Branded Health Service Medicines (Costs) (Amendment) Regulations 2023

Lord Hunt of Kings Heath Excerpts

Thursday 25th May 2023 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the Branded Health Service Medicines (Costs) (Amendment) Regulations 2023 propose a 27.5 per cent claw back rate which significantly exceeds that required by comparable countries, and which risks seriously damaging future investment in the research and development (R&D) of new drugs in the United Kingdom for the NHS, investment in the life sciences more generally, and the manufacture of branded medicines and their availability to the NHS; further regrets the short and insufficient consultation period for these measures of just 39 days over the Christmas period; and notes with concern that the UK’s share of global pharmaceutical R&D has fallen by over one-third between 2012 and 2020, and that the UK’s medicine production volumes, clinical trial delivery, and global share of new medicine launches have also all declined in recent years. (SI 2023/239)

Relevant document: 34th Report from the Secondary Legislation Scrutiny Committee (special attention drawn to the instrument)

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very glad to introduce this debate, and thankful to noble Lords who have stayed to take part in it. Underpinning this debate is a major concern about the current state of the UK economy, beset as it is with low growth, low productivity, workforce shortages, regional inequality and a dilapidated infrastructure; yet we have no industrial strategy. The Government have raised corporation tax; it is little wonder that Sir James Dyson recently accused the Government of having a “stupid” and “short-sighted” approach to the economy and business in the UK. Indeed, as Theresa May’s former chief of staff, Nick Timothy, put it on 8 May, there is an alarming decline in manufacturing as a percentage of GDP.

We ought, at least, to welcome the Prime Minister’s launch of the Government’s plan to create the UK’s place and cement it as a science and technology superpower by 2030. My concern is that the Minister and his colleagues in the Department of Health and Social Care are doing everything they can to inhibit that ambition. The life sciences industry is one of the most successful and important pillars of the UK economy, contributing more than £94.2 billion a year and 200,000 jobs in this country. Two-thirds of this is generated by the biopharmaceutical sector. The industry’s pipeline of new medicines is equally impressive.

We are at great risk of seeing this economic success falter under the watch of the Government, as companies are reducing their level of investment because of the imposition of a massive clawback that equates to one-quarter of sales revenue. We are already seeing very worrying trends in investment levels. From 2012 to 2020, the UK’s share of global pharmaceutical R&D spend decreased by more than a third. Since 2018, the UK has been falling down the global rankings across all phases of industry clinical trials. UK manufacturing production volumes have fallen by 29% since 2009. We all know that the NHS is far too slow to adopt new innovation and new medicines.

The UK is falling behind comparable countries as an early-launch market. Companies are making decisions to delay, or even not to launch, in the UK. These can be clinically important medicines that address many of the NHS’s priorities. Compared to leading countries in Europe—Italy, Spain, Germany and France—we have experienced the largest decline in our global share of new medicine launches between 2016 and 2021. This is the background to the statutory instrument that we are debating today.

I believe and hope this debate can influence the negotiations that have just started with the industry over the next phase of the voluntary scheme, otherwise known as VPAS—various noble Lords used to know it as PPRS. Under these regulations, companies in the statutory scheme will be required to pay to the Secretary of State 27.5% of their 2023 net sales income received for the supply of those medicines to the NHS.

The Government’s argument is that continued high sales growth in 2022 has led to an increase in the payment percentages in the VPAS scheme from 15% in 2022 to 26.5% in 2023, which is higher than was projected at the time of the 2022 statutory scheme consultation. As a result, the Government have ratcheted up the statutory scheme required payment rate. My argument is that both the voluntary and statutory schemes—companies have to be in one or the other, and can switch between them—are becoming a major impediment to future investment in the UK. The proposed rate of 27.5% will place the UK as a global outlier. In countries that operate similar clawback arrangements, current rates include 12% in Germany, 7.5% in Spain and 9% in Ireland, and all those countries spend more on medicines per head than we do. How on earth can the Government’s stated aim to grow the life sciences industry, as set out in the Life Sciences Vision and just recently articulated by the Chancellor, be delivered if industries expect to pay twice the level here that they do in Germany?

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[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister. I think he has responded in a positive way, which is gratifying and, I hope, sets the foundation for a proper negotiation with the industry to get a jointly owned voluntary scheme which will incentivise global pharma to invest in the UK.

For me, two or three themes come from this. First, the noble Lord, Lord Lansley, talked about the curiosity of a fixed drugs budget, and I found it curious when the Minister said we need value for money on medicines in order to have resources for front-line services. But medicines are a front-line service. Why is it a good thing to increase the number of doctors and nurses and buy more medical equipment, but it is suddenly shock-horror to spend more on medicines? What would we do without medicines? It is curious. I have never understood why the Department of Health has such a downer on the medicines budget, when it has just said—and I declare an interest as a member of the GMC—that it wants to see a massive expansion in medical school places. Why is the medicines budget regarded as such a negative factor? It defies all understanding; of all the great advances we have made in healthcare, how many have been made through new medicines? And I have to say that new medicines are rather easier to get than extra staff.

