Homecare Medicines Services (Public Services Committee Report)

Lord Markham Excerpts

Thursday 2nd May 2024 Lords Chamber

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

My Lords, I am a bit slow in getting up. I will blame my son Xavi, who is in the Gallery. I was playing with him a bit too much this weekend, so I apologise. Now I am up, I will be fine.

I start by thanking noble Lords, and particularly the noble Baroness, Lady Morris. This is a very important area about which, I freely admit, 10 days ago I knew very little. I guess it was my noble friend Lord Blencathra who raised awareness in the first place, but I think this has been an excellent example of what the House of Lords does really well, which is to realise that there is an area that needs looking at.

On the question from the noble Lord, Lord Carter, about whether we found a report useful: yes, definitely. I have a couple of ideas and I think the noble Baroness, Lady Wheeler, has some good ideas on some of the next steps. I thank all noble Lords on the committee for their contributions and I am pleased that it is felt that the department has responded positively. I must admit that, in briefings, you can always tell when officials get it, are keen and have the bit between their teeth—and that is definitely the feeling I got here.

I will spend a few minutes unpacking something that impressed me: it really came home to me just how important this is, not just in terms of patient treatment today but for how we all want to deliver the service in the future. I call it the four Ps, on why I think this is important. First, there is prevention. I think we all agree that more prevention needs to begin at home, with home treatments and home testing services, to create a fantastic service in this area.

The second P is primary care: we want more care in the community and that is going to happen only if we have these sorts of services working really well. Noble Lords have heard me say it many times, but Bromley-by-Bow is a perfect example: they are treating patients with type 2 diabetes and CBT patients in their home rather than in hospital. But that can happen only if we have a really gold-plated homecare service, which they are able to provide in that very small instance. What we are really talking about today is the professionalisation of that type of service, so we can offer it much more widely.

My third P is of course patient care, brilliantly described through his own personal experiences by my noble friend Lord Blencathra, and the effect that that had on him, but also with the Crohn’s disease example set out by my noble friend Lord Mott, and the realisation that, as annoyed as we all often are when we wait all day for a delivery that does not turn up, in these cases we know that there are real-life consequences. Those consequences do not impact only the individual involved; they have knock-on consequences for the rest of the health service if patients have to go into hospital for that treatment instead.

Fourthly, I see the future in the area of precision medicine. I have started to understand that, by seeing what the likes of BioNTech and Moderna are doing, using mRNA to fight cancers on your behalf. This is personalised treatment, which moves away from the model of mass manufacturing in big pharma factories to a point-of-care delivery of services. That is why it is so vital to get this right.

The report’s title, An Opportunity Lost, is a perfect way to capture what we are trying to do here. We all understand that it is a complicated area, and there are very clear reasons why a lot of it is delivered through the pharmaceutical industry. It makes sense to have that service connected to it all, particularly as a lot of their treatments become more complex.

I think all noble Lords would agree with the point of the noble Lord, Lord Blencathra, that we do not want the NHS to deliver on these areas, and that it has enough on its plate already. As the noble Baroness, Lady Morris, said, we need someone who is going to grab hold of this. Leadership and management 101 is that you need someone to lead a business, and that is clear here. We will be appointing and announcing that person very shortly. I cannot say it yet but, from some of the comments made today, I think that noble Lords will agree that it is a logical appointment. I probably should not go further than that. NHSE and its service delivery will be included in all of this. To the point of the noble Baroness, Lady Wheeler, all of this should absolutely begin now. A lot of this job is to make a fragmented service coherent.

As to what their job list should be, noble Lords set this out very clearly, and it is set out very clearly in the recommendations. I hope that that is clear in some of our responses, but I shall try to add some flesh to those bones. Number one on the job list is clearly data, and a common set of KPIs is fundamental to this. I was completely unclear on the sentence that the noble Lord, Lord Shipley, read out—it was probably more than one sentence. I was none the wiser, so there is definitely a mark of “could do better” there. As the noble Lord, Lord Mott, said, we need clarity, a common system of measurements and complete transparency all the way through, accompanied by a clear complaints system. No business in the world would get anywhere without that fundamental data, in as close to real time as possible.

Secondly, I completely understand why the regulatory lead has evolved in this way. It is natural that the MHRA looks after the medicines aspect, such as efficacy and any side effects. It makes sense that the General Pharmaceutical Council looks after some of the dispensing aspects, but at the core of these homecare services is the delivery of treatment. As the noble Lord, Lord Willis, suggested, that is why the CQC is the natural lead for doing that. I will not comment on the assessment of noble Lord, Lord Blencathra, on its involvement in this to date, but it is about making it very clear that it is a priority. That is key: what we have tried to do will be the future, so it should be a priority.

On the question from the noble Baroness, Lady Wheeler, my understanding is that meaningful conversations have begun towards that. It is quite clear that the CQC would be the natural lead because this is mainly about treatment and the delivery of healthcare services.

The third important thing on the job list is digital. It is amazing just how basic things are there. I am completely with the noble Lord, Lord Allan, that we should expect an Amazon-style delivery. We are all very used to that these days, where you get a message that your delivery is on the way. Providing that sort of information is not rocket science. We should definitely look at that, so that the service is at least as good as his cat’s service, if not—I hope—a lot better.

The fourth job is to provide clarity on the costings. As the noble Lord, Lord Willis, and others have said, the commercial confidentiality aspect should not be an issue. All we are saying is that, if they are charging £100 for an item, which includes both the medicine and the service delivery, there is an element—£20 or whatever it is—associated with the service delivery. My suspicion is that the power is with the pharma company here—that goes to some of the points raised by the noble Lord, Lord Carter. Often, the service is the tail-end Charlie in the whole set-up. As the noble Lord, Lord Carter, said, this is just basic operational and service delivery. We need to make sure that it is a very clear part of it in the contractual sense that the noble Lord, Lord Allan, referred to.

We need to do some training with our contractual negotiators. This is not just about driving down the price of the medicine—which I think we would all guess is the primary part of the negotiation—but, where there is a treatment component, is about making sure that the delivery is key. If the noble Lord, Lord Hunt, were here, that is exactly what he would say about value-based procurement. Small things going wrong with that can have huge consequences not just for the patients, as we have seen with the examples raised today, but through knock-on costs for the rest of the service.

For what I hope will be a constructive way forward, I propose that the senior responsible officer—the leader for all this—will be appointed soon. With noble Lords’ permission, I would like to invite him or her and the relevant NHS people to a round table with the noble Baroness’s committee. With them having had a bit of time to get their feet under the table, but not so much that they have already gone down the path too much, it would be excellent to have a hopeful round-table conversation. I hope that will be a constructive way forward to make sure that they are setting off on the right track.

As ever, when we finalise this all, I will write on any points that I have not covered, particularly on blister packs. We probably have been talking at cross purposes, so I will make sure that the point is understood and taken back.

In conclusion, this is definitely useful. As I say, I will come back to the committee with more thoughts, but one thing off the top of my head is that in the whole area of precision medicine there is just such an opportunity there for a whole new way of treating cancer—I hope that one day it will replace chemo, which we know is a blunt tool. There is a whole mechanism there for delivering which we will need to build on in these homecare-type areas, and that could be a very interesting area for the committee to look at.

I have learned a lot from this area, and I thank your Lordships for shining a light on it. I hope that noble Lords feel that we are getting the right attention paid to all of it. However, we absolutely need to continue to hold feet to the fire, and I know we can rely on all noble Lords, quite rightly, to make sure that we do that.

NHS England: Ovarian Cancer

Lord Markham Excerpts

Thursday 2nd May 2024 Lords Chamber

[Baroness Hayter of Kentish Town]

To ask His Majesty’s Government what assessment they have made of NHS England London stating that “anyone with ovaries can get ovarian cancer” in a social media post rather than referring to “women”, whereas at other times NHS England refers to “men” in relation to prostate cancer; and whether this wording has been market tested with women, including those for whom English is a second language, to ensure that it is fully understood.

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

We are writing to NHS England about NHS London’s social media post, to reiterate the expectation that biological sex should be front and centre of all health-related information. Removing language around biological sex has the potential for unintended health consequences. The Government are committed to upholding the rights of women and girls, which is why we are consulting on updates to the NHS constitution, including the use of clear language based on biological sex.

[Baroness Hayter of Kentish Town (Lab)]

I warmly welcome the Minister’s response, which is probably welcomed across the House. Given the Government’s welcome assurance that “single-sex wards” means “biologically single-sex wards”, will he also discuss with the GMC the video on its website that advises doctors to ask trans patients which wards they would prefer to go in? Perhaps he could also talk to the GMC about its practice of allowing doctors to change their gender on the register without any advice that they should inform patients of their biological sex. Although I approve of the Government saying so, it is very hard for patients to ask for a doctor of a particular sex for intimate care if they do not know the sex of their doctor.

[Lord Markham (Con)]

First, I thank the noble Baroness for all her work in this space. I will continue to work closely with her, including by writing to and meeting the GMC as necessary on all these matters. On her second point, while I respect that many clinicians may wish to keep their information private, we have to understand that, for many people, it is the patient’s right to be treated by someone of a particular biological sex and to know what that is. We have to make sure that those feelings and understandable sensitivities—which are sometimes religious—are catered for.

[Baroness Burt of Solihull (LD)]

My Lords, I totally agree that the wording looks a bit odd, to say the least, and that we should give special consideration to the wording for people for whom English is not their first language. However, there are tens of thousands of trans and non-binary people who would be missed out if we did not spell out that trans men can still get ovarian cancer and trans women can get prostate cancer. Does the Minister agree that what we need is clear, incisive language, so that everyone can be aware of the health risks that apply to them?

[Lord Markham (Con)]

Yes, absolutely. We all come at this from the perspective of making sure that health is front and centre, which is why the primary descriptors should be “man” and “woman”, as I think we all agree. Beyond that, we should clarify that “woman” may mean a “person with ovaries”—but the primary descriptor is “woman”. I hope that we can all agree on that.

[Baroness Meyer (Con)]

My Lords, given the lack of specific data on the consequences of NHS England’s adoption of gender-neutral language and services, does my noble friend the Minister agree that the millions of women who have been affected should have been consulted before such measures were implemented? Does he agree that, if medical records fail to document patients’ biological sex, clinicians would be at risk of giving trans people the wrong medication?

[Lord Markham (Con)]

Yes. Once again, I come at this from the perspective that health is the primary factor here. Clearly, a person’s biological sex is a key part of the information on their record that any clinician needs to know, so that absolutely needs to be primary.

