NHS National Health Inequalities Improvement Programme

Lord Markham Excerpts

Thursday 25th May 2023 Lords Chamber

[Lord Brooke of Alverthorpe]

To ask His Majesty’s Government whether the NHS National Health Inequalities Improvement Programme plans to review and improve the nutrition of free school meals.

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

The focus of the NHS healthcare inequalities improvement programme is the delivery of healthcare services. Free school meals are outside its remit. The Department for Education continues to keep school food standards under review. The current standards provide a robust yet flexible framework to ensure that pupils in England continue to receive high-quality and nutritious food. Developing healthy habits early in life can influence health in childhood and reduce the risk of diet-related diseases in later life.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I am grateful to the Minister for his reply. Who actually is responsible if one tries to change the formulation of school meals for children? In previous debates on obesity, he has stressed the importance of reducing calories. The Government have estimated the number of calories that need to go down to get child obesity down. As we are giving children so much sugar in school meals and such highly processed food, why do they not run a trial with less sugar and healthier food than we are doing at the moment to try to deliver on the calorie objective, which he has talked about previously?

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[Lord Markham (Con)]

First, I thank the noble Lord for the work that he does in this space; I know it is something very close to his heart. It is the school foods standards that set and define the formulation in the food and drinks provided by schools. That is all through the school day: breakfast, lunch and afterwards. They were due to be reviewed around the time of Covid in 2019; clearly, that did not happen then, so we are looking again at whether we should be reviewing those. Precisely in that, we shall be looking at levels of calorific intake.

[Baroness Manzoor (Con)]

My Lords, as my noble friend will know, in the short term a poor diet can lead to stress, inability to concentrate and tiredness. In the longer term it can lead to obesity, diabetes, high blood pressure and indeed heart disease. Of course, my noble friend will be aware that there are great inequalities within ethnic minorities. Can he say what the Government are doing to reduce the inequalities and ensure that micronutrients play an important part in the promotion of the food strategy?

[Lord Markham (Con)]

First, I wish my noble friend a happy birthday. I totally support her question. The most important thing with regard to inequalities—funnily enough, this was the answer to an earlier question—is the use of free school meals. I think we can all welcome the fact that 37.5% of children now receive free school meals and therefore a nutritious start to life. Clearly, that is the best way to make sure that children, particularly those with potential inequalities, are getting a healthy start in life, as well as the under-fours clubs to make sure that they get healthy food.

[Baroness Walmsley (LD)]

My Lords, according to Henry Dimbleby, the Government’s public food procurement system is dominated by a few very large corporations, creating little incentive for innovation or improvement. Can the Minister give us an update on the trials in south-west England, in which small, local, high-quality food suppliers can get into public procurement—for example, to schools and hospitals? I understand that early evidence reports better quality and choice at no increased cost.

[Lord Kamall (Con)]

My Lords—

[Lord Markham (Con)]

Absolutely. Again, there are also very good grounds for locally sourcing in that way in terms of the environment and reducing the carbon footprint. I must admit to not being very familiar with some of the pilots mentioned, so I will find out and get back to the noble Baroness.

[Baroness Finlay of Llandaff (CB)]

My Lords, the latest data from the National Child Measurement Programme showed that among 10 to 11 year-olds at school, almost 38% were overweight, of whom nearly two-thirds were obese. Do the Government recognise that this represents severe malnutrition in that cohort and that public health should be involved in the planning and inspection of school meals to try to improve that figure? These children will become health problems for the whole of the nation going forward unless their malnutrition is corrected.

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[Lord Markham (Con)]

I agree with the noble Baroness. It was said in answer to a Question not so long ago that the hypothesis about much of the reduction in increases in life expectancy in the G7 nations, apart from Japan, is that it is very much linked to obesity, and that starts early on in life. Education is a key part of that, but the things we are starting to do as regards the placement of foods in supermarkets are already having an impact, and the reaction of the industry to that has been the reformulation of some foods which has already taken out 14% of sugar and 20% of salt—but clearly there is a lot more to be done.

[Lord Kamall (Con)]

My Lords, I apologise to my noble friend the Minister and reassure him that I was not trying to answer the previous question. However, in answer to a previous question, my noble friend the Minister mentioned that the responsibility of school meals and nutrition lies with the Department for Education. Is he aware of any conversations and interaction between the Department for Education, the Office for Health Improvement and Disparities, and the Department of Health and Social Care?

[Lord Markham (Con)]

Absolutely. We work very closely together. The Healthy Start programme gives seven fruits a day to kids up to the age of seven to make sure that they get fruit and vegetables, and that is very much a joint initiative. Clearly, we need to be joined at the hip on some things, but as regards school meals, the DfE takes the lead.

[Baroness Merron (Lab)]

My Lords, the levelling up White Paper promised to design and test a new approach to ensure compliance with school food standards. Although pilot schemes were meant to start last September, a recent Written Answer from the Schools Minister stated that

“standards are being kept under review”,

with no sign of the pilot scheme. Have the Government given up on their promise and does the Minister consider the existing standards for school meals and the means of compliance sufficient to tackle nutritional inequalities across the country?

[Lord Markham (Con)]

As mentioned previously, the review did not happen because of Covid, and it is very much within the plans that it is time to look at school standards again. Clearly, that is key to making sure that there is a healthy diet in schools, and of course that goes across the board.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain whether the Department of Health is working with other departments to consider funding families entitled to free school meals with additional allowances during the summer vacation in the light of the current cost of food and the need, as he has acknowledged, to provide adequate nutrition to promote health in young people?

[Lord Markham (Con)]

Yes. It is worth reiterating that the 37.5% free school meal level is an achievement, as is the fact that all infant schoolchildren receive free school meals—higher than ever before. However, the noble Baroness is correct in terms of what happens during holidays. That is why we have the holiday activity fund, which in the summer holidays, for instance, provides meals for four of the weeks, as well as for another week in winter. Clearly, we need to keep that under review to make sure that that is sufficient.

[Lord Mann (Non-Afl)]

My Lords, currently some Jewish children are having to survive due to the funding formula on a bagel every dinnertime. Is that acceptable and, if not, which Minister will sort it out?

[Lord Markham (Con)]

I hope that every child would have something more nutritious and healthier than just a bagel. I will happily discuss that with the noble Lord; I am not familiar with that particular case but it is something I will happily take up.

[The Earl of Devon (CB)]

My Lords, in response to the noble Baroness’s question on the South West Food Hub, I was on the advisory board until last week. That project has now folded, purely through lack of engagement from the Cabinet Office and the procurement services. Can the Minister speak to his colleagues at the Cabinet Office to see whether they can re-engage in these dynamic procurement activities for local farmers?

[Lord Markham (Con)]

I would be happy to. I need to find out more first, and I would be delighted if there was some information or if we could meet on this, but I would be happy to take it up.

[Baroness McIntosh of Hudnall (Lab)]

The Minister has twice cited the figure of 37.5% of children now receiving free school meals, which, as he rightly says, is an achievement of a sort. However, if the standard of food those children are receiving is insufficiently good—and there appears to be some evidence of that from the information that has been going around the House this morning—adding to the number on the list of those receiving free school meals, although admirable in terms of the numbers, may be contributing to the problem. Does the Minister agree?

[Lord Markham (Con)]

I do not think anyone would say that the current school food standards are insufficient. I think the feeling is that it has been a while since they were changed because of Covid, and it is time to ask whether improvements can be made, because this is an ever-evolving situation. So I would not agree with that categorisation, but we should indeed always be looking to see whether we can make better choices.

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

Lord Markham Excerpts

Thursday 25th May 2023 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I thank my noble friend for his usual expert and comprehensive explanation of his regret Motion on this SI, which is so important for the future of the NHS and the UK’s pharmaceutical industry and life sciences sector.

While the Government’s argument for maintaining equivalence between the two schemes makes sense, we certainly do not want companies to choose to leave the voluntary scheme for better rates. We on these Benches fully recognise the strong concerns about the impact and potential damage that the 27.5% clawback rate will cause to the manufacturer of branded medicines, to the availability of those medicines to the NHS and its patients and to future investment in the research and development of new drugs.

I point out that this is the first opportunity, on such an important subject, that we have had to discuss in depth the key issues my noble friend and other speakers across the House have raised, since the short Grand Committee debate last October on pharmaceutical research and development spending. The Minister will recall that it was his first debate as Health Minister and that he surprised us all by bursting into maiden speech mode when he summed up the debate. He expressed his confidence that the Government

“through Life Sciences Vision … will develop the end-to-end improvements required to attract an ever-growing proportion of pharmaceutical investment to the UK”.—[Official Report, 13/20/22; col. 135GC.]

He also made the acknowledgement that growing the UK’s proportion of global pharmaceutical investment meant improving

“every aspect of the life science ecosystem”.—[Official Report, 13/20/22; col. 133GC.]

As my noble friend and other expert speakers have shown today, this is just not happening.

The continuing dramatic decline in the UK’s share of global pharmaceutical investment is clear evidence of this, causing the loss of billions of pounds to the industry over the past 10 years. We have heard the stark figures. The NHS faces huge challenges and obstacles to becoming an effective innovation partner in supporting the access to and uptake of new and innovative drugs, which are so critical to developing better outcomes for patients and creating a thriving life sciences ecosystem. If the NHS continues to be slow on the uptake of innovative medicines and treatments, the UK could lose its position as a world leader in life sciences, particularly with the rapid advancements in biotechnology and AI.