[Lord Markham (Con)]

May I just clarify? I completely agree that medicines are of course valuable. My comments were not about not spending money on medicines but about getting value for what we spend on medicines—not the quantity, not the quality, but the price that we are paying. I think that all noble Lords would agree that we want to make sure that we are getting the best value on pricing.

[Lord Hunt of Kings Heath (Lab)]

I fully accept that, but the sentiment that comes through is something that is shared throughout the National Health Service: that drugs expenditure, per se, is something to be held down. That is why, even though we have NICE, and bilateral negotiations—as the noble Lord, Lord Lansley, said—between NHS England and pharma companies in relation to specific drugs, at local level you have formularies and all sorts of mechanisms designed to ration medicines to patients. It is a curiosity about our whole approach. I agree with the Minister that one needs to start with a health budget. If we have—and I hope we do—new medicines coming on in relation to, say, Alzheimer’s, we will need to spend extra money in order to invest in them.

My second point—also made by the noble Lords, Lord Warner and Lord Allan, and my noble friend Lady Wheeler—is that it is very important that this is seen as a cross-government approach. If this is seen simply an issue for the Department of Health and NHS England in terms of the NHS budget, we will never get the kind of agreement that we need. If the Prime Minister is true to his word in terms of trying to reset the relationship—as the Minister implied—that is very welcome indeed.

This has been a very useful debate and I am very grateful to the Minister and other noble Lords. I beg leave to withdraw my Motion.

Motion withdrawn.

Pharmacies: Medicines at Home

Lord Hunt of Kings Heath Excerpts

Wednesday 17th May 2023 Lords Chamber

[Lord Markham (Con)]

Yes.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister referred to the Royal Pharmaceutical Society guidelines, but those were issued in 2013—some 10 years ago. If it was so important, why has it taken Boots and Lloyds Pharmacy so long to phase them out? Surely, the Minister recognises, as his noble friend said, that there must be automated ways of delivering blister packs safely, thereby helping very vulnerable people to take the right medicine?

[Lord Markham (Con)]

As noble Lords are aware, I hold the technology brief, so, if there are automated ways, I am absolutely all for them. As I learned while researching this Question, this is a complicated area, given the number of permutations of pills that can be there in each circumstance. I have not seen those solutions, but I will look into them.

Childbirth: Black Women

Lord Hunt of Kings Heath Excerpts

Wednesday 3rd May 2023 Lords Chamber

[Lord Markham (Con)]

First, through its local maternity and neonatal systems, every ICB is responsible for publishing an equity and equality plan. It will then be the job of both the CQC and the maternity surveillance system to measure them against that plan and make sure it is being kept up. Every area is different, but each needs a plan to address this issue.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister mentioned the Maternity Disparities Taskforce meeting on 18 April. Can he explain why the Select Committee was able to report that the task force had not met for nine months preceding the writing of its report? It does not look like the task force is putting much energy into this. Can he also say whether the work that is now being undertaken will take into account the fact that black women are regularly underrepresented in research and data, which leads to them being neglected in policy-making?

Long Covid

Lord Hunt of Kings Heath Excerpts

Tuesday 25th April 2023 Lords Chamber

[Lord Markham (Con)]

I thank the noble Earl for his question and for raising this subject generally; it is of key importance to all of us. In the area of long Covid, we are still learning. The reality is that there are a lot of situations where, thankfully, long Covid might end after 12, 14 or 16 weeks. For those reasons, it is not appropriate to define it as a long-term disability in legislative terms at this stage. At the same time, clearly, if people are suffering from conditions that mean they are unable to work for a length of time, they are absolutely able to get personal independence payments and the other payments that are due to them.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister will be aware that there is real concern about the rising number of inactive people of working age, due mainly to long-term sickness. I accept what he said about the time limits, but to what extent is he concerned that our failure to tackle long Covid appropriately will add to that labour market inactivity?

[Lord Markham (Con)]

I take issue with the statement of failure to deal with it. We pioneered this space. We set up 90 specialist adult centres and 14 specialist centres for kids. We have invested £314 million and 80% of people are seen within eight weeks of being referred. That shows that we are taking this seriously. The noble Lord is absolutely right that we want to ensure that we get as many people into work as possible. In the case of long Covid, we are definitely doing that.

Diphtheria

Lord Hunt of Kings Heath Excerpts

Tuesday 18th April 2023 Lords Chamber

[Lord Markham (Con)]

To be honest, I think the most effective method is to have the screening when people enter. Refugees come in from across the world so, to concentrate resources, it is best done on entry. The record speaks for itself; an 88% take-up rate is very high, comparable to that of the general UK population. I think we have got it right.

