up productivity and driving down waiting times—exactly what is needed. But I agree totally with the noble Lord, and we are going to ensure that the necessary functions are continued; it is the way they are delivered that we are changing.
The Lord Bishop of London
My Lords, I declare my interest as indicated by the noble Baroness, in that I am a former government Chief Nursing Officer. Following on from the noble Lord’s point, this is a very significant change not just to the NHS but to its workforce. We know from looking back that when there is a reorganisation of the NHS, attention and funds are distracted away from the front line and patient care. The announcement came on the same day as the publication of the NHS staff survey results, which highlighted that only 31% felt that there were enough staff to enable them to do their job, and that 45% felt unwell due to work-related stress. What action will the Government take to make sure that there is not a management distraction, through this reorganisation, away from the front line and patient care in particular? How will staff be supported during this transition, not least those who, I suspect, fear that their jobs are now under threat?
Baroness Merron (Lab)
I recognise what the right reverend Prelate is saying. I myself have experienced change in large organisations, and change is never easy. We are talking about job losses; we cannot shy away from that. But it is appropriate that I re-emphasise the reassurance of our respect for and thanks to all those talented and hard-working staff in both the department and NHSE. We will, as I said, work with trade unions on this change in order to be fair and transparent and to deal with it properly. Of course it is uncomfortable, and people naturally find it difficult.
It is also important to look at the benefits. Currently, we have rather too much micromanagement, which frustrates progress and staff. Reducing that is one of the liberations that this will provide, so we can innovate and get on with caring for patients.
On maintaining people’s morale, this is a big challenge for us because morale has not been good at all, so we will pay particular attention to this as we publish the workforce plan later in the summer. This work continues. Senior managers and transformation team are very alive to the points the right reverend Prelate has made, and they will continue in that regard.
Soft Drinks Industry Levy
Lord Bishop of London Excerpts(3 months ago)
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Baroness Merron (Lab)
I would be very pleased to write further to the noble Lord on this matter. I pay tribute to all of those community third sector organisations that work in line with government direction to reduce obesity. There are many aspects to this: it is not just about what community organisations can do but, for example, about implementing TV and online advertising restrictions for less healthy food. In all these ways, we will be able to make progress to reduce obesity.
The Lord Bishop of London
My Lords, we know well that diet and nutrition, and the infrastructure from which we can access the food that we eat, determine our health. These things continue to be unequal. The proportion of household income required to afford to follow the Eatwell Guide is 11% in the least deprived areas and 45% in the most deprived areas. What consideration will be given in the NHS plan to these wider issues—including the merits of reformulation policies—to improve the critical determinants of health?
Baroness Merron (Lab)
The right reverend Prelate is right to speak about the additional levels of ill health and obesity; a child of 11 in the most deprived areas is twice as likely to be obese as those in the least deprived areas. I can certainly assure her that the 10-year plan, which is soon to be made available, will take account of inequalities in all their aspects, including nutrition and food.
Musculoskeletal Health: Chiropractors
Lord Bishop of London Excerpts(3 months, 3 weeks ago)
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Baroness Merron (Lab)
I am certainly happy to have such discussions. Perhaps I could use this opportunity to say to noble Lords that part of the recently published elective reform plan sets out funding to boost bone density scanning—or DEXA—capacity, to provide an estimated 29,000 extra scans per year. The work goes on also to support workforce health. For example, we are commencing training so that over 200 doctors and nurses can undertake occupational health training and qualifications. The numbers of physios and OTs are increasing. This is very much work in progress. I certainly agree with what the noble Lord said about the impact and extent of this; it really does affect so many.
The Lord Bishop of London
My Lords, according to the Arthritis and Musculoskeletal Alliance report on health inequalities and deprivation, an important way to reduce health inequalities in these conditions, particularly in those groups of people who are underserved, is to help them to manage their own conditions. Often it is much harder because they often have more than one complex condition; often they are much more complex and are picked up much later. One of the recommendations was around moving NHS care into the community. Could the Minister tell us what the Government are doing to encourage the NHS to build partnerships with community groups, including faith groups, to seek to reduce inequalities in these conditions and communities?
Baroness Merron (Lab)
Working with community-based organisations, including faith communities, has come up a number of times in the 10-year plan consultation, as I am sure the right reverend Prelate will find. I would certainly associate myself with the comments about the importance of getting healthcare provided in the community.
Physician and Anaesthetist Associate Roles: Review
Lord Bishop of London Excerpts(6 months, 2 weeks ago)
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The Lord Bishop of London
My Lords, it is good to participate in this important debate and I am grateful to the noble Baroness, Lady Bennett, for having secured it. I declare my entry in the register of interests, specifically that I was formerly the Government’s Chief Nursing Officer.
This is clearly a complex issue, and I join other noble Lords in welcoming the Government’s recently announced review of the physician associates and anaesthetist associates. In building an NHS fit for the future, it is right that the right people with the right training and the right competence undertake the right roles. Over the last 20 years, we have seen an expanding of roles to release medical staff to do what only they can do; for example, the development of nurse-led assessment, advanced nurse practitioners and nurse prescribing, and the expansion of the role of pharmacists. In some sense, the development of physician associates and anaesthetist associates is part of this change. However, any change in role and the healthcare workforce needs to be carefully implemented and regulated. Therefore, I welcome the regulation of physician associates and anaesthetist associates, but I too question whether their regulation should take into account the outcome of this review, rather than moving ahead at present.