For the UK to become a destination of choice for cutting-edge research, urgent action has to be taken to reverse the sharp decline in industry clinical research trials within the NHS and to address the standstill we have reached in developing the comprehensive strategy on patient data and research that is vitally needed. We need to balance the safeguards for patients and public engagement with the ability of accredited researchers to access the data they need to develop the valuable research at the heart of innovative medicines and treatments. What consideration are the Government giving to further embedding research within the NHS, both to underline the importance of patient participation and to allow a more direct link between health and science? During Covid we saw how, with the right drive and attitude, this can be done successfully for vaccine development, with life-saving results.

That is why the background and context of the proposals in this SI are so important. Despite the “remote” risk optimism of the impact assessment, and all the flaws that noble Lords outlined, the SI’s proposals for a substantial clawback, in 2023, of net sales income for UK biopharmaceutical companies greatly increases the risk of them reducing their current level of R&D investment. I look forward to the Minister’s explanation of how other countries that have similar clawback schemes—Ireland, Germany and Spain—managed to keep their clawback rates considerably lower than half what is proposed in the UK. This was mentioned by a couple of speakers. What assessment have the Government made of the impact these lower rates would have on investment in the UK? Why do they think that AbbVie and Lilly chose to leave the voluntary scheme?

In 2023, manufacturers of branded drugs in the voluntary scheme will be required to return almost £3.3 billion—or 26.5% of sales—to the Government, up from around £0.6 billion in 2021 and £1.8 billion in 2022. ABPI says that this means that the money spent on branded drugs has declined by 14% in real terms over the past decade, despite rising demand. The noble Lord, Lord Warner, pointed out that, overall, the savings to be made are minor when compared with the likely damage.

On the consultation exercise, I look forward to the Minister’s explanation of how 39 days of consultation over the Christmas period was sufficient to provide this. This is made even starker by the fact that 32 out of 33 respondents opposed the proposals. One thing we know businesses need in order to invest their money is certainty, but they are not getting it.

Finally, today’s discussions have made a convincing case for taking a long, hard look at the current scheme and how it is working. Negotiations are under way for the new voluntary scheme for pricing, access and growth, and we will watch them carefully. The priority must be to find a solution that allows patient access to the best-quality treatments, with good value for the NHS and taxpayer, while ensuring a fair return for the industry. We need to secure arrangements that will build confidence and provide mutual benefit for the NHS and industry. Can the Minister provide an update on the early talks or negotiations that have taken place? I noted the comments of the noble Lord, Lord Warner, about how this SI’s approach could be paused in the light of any significant developments that are likely to take place.

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

I thank noble Lords for the debate, and I particularly thank the noble Lord, Lord Hunt, for bringing forward this important subject. It was clear from the contributions of noble Lords that we all want the same thing here, and this is a discussion about how best to achieve it. We all want the UK to be a

“science and technology superpower by 2030”,

as quoted by the Prime Minister. We all want a thriving life science sector, we want access to the best medicines for the NHS and we all want to ensure that the NHS is achieving value, in terms of money for the front line—I think we are united on those things. I also commend the fact that this debate was very much a discussion, so I will respond in that vein, rather than reading out a speech. I will try to discuss this from the Government’s point of view. I apologise if that means that I might not come across as quite as polished, but I would rather respond directly to the points raised.

We would all accept that we are striking a delicate balance here: between having value for the NHS—through, for example, the funding of £2.5 billion this year—and having value and making savings for frontline services, which we all want to see. While we are focusing on those, we also want to make sure that we do not go too far and damage what is, and what we want to be, a thriving sector.

The noble Lord, Lord Hunt, asked whether the Government are being complacent about this. The words of the Prime Minister, saying that he wants a negotiated outcome with the ABPI, are probably the strongest sentiment in terms of wanting a sensible, negotiated outcome. At this point, I say to the noble Lord, Lord Warner, that I am responding on behalf of the Government.

As the noble Lord, Lord Warner, pointed out, just today, the Chancellor is having a round table with the life sciences industry. That, too, is very much about getting a solution that works all the way round. Having said that, please remember that some of the comments I am making in this debate are about a balance. We are all aware that we are entering into a negotiation and obviously, in any negotiation, sides make points—sometimes at the negotiating table and sometimes publicly. Please take my comments in that vein; we want to make sure that a balance is brought to the debate.

[Lord Warner (CB)]

I am sorry to interrupt the Minister’s flow. He said that we are having the fruitful discussions that the Prime Minister wants with the industry and that they are starting to progress. However, the industry itself is starting with a figure in the single figures, nowhere near 27%. I am curious as to why we are having this discussion about progressing these regulations, as they seem to be going in totally the opposite direction from the aspirations the Prime Minister has.

[Lord Markham (Con)]

The mechanics behind this debate—I was planning to say that my noble friend Lord Lansley made this point—are about the alignment of the voluntary and statutory schemes. I think that we would all agree that it is sensible that the two are roughly aligned. We can argue over how high or low that figure should be, but we would agree, I think, that it is quite sensible that the two are aligned. If you had large disparities between the two, you would disadvantage, for instance, the members who have joined the VPAS system.

[Lord Warner (CB)]

I am sorry to interrupt the Minister again. We are talking about signals given to the outside world, in these discussions that are now taking place about the voluntary scheme. As the noble Lord, Lord Lansley, asked, rather elegantly, why do we have two schemes in the first place? There is something very odd about levelling up to a voluntary scheme’s level with a big increase and, at the same time, sitting down with the industry and saying how much we love it and that we want a new, agreed programme, when the industry is talking about figures which are nowhere near the figures in these two schemes. It seems almost politically inept.

[Lord Markham (Con)]

As I said, this is about the scheme and the pricing for this year. The negotiations happening now are about future years, while, technically, this debate is about making sure that the alignment is there for this year and its pricing. Given that the discount has been decided on for this year for the voluntary scheme, having alignment will ensure fairness, so that members in the voluntary scheme are not suddenly disadvantaged against the statutory scheme—which would happen if we were not putting in a similar price. It does not in any way predicate what a negotiated outcome might be for future years.

In terms of a future negotiation, if there was a VPAS-type scheme—again, everything is on the table—you would have the argument about alignment. Most people would accept, as my noble friend Lord Lansley was saying, that having an alignment between the two is a sensible mechanism. The real debate today is about what level that discount should be. Regarding the balance—and I am not making any value judgment about what the right level is—when this was first forecast in 2018, a forecast was put out about what the discount would be over a five-year period, and in year 5 it showed a discount in 2023 of 31.1%. Those were the projections made, at that time—in 2018—the ABPI welcomed the scheme as an innovative one. In fact, today, the discount is less than that, at 26.5%. This was all known and projected as part of the scheme at the time. That is not to say that, in these negotiations, it should not be reset or that we should not make sure that there is a sensible conversation, but I am trying to do this while making sure that there is a balance in the negotiation.

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[Lord Hunt of Kings Heath (Lab)]

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

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

[Lord Markham (Con)]

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

[Lord Hunt of Kings Heath (Lab)]

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

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

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

New Hospitals

Lord Markham Excerpts

Thursday 25th May 2023 Lords Chamber

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

My Lords, I will repeat a Statement made today in another place on the new hospital programme. The Statement is as follows:

“As we celebrate 75 years of the NHS this summer, we must continue to set up its success for the 75 years to come. At the heart of this is our new hospital programme, the biggest hospital building programme in a generation, which will help us deliver on our manifesto commitment to build 40 new hospitals by 2030. Today, I can reconfirm to the House our commitment for 40 new hospitals to be built by 2030.

We made our manifesto commitment in 2019, and in 2020 we listed 40 schemes as part of the new hospital programme. Since we formally launched the schemes, we have learned more about the use of reinforced autoclaved aerated concrete, more commonly known as RAAC. RAAC is a lightweight form of concrete that, between the mid-1950s and the mid-1980s, was commonly used in the construction of a number of public buildings, including hospitals—often on roofs and occasionally in walls and floors.

We now know that RAAC has a limited lifespan, with difficult and dangerous consequences for the people who rely on or work in those hospitals. I know that this has caused considerable concern to colleagues in this House, to NHS staff in those hospitals and to constituents who are treated in them.

We remain committed to eradicating RAAC from the wider NHS estate. As part of the spending review allocation up to 2024-25, we allocated the affected trusts £685 million in immediate support, but in some cases we must go further. Seven hospitals in England were constructed, either wholly or in major part, with RAAC, and an independent assessment shows they are not safe to operate beyond 2030. Two of the hospitals are already part of the new hospitals programme, namely the West Suffolk Hospital and the James Paget University Hospital. The five remaining hospitals have submitted expressions of interest to join the programme but are not yet part of it. Those are Airedale General Hospital in Keighley, Queen Elizabeth Hospital in King’s Lynn, Hinchingbrooke Hospital near Huntingdon, Mid Cheshire’s Leighton Hospital, and Frimley Park Hospital in Surrey.

We accept in full the independent assessment that these hospitals are not safe to operate beyond 2030. Today, I can confirm to the House that we will expand our new hospitals programme to include those five hospitals built with significant amounts of RAAC. Taken together with the two hospitals already in the programme, the seven RAAC hospitals will be rebuilt completely using a standardised design known as hospital 2.0, with the aim of completing all seven by 2030. I can confirm to the House today that these new hospitals will be fully funded.

I want to take a moment to thank all those who have campaigned so tirelessly for new hospitals to be built to replace the existing RAAC hospitals, including the Members for Keighley and for Shipley, who have championed Airedale vociferously; the right honourable Member for Surrey Heath, who campaigned so strongly for Frimley; the honourable Member for Huntingdon, who lobbied hard for Hinchingbrooke; the honourable and learned Member for Eddisbury and the honourable Member for Crewe and Nantwich, who led the campaign on Leighton Hospital; and the honourable Member for North West Norfolk, the honourable Member for North Norfolk, who is my PPS, and the right honourable Member for South West Norfolk, who all campaigned so assiduously for the hospital in King’s Lynn.