[Lord Hunt of Kings Heath (Lab)]

My Lords, coming back to the original Question, does the Minister accept that during the Covid pandemic the role that directors of public health played locally was critical to ensuring a co-ordinated and effective response? Does he agree that it is a great pity that the Home Office seems to have refused to engage with the Association of Directors of Public Health on this? Will he assure the House that the Home Office will start to engage with this organisation?

[Lord Markham (Con)]

I am probably best placed to speak about how we engage with the Home Office, which we have been doing pretty successfully. I agree with the noble Lord about the role that those public health directors played during Covid and will play going forward. UKHSA is very much committed to doing that as well. As I said, our record on interactions with the Home Office speaks for itself—it is pretty good.

Stroke Rehabilitation and Community Services

Lord Hunt of Kings Heath Excerpts

Wednesday 22nd March 2023 Lords Chamber

[Lord Markham (Con)]

I thank my noble friend and agree. When I was looking at the waiting lists of those in need of physiotherapy, I was delighted to see that 80% of people were waiting less than 18 weeks. A plan is being put in place for musculoskeletal priority patients, so that they do not have to wait any more than two weeks. The urgency of putting these things in place quickly is recognised.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister talked about the national integrated service. He will be aware that rehabilitation services are very patchy and that, over the last four or five years, the amount of time that professionals have spent with individuals has got less. Will this new integrated care service bring us up to higher standards and see consistent standards throughout the country?

[Lord Markham (Con)]

During the pandemic this was one of the areas that probably did not get enough time, for all the good reasons that we understand. Therefore, I am pleased to see that these pathways are being set out so that we can get back to the standards that we need. I believe this is something that we will see happening now.

Adult Social Care

Lord Hunt of Kings Heath Excerpts

Monday 20th February 2023 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, if the Government are moving in the right direction, why have they yet again delayed the implementation of the Dilnot report? Why have they taken no notice of the report from the Select Committee chaired by the noble Lord, Lord Forsyth, in 2019, which clearly gave the Government the route forward to deal with this perennial problem?

[Lord Forsyth of Drumlean (Con)]

Answer.

Health and Social Care Information Centre (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Lord Hunt of Kings Heath Excerpts

Wednesday 25th January 2023 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

At end insert “but that this House regrets that (1) the consultation on the statutory guidance that will direct NHS England’s handling of the medical data under these Regulations is being conducted in a rushed and piecemeal manner, and (2) the results of that consultation are not available alongside the Regulations to reassure the House that patient data will be used properly”

[Lord Hunt of Kings Heath (Lab)]

My Lords, let me say at once that I support the digital transformation of the NHS and the use of information to enhance patient outcomes. I want to see the NHS move faster in a digital world, but it is essential that there are safeguards in place to protect the integrity and confidentiality of patient data. I say that as I look back into the history of NHS data, where we confronted a number of occasions when this did not happen. That is why this is such an important debate. I am grateful to the Minister for the assurances he has already given in his opening speech, and through him I thank his officials for the way in which they have been prepared to engage with us over the past few months, which has been very helpful.

I remain of the view that it was a mistake to bring NHS Digital, or the Health and Social Care Information Centre as it was formerly known, into NHS England, and feel that there are some inevitable tensions and conflicts in so doing. I think the review that led to this overlooked the issue of the integrity of patient information and public confidence when it suggested that the two functions should be brought together. That was legislated for; here we are now, examining some of the details.

The noble Lord has already referred to the Select Committee’s disappointment about the way in which it considered this had been done in a rushed and piecemeal manner. I have no doubt the House will want to take account of the Minister’s response. It is a pity that the full statutory guidance is not available as we debate these regulations. I think, as a matter of principle, it would have been much more sensible if that had occurred.

The core issue is that in the passage of the Bill, and a number of noble Lords who are here took part in that debate, the Government gave assurances that governance arrangements would protect NHS England from marking its own homework, with independent oversight of governance decisions under the new arrangements. The noble Lord, Lord Kamall, the then Minister, said that

“I can assure your Lordships that the proposed transfer of functions from NHS Digital to NHS England would not in any way weaken the safeguards. Indeed, when I spoke to the person responsible in the department, who the noble Lords met, he was very clear that in fact we want to strengthen the safeguards and take them further.”—[Official Report, 5/4/22; cols. 2005-06.]

Having said that, when one comes to look at the arrangements, there are still some questions and doubts that we would like to put forward tonight. I pay tribute to medConfidential, which has raised questions on how some types of data will be handled under the new regime and whether, in pursuit of efficiencies, NHS England’s handling of the data will be less transparent and subject to fewer checks and balances. I think that expresses the issue and the potential tension in a nutshell.