[Lord Cashman (Lab)]

My Lords, I will make a simple point with which I hope the Minister agrees. Is it not to be welcomed that we come up with language that is inclusive and reaches as many people as possible, as the noble Baroness, Lady Burt, suggested, and as is indicated in the framing of the information we are discussing?

[Lord Markham (Con)]

Yes. To reiterate, I think that we should always use “man” or “woman” as the primary descriptor. For people with English as a second language, “woman” is very understandable. We can then be inclusive by saying a “person with ovaries”, so that we are absolutely clear. My remit here is health, so I want to make sure that most people, especially if English is their second language, understand who we are referring to when we say “woman”.

[Lord Patel (CB)]

My Lords, I am slightly reluctant to stand up and get involved, but I have done so previously, and I will continue to support the campaign led by the noble Baroness, Lady Hayter, to make sure that the words “woman” and “mother” are not removed from our language—I absolutely support that. I will muddy the waters a bit. There is, in medical terms, a syndrome called androgen insensitivity syndrome, which occurs in about two to five per 100,000 births. The person born is registered at birth as a female, because they have the phenotype of a female and external genitalia that resemble those of a female. They grow up as female, and the diagnosis is often not made until puberty, when they do not menstruate—but they develop breasts. They do not have ovaries. They often identify themselves as female for the rest of their lives, and they occasionally get married. I have looked after such a person myself. They are registered as female, they do not have ovaries and they sometimes have internal testes, which can become cancerous. So it is correct that only people with ovaries can develop ovarian diseases, including ovarian cancer. As I said, I have muddied the waters.

[Lord Markham (Con)]

I am not sure that there was a question there, so I might take the easy option of thanking the noble Lord for his comments—and for maybe muddying the waters—and moving on.

[Lord Collins of Highbury (Lab)]

My Lords, all noble Lords have raised the issue and the Minister has put it quite rightly: health has to be the primary consideration, language is quite important, and how do we reach difficult communities who are isolated, whether for community or religious reasons, and so on? On a visit to Kenya last year, I was able to see innovative practices. Women living with HIV are 60% more likely to get cervical cancer, so local treatment centres were being used as a way of testing and screening so that comorbidity was properly addressed. The success of these campaigns was because they were backed up by using individuals trained in the community to empower and educate their community. They provide a critical service by building trust and confidence, because many people are reluctant to be tested and screened in the way that noble Lords have been talking about. That innovation has been incredibly successful in Kenya. Does the Minister agree that we can learn from that sort of thing and start doing it in this country?

[Lord Markham (Con)]

Absolutely, and I hope noble Lords have seen that I am keen to learn from wherever. I would be interested to understand more in this case. As I think we are all saying in these arguments, it is about making sure that we are being sensitive and inclusive in language, but that we are also being very clear in our language about what we mean so that health always comes first.

[Lord Allan of Hallam (LD)]

My Lords, I recently looked at the prostate-specific antigen screening programme advice, which was very good and met the requirements that the Minister has set out. However, I got there only because of a Peer-to-Peer networking episode, where I bumped into another Peer who said, “You really need to go and look at the PSA screening”. It struck me then that this journey into screening programmes is still very confused and ad hoc. Will the Minister look at that and at how we can make sure that whoever you are and whatever your gender, your age and your other risk factors, you get the direction you need into the right screening programme?

[Lord Markham (Con)]

I thank the noble Lord; he is always very good at bringing up some of those cases. I will look into it and make sure that we do that.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I welcome the untangling of linguistic confusion and the implications for policy. However, when the Minister says, “When we say ‘woman’, we all know what we mean”, I am not convinced that that is true in policy circles. Increasingly, inclusive linguistic demands are that “women” includes men who self-identify as women, which means that by-women and for-women provision, such as rape crisis centres, domestic abuse support and so on, is actually not women-only at all. When the Minister says, “We all know what we mean by ‘woman’”, can he make it absolutely clear that he means “woman” as in “natal woman” and not those who identify as women?

[Lord Markham (Con)]

I guess what I am trying to say here—again, always with my health hat firmly on—is that I want to make sure that when we describe something in a health sense, I want that person to know that we mean them because we are doing something which applies to them, often in the case of ovarian or cervical cancer. By saying “woman”, obviously in most cases that will make it very clear that it applies to them—particularly to those with English as a second language—and they know what that means. To make sure we are covering all the bases, I am very happy that we have that secondary descriptor of a “person with ovaries”. I am trying to cover all the bases in an inclusive way so that the health message gets through.

Covid-19 Vaccination: Coronary Disease

Lord Markham Excerpts

Tuesday 23rd April 2024 Lords Chamber

[Lord Farmer]

To ask His Majesty’s Government what assessment they have made of the connection between COVID-19 vaccination and increased prevalence of coronary disease.

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

The Government are taking action to tackle cardiovascular disease and coronary heart disease, including through supporting improved uptake of the NHS Health Check England cardiovascular disease prevention programme. There is no evidence linking Covid-19 vaccines to increased levels of coronary heart disease. All vaccines used in the UK are authorised only once they have met robust standards of effectiveness, safety and quality set by the UK independent regulator, the Medicines and Healthcare products Regulatory Agency.

[Lord Farmer (Con)]

I thank the Minister for his reply. A considerable number of cardiologists, other medical practitioners and scientists have raised concerns about a link, especially among younger people, amid a pervasive sense of a lack of transparency. A reluctance to disclose the full gamut of information sits uneasily with the Government’s ongoing encouragement for people to get vaccinated. To resolve this, can the Government at least publish data on cardiac deaths in the ever vaccinated and never vaccinated by age group for 2022, 2023 and onwards?

[Lord Markham (Con)]

I thank my noble friend for this question. The ONS has provided this information and made it available for research purposes to make absolutely sure that we get to the bottom of this issue. For the understanding of noble Lords, every medical vaccine has side-effects, but the MHRA has investigated this, and the side-effect that people are worried about is heart inflammation. One to two people per 100,000 who have had a vaccine experienced side-effects, but, for people who have had Covid, it is 150 per 100,000. Having these vaccines is a much safer route to go.

[Lord Allan of Hallam (LD)]

My Lords, there is one substance that we put into our bodies during Covid that has been clearly linked to thousands of excess deaths: alcohol. Are the Government carrying out studies into what happened with alcohol consumption during the pandemic, who was most at risk and how we can ensure that in any future pandemics we do not see excess deaths? We are talking about 2,500 excess deaths during 2022.

[Lord Markham (Con)]

The noble Lord is quite right. There were much wider effects and impacts in the lockdown, and alcohol intake was one of them; mental health, particularly of our children, was another. My sincere hope is that these are the kinds of issues that the Covid inquiry should really be investigating: the wider impacts on society caused by lockdown.

[Lord Patel (CB)]

My Lords, a recent study published in Vaccine of a cohort of 99 million people who were vaccinated with one of the vaccines—either vector or messenger RNA vaccines—showed an increased risk related to myocarditis and pericarditis. The incidence, particularly among the younger people, was about one in 10 in a 1 million population, as opposed to the non-vaccinated who got Covid. That should be the comparison, not the non-vaccinated who did not get Covid. In those cases, things such as Guillain-Barré syndrome, which is a long-term viral fatigue syndrome, occurred at a higher incidence in non-vaccinated people than in vaccinated people, particularly with the Oxford/AstraZeneca number 1 vaccine, which was withdrawn. Therefore, it is a balance of whether the disease or the vaccine will make you more sick. With any treatment in any branch of medicine, there is always a risk to the treatment. There has to be a balance.

[Lord Markham (Con)]

I am sure I speak for the whole House when thanking the noble Lord for his expert understanding and insights. As he said, the evidence is very clear that while no vaccine is risk-free, what it saves you from is much greater. The very firm advice is that you are much better off having the vaccine.

[Lord Hannan of Kingsclere (Con)]

My Lords, may I ask my noble friend the Minister about the efficacy of the vaccine in preventing transmission? It does seem to be very good at keeping people out of hospital and keeping people alive, but we built the most immense edifice of restrictions around the idea that it was preventing the transmission of Covid. We had vaccine passports and travel bans, and it now seems that both the WHO and Pfizer knew at the time that its efficacy when it came to preventing transmission was negligible. Can my noble friend the Minister tell the House what his department’s latest assessment is of the vaccine’s ability to prevent giving Covid to other people?

--- Later in debate ---

[Lord Markham (Con)]

The main thing that the vaccine did was prevent any bad effects if you did get Covid. While it might not have reduced transmission much, its main benefit was that it reduced the effects if you had it, as well as hospitalisations and deaths. Making Covid a less serious disease, basically, enabled us to open up the country and we were one of the first to get going again because we knew that the disease no longer posed the high risk that it did before we had the vaccines.

[Lord Davies of Brixton (Lab)]

My Lords, I have some personal experience here. One week after I had my first course of Covid vaccination, I had an attack of pericarditis and ended up in St Thomas’ Hospital. I am convinced that there is a link, but it is important to look at the longer-term effects—having an attack of Covid causes more heart problems, as well as having a long-term impact on your general health.

[Lord Markham (Con)]

The noble Lord is absolutely correct. The MHRA study on heart inflammation, which he mentioned, said that there is that side-effect for one to two people per 100,000—unfortunately, the noble Lord seems to have been one of them. However, if you get Covid it affects 150 people per 100,000. On balance, if you have not had the vaccination, your risk is 22 per 100,000. The statistics are very clear.

[Lord Watts (Lab)]

My Lords, does the Minister think that we need to do far more on public awareness of vaccines and their benefits? All sorts of people out there are spreading malicious tales about the implications of taking them, whether for mumps or Covid.

[Lord Markham (Con)]

Absolutely. We are all very aware of the damage done by all the myths around the MMR vaccine 20 to 30 years ago and the impact that has had on people. The more we can get the message out, the better. As the noble Baroness, Lady Merron, asked me yesterday, we have learned that it is about making sure that we communicate to all groups so that we can make sure that ethnic minorities and other minority groups get that information.

[Baroness Merron (Lab)]

My Lords, after many years of stalled progress, the rate of premature deaths from cardiovascular disease continues to increase, for reasons that the British Heart Foundation describes as “multiple and complex”. The warning signs of this have been present for over a decade. As this phenomenon did not start with Covid, what assessment has been made of the contributory factors of government policy pre Covid and what steps are being taken to turn this around?