Taken together, the new hospitals programme represents a huge commitment to strengthening the NHS. Since 2020, we have committed to invest £3.7 billion by the financial year 2024-25, and we expect the total investment to now be more than £20 billion for the programme as a whole. Resolving the uncertainty over the RAAC hospitals, which today’s announcement achieves, in turn allows much-needed clarity for the rest of the new hospitals programme. The programme has already been divided into cohorts 1 to 4, with construction in cohort 1 already started. Cohort 1 contains eight schemes. Two hospitals are already open to patients, with the new Louisa Martindale Building at the Royal Sussex County Hospital in Brighton due to open later this year. Work at Moorfields Eye Hospital is due to start imminently, having cleared its final business case.

Cohort 2 comprises 10 schemes. The following schemes will now be ready to proceed, in line with plans set out by the respective trusts: the National Rehabilitation Centre; Derriford emergency care hospital in Plymouth; Cambridge Cancer Research Hospital; Dorset County Hospital in Dorchester; and St Ann’s Hospital, Christchurch Hospital, the Royal Bournemouth Hospital and Poole Hospital, all of which are in Dorset. A further two schemes within cohort 2, Shotley Bridge Community Hospital and the women and children’s hospital in Cornwall, will also be approved to proceed, but in line with the standardised design elements we are promoting through hospital 2.0, on which I will set out further details in a moment. As such, with the uncertainty that surrounded the RAAC hospitals now addressed, all the cohort 2 schemes can proceed, and they will be fully funded.

The cohort 3 schemes include major hospital new builds at Sutton, Whipps Cross, Hillingdon, Watford, Harlow, Leeds and Leicester. Today’s announcement confirms that those schemes will now proceed and be fully funded. They will be constructed using the hospital 2.0 standardised approach. It is worth reminding the House of the merits of using that methodology. First, although longer will be taken on the initial design, rather than each scheme beginning to construct to its own bespoke design, the current approach has meant that the average time from design to completion of a major hospital has been around 11 and a half years. By embracing modern methods of construction, we will massively speed up the construction phase and, in addition, accelerate Treasury and other government assurance processes. There has been much debate to date on when hospitals start, but the more important issue is when schemes are completed. A standardised modular scheme has been shown to work in other sectors—for example, when building schools and prisons—and is widespread across the private sector.

Today’s announcement confirms that all cohort 3 schemes can now proceed. In turn, enabling works that had been held up due to the uncertainty about the RAAC hospitals can now progress. I pay tribute to the right honourable and honourable Members who have campaigned so strongly for the cohort 3 hospitals to proceed. They include the right honourable Member for Uxbridge and South Ruislip, the right honourable Member for Chingford and Woodford Green, the right honourable Member for Harlow, the right honourable Member for Epping Forest and the honourable Member for Hertford and Stortford. I know that not all of them can raise points during this Statement, but the latter three have championed Harlow and its case. The Member for Carshalton and Wallington, to name just one, has raised these issues.

Turning to the hospitals in cohort 4, two of the schemes—West Suffolk Hospital and James Paget University Hospital—are RAAC hospitals. As I touched on a moment ago, they have been confirmed as part of the seven RAAC hospitals. They will therefore be funded for completion by 2030. Four hospitals in cohort 4 remain on track for completion by 2030: Milton Keynes University Hospital, Kettering General Hospital, Musgrove Park Hospital in Taunton and Torbay Hospital. Again, I pay tribute to the Members for those constituencies, including the Members for Milton Keynes South, Milton Keynes North, Kettering, Taunton Deane and Torbay.

The remaining seven hospitals within that cohort will also proceed as part of the new hospitals programme. The work will start on those schemes over the next two years, but they will be part of a rolling programme where not all work will be completed by 2030. That is a reflection of the disruption that two years of the Covid pandemic caused, as well as the pressure from construction inflation.

Some work within cohort 4 will start next year. That includes a new surgical hub at Eastbourne, alongside the discharge lounge already under construction. We will discuss key worker accommodation on the site with the trust, as part of engagement with the local housing association. At Charing Cross Hospital in Hammersmith, work will begin on temporary ward capacity to enable the floor-by-floor refurbishment to proceed. In Nottingham, work will begin on a new surgical hub and three new operating theatres will begin as part of the wider redesign, taking forward the Ockenden report recommendations. In Lancashire, a new surgical hub will be opened at the Royal Preston Hospital, which is due to be completed this year. We will reconfigure services across two trusts. I am sure that one of those sites will be of interest to Mr Speaker, as it is expected to be near Chorley. We are in active discussion with the Royal Berkshire Hospital, given the problems with the existing site, which had already made a 2030 completion date very stretching. In addition, we are building three new mental health hospitals in Surrey and Borders, Derbyshire, and Merseyside.

Turning to Devon, I pay tribute to my honourable friend the Member for North Devon and my right honourable and learned friend the Member for Torridge and West Devon, who have secured new community diagnostics centres at North Devon. The new discharge hub is near completion, and we will take forward discussions with the trust and the local housing association on key worker accommodation over the next two years, as the first part of the North Devon new hospital build. We will discuss the original refurbishment proposal alongside the new build hospital 2.0 option.

In summary, the cohort schemes will all proceed, but the commitment to completion by 2030 applies to the 40 schemes set out today, which meets our manifesto commitment to build 40 hospitals by 2030.

Finally, let me set out the merits of the hospital 2.0 approach. Building new hospitals this way has clear advantages. Construction experts estimate that, with modular design, the efficiency saving will be in the region of 25% per square foot. That is essential in addressing the pressures of construction inflation and unlocking the additional schemes that are being observed as a result of the RAAC announcement.

There is one key risk to today’s announcement: the plan announced by the party opposite. As we speed things up, it is determined to grind them to a halt. The plan it set out on Monday said,

‘as a first step, before we commit to any more money, we’d make an assessment of all NHS capital projects to make sure money is getting allocated efficiently’.

So the risk to these schemes is from those on the Benches opposite.

Today’s announcement confirms over £20 billion of investment for the NHS estate. It confirms that all seven RAAC hospitals, which NHS leaders have called on the Government to prioritise, will be prioritised, with complete rebuilds using modern methods of construction. It will allow all cohort 2 schemes to proceed once business cases have been agreed, and modular build will be used for two of the schemes. It gives trusts the certainty to begin enabling works on major schemes in cohort 3 and a package of early work for schemes in cohort 4, two of which will be accelerated as part of the RAAC programme.

In 2019 we committed to the biggest hospital building programme in a generation, and today we confirm the funding to build 40 hospitals by 2030. I commend this Statement to the House.”

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[Lord Allan of Hallam (LD)]

My Lords, when I worked in business we had a maxim that we should always try to undercommit and overdeliver as a way of pleasing clients. It feels like the opposite is applying here, with the Government scrambling to show that they are not underdelivering on their overcommitment. Of course, 40 hospitals was a classic election promise, oversimplifying a much more complex need, with the reinforced autoclaved aerated concrete hospitals being one of those such complications that emerged once they had turned over the aerated concrete block.

I do not expect the Minister to comment on the election promise, but I hope he can comment further on three aspects of the Government’s programme that he has set out. The first is the modular hospital design approach, which certainly seems a very smart way to proceed if it can provide more and better-quality hospital capacity at lower cost. Of course, any negative impact of failures in design will be multiplied if you are using a similar, consistent design. We should remember that RAAC was the future once, and public buildings were built according to that specification because it was seen to be cheaper and better back in the 1950s and 1960s. What assurances can Ministers give us that they will get it right this time and that the modular approach being used everywhere is the right one? By the way, on branding, 2.0 is now very 1.0, and it might be more appropriate to call it “the metahospital” or “Hospital.AI” these days.

The second is the planning process, which the noble Baroness, Lady Wheeler, raised. It does not matter if the modular design allows much quicker construction if everything is held up in seeking the relevant permissions to build the hospital in the first place. I would be interested to hear how many of the schemes have been given planning permission already and the extent to which the Government see planning as potentially a disruptor to their plans.

Finally, on the risks, if there are delays or cost overruns, which we hope there will not be—but inevitably one sees those with schemes of this kind—I look for assurances from the Minister that the contracts are written in such a way that any additional bills will not fall back on the taxpayer and, crucially, that if some schemes overrun or get into difficulties and incur extra costs, it will not mean that other schemes in the programme have to be cancelled as the overall budget runs short.

[Lord Markham (Con)]

I thank noble Lords for their comments. On a personal front, this is a project I have been working on directly. It is very close to my heart and is something that I am delighted to be able to put forward. I would like to mention a couple of hospitals that probably did not get quite the prominence they deserved in the earlier Statement, which happen to be quite close to my heart as well: the North Manchester General Hospital, which is one of the Cohort 3 hospitals. I have worked closely with Manchester City Council in the past on the redevelopments around Manchester Mayfield, and that is very much part of the plans. Also, being an ex-deputy leader of Westminster Council, I am excited by the plans around St Mary’s, where we are looking at a couple of alternative sites. That will be in conjunction with the plans for the refurbishments of Charing Cross and Hammersmith so we have got three hospitals in one. Just to clarify an earlier statement: the surgical hub is planned for Chorley and South Ribble Hospital rather than the Royal Preston Hospital.