This was reinforced by the comments of the National Data Guardian, to whom I pay tribute for her strong involvement in these matters. In December, Dr Nicola Byrne expressed concern that, in the statutory instrument before us, there is no recognition of the need to have independent oversight. She noted that provisions to obtain independent advice from specialists and experts to advise on and scrutinise NHS England’s exercise of its data functions, which were originally included in a previous draft of the SI, had been removed. She reminded the Government that the commitments to putting the current, non-statutory provisions safeguards regarding oversight into regulations had been made by officials to the House of Commons Science and Technology Committee. I understand from the briefing we received last night that the advice received by the Minister’s officials was that it is not possible, due to the nature of the statutory instrument and the original primary legislation. It is, though, a pity.

In relation to the membership of the Data Advisory Group, the National Data Guardian referred to the arguments put forward by the department for having NHS England representatives on the group present in their capacity as senior individuals with responsibility for data access. I think they are not full members, but they will be present. The department’s argument is that that will support more efficient discussions regarding applications for data access. I can see that, clearly, officials may need to make presentations. I think it is a bit of grey area when they are members, albeit not full members, of the actual group. The National Data Guardian reiterated that moving from a completely independent group to a hybrid model could affect public trust, particularly when advice is given and decisions are made on the internal uses of data.

We need to be clear why NHS Digital had an entirely independent oversight group. It was for very good reasons; it was put in place following the 2014 Partridge review which was conducted due to concerns about the way that patient data had been shared with insurance companies. There was a huge furore at the time. It was interesting that one of the resulting proposals after Partridge was the disbanding of an oversight group which involved staff members for a new independent oversight group. A public consultation in 2015 found support for this change. This is now being reversed. My fear is that something may go wrong with patient data and the department will come back and say, “Actually, we should make this an independent function”.

We have dealt with the issue of timing, and tonight the Minister has given an assurance that the outcome of the internal review into how well the transfer has gone will be made public—that will be very welcome. I will go just one step further and say that I hope the Minister may be prepared to brief parliamentarians on this at the same time.

The noble Lord also answered a question about social care that was asked in our briefing. I think he said there would be a person from a social care field on the group, which is definitely welcome. I suggest that discussions take place with the Local Government Association and the Association of Directors of Adult Social Services to make sure that they are fully involved and supportive of this happening.

So I remain of the view, as I have made clear, that it has been a mistake to bring NHS Digital into the NHS executive. Whatever the structure, one has to build in rigorous safeguards. The key here is the integrity and confidentiality of patient data. It is pretty clear that if the NHS is to be at all sustainable, it has to embrace the digital revolution and it has a long way to go. So I am right behind the Minister in what I know he is personally seeking to do. It is just that if anything that goes wrong with patient confidentiality, the whole thing can fall down. That is why this is so important. I very much look to the noble Lord and NHS England officials to ensure that we recognise that the integrity of personal patient information is important. I beg to move.

[Baroness Brinton (LD)]

My Lords, I echo the thanks of the noble Lord, Lord Hunt of Kings Heath, for the helpful and detailed discussions that the Minister, his predecessors and officials have had with the small group of us who have been worried about this issue, even before the Health and Care Bill started its passage through your Lordships’ House. Although some of us were more expert than others, and I was definitely not one of the expert members of the group, I care greatly about the digital revolution and ensuring that patient data is kept confidential.

The noble Lord, Lord Hunt, said that he supports improving and transforming data in the NHS. That cannot come soon enough. I have said before in this House, and it is still true probably a decade on from when I first said it here, that for my monthly blood tests I have to print out, photocopy and send copies to my hospital consultant because the hospital that I go to and the hospital that processes my blood tests do not use the same data system. That is ridiculous. It needs to change.

It is a real problem, as the noble Lord, Lord Hunt, set out, that the consultation and draft statutory guidance have been rushed through. I want to set that in the same context as that to which he referred, about perhaps going at a slightly slower pace while wanting the revolution to start. That might have been helpful. Omitting organisations such as the BMA from seeing the original statutory guidance raises the question: who else has not seen it? The question is almost impossible to answer. However, the detail of how this is going to work in practice inside the NHS will be the business of all clinical and administrative staff at all levels. It is vital that it works.

The Minister will know that I have repeatedly raised concerns about patient data and how people were not consulted in the two previous patient data and care.data communications. Both had to be held back because there has been outrage from the public that they were not given the chance to understand how their data would be used. Earlier this week, the Mirror reported that Matt Hancock had talked about handing over private patient medical records and the Covid test results of millions of UK residents to US data company Palantir fairly early on in the pandemic. It had offered to hold its data in its Foundry system, clean it and send it back to the NHS. I spoke about this in the Procurement Bill because I am concerned about how data can be kept truly confidential. Regarding the GP data for planning and research, the NHS has already published its federated data platform details, which is called by the Mirror the Palantir procurement prospectus. Perhaps I may ask the Minister, as an example of transparency for the new NHS England digital processes set out, whether organisations such as Palantir that are handling data records will absolutely not be permitted to use that data—even anonymised or deidentified—outside the purposes of the NHS, other than for agreed research being used in what my noble friend Lord Clement-Jones would say, if he were able to be in his place today, was a safe haven, thereby ensuring that that patient data remains completely confidential. The Minister knows, because I have said it before, that the problem is that in the past it has been possible to identify patient data when it was pseudonymised. I want confirmation that deidentifying really means that individuals cannot be tracked down and, most importantly, that the data will not be used elsewhere or sold on.