[Lord Markham (Con)]

Deaths from heart disease among those under 75 are down by about 20% compared with 2010, which is a clear trend. Notwithstanding that, we are very aware—Sir Chris Whitty is concerned about this—that Covid meant that a lot of people did not get basic heart and blood pressure checks. That is why we have introduced the Midlife MoT, which is designed to give people a 10-year risk analysis; have put blood pressure devices in pharmacies and all sorts of other places to get 2 million checks; and have a workplace heart disease strategy check. All this is designed to get that prevention in place so that people are aware of and understand the risks.

[Baroness Finlay of Llandaff (CB)]

My Lords, does the Minister agree that, although we are talking about heart disease, we must also remember pulmonary embolism from clotting disorders, which can persist for up to six months after even a mild Covid infection? A massive pulmonary embolus is another cause of mortality in people who have Covid. One of the problems with the virus is its ability to mutate, but the evidence is that vaccination, even if it does not give you complete protection, moves you from obtaining serious Covid to having milder Covid. That risk of thromboembolism also needs to be monitored in the long term in relation to Covid infections, including for those who have had a mild infection and those who have long Covid.

[Lord Markham (Con)]

The noble Baroness is absolutely correct: a vaccine helped you avoid not just heart disease but all the other impacts of Covid that she mentioned, including long Covid and a whole list of other things. Again, the undeniable advice is that it is much better to have the Covid vaccine.

NHS: Long-term Sustainability

Lord Markham Excerpts

Thursday 18th April 2024 Lords Chamber

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

I also thank the noble Lord, Lord Patel, for initiating this debate today. I am very happy to start off by answering the question of the noble Lord, Lord Hacking, by praising the NHS. The very ethos of the debate that the noble Lord, Lord Patel, brought up today is that, as critical friends, we know that we need to look at the challenges that the NHS is facing if it is going to be sustainable for the next 75 years.

I welcome the noble Baroness, Lady Ramsey. I enjoyed her journey and I shared some of her difficulties in finding her way around this building. I think I sum up the views of the whole House by saying that we are delighted that she has found her way to be with us here today and, generally, in the House of Lords.

I also thank all noble Lords for the constructive way in which this debate has taken place. Again, I praise the noble Lord, Lord Patel, for the way he framed this whole debate to bring that about. There were a lot of very thoughtful contributions, and in many ways we built on the debate that the noble Lord, Lord Scriven, called about six or nine months ago—this debate was very much in keeping with that. I particularly enjoyed the passion that the noble Baroness, Lady Boycott, brought to it all. I thought that at this stage I probably should not declare an interest in Costa Coffee—which I do not have, by the way. There were very many thoughtful contributions which I hope I will be able to build on, but I single out those by the noble Baroness, Lady Murphy, and the noble Lord, Lord Warner.

I want to avoid this being a political debate. Maybe contrary to some of the points of the noble Lord, Lord Hunt, we are seeing similar challenges across all four NHSs—across all four nations. I am afraid to say that maybe the worst-performing of those, from the records that many noble Lords will remember, whether we are looking at waiting lists or a number of other records, was Wales. These are challenges that we are all facing at this point. However, I want to be united in this debate in looking at the positive way forward.

I recognise that many noble Lords, including the noble Lords, Lord Hunt and Lord Warner, and the noble Baroness, Lady Murphy, brought up the overcentralised nature of the NHS. However, I disagree with the noble Lord, Lord Hunt, that this is due to direction from Ministers. The whole point of trying to set up the ICBs, as referenced by the noble Lord, Lord Carter, is to reverse that and put more power at a local level. These are early days in the life of ICBs but we definitely see them as the way forward.

I hope to answer the points made by the noble Lord, Lord Kakkar, and the noble Baroness, Lady Cavendish, on trying to make this into a long-term conversation. I freely accept that probably at this part of the political cycle we can have only so much of a conversation. However, on my part, whichever role I may or may not be in post election, I undertake to take part with whoever is in power in what I hope will be a constructive conversation. It needs to be the sort of environment where, as the noble Lord, Lord Allan, says, code wins the argument, and people are coming from all around and can have those sorts of constructive conversations. I think that will include a new contract between the NHS and the people, as the noble Baroness, Lady Hollins, says.

I will start by echoing some of the financial realities that the noble Lords, Lord Bethell, Lord Mawson and Lord St John, brought up. The reality of the situation is that we spend about 10% of our GDP on the NHS right now. It is going up as a proportion year after year, and it will go only one way. At the same time, no one is proposing major injections of cash. I think we all recognise the financial situation; the proposals that Labour made, for instance, amount to less than 1% of the NHS budget. Therefore, I think that what we can all unite on right now is that this is an argument not about pumping in lots more money but about finding other ways to try to make the NHS more sustainable, in many ways using, as the noble Lord, Lord Warner, says, a “tough love” approach where that is appropriate.

I want to talk about the things we are doing in terms of the infrastructure and capacity, as the noble Baroness, Lady Murphy, mentioned. When I talk about infrastructure and capacity I am talking about the labour supply, the productivity plan and the capital estate, and I then want to combine that with the new way we need to engage, whether it is around technology, prevention or primary community care, which to my mind are the ways in which we will create a sustainable NHS going forward.

Starting with the labour supply, I completely agree with the point made by the noble Lord, Lord Hacking, that staff are at the heart of every successful organisation. That begins with making sure that we have the right number of staff, which is what the long-term workforce plan is all about—trying to make sure that we have the proper recruitment, training and long-term resources.

However, more important than any of that are the points about retention and the right culture, made by the noble Baronesses, Lady Hollins and Lady Finlay, respectively, so that people feel that they are valued and are in a caring and supportive environment rather than the bullying environment we have seen all too often. In answer to the questions from the noble Lord, Lord Carter, and the noble Baroness, Lady Cavendish, I say that the Messenger report is vital.

The role of management is fundamental. In answer to the question from the noble Lord, Lord St John, I can say that when I first came into this, I did a lot of work trying to look at hospital performance. I did all sorts of analysis, looking at demographics in a local area and the relative funding. No matter what I did, there was always at least 50% unanswered in the multiple regression analysis and so on. The conclusion I came to, which is probably not earth-shattering, was that that 50% performance is all about the management, leadership and culture that drives it.

As the noble Lord, Lord Kakkar, said, a lot of that is allowing people to work at the top of their profession. If you allow them to do that, that is when they can make the new developments and innovations. That means using technology and AI to help reduce administration, which I will come to later when I talk about the productivity plan. It will also mean some uncomfortable conversations, using other staff to do some more of the administrative parts. Again, I totally support, welcome and appreciate the moves that the noble Lords, Lord Hunt and Lord Scriven, are making in the use of things such as physician associates, which is about trying to take away a lot of that burden so that doctors really can practise at the top of their profession.

In response to the point made by the noble Baroness, Lady Tyler, about productivity, that needs to be and is being put into a detailed plan that we can all review. We will have the opportunity to do so around July. As the noble Baroness, Lady Merron, said, we absolutely identify that we need to replace the inefficient IT estate, among other things. It is doing a lot of the basics in PCs, wifi and all the things mentioned by Joe Harrison, whom I know well; I work with him every week. It is about systems, EPR and arming the staff and clinicians with the basic equipment. You can start small, as the noble Lord, Lord Mawson, said. As well as electronic patient records and the FDP, those are the things from which we will get productivity improvements. When I talk about figures such as the £35 billion, I am talking about increased output, not savings. I am talking about how we can get increased treatments and output—and definitely by using the things mentioned by the noble Lords, Lord Reid and Lord Carter: payment by results and the right incentive systems; and, as the noble Lord, Lord Crisp, said, the use of the independent sector to supply, where relevant.

Of course, vital to all this is the capital estate. That is why the new hospital plan is a vital part of this. The work shows that if you put the right digital instruments in place and the infrastructure into hospitals, you get 10% more productivity. In answer to some of the questions from the noble Lord, Lord Warner, I say that if you put the right real estate in as well, the combination gives you 20% more productivity. That is not just time output but reductions in the length of stays. We all know that the sooner you can get people home, they are more likely to go on and live successfully in their environment.

Regarding the points around adult social care and the training and qualifications of the staff, which were made by the right reverend Prelate the Bishop of Newcastle, the noble Baroness, Lady Warwick, and the noble Lord, Lord Turnberg, I totally agree. That is what we are trying to do. We have for the first time introduced a qualification for adult social care staff and training. We have put 18,000 different adult social care providers into a system where they can put up training and get easy management of payments for it all. More needs to be done long term for a fundamental funding model; that goes to the points raised by the noble Baronesses, Lady Warwick and Lady Cavendish. That will involve a covenant of care but, honestly, we need to do more work on long-term funding solutions.

I cannot say enough about prevention. My noble friend Lord Bethell said to me, “Very simple, your speech today: prevention, prevention, prevention”. There are a few more things but I will definitely add a few “preventions”. The long-term workforce plan and productivity plan are designed towards that. The screening programme that we are doing is because Chris Whitty’s biggest concern is that simple things such as blood pressure which were missed during Covid will now lead to excess deaths in heart disease. As the noble Lord, Lord Patel, mentions, those simple blood pressure measures and mid-life MoTs are fundamental to what we are trying to do. I will take a leaf from the book of the noble Lord, Lord Allan, because it is right: we need the champions in that space.

I agree with the points made by the noble Baroness, Lady Boycott, on the importance of dentistry and early check-ups being needed for the prevention agenda. Our new plan regarding school checks and water fluoridation is all to help with that. I see a future world, of which I will talk more later on, where you have a much more targeted screening programme. In addition to our mid-life MoTs, which are blanket programmes, AI needs to be used to help target screenings so that we can really help people in prevention.

I agree on the ever-increasing use and funding of acute hospitals, which none of us has solved, as raised by many noble Lords. There is a need to rebalance this towards primary and community care. I look forward to the report of the committee of the noble Baroness, Lady Pitkeathley, on the integration of it all and what we can learn from its points. Things such as Pharmacy First are good ways ahead. We have seen 98% of pharmacies sign up and already there have been 125,000 consultations. With the dental plan, we have had 500 new surgeries and a 50% increase in the numbers taking adult NHS patients. However, we need the new model of care mentioned by the noble Lords, Lord Scriven and Lord Crisp, care that is away from the acute hospital and in the community. I cannot speak more highly of the Bromley by Bow Centre, which I visited. The noble Lord, Lord Mawson, should be very proud of everything that I saw there. Of all the visits that I have done in almost two years in this job, it was one of the ones that I enjoyed the most and was most impressed by. That is the model we should take going forward.