I am not quite sure on the point from the noble Baroness, Lady Wheeler, about the target being abandoned. What we were saying before was not that at all. We were saying we are positive about how it is progressing. To the point from the noble Lord, Lord Allan, about overpromising and underdelivering, I am sorry for the branding of the hospital 2.0 approach, and I take the blame for that. In terms of MMC, I was at one of the plants the other day, and it really is amazing the way its builds them and the speed with which they will go up. Many buildings have built like that for a long time. When I was up there, I saw them constructing the new Everton stadium, which is just one example. I believe that they will give the necessary speed we need for them all.

In terms of the funding, the estimate, as mentioned, is more than £20 billion. Each hospital has an indicative allocation. They are fully funded. We are not publishing them for obvious reasons: when you go out to tender, you do not want to tell the marketplace what you are expecting to pay. I hope noble Lords understand the reason for that. I am confident that the funding is in place. The hope in all of these things, as we have seen in the prison space and the schools space, is that if the first hospital costs £100 to build, the next one costs £95, the next one £90, the next one £85 as you get the economies of scale. So, you should be seeing 20% to 25% reductions, as you do a large production line. The benefit of all this is that there is such a mass volume of them all that you get the economies of scale. I genuinely hope that this will become the way we build hospitals for generations to come. It is very much cross-party, something that we all believe is a good way forward.

Some hospitals, as mentioned—as part of the timing and to try to make sure it all works in terms of the funding envelope—have been pushed into the 2030-35 bracket. They were mentioned in the Statement, and we have been speaking to them about that. They include Eastbourne, the Royal Berkshire, all the ones around St Mary’s with the complications there, Lancashire and Charing Cross to name just a few. In all those cases, they understand the reasons, and I think most people understand the need to prioritise the RAAC hospitals as a matter of absolute urgency.

On the questions about the planning process, we are on target. Obviously, you do not want to get planning permission too early, given the time it takes. In all the programmes I have seen, we do not yet have planning permission because we do not yet need it. I am confident that we are on track. We know that there are always X factors in these types of projects but, when you have so many, you want the flexibility to move some forward and some back, in a portfolio-type approach. That is well known when you are running as many projects as this.

At this stage, in all honesty I can say that we are as confident as we can be that we are on target to build them. Undoubtedly, there will be bumps in the road, and we are grown up enough to know that there are challenges, but I can say with a high degree of confidence that this really is the best approach. We will have world-class hospitals that will be state of the art, not only in their design but in their use of digital technology. A hospital today that is fully digitised costs 10% less per patient. With these hospitals, we should be looking at savings of 20% or more. That will really make a material difference to how we treat patients, increase productivity and be seen as the real way forward. I am very hopeful that the economics will become so compelling that this programme will not stop at 40 hospitals—in fact, 45, because of the extra ones we have brought in—and will become a rolling programme across the whole estate.

I am sure that we will have many more questions on this. As I say, it is my pet subject, as the priority lead, so I would be happy to talk about it in greater detail at a suitable juncture.

[Baroness Wheeler (Lab)]

Can the Minister say something about NHS maintenance costs, which I did ask about? I do not have the actual question in front of me, as my speech has just been taken away, but if he would like to write to me on that, it would be helpful.

[Lord Markham (Con)]

Yes, I will happily write. We are spending a record amount in capital. The current capital budget is about £12 billion, which is a 50% increase on 2019. Speaking of underpromising and overdelivering, believe it or not, we have been hiding our light under a bushel regarding the hospital upgrades. Just this morning I visited Frimley, one of the RAAC hospitals, and they said, “Oh, we’ve just had a new hospital at Ascot”. We have not called that a new hospital but they refer to it as such, and when you see it, it is a new building. It is not massive, but by most definitions it is a hospital.

I will happily provide that extra detail and information. We know that there is a lot to be done on maintenance, but we are putting more resources into it.

Pharmacies: Medicines at Home

Lord Markham Excerpts

Wednesday 17th May 2023 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government what steps they are taking to ensure the provision of essential services provided by pharmacies, particularly the assembly of blister medicine packs, to support the safe administration of medicines at home by patients, care workers and unpaid carers.

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

Pharmacies in England do an incredible job, dispensing over 1 billion medicines every year and supporting patients with their medication. Where appropriate, that includes blister packs or other medicine adherence aids. To support patients with taking their medication, we have introduced structured medication reviews in general practice and extra support in community pharmacy. On 9 May, we announced an additional investment of up to £645 million in community pharmacies over this and next year.

[Baroness Wheeler (Lab)]

My Lords, given the urgent need to get thousands of people out of hospital and provide care and support in the community and in their homes, it is surprising that the Government do not recognise the importance of having a national or local data overview of the scale of funding for this essential core service for home care, which is being withdrawn from hundreds of chemists across the country. Hard-pressed domiciliary care workers, providing daily care to thousands of people in their homes, depend on blister packs to administer medicine safely. They will not have the time to sort out multiple medicines each day for their clients, or to risk responsibility for possible mistakes and overdosing. Are the Government saying that, in the future, it is okay for the complex task of sorting out daily medicine doses to be yet another burden placed on unpaid carers, on top of everything else that they have to do? How will people living on their own be able to cope and stay safe?

[Lord Markham (Con)]

NICE and the Royal Pharmaceutical Society are clear that they do not recommend widespread adoption but prefer a case-by-case basis. There are many examples of where blister packs are not appropriate: some pills cannot be stored next to each other, some pills need to be stored in their original packaging and some blister packs cannot have more than four pills. So it is clear that you need a case-by-case review to make sure of what is right for the patient.

[Baroness Manzoor (Con)]

My Lords, the Government have the excellent Pharmacy First initiative. Can my noble friend the Minister say what the Government are doing to support community pharmacists with technology, and to advise those with chronic diseases, such as diabetes and heart disease, what their roles and responsibilities could be in relation to the technology that may be available to them?

--- Later in debate ---

[Lord Markham (Con)]

I thank my noble friend. She is right to stress the importance of how we support Pharmacy First as a way of delivering primary services and supporting pharmacies in and of themselves. Technology will play a key part in that, both in terms of navigating the patient, when appropriate, to use the pharmacy and by allowing them to book pharmacy appointments.

[Baroness Finlay of Llandaff (CB)]

My Lords, an estimated £300 million-worth of prescribed NHS medicines are wasted every year. Over half of those come from medicines either disposed of in care homes or returned to pharmacies. Do the Government have plans to ensure that, where terminally ill patients are being cared for at home, “just in case” medication, which is personalised, is available so that if a crisis arises out of hours it can be dealt with rapidly and appropriately, and so that some of that wastage could be decreased?

[Lord Markham (Con)]

Absolutely. That is one of the major reasons why blister packs are not always the right solution, because there are many cases of wastage in exactly the way that the noble Baroness has mentioned. Wastage is one of the many reasons why both NICE and the Royal Pharmaceutical Society have come out against the blanket use of blister packs.

[Lord Winston (Lab)]

My noble friend on the Front Bench is absolutely right. As somebody who is currently taking hourly medication, I can tell the Minister that it is extremely difficult to keep that up. Does he not recognise that we need to have set blood levels for many drugs, and that it is really important that those are not delayed if we are to have proper pharmaceutical action in the blood stream?

[Lord Markham (Con)]

Yes. There are occasions when it is absolutely appropriate that medicines are packaged in that way; I am sure we all have plenty examples of friends and relatives for whom that is very useful. The whole point is that the blanket application of blister packs is not the right approach.

[Lord Allan of Hallam (LD)]

My Lords, the Government’s welcome plans for pharmacists to play a broader role in primary healthcare depend on there being pharmacies present in every area of the country, yet we have seen hundreds of community pharmacies close over recent years. If this trend is not reversed and there are even fewer community pharmacies in a year’s time, would it be reasonable for us to see this as a failure of government policies?

[Lord Markham (Con)]

No. What I want to be tested on is how many people are using their pharmacies for primary appointments—that is the real measure. I think we will see a marked change, and we will see it as a real convenience. The fact that this will drive more footfall to pharmacies will mean that more pharmacies will probably gain extra business and stay open. We have 24,000 more pharmacy workers than in 2010—there has been an increase in that number since then.

[Lord Jackson of Peterborough (Con)]

My Lords, on the subject of support services, is my noble friend the Minister aware of, and does he deprecate, the widespread practice of catheterising very elderly people who are only temporarily immobile or infirm? In the long term, that reduces their independence and adds to the cumulative costs to the state of their care, particularly to primary care, the NHS and local authorities.

[Lord Markham (Con)]

Yes.

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Markham (Con)]

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

[Lord Patel (CB)]

My Lords, medicines reconciliation —the right drug to the right dose at the right time—is an important part of managing diseases, particularly for patients who are on multiple medications. Blister packs were seen as one of the solutions to reduce risks, as 10% to 15% of older people on multiple medications end up in acute medical wards. If blister packs are not the solution, what solution does the Minister propose to reduce issues with medicines reconciliation?

[Lord Markham (Con)]

I am sorry: I will try to be clear to make sure that I am fully understood. There are many, many people for whom a blister pack is absolutely the right solution. Basically, what has been put in place here is a structured medicine review, so that, in each case, it will be the responsibility of the pharmacist to make sure that they have the right solution for the patient. What I am saying equally is that blister packs are not a blanket solution, and it needs to be done on a case-by-case basis.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, I cannot claim any expertise in this matter; I have just been listening to the conversation that has been going on. My noble friend’s original Question referred to the burden on carers. I have not heard the Minister say much about that, particularly when the negotiation over what is the right way of dispensing certain kinds of medicine presumably has to go on between a patient, a pharmacist and, presumably, a doctor somewhere in it, or somebody representing the patient who would, in many cases, be the carer. In what way are carers being helped to engage in that negotiation, with all the knowledge and expertise that they bring about what actually works in the circumstances?