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I have tried to answer most of the concerns. I will follow up in detail by writing. If we feel that there is anything that is still not secure enough, I am very happy to call a meeting so that we can go through it all. I thank noble Lords for their comments and for the spirit of the debate tonight. I again thank the noble Lord, Lord Hunt, for ensuring that we managed to cover those points, because we can all see the benefits of a common platform and the digital ability—the ability not to have to print out and fax or email your results—that could come. My letter bag is very full of loads of those sorts of cases, so we can all see the benefits, but at the same time maintaining public confidence is key. There is nothing that can ensure that a great utopian opportunity is a defeat snatched from the jaws of victory if the public do not have confidence in it. With that, I commend the Motion to the House.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister and other noble Lords who have spoken in this debate. I should say that I am particularly grateful to the noble Baroness, Lady Brinton, as she and I have been working on this for quite some time, along with the noble Lord, Lord Clement-Jones, who unfortunately could not be here tonight.

I very much take the substantive point. If you look at care.data, essentially the people running it were very careless in terms of the confidentiality of patient information. That set back the whole programme for a number of years, and that is the lesson that we need to remember. The noble Baroness, Lady Finlay, raised some very important points, including about Wales, on which the Minister has responded in terms of the agreement that has been reached with the Welsh Assembly Government, but her point about the security of local NHS data is very relevant to the way we are going forward.

On the issue of commercial companies, 20 years ago, I took through the legislation to allow the NHS or the Department of Health to agree with commercial companies a very legitimate use of patient information. We had in mind the research institutes and pharmaceutical companies, because we have such a rich information source in the NHS, and we wanted to do that to encourage new medicines and speed up their introduction to NHS patients. The problem is that as it has proceeded there has been a lack of transparency, and this wretched commercial incompetence has undermined confidence in what is happening. It is perfectly legitimate to seek to use this information, provided patient confidentiality is preserved, for the enhancement of our knowledge and understanding and future treatments. Clearly that is in everyone’s best interests.

On UTOPIA, mentioned by the noble Lord, Lord Allan, I could not help thinking of “Utopia, Limited”, the Gilbert and Sullivan opera. The alternative title is “The Flowers of Progress”. He went through the list: Avon FHSA, the Exeter system, NHS AI Lab, Connecting for Health. Such happy memories. The point that he raises is that the NHS and the Department of Health have a constant need and desire to restructure. We know this is displacement activity. Even now one hears that NHS England wants to reduce the number of regions and you think, “For goodness’ sake! Can you not understand that it’s completely hopeless thinking a restructure will have any impact whatever on the task in hand?”

This is the substantive point: we know that we are going to be back here debating an SI at some point which will take NHS Digital out of NHS England and establish a separate body. No one will take a bet on it, because we know it is going to happen, and I am afraid that this instability really detracts from the core purpose of what we are seeking to do. My noble friend Lady Merron raised some very pertinent points about the information, the lack of final guidance, the impact on staff and the big question about patients knowing whether their information is being used, which I believe from the advice I have received is possible. I hope that, as the work gets taken forward, this will be taken very seriously by NHS England. The Government will find that patients will have much greater confidence if they get that information, and that most of us will be absolutely supportive of why that information has been used.

Finally, I thank the Minister for his constructive response and the parliamentary briefing that he has offered on the 12-month review; I also think the information about Wales has been very helpful indeed. Having said that, we wish him and his officials the very best in taking this work forward, and I beg leave to withdraw my amendment.

Amendment to the Motion withdrawn.

National Health Service (Primary Dental Services) (Amendment) Regulations 2022

Lord Hunt of Kings Heath Excerpts

Tuesday 24th January 2023 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the changes to dental contracts in the National Health Service (Primary Dental Services) (Amendment) Regulations 2022 (SI 2022/1132) will not have a significant impact on improving access to dental treatment whilst current workforce shortages persist.

Relevant document:18th Report from the Secondary Legislation Scrutiny Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is good as ever to know that dentistry excites such interest amongst your Lordships. I am very grateful for those noble Lords who are going to take part in what I think is a very important debate tonight.

Like many aspects of the NHS, our dental services are under great pressure at the moment. Indeed, there are reports that some patients are resorting to DIY dentistry and removing their own teeth because they cannot get access to an NHS dentist. In August 2022, the BBC reported that, based on a survey of 7,000 NHS practices, nine out of 10 NHS dental practices across the UK were not accepting new adult patients for treatment under the NHS. The BDA believes that NHS dentistry is facing, as it calls it,

“facing an existential crisis with the service hanging by a thread”.