That centre is doing exactly what the noble Baroness, Lady Chisholm, mentioned, in looking at the whole health of the person and seeing how it can really care for them in the community. Of course, that requires community nursing. My mother was a community nurse, so I realise that. It needs to be backed by technology. I am proud to say that I have been responsible for the app for the last 18 months and we have gone from 10% of people having their medical records to over 90%. As the noble Baroness, Lady Merron, said, we now have 33 million people using the app for digital prescriptions, medical records and appointments, which the noble Baroness, Lady Pitkeathley, had an example of just the other day.

We do need to broaden things out, so more people realise all the features that are on the app, but we really do see the app as the front door of access to the NHS. It will deal with future therapies, whether musculoskeletal, as many noble Lords have mentioned, or mental health. That gives opportunity for it all. On the point made by the noble Lord, Lord Parekh, the app does allow people to take control and to take power away, sometimes, from the experts, giving them control and putting the power in their own fingertips.

Data and AI are fundamental to this, to enable the sort of precision medicines my noble friend Lady Blackwood mentioned. I thank her, and Genomics England for all the work it is doing to lead on this. It is an institution we should rightly be proud of. That is the future of medicine, but it is all underpinned by the data. Funnily enough, I have kicked off cataloguing of that, because it is fundamental.

On adult care, we have increased digitisation from 20% to 60% quite quickly. Having the data at the heart of this will allow competition and innovation to take place. But we need to make sure that that conversation happens in the right way, so that we bring the public with us on that journey.

I hope that gives a vision of the things we are trying to do to put the infrastructure in place—the supply, workforce, technology, IT and capital—accompanying that with new ways of working, whether it is a focus on prevention, more input into primary and community care, or using AI, technology and genomics to lead the way forward. I think we all agree that that is the only way we will get a sustainable health service going forward.

I thank the noble Lord, Lord Patel, and all noble Lords who have contributed for the spirit of the debate and its thoughtfulness. I give special thanks again to the noble Baroness, Lady Ramsey, for choosing this debate for her maiden speech, and I thank the noble Baroness, Lady D’Souza, for joining us on her 80th birthday. As ever, I apologise to those whose contributions I have not managed to cover completely, and I promise to write giving a thorough wrap-up.

Cass Review

Lord Markham Excerpts

Wednesday 17th April 2024 Lords Chamber

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

I thank the noble Baronesses for their important points and for their sensitivity.

First, I echo the Secretary of State’s gratitude to Dr Cass and her team for undertaking a considered, comprehensive and courageous review into an extremely contentious area of healthcare. Officials have described this to me as probably the best report they have seen, in its excellence, thoroughness and sensitivity. Since NHS England commissioned the review in 2020, it has meticulously unpicked what went wrong, what the evidence really shows and how to design a fundamentally different service that better serves the needs of children.

Noble Lords and Baronesses will be aware of why this review was commissioned, but it is worth repeating here. The statistics are startling. As recently as 2009, the NHS’s sole gender identity development service at the Tavistock and Portman trust received fewer than 60 referrals for children and young people, with just 15 being adolescent girls. Since then, demand has surged. In 2022, more than 5,000 children and young people were referred to gender identity clinics, almost three-quarters of whom were female. The near uniform prescription of an irreversible medical pathway on the basis of sometimes very minimal evidence was imposed on these children and young people with complex needs without full and thoughtful consideration of their wider needs, including neurodiversity, trauma, mental health conditions or who they loved.

In her Statement in the other place, the Secretary of State outlined the immediate priorities for taking forward the recommendations from Dr Cass’s report. This includes looking closely at what needs to be done to curtail loopholes in the prescribing practices of private or online providers to ensure that they fall in line with Dr Cass’s recommendations. In answer to the noble Baroness, Lady Merron, the CQC is on this, and made it clear to all providers straightaway. We hope that legislation will not be required, but we are prepared to table it if necessary, because we need to send out a very clear message.

Private providers have been put on notice. Prescribing is a highly regulated activity and the CQC has not licensed any gender clinic to prescribe hormone blockers or cross-sex hormones to people under the age of 16. Any clinic that does may be committing extremely serious regulatory offences, for which it can have its licence revoked and its clinicians struck off.

On the point made by the noble Baroness, Lady Merron, I share the view of Dr Cass and the Secretary of State—I know that noble Lords share it, too—that it is completely unacceptable that all bar one adult gender clinics refused to co-operate with the University of York research into the long-term consequences of treatment received at the Tavistock centre. To be completely honest, I do not understand how they could be allowed to do that and I think we all are united in saying that that is simply not acceptable. That is why we have gone back so strongly on exactly that point.

Since the publication of Dr Cass’s interim report in 2022, NHS England has made a series of important changes. On 31 March, the Tavistock clinic finally closed, having stopped seeing new patients a year earlier. To answer the points made about new services, two new regional hubs have been opened in partnership with the country’s most prestigious children’s hospitals to ensure that children are supported by specialist multidisciplinary teams, and another will follow in Bristol later this year. In the last few weeks, NHS England has made the landmark decision to end the routine prescription to children of puberty blockers for gender dysphoria. On the day of publication of Dr Cass’s final report, NHS England announced it was stopping children under 18 receiving adult gender services with immediate effect, and an urgent review on clinical policy for cross-sex hormones will now follow without delay.

Children are at the heart of this debate. Dr Cass’s report demonstrates that they deserve healthcare that is compassionate, caring and careful. Their safety and well-being must come above any other concern. That is why the Government will work with NHS England to root out the ideology that has caused so much unnecessary harm, and to give the next generation access to holistic care and protect our children’s future.

I turn to the other points raised. In addition to the three clinics mentioned, eight regional clinics will also be set up to make sure we can provide services on this. Within all that, the point about providing continuity of care up to 25 will be a key part of that. On mental health treatments generally and helping people on that, that is what the £2.3 billion investment has all been about in terms of developing the hundreds or thousands of extra places.

With regard to clinical trial timings, that is a difficult one. I think all noble Lords agree—this was very much a feature of the round table we held after we had the question on gender identity—that there is a general feeling that of course you do not want to settle on any course of treatment for a young person while they are still at that stage of life, in terms of puberty, where they have not had a chance to discover their own feelings. We all know that it is a complicated time and so, more than anything, we want to make sure that people are not set on a course of action that is irreversible before they really know their own minds and bodies and what is appropriate in that situation. That is why we are so firm in trying to follow the Cass guidelines to make sure that that is not available in those circumstances. To be open and honest on that point, I am not absolutely sure whether those clinical trials are compatible with that, but I will come back in more detail on that point. I hope that that answers the points for now, and I look forward to answering other points raised.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, this is a deplorable situation. It is a formidably good report and I commend the Government on their firm action following its publication. I question why it took the NHS quite so long to stop the routine prescription of puberty blockers to children under 18—that seems rather slow off the mark.

However, I have a more important point. I fear that one of the great damages from all this is to one of our national and international centres of excellence. The Tavistock clinic has been in existence for over 100 years. It was started by Hugh Crichton-Miller for the treatment of soldiers with shellshock. It has been the home of John Bowlby, Lily Pincus and RD Laing. It has done incredibly important work in terms of mental distress, mental health and emotional well-being. It is a national and international centre of training, with about 2,000 students a year. If I may take up the Minister, for whom, as he knows, I have an inordinate regard, I think he said that the Tavistock clinic had closed. It has not closed; the gender reassignment clinic has closed for ever. I ask the Minister and everyone in this House to try to help reclaim the reputation and the respect that the Tavistock clinic rightly deserves.

[Lord Markham (Con)]

Yes, absolutely, and I thank my noble friend for correcting me and giving me the opportunity to correct that. Again being very honest, this shows that part of the challenge in setting up the new services is that this has become such a difficult, toxic space, and finding and recruiting staff who want to work in this area is a real challenge as well.

[Baroness Hayter of Kentish Town (Lab)]

I thank the Government, the Minister and indeed the Opposition for their very robust response and welcome to the report. I am really sorry that the Lib Dems have chosen to use Stonewall’s briefing in what we have heard tonight; I hope that is not the whole of the Lib Dem position.

I note that the Government have already met with the GMC over the weekend, and they have been in contact with the CQC. However, just last month, the Royal College of General Practitioners tried to cancel a conference posing exactly the questions covered by Dr Cass in her excellent report. It allowed this conference—it was called “First Do No Harm” and I had the privilege to open it—only after an enormous amount of persuasion; it did it under duress, with bad grace and some hostility. That was the Royal College of General Practitioners.

Will the Government also meet the Royal College of General Practitioners and indeed the Royal College of Psychiatrists, the Royal College of Nursing, the Professional Standards Authority and all the other regulators, many of which seem to have been blind when all this was going on, and ensure that they all engage with the conclusions and the recommendations of Cass, whether those professionals over which they have oversight are working in the NHS or in the private health sector? These puberty blockers were being prescribed years after we knew they were irreversible, when Stonewall still said they were reversible, and when the doctors should have known but still prescribed them. Will the Government therefore engage with all those regulators to ensure that Cass is implemented in full?

[Lord Markham (Con)]

Yes, and that is an excellent point. Again, I thank the noble Baroness in this area. The questions that she raised earlier in the year in terms of some of the language from the GMC really added to the debate and represented a step forward. Therefore, although I am sure it is happening already, I will doubly check that it is.

[Lord Sandhurst (Con)]

My Lords, my focus is on the misuse of drugs for unlicensed purposes. It is perfectly proper and sensible that drugs are used for unlicensed purposes in the right circumstances. For example, in the case of children, drugs are not tested on them; they have been tested and licensed for use on adults, and they are used quite properly—it is called “off-label”—for children for the same purposes. However, in this case, as Cass has found at paragraphs 20.11 and 20.12 of her report, in the case of puberty blockers there was what she describes as a “system weakness” in that off-label use. It went beyond the usual level of permissiveness in extending use to a very different indication. So she has recommended, in recommendation 32:

“Wider guidance applicable to all NHS services should be developed to support providers and commissioners to ensure that innovation is encouraged but that there is appropriate scrutiny and clinical governance to avoid incremental creep of practice in the absence of evidence”.


I have two questions. What steps are the Government taking to implement this important recommendation as a matter of urgency? It will not just be puberty blockers; there will be drugs used in a range of fields. Who will be charged with the responsibility for creating this guidance and then implementing it?