--- Later in debate ---

[Lord Markham (Con)]

The noble Baroness is absolutely correct. It is the patient, or often their proxy or carer, who absolutely should be considered in this. It is the responsibility of the pharmacist to make sure that they are taking that into account. Again, I say very clearly to patients or pharmacists: if patients do not believe that they are getting the right packaging, and they believe that they need blister packs, they should absolutely be speaking to the pharmacist and the pharmacist should be providing that solution.

[Lord Scriven (LD)]

My Lords, the Minister said that there were an extra 24,000 pharmacists. He will be aware that community pharmacists have complained that primary care networks are poaching them because they can afford to pay them more and community pharmacy is £1 billion short for providing existing services. What are the Government doing to plug that £1 billion gap in order to ensure that there are enough community pharmacists?

[Lord Markham (Con)]

As I say, I do not recognise those numbers. I do recognise that we are putting £645 million more into this space to fund this, and also that this will drive more people into pharmacies, who will not only go there for an appointment, but, no doubt because they are already there, they will generate other business off the back of it. I think and hope that this will actually reinvigorate the local pharmacy sector to the good of local communities and local people.

Autism: Diagnosis Targets

Lord Markham Excerpts

Tuesday 16th May 2023 Lords Chamber

[Lord Touhig (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and I declare my interest as a vice-president of the National Autistic Society.

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

We recognise that not all areas are meeting the NICE recommended maximum of 13 weeks between a referral for an autism assessment and a first appointment. In 2022-23, we invested £2.5 million to test and improve autism diagnostic pathways. In 2023-24, there is a £4.2 million grant to improve services for autistic children and young people. In April, NHS England published a national framework and operational guidance to help the NHS and local authorities improve autism assessment services.

[Lord Touhig (Lab)]

My Lords, by next year 190,000 patients are expected to be waiting for an autism diagnosis—it is already 130,000, and 67,000 of them have been waiting for more than a year. Research shows that there is a widening gap between the number of people who need to be seen and the number of staff available. In the last four years, we have managed to recruit just 19% more staff. The letter that the Minister helpfully sent us in April indicates that he is as concerned about this matter as any of us in this House. We appreciate that, but my question is simple: what is being done to recruit more staff?

[Lord Markham (Con)]

I thank the noble Lord, both for his question and for his interest and work in this space. The House will know that this topic is quite close to my heart as well. It is an area of challenge. We have more demand than ever. We are committed to recruiting more staff. We have a recruitment target for next year of 27,000. Very promisingly—I hope I will have time to go into this in more detail later, or I will speak to the noble Lord afterwards—there is a pilot scheme in Bradford looking at children’s early years scoring and how that can be used as a precursor to screening and testing.

[Baroness Browning (Con)]

My Lords, I too declare an interest as a vice-president of the National Autistic Society—I am always pleased to work alongside my colleague, the noble Lord, Lord Touhig, on these matters. Very often, parents, in desperation, particularly want an autism assessment when their teenagers get to the stage where they are leaving school and going on to further education or other types of study. Without that assessment, no decisions can be made. We have many excellent centres around this country, particularly places such as the Lorna Wing Centre, where assessments can be made. Is it not time that the Government outsourced some of this, as long as the NICE guidelines are followed in giving that assessment, to ensure that the list that the noble Lord announced to the House is reduced much more rapidly than is happening at the moment?

[Lord Markham (Con)]

Yes, absolutely, we need to look at all areas where we can increase and expand supply, including use of the private sector. I am sure I will be asked about ADHD later on and the “Panorama” programme, which shows that there are some pitfalls in all that, but provided they are assessing according to the NICE guidelines, it clearly has to be sensible to use as much supply as possible.

[Lord Addington (LD)]

My Lords, would the Minister agree that when you delay an assessment, you delay support from the entire structure of government, which we have said should be helping? What help is his department getting from the Department for Education and the Department for Work and Pensions to ensure people are getting to these assessments? If they cannot get the full assessment, can some intermediate steps be taken to ensure that people actually get the help they are entitled to?

[Lord Markham (Con)]

We are working closely with the Department for Education. The Bradford pilot scheme I mentioned takes the early years foundation stage profile scores of children. It knows that if you have a low score, you are far more likely to have autism. That triggers a multidisciplinary team to come in and inspect. That is a way that we can use that as an early warning indicator and then follow it up with volume. I hope that working very closely with the DfE in this space will be a real way forward.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the Minister has already anticipated receiving this question—I would not want to disappoint him. He is clearly aware that there is some question over the reliability of some diagnoses that are being offered, particularly in the private sector, for ADHD, which is another neurodevelopmental disorder. Is he confident that, in trying to scale up the availability of diagnosis, which is obviously an admirable aspiration, the quality of those diagnoses will be maintained? Are the NICE guidelines sufficiently robust to ensure that?

[Lord Markham (Con)]

As we all know, it is a complex area, and there is no black and white diagnosis of autism. The noble Baroness’s point is absolutely correct: we need to make sure that the quality is there. The Bradford pilot has now been running in 100 locations. Every child has to get an early years profile score. If we can show the linkages and follow that up with the screening programme, that will be very promising; but, absolutely, we have to make sure that the right assessment is made.

[Lord Kamall (Con)]

My noble friend the Minister has rightly said that it is important to expand supply and work with the private sector. Can he tell me about the work that the department is doing with civil society organisations and charities in expanding supply?

[Lord Markham (Con)]

Yes, when I talk about supply, it is in all these fields. There are organisations of which I have personal experience, including the National Autistic Society, which does tireless work and has helped me out personally. So I know just how good they are in this situation. Absolutely, the whole strategy in this space is to expand supply by both the private sector and the independent and charity sectors.

[Lord Sahota (Lab)]

My Lords, on autistic children, do the Government keep separate facts and figures for minority communities? I have encountered quite a few ethnic minority children who are suffering from autism. Are there separate facts and figures anywhere for these children?

[Lord Markham (Con)]

Clearly, we pull together all the numbers. Typically, about 2.9% of children and young people are diagnosed with autism. I do not know whether that is different among ethnic minorities. I will happily research that and write to the noble Lord.

[Lord Dobbs (Con)]

My Lords, may I ask my noble friend about artificial intelligence—AI? It is going to have a transformational impact on our National Health Service, for good, or possibly for ill. It will transform diagnosis, treatment, outcomes and—who knows?—it may even help us to make appointments more effectively. Of course, it will have an impact on those who work in the National Health Service as well as those who are treated by it. Have the Government started getting to grips with analysing what lies ahead with artificial intelligence? If not, I encourage them to do so very quickly because I believe that the impact of this will come much more rapidly than we might perhaps think at the moment.

[Lord Markham (Con)]

First, I totally agree with my noble friend’s sentiment about the power that AI, when done in the right way, can have in this space. Clearly, the stress is on the words “the right way”. I think it is fair to say that we are all on the nursery slopes as regards what it can do. I have seen how effective it can be in taking doctors’ notes, recording a meeting and drafting action points, which a doctor can then review. I am sure that we would all agree that that is very promising. There are future generations of AI being talked about that may be able to perform diagnosis. In the 10 to 15 years of looking ahead in the long-term workforce plan, these are some of the things that we will have to try to take into account. However, we are in the very early stages.

[Baroness Merron (Lab)]

My Lords, when it comes to autism services, we know that there are major disparities across the country which predate the pandemic but which were made much worse by it. The number of people waiting for an assessment has grown by 169% from pre-pandemic levels. How will the Minister ensure that the national framework and the standards for autism assessment within it are deliverable at a local level and in every part of the country?

[Lord Markham (Con)]

First, each ICB now has to have a lead for autism and learning difficulties. The noble Baroness is correct that there are some disparities— I am sure that she is aware of the two ICBs which have restricted their services quite significantly, although, thankfully, they are now rowing back on that. We need to make sure that we are on top of all of them. As the noble Baroness is aware, I and other Ministers are taking a personal interest in this. Clearly, there is a lot of work to be done.

[Lord Trees (CB)]

My Lords, what are the Government doing? Are they supporting research to find out the causes of this apparent huge increase in autism which we have seen in recent years?

[Lord Markham (Con)]

There are a couple of factors. Obviously, the strains and stresses of Covid have brought a lot of these things out into the open. It is good that people are becoming much more aware. My experience dates back 20 years when no one had even really heard of Asperger’s, so it is good that we are aware of it today. It is also good that many more people are now diagnosed with it.

NHS: Allocation of Financial Resources

Lord Markham Excerpts

Thursday 11th May 2023 Lords Chamber

[Lord Roberts of Llandudno]

To ask His Majesty’s Government what financial resources are being allocated for (1) additional beds, (2) extra ambulances, and (3) the recruitment and training of extra NHS staff.

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

The delivery plan for recovering urgent and emergency care services sets out how we will provide 5,000 additional permanent beds, backed by £1 billion of dedicated funding to support capacity. We are also providing ambulance services with £200 million of additional funding in 2023-24 to grow capacity and improve response times, alongside delivering 800 new ambulances. We are committed to publishing a long-term workforce plan for the NHS, which will be published shortly.

[Lord Roberts of Llandudno (LD)]

My Lords, over the years, we have had many promises for the NHS. I wonder how the 40 new hospitals are getting on. We were also promised £350 million a week if we came out of Europe. The present Prime Minister made promises earlier this year; are they any more sound? Are there 5,000 more hospital beds, 800 extra ambulances and thousands of staff? Given the conflict over nurses’ pay and other NHS pay and conditions, we are suspicious. I ask the Minister for a full, detailed Statement on the funding and progress of all these pledges.