The problem predates the pandemic, but it has now reached an unprecedented scale. The BDA estimates that over 40 million dental appointments have been lost since the start of the pandemic. Those from low-income or vulnerable groups are being disproportionately impacted, with 1 million new or expectant mothers having lost access to care since the start. Dentistry has been subject to cuts unparalleled in the NHS; in real terms, estimates suggest that net government spend on dentistry in England was cut by over a quarter between 2010 and 2020. The BDA argues that chronic underfunding and the current NHS dental contract are to blame for long-standing problems with burnout, recruitment and retention. We know morale among NHS dentists is very low, and we are facing an exodus of them from NHS practice.

The regulations before us today are welcome, but they will not turn this around. Under the regulations, subdividing band 2—putting more complex treatments into categories 2b and 2c—should hopefully reward dentists’ time and input more accurately. More generally on access, I understand the NHS has started commissioning “access sessions”, remunerated using a sessional fee in practices with an NHS contract in the north-east, using existing flexibilities within the current regulations. I hear that this scheme has worked very well, and I congratulate the commissioners and providers on this. Can the Minister confirm this and say whether it is to be rolled out across the country? I certainly think that this should be a priority. Because it can be done under existing regulations, and because of the protracted delay in moving from the long pilot scheme we have had to a new contract, this surely is an area where Ministers could make some progress in the short term, provided they provide resources to the health service to do so.

We are debating one element of a package that was announced by the Chief Dental Officer last year, designed to improve access. Two weeks ago, we agreed on one of those planks—regulations which gave dental care professionals the ability to open new courses of NHS dental treatment when they are trained and competent to do so. I do not want to go over the ground again; I think that this is a significant change that should be applauded, but there are still blockages in making it work effectively.

First, under previous regulations, a DCP would have needed a performer number to open a course of treatment, and with that would have come associated pension benefits. I understand that, under the recently issued guidance from the NHS, the DCP has to demonstrate competence by entering their GDC registration number, but the dentist whose performer number appears on the NHS form signing this off actually accrues the pension benefit. That does not seem to me to be fair, it is potentially discriminatory, and I wonder if the Minister could give me some justification for that, perhaps in writing.

Secondly, work has been going on for over a decade to allow DCPs to give local anaesthetics without having the direction of a dentist. Can I ask when that is going to be implemented?

Thirdly, given that the current system of remuneration of our dental schools means that it is much more attractive financially to train dentists, will they be incentivised to train more DCPs? If not, how are we going to see a substantial increase in DCPs? If I may just take the Minister back to our debate two weeks ago and the decision to exclude overseas dentists from working as DCPs, I still fail to see the justification for that.

The third plank of the package announced by the Chief Dental Officer to improve access was in relation to NICE guidance published in 2004. The concept of six-monthly recalls is embedded in our society and among patients, but it is not evidence-based and recall intervals need to be tailored to risk—in some cases, six months may be appropriate, but not all. The time taken up by unnecessary recalls could be used to grow access, and I would like to know how the Government intend to make sure this guidance is complied with.

Putting this all together, it is inevitable we come back to the issue of the critical shortage of workforce. Opening new dental schools is clearly one solution—I would like to see that—but we know that it takes up to 10 years from taking the decision to open a new school to clinicians entering the workforce. We clearly do not have 10 years, so we need to train more dentists, but in the near-term we have got to make NHS dentistry a more attractive option to improve retention of existing clinicians, while also making it easier for overseas dentists to work in the NHS.

The obvious way to make NHS dentistry more attractive to dentists in the UK is by increasing the budget for NHS dentistry. Given the real-terms cuts that we have seen—a quarter since 2010—this is essential.

In the short term, overseas dental professionals are one key to addressing the workforce pressures and ensuring access to NHS dentistry. One way that we can achieve this quickly is by streamlining the GDC processes for accepting individuals on to the register. This can be done by the UK striking more mutual recognition agreements for dental qualifications with countries of comparable standards and creating more places for the overseas registration exam. The GDC’s current mutual recognition of EEA-qualified dentists is also vital in boosting short-term applicant supply; this must not be removed.

Then there is the performers list validation by experience process, which all dentists not qualifying in the UK must go through to practise in the NHS—it needs standardising, simplifying, and streamlining. Does the Minister agree?

We also need to look at the work dentists do. I was briefed by BUPA that 24,272 dentists did some NHS work in England in 2021-22, but 15% of the workforce—almost 4,000 dentists—did no more than one patient course of NHS treatment a month on average; that seems quite extraordinary. How can that be justified? Can the Minister confirm that dentists do keep their performer number active by that process, which means that their historically earned NHS pension is dynamised on an annual basis? How can that possibly be justified?

Finally, we want to hear from the Government what priority they give to NHS dentistry. I put it to the Minister: is he content to see the dismantling of the service with access problems, piling up the misery of millions of people, and the frightening growth in self-treatment? Let me remind him of the BDA’s belief that

“NHS dentistry is facing an existential threat and patients face a growing crisis in access, with the service hanging by a thread.”