[Lord Markham (Con)]

With the wonders of modern technology, I hope I can answer two questions in one. On the previous question, yes, the regulators have been communicated with about making sure that it is very clear. On that point, I say to my noble friend that the regulators have been charged with making sure that very clear guidelines are put out on the drug use that he mentions; those are being set right now. While I am clearing stuff up, to be clear and to save me correcting it later, it will be eight clinics in total when they are all there; I might have said that it was eight additional clinics.

[Lord Young of Norwood Green (Lab)]

My Lords, I too pay tribute to the Government, and to Dr Cass especially, for a magnificent report that took both determination and courage; let us not underestimate that. She has achieved a huge amount: we now have four clinics up and running with people who understand the need to counsel young people. What we do not know is how many thousands of lives have been wrecked by the indiscriminate use of puberty blockers and hormones; it may eventually be uncovered. I also pay tribute to our party and our shadow Health Minister Wes Streeting for unequivocally backing the Cass report and committing the next Labour Government, should that be the case, to an evidence-based situation.

I put it to the Minister that puberty is not something that ends at 18. Dr Cass rightly defines it as a process that could go up to 25. She recommends that those services should include that kind of counselling, and I would welcome some confirmation from the Minister that that will be the case. There is still more work to be done on this. I have said on previous occasions that this is a cult that has invaded a lot of the institutions of government and other institutions. It is not going to just lie down quietly; there will be attempts to evade this legislation, and we should be on our guard against that.

I want to end on a positive note. I welcome the Statement. I pay a further tribute to Dr Cass, a woman who came out of retirement and was probably looking for a nicer and easier thing than this to deal with. This Chamber owes her and her civil servants a real debt of gratitude.

[Lord Markham (Con)]

I remember that it was the noble Lord who, in the round table that we had on this, made very clearly the same point I was making earlier about puberty and age. It is only when you are right the way through it that you really are in a position where you start to know your own mind and your own body. I agree with the noble Lord that it can be as late as 25, and that is why that is definitely the intention behind the eight clinics that are being set up—that they can provide that continuity right up to the age of 25, given that there is such a state of flux in a young person’s life.

[Baroness Finlay of Llandaff (CB)]

My Lords, I thank the Government for giving us this opportunity. Dr Cass’s report is incredibly important. She has taken a scientific, as well as a kind, humane and humanitarian, approach to the children affected and to the way the report is written. In the recommendations, as well as the discussion over puberty blockers there is the importance of ongoing research, research capacity and data. One finding that emerged for her was that there was a lack of consistent collection of data, which means that for many of these children, the people who were looking after them were, in effect, flying blind. That cannot be allowed to continue in future.

Her recommendation 17 is that:

“A core national data set should be defined for both specialist and designated local specialist services”.


Recommendation 18 is that:

“The national infrastructure should be put in place to manage data collection and audit and this should be used … to drive continuous quality improvement and research in an active learning environment”.


My question to the Government is whether, among the organisations listed, there are also discussions with the Royal College of Surgeons, because there is also surgical intervention undertaken in some of the processes. Without a database of the numbers that undergo a surgical intervention, the type of intervention and the complication rates, and monitoring the effect of that surgery on quality of life, we risk carrying on flying blind with clinical treatments that are literally life changing.

[Lord Markham (Con)]

I thank the noble Baroness. She is absolutely right: it is only in that lack of data environment that, dare I say it, ideology can fill in the vacuum and start to drive the sorts of behaviours that we see. Data is always the best way to cut through and provide light when there is a lot of heat in an argument. She makes an excellent point about the Royal College of Surgeons. I am sure that it has been contacted along with all the other bodies, but we need to make sure that is covered off. As ever, I will come back in detail in writing to all noble Lords who have raised points. I will make sure that point is addressed as well.

[Baroness Deech (CB)]

My Lords, my gratitude to Dr Cass is that the report has given the rest of us the strength to challenge something that we knew was irredeemably harmful. I have two questions for the Government. First, will they remind the NHS of the law? Gillick competence—I am abbreviating it—states that:

“Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment”.


It is simply impossible for any child under the age of 16 to understand what is meant by sex change or puberty delay. They cannot get their heads around it or possibly comprehend what it will mean for them in future, so Gillick competence has to be remembered.

Secondly, will the Government also remind the NHS that young people and others are confused and possibly endangered by the ridiculous use of phrases saying that “people who have ovaries” or “people who have cervixes” should come forward for treatment and so on? Can we please restore the word woman, or indeed girl, when it comes to medical treatment?

[Lord Markham (Con)]

To take the second point first—it was also made by the noble Baroness opposite—that is absolutely right; it can be a real danger. People with English as a second language might not understand that a “person with ovaries” refers to them. It needs to be very clear. It is fundamental that the first description has to be “male” or “female”; you can then put additional parentheses after that.

The noble Baroness’s first point is exactly right. Until young people are through the age of puberty and its effects, they are not in a real position to make up their own minds. That does not mean that they should not be supported during that process, but it does mean that we should not be doing anything irreversible.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I watched the Secretary of State’s introduction to this Statement on Monday, live from my office. She asked the other place to

“bear the sensitivities of this debate in mind”.—[Official Report, Commons, 15/4/24; col. 55.]

I am afraid that it is clear from the printed record before us, and was even clearer watching the Secretary of State speaking, that it was delivered in a triumphalist, dogmatic tone, which meant that she did not follow her own prescription.

The Statement speaks of “myths” but fails to acknowledge the agency and lived experience of children and young people. I have two questions for the Minister. Can he reassure me that we are not going to lose, in this ideological debate, the need for massively more investment in services for children and young people in the NHS? The noble Baroness, Lady Burt, referred to the huge waiting lists that are behind the report we are discussing today.

The Statement also did not mention—and I think we have to acknowledge this—that hate crime against transgender people hit a record high in figures out last October. I hope that the Minister will agree with me that children and young people seeking gender identity services should not have to live in a society where their experiences are used as a political football. They should not be treated as a weapon in the culture war. They should not have to live in a hostile society.

[Lord Markham (Con)]

First, I think I speak for the whole House in agreeing that no one, under any circumstances, should feel that they live in a hostile society —whatever case it is, whether it is transgender, race, sex or whatever. I totally agree with the noble Baroness there. I will absolutely clarify this in the follow-up in writing, but I know that, in this specific area, the NHS has already committed £18 million in this space. Of course, this is quite separate from the £2.3 billion that I mentioned before in the mental health space generally, which, from memory—and I will absolutely clarify this—is the provision of 350,000 extra places for young people, because we know how much the demand is out there.

[Baroness Jenkin of Kennington (Con)]

My Lords, I am grateful to the Noble Baroness for clarifying the Lib Dem position because, unfortunately, the page on the website has disappeared this afternoon. May I ask my noble friend whether the Government acknowledge that a conversion practices Bill would have a detrimental effect on the recruitment of clinicians to the new children’s services, as highlighted in the Cass Review?

[Lord Markham (Con)]

I must admit that I am not sure that I quite understood the question from my noble friend.

[Baroness Jenkin of Kennington (Con)]

There are a number of conversion practices Bills currently in play, and Cass has said that such a Bill would have a detrimental effect on the recruitment of clinicians, because they would feel a chilling effect before they would apply.

[Lord Markham (Con)]

Understood. Again, I will come back in detail on that point. One of the points made to me about the difficulties of trying to recruit to these eight new services was that, when this is such a toxic space, how do you get good-quality people? I think we agree we need that more than ever, because it is such an essential and sensitive area. So I will take that back and make sure that nothing we are doing, such as that legislation, should have that sort of chilling effect.

[Lord Allan of Hallam (LD)]

My Lords, if I could add to the Minister’s correspondence list, this is really following up the point made by the noble Baroness, Lady Finlay. Dr Cass rightly highlights that we need data about all the young people who present to the services—what service they received and what happened to them over time. Can the Minister include in his letter the measures that the Government will be taking to encourage those young people to participate? If they feel intimidated or that the data is going to be used against them, they are going to opt out, and then we are not going to have the dataset we need to understand the best treatment.

[Lord Markham (Con)]

That is an excellent point—yes.

Midwives: Bullying

Lord Markham Excerpts

Tuesday 16th April 2024 Lords Chamber

[Lord Hunt of Kings Heath]

To ask His Majesty’s Government what assessment they have made of the impact of bullying of students and newly qualified midwives in the NHS on (1) retention of staff, and (2) the treatment of pregnant women, as highlighted in the #Saynotobullyinginmidwifery report published on 12 November 2023.

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

This report makes difficult reading, highlighting unacceptable levels of bullying in midwifery. We know that culture and leadership have a significant impact on retention and staff experience. NHS organisations should have robust policies in place to tackle bullying and harassment. Through the NHS long-term workforce plan and the NHS equality, diversity and inclusion plan, we are seeking to expand the workforce and make the NHS a better place to work.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the Minister. As he says, all NHS trusts have those robust policies. The problem is that they are not coming out into practice. This report describes the experience of midwives working in a toxic culture. One newly qualified midwife is quoted as saying that they were left

“burnt out by bullying and the terror of working on understaffed wards”.

Another said:

“I would return home crying most days and became suicidal from the fear and treatment at this trust”.


Does the Minister accept that much more fundamental change is required to deal with understaffed maternity units, NHS trusts preoccupied with reputation management over patient safety, and a reluctance to take whistleblowers seriously?

[Lord Markham (Con)]

I thank the noble Lord for his work in this whole area. That is genuine appreciation, because I know that he looks not just at bullying in this area. He is a very important conduit and I am personally grateful for the work he does on this and how much he cares. It is a combination of all the things that he mentioned. I had a meeting with the chief midwife on this subject this morning because of it being brought to my attention. I was actually quite reassured. Each trust now has what is called a quad leadership team, where the chief midwife, a neonatologist, an obstetrician and the general manager spend time together in a six-month process where they work together as a team on how they will address all these vital cultural issues.

[Baroness Burt of Solihull (LD)]

My Lords, among the very disturbing elements in this report is the way that midwives are bearing the brunt of the toxic culture and dangerously low staffing levels, which are causing over half of midwives to consider leaving their organisation. Despite what the Minister just said, the Ockenden report was over two years ago. Is he satisfied with this rate of progress? Should we not consider a statutory inquiry—a recommendation of this report—before more midwives leave and more babies die?

[Lord Markham (Con)]

We have the highest level of staffing ever in midwifery, 5% up on last year and 21% up on 2010, against a background of static births. I want to address that point on staffing; staffing levels are high. However, as the noble Baroness says, there are issues around culture. On the national inquiry, again, every one of those 150 trusts was visited by the CQC in the last year or so and action plans made on how to address this. We know what we need to do; we just need to get on and implement it.