[Lord Markham (Con)]

We have been giving a lot of Statements. Just this week, I was telling the House about the primary care plan; we announced the social care plan earlier in April; and we had the emergency recovery plan and the elective recovery plan. The plans are in place, and they are starting to show improvements, which will continue.

[The Lord Speaker (Lord McFall of Alcluith)]

The noble Lord, Lord Campbell-Savours, is taking part remotely.

[Lord Campbell-Savours (Lab) [V]]

My Lords, is it not possible that the great British public just might be prepared to see a far greater proportion of their taxes diverted from ill-thought-out and often totally unnecessary tax concessions to the better off, which invariably fail any incentive testing anyhow, in favour of a properly funded National Health Service that slashes waiting times, properly funds health professionals and meets the health requirements of the British people? That is what the public want. Just ask them and look at the polling data.

[Lord Markham (Con)]

We are putting in record investment. Right now, we are spending about 12% of our GDP on health services; a few years ago, the figure was more like 7% or 8%, so there is record investment. I think the whole House would agree that how we use that investment is the most important thing. We have seen that certain hospitals have a 13% lower cost per patient treatment than others because of effective use of technology. That is where I want to see investment take place.

[The Lord Bishop of St Albans]

My Lords, I welcome what His Majesty’s Government are doing to try to get on top of this very difficult problem. Will the Minister give us a little more information, particularly about ambulance services? In Hertfordshire, which is in my diocese, category 2 call-outs, for strokes and hearts attacks, should have an 18-minute response but the response is averaging two hours and six minutes at the moment. There is a great deal of anxiety among ordinary people when these things happen. When do we think that the money going to the ambulance service is going to bring response times down?

[Lord Markham (Con)]

I am pleased to say that the figures announced today show that response times are coming down. For category 1, the most serious, we achieved the 15-minute target for 90% of calls. We are moving in the right direction, albeit there is a lot more that needs to happen in this space. That is what the investment in 800 new ambulances is about, as well as the £200 million of funding. Most importantly, it is about making sure we have the right services in place. Some 50% of ambulance calls do not result in a trip to the hospital. There are fall services, which are often best placed to help, which will pick people up in their home.

[Baroness Blackwood of North Oxford (Con)]

My Lords, I declare my interest as chair of Genomics England. Some 3.5 million people live with rare diseases but only 5% of those conditions have a specific therapeutic. Condition management is essential, but patients struggle to find it because of poor awareness and a shortage of specialist clinicians and nurses. The England Rare Disease Action Plan 2023 commits to a workforce strategy but it does not commit to anything on capacity. What are the Minister’s plans to resource the rare disease workforce?

[Lord Markham (Con)]

This will be another element covered in the long-term workforce plan, making sure that we have got every route covered. My noble friend mentioned signposting people to those services. We are shortly launching a new app service—some 30 million people already have it—to make sure we are signposting to the place where people can get the right treatment for everything, including rare diseases.

[Lord Laming (CB)]

My Lords, does the Minister agree that one of the best ways to help the health service would be if the Government would allocate money dedicated to social care services? This would relieve the pressure on beds. Many beds would be relieved—thousands of beds—and it would prevent people having to go into hospital. Is that possible?

[Lord Markham (Con)]

Yes, and we are doing it. We have committed to an up to £7.5 billion increase in funding over the next two years. We announced last month a social care plan which is addressing this and reforming the sector, and we are starting to see the changes.

[Baroness Merron (Lab)]

My Lords, the Royal College of Emergency Medicine described as unambitious the Government’s plan to see 76% of A&E waits meeting the four-hour standard by 2024. As this target has not been achieved in the past two years, how does the Minister see it working to drive down waiting times? How will the Minister ensure that hospitals are not prioritising patients with minor conditions at the expense of those in greater need of admission simply to allow them to meet the target?

[Lord Markham (Con)]

Numbers out just this morning show that we are now at 75% of people being seen within four hours, so we are close to the 76% target. That is the best since September 2021. I am the first to admit that we want to go further, as the noble Baroness states. It is about making sure we have got the care in the right places. We are triaging to make sure that the most important cases are seen first and, as I mentioned in a previous answer, we have things such as fall services, which can avoid trips to A&E in the first place, and more primary care in place to avoid visits in the first place. That is what the primary care recovery plan is all about.

[Baroness Jolly (LD)]

My Lords, sometimes the NHS is a bit like a greedy child, always needing more. In his Question, my noble friend mentioned additional beds, extra ambulances, and recruitment and training. Will the Minister tell us what budget each of these items comes from? Will the Minister enlighten the House about this issue?

[Lord Markham (Con)]

The budgets are in the allocations for each ICB and each hospital, and within them there are specific allocations to make sure that these fundings are rooted in the place where they have the most effect. As for making sure that really does happen, it is the responsibility of each ICB to make sure it is doing that. Ministers hold them to account by each having seven ICBs to take care of and make sure that they are hitting those targets.

[Baroness Manzoor (Con)]

My Lords—

--- Later in debate ---

[Baroness Manzoor (Con)]

My Lords, I very much welcome the significant sums of money that have been put into the NHS to date by the Government. It is not just increases in beds that we need in hospitals. We live in an age where we have made significant inroads and innovation in technology, diagnostics and so forth, including artificial intelligence. Will my noble friend the Minister say how new technologies are being used to ensure that patients are not needing the extra beds in hospitals and creating the old mistakes we know of?

[Lord Markham (Con)]

I shall answer quickly. As I said, there is already a 13% lower cost in a hospital which is digitally mature. We have virtual wards going in to make sure that we can treat as many as 50,000 patients every month to improve the flow and improve services.

[Lord Stirrup (CB)]

The Minister has mentioned the long-awaited workforce plan. While we have been waiting we have seen a number of interesting initiatives, such as the greater use of pharmacies and the proposal to put SAS doctors into GP surgeries. Will the workforce plan look holistically at the totality of healthcare professions and qualifications, so that in future the workforce can be used in the most efficient way possible?

[Lord Markham (Con)]

Absolutely. The plan is looking at the use of Pharmacy First, as the noble and gallant Lord mentioned, and at the use of technology and the productivity improvements that will make. It is looking at the use of apprenticeships and at how we can bring people back into the nurse and doctor workforce. It is obviously looking at things such as pensions, which we are improving so we can retain more of our doctors. It is a holistic and very detailed study. I know it is taking a while to come out, but it will be worth the wait.

Recovering Access to Primary Care

Lord Markham Excerpts

Tuesday 9th May 2023 Lords Chamber

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

My Lords, I shall now repeat a Statement made in another place:

“Madam Deputy Speaker, with permission, I would like to make a Statement on the primary care recovery plan. For most of us, general practice is our front-door to the NHS. In the last six months, over half the UK population has used GP services, and GPs in England carry out around 1 million appointments every single day. They are doing more than ever. General practice is delivering 10% more appointments a month than before the pandemic; the equivalent of the average GP surgery sees an additional 20 patients every working day. There are more staff than ever, with numbers up by a quarter since 2019, and we are on track to deliver our manifesto target, with an additional 25,000 staff already recruited into primary care. We are investing more than ever, too, with the most recent figures showing that funding was around a fifth higher than five years before, even once inflation is taken into account.

But we know that there is a great deal still to do. Covid-19 presented many challenges across the health service, leaving us with large numbers of people on NHS waiting lists, which need to be tackled. In general practice, patient contacts with GPs have increased between 20% and 40% since the pandemic. As well as recovering from the pandemic, we face longer-term challenges, too. Since 2010, the number of people aged 70 and above has increased by a third, and this group attends five times more GP appointments than young people. Not only that, but advances in technology and treatments mean that people understandably expect more from primary care systems.

Today I can announce our primary care recovery plan, and I pay tribute to my honourable friend the Member for Harborough for this plan. I have deposited copies of the plan in the Libraries of both Houses. Our plan will enable us to better recover from the pandemic, to cut NHS waiting lists and to make the most of the opportunities ahead by focusing on three key areas: first, tackling the 8 am rush by giving GPs new digital tools; secondly, freeing up GP appointments by funding pharmacists to do more, with a Pharmacy First approach; and, thirdly, providing more GPs’ staff and more appointments. NHS England and my department have committed to make over £1.2 billion of funding available to support the plan, in addition to the significant real-terms increases in spending on general practice in recent years. Taken together, our plan will make it easier for people to get the help they need.

The plan builds on lots of other important work. Last year, we launched the elective recovery plan, which is making big strides to reduce the backlog brought by Covid-19. We eliminated nearly all wait lists over two years by last July, and 18-month waits have now decreased by over 90% since their peak in September 2021. By contrast, in the NHS in Labour-run Wales, people are twice as likely to be waiting for treatment than in England. They still have over 41,000 people waiting over two years and nearly 80,000 waiting over 18 months.

In addition, this January, I came before the House to launch our urgent and emergency care plan, which is focused on how to better manage pressures in emergency departments, with funding to support discharge to improve patient flow in hospitals. Today’s plan is the next important piece of work.

Turning to the detail of the plan, our first aim is to tackle the 8 am rush. We will do this by providing GPs with new and better technology, moving us from an analogue approach to ways of working in the digital age. An average-sized GP practice will get 100 calls in the first hour of a Monday morning, but no team of receptionists, no matter how hard-working, can handle such demand. About half of GPs are still on old analogue phones, meaning that when things get busy, people get engaged tones. We are changing this by investing in modern phone systems for all GPs, including features such as call-back options, and by improving the digital front-door for even more patients. In the GP practices that have already adopted those systems, there has been a 30% improvement in patient feedback on their ability to access the appointments they need. This also reflects the fact that online requests can help find the right person within the practice, such as being directed to a pharmacist for a medicine prescription review or to a physio for back pain.