The main points I will make are around clarity and trust. Noble Lords will often hear me speak in this place about the essential commodity of trust in healthcare and the health of the nation. Research carried out by Healthwatch found that the public awareness of physician associate roles is mixed, particularly among older people, who are less likely to know the difference between a PA and a GP. Clear information needs to be given to people about the healthcare worker they are seeing, and they need to be reassured that they are competent and working to clear standards.
I am encouraged to hear that both roles and standards will be examined in the review, but can the Minister tell us whether what and how information is given to the public will be part of the scope? I also wonder whether we can learn from past changes, such as the introduction of nurse prescribing, to help us understand how we bring about this type of change.
Giving clarity is a vital step towards ensuring trust, particularly in primary care. We must ensure that we are transparent and that we focus on building trust as a priority. I also speak from a London perspective, where the memory is fresh of the great losses during Covid that were disproportionate in some communities, especially those that still struggle to reach the health service—their trust in primary care is low. Will the Government assess the distribution of physician associates as part of the review and examine how patients might have greater clarity about who they are seeing at an appointment? This is especially important where communication might be difficult, such as when English is a second language. According to the Royal College of General Practitioners, GPs in more deprived areas are responsible for caring for more patients than those in affluent areas. It would be helpful to know how physician associates fit into that picture.
Looking more generally at the workforce and the long-term workforce plan, which accelerates the expansion of physician associate and anaesthetist associate roles, do the Government plan to change the projections of this expansion based on the outcome of the review? What impact will this have not just on the plan but on the wider workforce?
The issue of supervision has already been raised in the debate. While I welcome the diversification of roles in the multidisciplinary team to ease pressure where it is appropriate, it is absolutely clear that the supervision of those roles is important. Who is supervising them? Who are they accountable to? That is particularly the case when there is pressure already on our health service.
When the long-term workforce plan was first published, I am not sure that it answered the question related to supervision. On apprenticeship schemes for roles such as this, what progress has been made to ensure that in hospital settings and primary care, funding is given for backfilling? When apprentices are paid and have time for study, is the hospital or the primary care setting able to backfill with staff? If the Minister has any insight into how this has progressed since the plan was published, I would be grateful to know.
The role of the physician associate is a controversial topic, as has been highlighted in this debate. It is having a very clear impact on team dynamics. Within some of those teams, staff are reporting bullying. Staff morale is low, including that of the physician associates and anaesthetist associates. I wonder whether this should be a high priority for the Government and a dimension of the review.
Finally, I hope that the Government will learn from this review and that the learning they undertake will be transferred to other areas of health. As the Government shift from sickness to prevention, from hospital to community, as part of their 10-year plan, it is likely that diversification—in primary care but also elsewhere—will be required and will need to grow. Therefore, there is an opportunity to learn from this review and to roll that learning out. I look forward to hearing from other noble Lords on this important issue and from the Minister when she responds.
Fracture Liaison Services
Lord Bishop of London Excerpts(6 months, 2 weeks ago)
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The Lord Bishop of London
My Lords, it is very good to participate in this important debate on the fracture liaison service, especially since the issue of prevention in healthcare seems to be gathering pace. I thank the noble Lord, Lord Black, for having moved this debate.
We have heard that the fracture liaison service identifies people at risk of osteoporosis and reduces the risk of long-term fractures. Treatment provided by the fracture liaison service is often excellent, and often nurse-led. But, as we have heard, there are just not enough of them. Like many aspects of healthcare that we discuss in your Lordships’ House, provision varies by region, and there are also other inequalities of access to these services. We know that bone density decline can be accelerated by other factors, including smoking, diet and other illness.
We often discuss the fact that those living in the most deprived areas have consistently worse health outcomes and are therefore likely to be most impacted by the lack of coverage of this service. We have already heard in the debate that another element of inequity is that osteoporosis impacts women more than men: 50% of all women over 50 are affected. Last month, a study showed that menopausal women of Chinese and black African backgrounds are almost 80% less likely to be prescribed hormone replacement therapy, and less likely to receive appropriate care during menopause. While this debate is not about hormone replacement therapy, it has a lot to do with equitable access and is therefore significant to this debate.
Fracture liaison services demonstrate genuine value for money, as we have heard, and the Government should be keen to recognise and promote this. It is through services such as these that the shift from sickness to prevention and from hospital to community will happen. Evidence shows that for every pound spent on a fracture liaison service, £3.26 is saved. Given that hip replacements take up 1 million acute bed days a year and are often preventable, rolling this out is an important decision in forwarding the Government’s agenda on the NHS.
We have heard already in this debate that many ICBs may well be ready to go with such services. However, the Royal Osteoporosis Society reported earlier this year the closing of the South Nottinghamshire Fracture Liaison Service, with the ICB citing serious financial pressures and the lack of a government mandate as reasons for stopping commissioning the service. Commissioning pressures on the part of ICBs is an issue that often comes up when we talk about prevention, particularly shifting from acute to preventive services. I know that ICBs face serious financial pressure and challenges from acute services that often override prevention; however, if the Government are going to prioritise prevention and reduce health inequalities, there must be a way for ICBs’ commissioning decisions to stand against that pressure.
I welcome the promise of 100% coverage by 2030, so I look forward to hearing from the Minister what actions the Government will take to make that happen. Will this be considered in the formation of the NHS 10-year plan, so that health inequalities can be prioritised?