Are the Government essentially saying that they are content for this to happen? If not, then we need to see concrete plans to increase resources and the workforce to ensure that patients who want NHS treatment can get it in a timely way, confident in the quality of care they receive.

When I was Minister for Dentistry from 1999 to 2003, the then Prime Minister Tony Blair made a pledge that any patient who wanted to see an NHS dentist would be able to do so—and we achieved it. It can be done with strong leadership and the support of the profession. I hope the Minister will tell us whether the Government are going to go down that route tonight. I beg to move.

--- Later in debate ---

I hope that this will be seen as the first step along the way. As ever, I will endeavour to write in detail to everyone to make sure that I have reported on all the other points raised tonight. I thank the noble Lord, Lord Hunt, for bringing this matter to us for discussion. I hope that he would feel that, rather than a regret Motion, this is more a good opportunity to discuss measures which we would all agree are sensible first steps, with more needed to come. Before too long, I hope to be standing here able to talk in much more detail about those further steps.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to noble Lords who have taken part in this short debate. As the Minister mentioned fluoridation, I should just remind the House that I am president of the British Fluoridation Society and patron of the National Water Fluoridation Alliance. I agreed with the noble Baroness, Lady Bennett, when she talked about the WHO and preventative measures. The single most important measure would be to introduce fluoridation where it is not present at the moment. I was delighted when the Government took powers back to themselves to do this. I know that progress is being made: I just urge the Government to speed it up.

I also say to the noble Baroness, Lady Bennett, that she is right to identify the levelling-up Bill. It is a long Bill, but there is room for more amendments in relation to health. There are some already, but I would encourage her to think about that. She and the noble Lord, Lord Allan, raised the issue of the south-west. I had a meeting today with Stonewater, a very large social housing provider, which is very concerned about the lack of housing in the south-west. I would definitely make the link between housing and health, which is a very important issue if we are serious about levelling up.

The noble Lord was right to identify that these problems started before the pandemic, and that we are now facing particular issues, but the underlying structural issues are still not being dealt with. I also agree with him about post-implementation evaluation. I hope that the Minister, when he responds in writing, might be able to say something about that.

My noble friend Lady Merron was absolutely right to hone in on retention and recruitment. Although there are various initiatives, at the moment I do not think enough is being done to retain the profession within NHS dentistry. We need to do very much more about that. Her point about practice information going on the NHS website is really important, and I hope that the Government will respond to it.

Ultimately, it comes back to prioritisation and money, and I was grateful for what the Minister said. I am delighted that his wife is present to hear our debate, and indeed that he is celebrating his father’s 80th birthday. It reminded me that I took my wife with me—for a romantic 50th birthday celebration—to address the Pharmaceutical Services Negotiating Committee dinner. She has never forgotten that or forgiven me for that great sin, nor has she forgiven Alan Milburn for making me do it.

Anyway, the point is that we come back to the workforce strategy, because without a properly funded workforce strategy, with numbers, we will not get anywhere. In the meantime, there is still a lot that can be done to streamline GDC processes, recruit dentists from overseas and, crucially, give dentists currently in the profession but not doing NHS work some confidence that it will be worth their while to do NHS dentistry.

I was very interested in the point the Minister made about the cost for dentists coming into NHS dentistry and starting a new practice. He will, of course, have been interested in what Wes Streeting had to say about the future of primary care. He came in for some criticism for suggesting that maybe the current model of GP partnerships might not always be the right one. He is absolutely right that we have to think rather radically about how we will develop primary care in the future.

The argument for a proper strategy for dental access for NHS patients is very persuasive indeed. Having said that, I thank noble Lords and beg leave to withdraw my Motion.

Motion withdrawn.

Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022

Lord Hunt of Kings Heath Excerpts

Monday 9th January 2023 Grand Committee

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

I thank noble Lords, and declare what is a kind of interest, in that my wife, as many noble Lords have heard me mention before, is an international dentist. For my sins, I had the joy of helping her to fill out one of these international GDC registrations—so I have a little bit of knowledge in this space. It was not the most riveting exercise of my life, but I do have some knowledge.

I beg to move that the order be approved. International dental care and nursing professionals form a vital part of the NHS workforce and make an important contribution to the delivery of healthcare in the UK. The GDC and the Nursing and Midwifery Council are the independent statutory regulators for the dental and nursing and midwifery professions in the UK, and nursing associate professionals in England, respectively. They set registration standards for healthcare professionals who wish to practise in the UK.

International professionals who wish to practise here must meet the same rigorous standards that we expect of UK-trained professionals. We believe that it is in everyone’s interests that such professionals can use registration processes that are a fair test of their professional competence and that provide them with a clear route to registration. We are reforming the legislative framework for the regulation of healthcare professionals to better protect patients, to support our health services and to help the workforce to meet future challenges. Ahead of this, action is required to provide the GDC and NMC with greater flexibility to amend their international registration processes. This will help the regulators ensure that future international registration pathways are proportionate and streamlined, while continuing to robustly protect patient safety.