In doing so, we will make the most of the 25,000 more staff we now have in primary care. Today’s plans fund practices without this technology to adopt it, while also providing them with staff cover to help them manage a smooth transition into this technology. Indeed, many small GP practices find it hardest to fund new technology, or to manage the disruption that comes with transitioning to new ways of working, so we are funding locum cover alongside the tech itself. Notwithstanding that, people will always be able to walk in or ring if they prefer; if someone wants to ring up and see someone face to face, these investments will make that easier, too.

We also want to make sure that patients know how their request is going to be handled on the same day that they make contact. Clinically urgent issues will be assessed on the same day, or the next day if raised in the afternoon. If the issue is not urgent, an appointment will be scheduled within two weeks, but, crucially, people will not be asked to call back tomorrow. Instead, they will get their appointments booked on the same day or be signposted to other services.

The second area of this plan is Pharmacy First. As well as giving GPs new technology, I know that we need to take pressure off GPs where possible by making better use of the skills of all clinicians working in primary care. We saw the incredible role that pharmacists played during the pandemic—their capacity to innovate and deliver for the communities that they served, freeing up GP appointments in doing so—so the second part of our plan is to introduce a new NHS service, Pharmacy First, on which we are already consulting with the Pharmaceutical Services Negotiating Committee.

Some 80% of people live within a 20-minute walk of a pharmacy, so making it easier for pharmacists to take referrals can have a huge impact. Referrals might be from GPs, NHS 111 or, from next week, urgent and emergency care settings. Community pharmacists already take referrals for a range of minor conditions, such as diarrhoea, vomiting and conjunctivitis, but with our Pharmacy First approach we can go further still. We will invest up to £645 million over the next two years so that pharmacists can supply prescription-only medicines for common conditions, such as ear pain, UTIs and sore throats, without requiring a prescription from a GP.

One of the most significant shifts we are making is in oral contraception. Pharmacists can already manage the supply of contraception prescribed elsewhere; from later this year, they will also be able to start women on courses of oral contraception. This is another way in which we aim to reduce the barriers to women accessing contraception, in light of our women’s health strategy. Pharmacists will also be able to do more blood pressure checks, which is one of the most important risk factors for cardiovascular disease. Not only will those kinds of steps make it easier for people to get the care they need; we expect that they will release up to 10 million appointments a year by 2024-25.

The third part of our plan is about providing more staff and more appointments. We are making huge investments in our primary care workforce, and are on track to meet the manifesto commitment of 26,000 more primary care staff by next March, meaning that we have more pharmacists, physios and paramedics delivering appointments in primary care than ever before. In 2021, we hit our target of 4,000 people accepting GP training places, and our upcoming NHS workforce plan will set out how we will further expand GP training. We are also helping to retain senior GPs by reforming pension rules, lifting 9,000 GPs out of annual tax changes. These are the pension reforms that the British Medical Association welcomed, describing them as ‘significant’ and ‘decisive’ changes and citing them as ‘transformative for the NHS’.

As well as freeing up more staff time, our plan cuts bureaucracy, too, so that GPs spend less time on paperwork and more time caring for patients. We will remove unnecessary targets, improve communication between GPs and hospitals, and reduce the amount of non-GP work that GPs are being asked to do. For example, patients are often discharged from hospital without fit notes, meaning that they then have to go to their GP to get one. By the end of this year, NHS secondary care services, which understand those patient conditions better, will be able to issue fit notes, and we have streamlined the number of targets on primary care networks from 36 down to just five. Taken together, this work will free up around £37,000 per practice.

Today’s primary care recovery plan funds and empowers our GPs and pharmacists to do more, so that we can prevent ill health, keep cutting NHS waiting lists and improve that vital front door to the NHS for many millions of people. I commend this Statement to the House.”

--- Later in debate ---

[Lord Shipley (LD)]

My Lords, I support the comments made by the noble Baroness, Lady Wheeler, on the Statement. We on these Benches welcome the aspirational nature of what the Government are proposing. During the Covid pandemic, we all learned that community pharmacists play an absolutely key role in supporting the health system. In my personal experience of securing additional injections, I was very impressed by how well the whole NHS system worked in delivering the inoculation service through community pharmacies. One of the good things about it is that you can book a slot, in the same way you book a slot with a GP. However, for this to succeed—and to free up 30,000 GP slots, as the Government intend—booking an appointment with a pharmacist needs to be just as easy. We then need to be very clear about what pharmacists will do, and what GPs will no longer have a contractual obligation to do.

On the workforce shortages that have been referred to, it would help if the Minister could explain whether the manifesto commitment to deliver 26,000 more primary care staff by next March is deliverable. It is difficult to see how the Government will do that unless more money is made available, so I seek the Minister’s confirmation that more resource will be delivered on the back of this initiative to ensure that it happens.

I will ask the Minister three further questions. First, were patients of different backgrounds, genders and geographies involved in drawing up the plan, and can he outline the patient involvement? Secondly, is there sufficient qualified staff of all professions to deliver the multidisciplinary plan? Finally, as the noble Baroness, Lady Wheeler, asked, when does the Minister does expect the new plan to be up and running?

[Lord Markham (Con)]

I thank noble Lords for their comments and appreciate the general welcome for the tenets of the plan from all sides. I want to say that, rather than “too little, too late”, this is actually a plan that bolsters a service that is already on target for an increase of 50 million appointments from 2019—a service in which we are seeing a 10% increase per month versus pre-pandemic levels. I think that, on anyone’s reckoning, that is a pretty impressive achievement. The Pharmacy First plan that we talk about will free up another 10 million appointments a year in addition to that. Also, the use of digital technology will make it easier to get appointments and ensure that those who need them most can get them. It will ease the 8 am frustrations that we are all too aware of.

Addressing the comments on the pharmacy closures that have happened, this can only help pharmacists by increasing the income-generating services available to them and increasing the footfall into those pharmacies. This can only improve their income and so their overall viability. So I hope we will see, from all of this, an increase in the number of community pharmacies. To answer the point, we will be setting up booking systems so that you can digitally book your pharmacy appointment. Equally vital will be the use of the NHS app and other technologies, such as 111, to navigate through services, so you know when you should be booking an appointment with a doctor and when you should be booking it with a pharmacy. The use of technology will be a vital element in all that.

On the workforce, I absolutely acknowledge, as I think we all do, the importance of making sure we have the right workforce in place. That is why I think we are all pleased with and all supportive of the pension changes that will increase and retain the numbers of people. I am afraid I cannot give any more news on the date of the workforce announcement, but I can say that, as mentioned before, substantial work is going on in this place. Yes, we are committed to the increase of 26,000 staff, and this whole package has £1.2 billion of funding behind it, of which £645 million goes into the community Pharmacy First plan, because a vital part of all this, as noble Lords have said, is making sure that we have we have the qualified staff in place to do it.

So, I think we have a good plan here and it is probably best to hear what the industry has said. We have seen a welcome from across the board.

“This is the most significant investment in community pharmacy in well over a decade”


came from the Pharmaceutical Services Negotiating Committee. The Boots CEO said:

“We are really pleased … Our Boots pharmacy teams sit at the heart of communities, offering easy to access care and expert advice; it is great news that they’ll be able use their clinical expertise more widely to help patients”.


I really see this as a transformational step forward, united with the digital technology which will make huge differences. With that, I commend a plan that will make a real difference to patients and the services they receive from GPs in the community.

[Baroness Bottomley of Nettlestone (Con)]

My Lords, I commend this plan most warmly. It has long been said that family doctors are the jewel in the NHS crown, but of course there has been a total transformation in the primary care team: it is not simply family doctors but a much more complex team, and the frustration so many of them feel is that they work to the minimum of their ability rather than the maximum. As I understand this, it will enable people to work to the maximum of their skills and use their training to extremely good effect.

The other great difficulty is that patients want to be treated like partners—they want information, they want contact—so opening up the opportunity to use pharmacies far more is going to be extraordinarily important. Will my noble friend say a little more about the contribution of the NHS app? Obviously, it will take time for people to be really comfortable with it, but it seems to me that this could be a transformational component in releasing family services and making them more available.

[Lord Markham (Con)]

I thank my noble friend for her comments and completely agree that this plan is all about making sure that we are using our most skilled practitioners in the most effective way. We want to make sure that those people who really need to see a doctor get to see one when they need to, but that patients in need of other treatments that can be delivered by a community pharmacist, a nurse or some other medic, such as a physio, are seen by the right people. Fundamental to the navigation of all that is the use of technology and the NHS app, as my noble friend mentioned.

What I see is the app really helping inform people—giving them their patient records so they can do their own research and understand and take ownership of their own health. We all know that, just as we have seen in the space of banking and other areas, giving people ownership, so they can take control of their health, is fundamental. Once they are armed with that information, they can be helped to navigate to the point of most use. That is where I see fundamental change: it is an area where we will see such change in the way we all address our NHS services and look after our own health. I truly believe that it will be one of the most fundamental changes we will ever see in this space.