[Lord Lucas (Con)]

My Lords, I am grateful to my noble friend for his replies. I am much more grateful to the many midwives who have helped my family over the years. They give an extraordinary service. If we are not to have an inquiry, will my noble friend make sure that his ears and doors continue to be open when things are not going as well as they should? The NHS has a habit of closing doors on things and making it difficult to interact with it. Bullying is not the only problem. There is a succession of problems which need bringing out into the air, such as overmedicalisation, the failure to implement the better births policy, and the regulatory culture overseen by the NMC. The Minister could help with that.

[Lord Markham (Con)]

I agree with my noble friend. Over the last 18 months, I have appreciated the power of this House and of these Questions. Each time I get one, it sets off a process. In this case, I undertook to meet the Chief Midwifery Officer to make sure that feet are being held to the fire. I know that Minister Caulfield is doing this. It is to the credit of the House that it has this scrutiny role.

[Lord Mackenzie of Framwellgate (Non-Afl)]

My Lords, my maiden speech in this House was on bullying in schools. Can the Minister tell me whether there is an anonymous hotline for whistleblowers to report unbecoming conduct in the health service? It is so important to have one.

[Lord Markham (Con)]

The noble Lord is absolutely correct. It is crucial. We have a whistleblowing system. It has had over 100,000 reported instances. We are trying to inculcate a culture where people feel able and free to stand up and point out an issue.

[Lord Allan of Hallam (LD)]

My Lords, workplace bullying is particularly toxic where managers are involved. This is where non-executive members of the NHS trust boards may come into their own if complaints involve executive members. What is being done to help non-executive members of trust boards be more responsive and able to deal with bullying complaints?

[Lord Markham (Con)]

The noble Lord is absolutely correct. This is the role of non-execs. Having done a bit of work on the Lucy Letby case, I understand that the non-execs should have said something. Obviously, the executives should have found out, but the non-execs clearly had a role. This is an excellent question. I have to be honest and say that I need to come back on it, if I may, so that I can give the noble Lord a full answer and make sure that this is happening.

[Baroness O’Grady of Upper Holloway (Lab)]

My Lords, does the Minister agree that we also need to tackle the conditions in which bullying can sometimes flourish? The Royal College of Midwives—the union representing midwives—published a report last week showing that over 100,000 hours of unpaid overtime are performed by midwives every week. Some 60% of midwives believe that staffing at their workplace is unsafe. Three-quarters of student midwives are expecting to graduate with £40,000 of debt. Surely it is time that we gave midwives the respect and the pay rise that they deserve.

[Lord Markham (Con)]

I agree. As ever with these things, there are a number of issues, of which pay is one. The introduction of the £5,000 a year support that we now give to all students is an important help with regard to debt. Work conditions are important, but key to it all is the culture. I have seen many examples where that has not been great. I was quite impressed by the Chief Midwifery Officer saying that every trust now has a midwife retention person whose job is to get into all these issues and make sure that they are addressed.

[Lord Boateng (Lab)]

My Lords, how many of the midwives recruited to deal with the current midwifery crisis in the NHS were trained and qualified in the United Kingdom? On a recent visit to Ghana, I visited a child oncology unit, which, in the past year, had lost a fifth of its clinical nursing staff, who were trained, qualified and paid for by the Ghanian taxpayer—to the benefit of the NHS. How is that ethical or right?

[Lord Markham (Con)]

I will come back to the noble Lord with the exact number, but he is correct: the long-term workforce plan is all about making sure that we have the right resources and infrastructure to train the required number of people. Behind that, we have funded an extra 150 spaces this year and we have a target to increase them by 1,000 by 2026. It is absolutely as the noble Lord maintains: we are putting training in place domestically, as well.

[Baroness Cumberlege (Con)]

My Lords, does my noble friend share my view about the evidence that, when midwives and other clinical staff understand the importance of continuity, it leads to safer care and better outcomes for both the mother and the baby? One of the midwives quoted in chapter 2 of the report that was sent to us—I thank my noble friend for that—says that working in a continuity team was the best, most rewarding time in their career. Continuity is absolutely critical; it comes up in a number of reports, some of which I have had a part in writing. We know that you need continuity if you are going to make a real impression on the midwifery service and that the women who are party to it must really understand what continuity does and can achieve.

[Lord Markham (Con)]

I thank my noble friend, who has been a tireless campaigner on continuity of care. I challenged the chief midwife on this just this morning, and the objective behind the long-term workforce plan is to make sure that we have the resources in place to maintain that, starting with ethnic minorities. We all know that there is a disparity of outcomes in terms of inequality, so the first priority for continuity of care is that setting, but the objective is to spread that across the whole system.

Immunisation: RSV

Lord Markham Excerpts

Tuesday 16th April 2024 Lords Chamber

[Baroness Ritchie of Downpatrick]

To ask His Majesty’s Government when a decision on eligibility for a potential 2024 respiratory syncytial virus immunisation programme will be confirmed, and whether this will be aligned to the Joint Committee on Vaccination and Immunisation’s September 2023 advice.

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

The Government have made a policy decision on the eligibility of a potential RSV programme, which is in line with the JCVI’s September 2023 advice. We are working through the full business case, with costing and operational delivery, for final agreement in line with an autumn start.

[Baroness Ritchie of Downpatrick (Lab)]

I thank the Minister for his Answer, but what plans and resources, both staff and finance, are in place to enable the immediate implementation of any RSV immunisation programme for young infants and older adults, in line with the JCVI’s advice, once the ongoing market engagement and tender process is complete?

[Lord Markham (Con)]

That process is absolutely going on at the moment, as well as operational delivery aspects. For infants, it depends on whether we choose a vaccine that goes into the pregnant mother or the infant, as the delivery mechanisms are obviously different. We are looking at the effectiveness of not just one vaccination versus the other but the delivery mechanism. There is a different delivery mechanism for the group aged 75-plus. The full programme business case is considering exactly that to make sure that we can deliver in the autumn.

[Lord Allan of Hallam (LD)]

My Lords, will the Minister commit to making the vaccination records for new programmes such as RSV available through the NHS app from the outset? I ask this as a parent who has just had to verify his teenage children’s MMR status by hunting down the red books last seen a decade ago to find the tatty piece of paper that is the only record of it. I now have a digital copy through my camera phone, but it would be much more useful to have this kind of record in the NHS app.

[Lord Markham (Con)]

It will not surprise the noble Lord to learn that I totally agree. It is absolutely on the road map. I cannot promise it is there today; it is more there for adults. The child digital red book is another objective we are working on, but that is taking slightly longer. But in terms of direction of travel—yes, absolutely.

[Lord Patel (CB)]

My Lords, I congratulate the noble Baroness, Lady Ritchie of Downpatrick, on pursuing this even before we had vaccines available. Now we have succeeded in getting the vaccine, but why has 75 years been chosen for adult immunisation, when we know that the incidence and prevalence of RSV infections is much more common for over-65s?

[Lord Markham (Con)]

I too add my thanks; the noble Baroness is very good at holding our feet to the fire, and it is very important and appreciated. Regarding the age group, we are being guided by the scientific advice on what is most cost-effective.

[Baroness Merron (Lab)]

My Lords, earlier this year we discussed the busy pipeline of new vaccines, including those for RSV, which, coupled with the concerning decline in the uptake of immunisation, does point to the need for a fresh look at delivery mechanisms. What steps are being taken to move beyond traditional arrangements, and when can we hope to see an improvement plan in place, in readiness for the RSV immunisation programme?

[Lord Markham (Con)]

Of course, the communication needed for each one is different, and that is a vital consideration. As I said, we found that, often, it is easier to put RSV in the infant rather than the pregnant mother. It is a question of considering which is the most effective way to get the best outcome and the highest take-up rate. That is one of the key criteria we are looking at. Regarding general communication, the noble Baroness will be aware that, on MMR, we have challenges in both London and the West Midlands. That has shown that you need other communication routes to get to some ethnic minority groups, using technology such as the app. There is no one silver bullet —you need a series of measures in place.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, is the Minister confident that the implementation programme will take place before the 2024-25 winter period, as promised in previous iterations of this Question?

--- Later in debate ---

[Lord Markham (Con)]

The goal is absolutely to make sure that the JCVI advice is there for the key winter period the noble Baroness mentions. That is the programme we are working towards, and this is where the logistics come in. It is not just about the effectiveness of each vaccine but, in terms of the maternal versus infant vaccination to which I referred, being confident of getting it in people’s bodies in time.

Pandemic Preparedness

Lord Markham Excerpts

Monday 15th April 2024 Lords Chamber

[Baroness Deech]

To ask His Majesty’s Government what is their state of preparedness for the next pandemic.

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

The Government continue to plan and prepare for a range of pandemic and emerging infectious disease scenarios. These include respiratory diseases such as flu and diseases spread by contact, vector-borne or through oral transmission. This built on lessons learned through Covid-19. We are working with partners to strengthen our pandemic preparedness and to build a flexible and scalable response that can be adapted to any threat that the health and social care system faces.

[Baroness Deech (CB)]

My Lords, that is not very reassuring. With all due respect to my noble and learned friend Lady Hallett, the remit that she has been handed is too wide, too deep, too long and too expensive, not least due to the lawyers. It seems to be looking backwards rather than forwards. We do not need to know who said what to whom in the middle of the night a few years ago; we need to know whether we have innovative vaccine labs, ventilators, the right medical staff, preparedness with PPE, supply lines and so on. I suggest to the Minister that either my noble and learned friend’s remit be cut down or he set up a quick and short inquiry, looking forward to the next pandemic, which could be with us within months. Sweden managed its inquiry in two years. This one will take too long.

[Lord Markham (Con)]

I totally agree with the noble Baroness. What I am interested in as a Health Minister is what lessons we can learn so that we are better prepared next time round. My understanding is that stage 1 is going to be reported in early summer, and that should give us some of those findings. I completely agree that that is what really matters.

[Lord Browne of Ladyton (Lab)]

My Lords, an international pandemic treaty and government policies from 2021 are currently being negotiated by the World Health Assembly, aimed at preparing for the next global health emergency and preventing a repeat of what South Africa called vaccine apartheid, where countries had vastly unequal access to vaccines and drugs. Next month, World Health Organization member states are expected to vote on the final text. Where do we stand on the key issue of pathogen access and benefit sharing? Do we stand on the side of the group for equity or with those rich countries that have suggested that such an approach would undermine their sovereignty?