We plan to take forward all the proposals we consulted on and have made one small amendment to the order in the interests of patient safety. This relates to the requirement that a qualification relied on by international applicants to the dental care professionals register can no longer be a diploma in dentistry. This change introduces fairness and consistency between the UK and international routes, as UK-qualified dentists cannot apply to join the DCP register using their dentistry qualification. The GDC also expects that increasing the capacity of the ORE exam will support international dentists applying to join the GDC’s register. The amendment will allow the GDC to process applications from dentists to join the register as DCPs that are received up to the day before the order comes into force. This guarantees that any live DCP title applications submitted before the legislation is passed will be processed.

I draw the Committee’s attention to an issue raised by the Secondary Legislation Scrutiny Committee, which noted that the Committee may wish to seek reassurance on how appropriate safety standards will be maintained. The primary purpose of professional regulation is to protect patients and the public from harm. Any new or amended registration pathways will be based on applicants meeting the same standards of training and knowledge as UK-trained professionals. These standards are set by the independent regulators in consultation with the professions, the public and education providers.

The order provides the GDC with greater flexibility to apply a range of assessment options for international dentists and dental care professionals. The GDC will have much greater freedom to update its overseas assessment fee, content and structure, now and in the future, as these will no longer be set in legislation that requires Privy Council approval to be changed. The requirement that dental authorities provide the ORE is removed, allowing the GDC to explore alternative providers. Candidates who were affected by the suspension of the exam during the Covid pandemic will be provided with extra time to sit it.

I understand that the GDC will first consult on the new rules in its international registration processes, which will come into force 12 months after this order is in force. It plans to increase the capacity of the ORE exam and support greater numbers of international dentists to join the register more quickly.

The order also includes a charging power, so that fees can be charged to international institutions for the cost of recognising their qualifications. This will support the GDC in registering individuals either based on an assessment of their qualifications, skills and training or by recognising the qualifications they hold.

On changes to the Nursing and Midwifery Order 2001, the NMC will have the flexibility to use two pathways in addition to its test of competence, which will remain its primary registration assessment. The first is recognition of an international programme of education. The second is qualification comparison, whereby the NMC may ascertain whether an international qualification is of a comparable standard to a UK one. The draft order also clarifies the NMC good health and good character declaration requirements. I commend this order to the Committee.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I first declare an interest as a member of the General Medical Council. I welcome this order and pay tribute to the NMC and the General Dental Council for their work—and particularly to my noble friend Lord Harris, who so eminently chairs the GDC.

As the Explanatory Memorandum makes clear, this is in a sense an overture for a suite of orders that the Minister will bring in relation to all the registering bodies, essentially to streamline the fitness-to-practise processes—in the case of the GMC, to enable the statutory registration of physician associates and anaesthetist associates—and to update the governance of these bodies.

I noted in paragraph 10.4 of the Explanatory Memorandum the statement:

“The Department’s view is that it is for the regulators as independent bodies”.


I ask the Minister to assure me that in those new arrangements and governance processes the Government are as committed to these bodies continuing as independent entities as they have said during the consultation process.

I also raise with the Minister the one area in which I think the consultation produced disagreement in relation to the proposals, which is in regard to the DCP register and the fact that, as I understand it, dentists qualifying overseas are not to be allowed to come on to the DCP register. This was raised in Committee in the Commons. The Minister said:

“The change introduces fairness and consistency between UK and international routes because UK dentists cannot qualify or apply to join the DCP register using their dentistry qualification in other countries.”—[Official Report, Commons, Delegated Legislation Committee, 6/12/22; cols. 7-8.]


The point I want to put, which has been put to me by a dental practitioner, is that we are biting off our nose. We are disallowing future working by dentists from overseas in the professions covered by the DPC. The dentist said to me:

“I am working alongside four experienced dentists, three in the UK under the Homes for Ukraine scheme and one under the Afghan resettlement scheme.”


If this change occurs in the future, I think that they may be covered by the current grandparenting provisions. However, if this were to happen in the future,

“their livelihoods and contributions that they could make to our society would be severely constrained. Even with excellent English, overseas dentists are waiting some time … to sit the overseas registration exam”,

which allows them to practise as dentists, although I know that the GDC is considerably improving their performance to allow them to. The dentist went on to say:

“In the meantime, if the GDC implements this restrictive measure, overseas dentists could then take employment only as trainee dental nurses”,


which is really wasteful of their abilities.

I would like further clarification from the Minister about why this is taking place. Given the workforce challenges in the dental profession at the moment, I question whether this is the time to implement a new provision simply because dentists in the UK cannot be recognised in other countries. Perhaps the Minister would be prepared to look at this again.