[Lord Markham (Con)]

I think our record in this speaks for itself. I am very proud of the action that we took as a Government to make sure that the AstraZeneca vaccine was prepared quickly, put in arms quickly and offered all around the world on a not-for-profit basis very quickly. Action speaks louder than words, and that is something that we are well-prepared on. I have been involved in some of the conversations about world pandemic preparedness. There is action that we think we can take collectively as a world, but what we are not prepared to see happen is our sovereignty—the management of our health services—being ceded to other countries.

[Lord Allan of Hallam (LD)]

My Lords, procurement during the pandemic has left a bitter taste in the country. While many good citizens stepped up in the public interest, there are legitimate concerns that others were profiteering at that difficult time. Can the Minister give a firm commitment there would be no VIP fast lane if there were another pandemic? Are the Government putting in place a much more transparent emergency procurement system as part of their preparedness planning?

--- Later in debate ---

[Lord Markham (Con)]

I think it is understood and accepted that the VIP fast lane was not a good way of going ahead; lessons have definitely been learned. At the same time, I refer to the fact that 97% of all procurement fit the bill and worked very well. Yes, 3% did not and lessons need to be worked on, but we should remember that, in those extraordinary times, 97% was pretty good.

[Lord Robathan (Con)]

My Lords, my noble friend the Minister has talked about lessons learned. Is not one lesson that was learned the terrible impact that the lockdowns had on our economy and society, children’s mental health, cancer rates and so on? In future, can we make absolutely certain, before taking any drastic step like a lockdown, that we weigh up the costs and benefits of such a policy?

[Lord Markham (Con)]

Absolutely. To respond to both this question and the earlier question from the noble Baroness, Lady Deech, the other things I would like to see the inquiry look at are the lockdown and comparisons with countries such as Sweden, what lessons can be learned across the whole health system, the impact on the mental health of our children and a lot of the other areas that my noble friend mentioned.

[Lord Patel (CB)]

My Lords, the WHO has identified Nipah virus as a priority candidate for the next pandemic. It belongs to the same group of viruses as the measles virus. Fortunately, Oxford University has developed a vaccine that went into human trial last week. The lesson therefore is that we should identify the organisms that are likely to cause pandemics and be prepared ahead of time with the vaccines; several other candidates have also been identified. For that to happen, we require a global conglomerate to focus on development of vaccines. Do the Government have any plans to establish one?

[Lord Markham (Con)]

We definitely look to work closely with our colleagues, and I have spoken to my Health Minister counterparts on this. One of the lessons from the pandemic was that you also need to have your own capability. The work we have done on the100-day mission, and the strategic relationship we have entered into with Moderna—which can develop vaccines in as little as four to six weeks to answer some of those unknowns—is very powerful.

[Baroness Wheeler (Lab)]

My Lords, it is now two years since the UK Health Security Agency replaced Public Health England. As we await the Science and Technology Committee’s report on the threat caused by zoonotic diseases such as Covid, avian flu and Ebola, can the Minister update the House on the progress the agency is making in building resilience in these areas? It reported last year on global work on developing pandemic-fighting tools but not on the nitty-gritty needed to tackle underlying problems still hampering us, such as tackling widespread health inequalities, building systems for vaccine resistance and raising public awareness of the threats we all face.

[Lord Markham (Con)]

I thank the noble Baroness. The UKHSA has been working and there are four main areas we want to be responding on. First, there is the vaccine, and the 100-day mission is all about making sure that we have the vaccines quickly. We have 100 million vaccines prepositioned for flu and 250 million for other diseases. Secondly, there is the manufacturing scale-up. We have a fund in place so that we have UK domestic production capability to produce vaccines quickly. Thirdly, there is the stock of PPE, and, fourthly, there is the diagnostic capability. That is how the UK Health Security Agency is making sure we have all the bases covered.

[Lord Hannay of Chiswick (CB)]

My Lords, will the Minister turn again to the answer he gave to the noble Lord, Lord Browne of Ladyton, about the international aspects of this? Does he not accept that throwing in the slightly abusive reference to the word sovereignty is simply a kind of “get out of jail” card to ensure that, next time round, again, equitable distribution across the world will not be achieved?

[Lord Markham (Con)]

Excuse me, but I think we will find that Britain was a world leader in developing a vaccine and making it available all round the world on a not-for-profit basis. If any noble Lord can come up with examples where countries have done more than we have in this space, I would be delighted to hear them. I, for one, am proud of what we did.

[The Lord Bishop of Leeds]

My Lords—

--- Later in debate ---

[The Lord Bishop of Leeds]

My Lords, do the Government have a preprepared communications plan for the eventuality of another pandemic—which could be next week, next year or whatever—so that it is not made up on the hoof? We remember that, in 2016, there was a big exercise in London which was forgotten about when we got to the actual pandemic. Are those provisions being put in now and preparations being made?

[Lord Markham (Con)]

That is all a part of what I referred to as having a toolkit for a flexible response. The problem always in these things is that you tend to fight the next war on what happened in the last one. We have to be careful in what we do and that we are not trying to fight the next pandemic on the last one, because inevitably it will be different. Having a flexible and scalable response, including communications, is vital.

[Baroness Chakrabarti (Lab)]

My Lords, the Minister says that we have a—

--- Later in debate ---

[Lord Turnberg (Lab)]

My Lords, some years ago, when I was chairman of the Public Health Laboratory Service, we had 31 public health laboratories dotted around the country. Their role was to track and trace the sources of infections. We lost those in a review of the Public Health Laboratory Service, and I resigned as a result of that. What a loss that has been. What efforts are being made now to replace those laboratories which can do the track and trace that we desperately need?

[Lord Markham (Con)]

As the noble Lord mentions, one of the key pillars is having diagnostic capability. The noble Lord will be aware that, for the sequencing of all the different Covid strands, it was the UK that they were sent to because our diagnostic and sequencing ability is second to none. I am assured that that capability still exists and, with that, our ability to scale up diagnostic testing very quickly.

Stroke Treatment

Lord Markham Excerpts

Wednesday 27th March 2024 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government what steps they are taking to improve treatment and care for those of working age who are affected by stroke.

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

The Government are taking three major steps to improve treatment and care for strokes: first, a whole series of prevention measures to help avoid a person having a stroke in the first place; secondly, an updated and evidence-based stroke care pathway using AI, the latest technology in stroke rehabilitation, to maximise the chances of recovery; and, thirdly, post-stroke rehabilitation care and support to maximise the chances of recovery.

[Baroness Wheeler (Lab)]

I thank the Minister. We know that one in four strokes happen to working-age people, and that it is also a leading cause of disability. Speech and physiotherapy support after stroke is therefore vital, because it helps recover key skills such as motor functions and cognitive ability, and it can be the difference between returning to work and not returning, or giving up altogether. With serious delays across the country in getting people to hospital and scanned, and in providing the speech and physiotherapy that is needed, and with chronic staff shortages across the country in hospital and community settings, good care is just not the reality for thousands of stroke sufferers. Some 40,000 people missed out last year on essential six-month, post-stroke reviews. When will the up and coming major conditions strategy be published? How will it specifically support effective stroke rehabilitation and recovery, and what timescales will be set for that?

[Lord Markham (Con)]

I thank the noble Baroness for her tireless work in this area. As she quite rightly points out, aftercare and rehabilitation is the vital third leg of the three-step process I spoke about. In the major conditions strategy we talk about how we are basing it on a national model for an integrated stroke care service, based around personalised, wraparound care, for as long as is needed, with reviews every six months. I have seen some fantastic examples when I have been out and about, such as in Royal Berkshire and Leighton. The proof of the pudding is in the results; we have seen the number of people who are achieving a full recovery increase from 16% to 48%. That is the target we are going after.

[Lord Kakkar (CB)]

My Lords, I draw noble Lords’ attention to my registered interests. The Minister mentioned the importance of prevention, which of course is not only primary but secondary prevention. In that regard, for both patients with atrial fibrillation at risk of a stroke and those who have had a stroke, it is vitally important that appropriate therapies, innovations in therapeutic intervention, and broader cardiovascular risk management are provided. Is the Minister content that we have a strategy that provides those opportunities, both for primary and secondary prevention of stroke?

[Lord Markham (Con)]

The noble Lord is quite right. Many noble Lords will have heard me echo Sir Chris Whitty’s words that his major concern about the whole Covid period was that people missed out on blood pressure and cardiovascular checks, which can be early-warning indicators. That is why we see prevention as a major leg of what we are trying to do, through having blood pressure checks and inviting everyone to have their health check every five years. What we are working on, and will be bringing out shortly, is greater use of digital for health checks, to do precisely what the noble Lord says.

[Baroness Browning (Con)]

My noble friend wrote to me in response to an Oral Question on the subject of strokes to explain how AI is enabling many hospitals now to be able to diagnose within the three-hour timeframe and give appropriate treatment, thus enhancing the recovery of stroke patients. I mentioned it to my local general hospital, and I am sorry to tell him that it does not have this AI technology. When does he think it will be rolled out nationally?

[Lord Markham (Con)]

This AI service, Brainomix, is one of the ground-breaking services that are part of the future of the NHS. It is part of the whole service, which will include video triaging. It is currently in 65% of hospitals, and I am sorry that it is not in my noble friend’s hospital. We have a target to increase that quite rapidly to 75%. I will look into the particular hospital that she mentions. It really is ground-breaking; overall, where we have got everything in place, full recovery has gone from 16% to 48%.

[Lord Allan of Hallam (LD)]

My Lords, to follow up on the issue of screening, atrial fibrillation is a well-known risk factor for stroke, but fortunately can now be checked for with some very cheap devices that connect to smartphones. What progress is being made on AF checks as part of screening programmes and routinely when high blood pressure is checked for? Can the Minister look particularly at the invites for the screening programme? I received one saying that I should come in for an AF check, not a stroke risk check or a cardiac risk check; they could be made much more user-friendly.

[Lord Markham (Con)]

The noble Lord is right to point that out, and I hope we are correcting it. I have seen the mobile app and digital being used to do all these things—I have even seen applications which can measure your blood pressure and pulse as you look at it. We need to check some of the accuracy around that, but it is all part of the programme. However, we need to make sure that it is in everyday English.

[Baroness Pitkeathley (Lab)]

My Lords, many family carers who provide care for stroke patients are also of working age. If they have to give up paid employment, it results often in the kind of debt that is currently in the news as a result of having to pay for care. What help can be given to those carers? I acknowledge that the Carer’s Leave Act was a welcome step forward, but that is only unpaid leave. What else can the Government provide for carers in these circumstances?

[Lord Markham (Con)]

The noble Baroness is right: carers are the hidden army who give so much support, not just in the area of strokes but across the board. As the noble Baroness said, we have put in place some steps, such as enabling leave and enabling people to claim benefits. I accept that that is not the whole enchilada, so to speak, but it is a step along the way.

[Baroness Meacher (CB)]

My Lords, I had a major stroke a year ago, and I am actually fine. I want to applaud the NHS. It has been truly remarkable, providing a machine beside my bed to monitor my heart every night. I also have atrial fibrillation. The NHS has monitored me incredibly carefully, with endless contact and the monitoring of my medication to ensure that it is exactly right—the GP was on to me this morning. The NHS has been completely wonderful, and it is worth saying that, as a patient.

[Lord Markham (Con)]

I am delighted to hear those good examples. As I say, we have had some very good results. The challenge is to ensure that everyone can have the sort of experience that the noble Baroness has had, which we are keen to do.

[Baroness Lawlor (Con)]

My Lords, does my noble friend agree that it might be worth looking further into post-stroke care, following what the noble Lord on the Cross Benches said? I have visited hospitals in France, where post-stroke patients, be they of working age or non-working age, are encouraged to get back to work and be fit for work. Sadly, in my own local hospital I have seen academics of working age discharged without provision for the speech therapy or physiotherapy which would allow them to continue working. This is something that we could learn from our French friends.

[Lord Markham (Con)]

That is what these SQuIRe centres are about—trying to roll out best practice. As I mentioned, I have seen fantastic examples, including simple things such as at Leighton Hospital, which gets every patient, not just stroke patients, to exercise for a couple of hours each day. That makes a difference to their length of stay and their ability to go back into the community and into the workplace.

[Lord Hunt of Kings Heath (Lab)]

My Lords, to follow on from the encouraging intervention of the noble Baroness, Lady Meacher, the Minister will know that, in 2010, London centralised hyperacute services into a small number of expert units. What progress are we making throughout the rest of the country, because in some parts it has been disappointingly slow?

[Lord Markham (Con)]

The stroke quality improvement for rehabilitation—SQuIRe—services are where we are trying to take best practice from London, France and around the world and roll it out. The good news is that we have the model; it is based on a national model for an integrated community stroke service. We have got that in 65% of locations, with the goal of making it 75%.

[Lord McColl of Dulwich (Con)]

My Lords, as there are 40 million people at risk of stroke because they are obese or overweight, would it be a good idea for the Government to recommend, as I have done for some time, that people have one fewer meal a day? That would reduce their weight and their expenditure.

[Lord Markham (Con)]

My noble friend is correct that weight and obesity is a major factor in all sorts of conditions, including strokes. Encouraging people to eat correctly, in a healthy manner, is absolutely the right way to go.

As this is the last time that I will see your Lordships, I wish all noble Lords a happy Easter. I for one am looking forward to the break.

Sodium Valproate and Pelvic Mesh

Lord Markham Excerpts

Monday 25th March 2024 Lords Chamber

[Baroness Cumberlege]

To ask His Majesty’s Government what are the timescales for, and what progress has been made on, a response to the Patient Safety Commissioner’s report on options for redress for those harmed by sodium valproate and pelvic mesh, published on 7 February.

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

The Government commissioned the Patient Safety Commissioner to produce a report on redress for those affected by sodium valproate and pelvic mesh. We are grateful to the commissioner and her team for completing this report and our sympathies remain with those affected by sodium valproate and pelvic mesh. The Government are now carefully considering the PSC’s recommendations and will respond substantively, hopefully in the coming months.

[Baroness Cumberlege (Con)]

My Lords, I thank my noble friend for that reassuring reply. However, as it has been five months since the Government received the advice from the Patient Safety Commissioner in October 2023, how much more time do patients and families need to wait for the redress that they so desperately need?

[Lord Markham (Con)]

My Lords, I thank my noble friend for her tireless work in this area. It is something which, in the Chancellor’s very own words—because it was the Chancellor who, as Health Secretary, first commissioned the report—remains a top priority to both him and the Government. That remains the case. I spoke to Minister Caulfield about it just this morning, and it is a complicated area, but it is something that we are very keen to redress in the next few months.

[Baroness Uddin (Non-Afl)]

My Lords, I am really grateful to the noble Baroness, Lady Cumberlege, for raising this issue. On previous occasions, I have raised my ongoing concerns about the use of sodium valproate, especially for patients with mental health issues incarcerated in hospital. Do the Government collect information on how many people have been prescribed this terrible medication in some cases, and whether it is being disproportionally applied, particularly to young men from minority communities in the mental health institutions?

[Lord Markham (Con)]

I thank the noble Baroness. I will provide the precise figures, but the incidence has gone down by 34% in terms of the amount that has been prescribed. At the same time—and this is particularly fitting, as tomorrow is National Epilepsy Awareness Day—for some people, this is the only treatment for epilepsy that will work for them. It is therefore important to make sure that protocols are in place for prospective mothers and prospective fathers to make sure that, in those cases, they are not being prescribed sodium valproate, because in other cases it is often the only medicine that works.

[Baroness Finlay of Llandaff (CB)]

My Lords, given that, sadly, errors and problems repeatedly occur in the NHS, how are the Government working with the devolved Administrations to ensure that a redress scheme is designed to be fit for the future as well as fit for the recognition of harm that has occurred? What will they do to ensure that trust in the NHS is maintained by an approach that encapsulates prospective monitoring and listening to patients and relatives for early detection of adverse events and avoids cumulative errors?

[Lord Markham (Con)]

I thank the noble Baroness. I was actually speaking to Minister Caulfield about this just this morning, because she is in regular touch with the affected patient groups. They were talking precisely about some of the things around the Scotland NHS scheme in place in terms of redress. It is fair to say that there are some concerns in patient groups on some aspects of this, but underlying what the noble Baroness says is making sure that, whatever we do, we are trying to do it consistently across the UK because there should be one consistent approach. Likewise, we are learning lessons from these things as well.

[Baroness Burt of Solihull (LD)]

My Lords, an ex-constituent of mine, after years of excruciating pain, the onset of returning cancer and no care plan, finally borrowed $47,000 to have the failed mesh implant removed in America. She now has her life back but is in deep debt. However, we learn that the Government will consider redress only in 2025. Can the Minister hazard a guess as to how many more mesh-induced deaths will have occurred by the time a single penny is paid out in compensation at this rate?

--- Later in debate ---

[Lord Markham (Con)]

The 2025 date is the timetable that the Patient Safety Commissioner recommended in terms of financial redress. The point that the noble Baroness makes, quite rightly, is about the non-financial aspect: if you are suffering pain from it all, you want to be treated as quickly as possible. That is why we have set up these nine specialist centres to allow exactly that sort of redress to occur.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can I remind the noble Lord that, of course, it was not a matter of months since this first recommendation came? The noble Baroness, Lady Cumberlege, recommended a redress scheme some years ago. Why was it rejected in the first place, and why are we waiting many more months, as the Minister said, when, as the Patient Safety Commissioner has said, the intention is

“an initial, fixed sum in recognition of the avoidable harm they have suffered as a result of system-wide healthcare and regulatory failures”?

Why are the Government being so slow to respond?

[Lord Markham (Con)]

That is precisely what I put to Minister Caulfield this morning. She commissioned the review because her feeling was that the period from when my noble friend’s initial report came in until when Maria Caulfield was in post was too long. So it was absolutely she who commissioned it last year, and it is absolutely she who very much said that she is determined that there should be a substantive reply from us in the next few months.

[Baroness Bennett of Manor Castle (GP)]

My Lords, at the launch of the Patient Safety Commissioner’s report the victims of the Primodos scandal expressed great distress as they felt that they had been airbrushed out. Of course, the noble Baroness, Lady Cumberlege, recommended that they should receive redress, and they were treated the same way in the report as the sodium valproate and vaginal mesh victims. Can the Minister tell me what will be done to provide redress and ensure that there is appropriate treatment for the victims of Primodos?

[Lord Markham (Con)]

Again, these are difficult areas. My understanding is that we are working from the conclusions of the expert working group in 2017, and its review of all the evidence was that it could not find a causal link between Primodos and the impact it had during pregnancy. This was again reviewed by the MHRA when more information was brought up in the last year. So I am afraid that, as we stand today, the evidence is not there that suggests that causal link.

[Baroness Wheeler (Lab)]

My Lords, the Patient Safety Commissioner’s report is all the more valuable because it is drawn from patients’ experiences, including physical, psychological and emotional impacts and their daily struggle with accessing health and other key services such as social security benefits and special educational needs support for the valproate-harmed children they are raising. What is being done to support mothers and families as they cope with the indecision and delay over the Government’s response to the commissioner and await the vital support they need?

[Lord Markham (Con)]

We have completed four of the initial recommendations in the report of my noble friend Lady Cumberlege, and another three are in process. The most important of those, to answer the noble Baroness’s question, is the setting up of these nine specialist centres which can provide the support needed, not just in terms of redress surgically or treatment-wise but in terms of the support that people need to help them cope with the issues.

[Baroness Blackwood of North Oxford (Con)]

My Lords, as important as this report and these findings are, this is part of a wider problem. Some 4,000 babies die due to pregnancy-specific conditions in the UK every year, but 73% of drugs given to pregnant women have no safety information. That is clearly unacceptable. The Minister knows that I have raised this issue with him before; please can he give an update on progress towards putting this right?

[Lord Markham (Con)]

My noble friend is correct on this. Probably the best way to do that is to come back in detail in writing, because it is vitally important.

[Baroness Brinton (LD)]

My Lords, in response to the noble Lord, Lord Hunt, the Minister said that Minister Caulfield had commissioned this report, but he misses out at least three years of work earlier. There was the report of the noble Baroness, Lady Cumberlege, and there was a long debate during the passage of the Health and Care Act when Nadine Dorries said she would look at commissioning something and then refused to do so. This is not recent history. Will the Minister please give this House a date on which the Government will come back to Parliament with a response?

[Lord Markham (Con)]

The point I was making was that Minister Caulfield absolutely agreed with the point the noble Baroness makes that the delay had been too long, and so it was she who came forward and said that she wanted to commission the Patient Safety Commissioner to report exactly in this area. So that was her being proactive on all this. In the same way, she says that she is determined to get a response back in the next few months. I cannot give a specific date yet, because it is a complicated area which involves industry, many government departments and the devolved authorities. However, as the Chancellor said, this remains a top priority area for both the Chancellor personally and the Government.