[Lord Boateng (Lab)]

My Lords, there is much in the Statement that is welcome, but I know from my own time, many years ago, as a very junior Minister in the Department of Health, but also more recently, as Chancellor of the University of Greenwich, with the role we play in the training of pharmacists, that small, independent community pharmacists have a real challenge in finding the space and capacity to provide advice and assistance to clients in conditions of sufficient privacy. What proposals will the Government come forward with, and with what funding, to assist the small independents—we are not talking about Boots and the big guys and gals but about the small independent pharmacists? What capital assistance is going to be provided to the small community pharmacists on our high streets who can potentially play such an important role, to enable them to structure their premises in a way that enables them to give the information that the Government are suggesting they should give in preference to GPs?

[Lord Markham (Con)]

The noble Lord makes a very good point. It is really making sure that the independents can play a very important role. It is, where necessary, making sure that whole-estate planning takes that into account. A lot of the work I have been doing with Minister O’Brien—he heads the GP space while I look after the capital space—is looking at how we can create the sorts of models where you can put pharmacies alongside GP surgeries, in many cases, and make sure that that capability is there. I freely admit that capital is at a premium within the system, so we have to be creative in the ways we use it, but the noble Lord is absolutely correct that this is a key way to make sure we have a network of independent pharmacies that can really serve their local community.

[Lord Bellingham (Con)]

My Lords, I thank the Minister for the Statement and put on record my gratitude to him and other junior Ministers who played a very important part in making sure that this initiative has been brought to fruition. I pay tribute to the local surgery in my own community in Norfolk, the Great Massingham and Docking surgery, where the receptionists are invariably incredibly patient and polite to everyone and the doctors are quite outstanding—they have a lot of very satisfied people in the community because of their attitude to local people who may have ailments. But, obviously, they are under pressure, and that is why I welcome the Government’s announcement on Pharmacy First and on recruiting new GPs. Can my noble friend tell the House whether the Government’s commitment to recruit an extra 6,000 GPs by the end of this Parliament is on course? Has the number of GPs in training increased? Can he just clarify those two points?

As the noble Lord, Lord Boateng, pointed out a moment ago, pharmacies are often at the centre of communities. Apart from anything else, pharmacists often have a really strong relationship with patients because they see them on a regular basis, understand their needs and see them consistently—which, unfortunately, is not always the case with doctors. That is why I support the Pharmacy First initiative, which could be a lifeline to a lot of pharmacies that are under pressure. They will be able to prescribe many more medicines, but can my noble friend tell the House whether they will be able to prescribe antibiotics for some of the conditions he mentioned? If that is the case, that would be a very positive extension to the services that they provide.

[Lord Markham (Con)]

I thank my noble friend. As evidence of the good work that receptionists do under trying circumstances, in a recent survey 91% of patients said that their needs were met. On the target of having 6,000 extra GPs by the end of this Parliament, currently we have increased the number by 2,000 but, in all honesty, I think the feeling is that we will struggle to meet the 6,000 target—I believe that is something that Sajid Javid, as Minister, said before. But there is a 50% increase in the number of graduate trainees since 2014, with more than 4,000 currently in training. So we have made steps in the right direction, albeit not as far as we would hope.

On the supply of antibiotics, the idea behind this is that there will be certain agreed treatments that the pharmacist will be able to give. Clearly, UTIs is an example where you often need antibiotics to clear those up, and in those circumstances there will be agreed treatments that pharmacists can give: provided that, in the pharmacist’s judgment, the symptoms warrant it, the pharmacist will be able to enable the supply of antibiotics. On all those, this is a very positive way forward.

[Lord Mann (Non-Afl)]

The Government’s housing policy is to build, or to have built, 300,000 new houses a year. Has that been factored into this announcement? Is it the Government’s view that these new houses are a problem for primary care provision, or can the Minister assure me that the funding formulas are sufficiently robust that new housing is seen as an opportunity for primary care?

[Lord Markham (Con)]

The noble Lord is quite correct to point out that, where you have a number of new houses in a local community, you need to make sure that there are primary care services to serve them as well. Funnily enough, just today I was having a conversation with Housing Minister Maclean on this very subject, about changing the way that we look at Section 106 payments—or CIL payments, as they are called these days—to make sure that the provision of the primary care estate is one of the key elements that can be funded through that. I know that DLUHC colleagues are very much on board with that, because absolutely fundamental to the point that the noble Lord makes is that we need to make sure that, alongside the new housing, which we all agree is very important, there are sufficient primary care services as well.

[Baroness Young of Old Scone (Lab)]

My Lords, I thank the Minister for the Statement but regret that it concentrates on more GP and other ancillary services to meet rising demand rather than focusing on the causes of that rising demand. A major source of pressure on GPs is due to the complications of diabetes, yet inadequate action is being taken on obesity, often in the face of pressures from the food lobby. Similarly, the Minister talked about the rising number of over-70s—I should declare an interest—yet much of that pressure is due to elderly people failing to get adequate social care and falling back on general practice because they have nowhere else to go. Yet, over the last 13 years, the Conservative Government have absolutely run away from any sort of reform agenda for social care. Will the Minister comment on whether new phones are going to plug even the short-term pressure, and will he tell us what sustained long-term solutions to managing down the demand for GP and other ancillary services his Government are thinking of?

[Lord Markham (Con)]

First, I completely agree with the noble Baroness’s point that prevention is better than cure—I think we would all subscribe to that—and that is what the Government’s manifesto pledge of five years’ more healthy life is all about. On how the app comes into that, it all comes down to people taking more control of their own health, such as by being able to receive reminders that it is time for their cervical smear or heart MoT, so that they can start to take ownership of their own health. Towards that, the community pharmacists have already provided 1 million blood pressure checks, through which 300,000 people were found to have high blood pressure. That is a prime example of where this expanded network really can get on to the prevention agenda, which we all agree is absolutely key to helping solve the health situation going forward.

Childbirth: Black Women

Lord Markham Excerpts

Wednesday 3rd May 2023 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, in begging leave to ask the Question standing in my name on the Order Paper, I draw the House’s attention to my interests in the register.

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

While births in England are among the safest globally, we must do more to tackle maternal disparities. Local maternity and neonatal systems have begun to publish action plans to tackle disparities in outcomes and experiences in maternity care at a local level. The Maternity Disparities Taskforce, which held a meeting on 18 April, brings together experts from across the health system, government departments and the voluntary sector to explore and consider evidence-based interventions to tackle maternal disparities.

[Baroness Thornton (Lab)]

I thank the Minister for that Answer. On 17 April I asked the Government about discrimination in the UK experienced by people of African descent—the Minister for Equalities pooh-poohed this report and strongly rejected most of the findings of discrimination. The following day the House of Commons Women and Equalities Committee published a report which said that black women are four times more likely to die in childbirth than white women in the UK. Does the Minister now accept that there was a point to my Question, and that research conducted on behalf of the Government since 2000 has shown that black women as a group have consistently remained at the highest maternity risk?

I would also like to ask the Minister about continuity of carer, which means having the same midwife throughout your pregnancy. It is a cornerstone of the Government’s and the NHS’s commitment to deliver safer maternity services, and indeed the report itself says that it is one of the ways to overcome barriers and improve communication and understanding throughout a pregnancy. When will the Government invest in the recruitment of midwives, bringing up their strength by 2,500, which the Royal College of Midwives says is essential to deliver this personalised care?

[Lord Markham (Con)]

I thank the noble Baroness; there were a number of questions there. I accept that there is a disparity, which is why the Maternity Disparities Taskforce was set up. I was speaking to Minister Caulfield just this morning, and I assure noble Lords that this is very high on her agenda. That is why, in providing continuity of maternity care, the focus is on making sure that people from ethnic minorities, particularly black women, get priority.

[Baroness Manzoor (Con)]

My Lords, this is not a new issue. I am pleased to hear that the disparities task force has been set up, but can it look not just at the issues of workforce planning—there is a shortage of midwives—but at the additional antenatal care that black and ethnic-minority women need because of underlying causes, and at the care they receive during labour?

[Lord Markham (Con)]

My noble friend is right. I was speaking to Minister Caulfield about this very subject this morning. She pointed out that a lot of the reasons for the differences are underlying health conditions and factors such as smoking, weight and alcohol consumption, as well as diabetes. Education is a key part of this, as is continuity of care, and making sure that there is prenatal and postnatal care is absolutely a focus.

[Baroness Walmsley (LD)]

My Lords, the NHS published equity and equality guidance in September 2021 aimed at improving maternal health for mothers and babies from black and other ethnic groups and those from the most deprived areas. However, no implementation plan or scrutiny mechanism has been developed, so how will implementation and adherence to these strategies and guidelines be assured? Who will report on progress, or the lack of it?

[Lord Markham (Con)]

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

[Lord Hunt of Kings Heath (Lab)]

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

--- Later in debate ---

[Lord Markham (Con)]

The noble Lord is correct that data is an issue. A lot of the frustration that Minister Caulfield expressed is about the fact that we are having to look in the rear-view mirror, because the data is about two years old. One of the fundamental things is to get that live data so that we can see what action works and where more needs to be done.

[Baroness Berridge (Con)]

My Lords, it is also sad to note that the rate of black babies being stillborn is 6.9 per 1,000 births, as opposed to 3.6 per 1,000 for white babies. Can my noble friend the Minister please confirm that each trust is under an obligation to collect that kind of data and do specific research as to why a modern country has that really sad rate of higher mortality?

[Lord Markham (Con)]

That is what the equity and equality plans are all about: understanding the local needs of an area. As I mentioned before, a lot of this is often due to the underlying health conditions of that ethnic-minority group. Also, many of us take for granted the fact that we are very clear on how to access medical services, but a lot of people from these ethnic minorities do not have the experience—for want of a better word —of accessing them. A key part of the plan also needs to be about how we can make this care accessible for all these groups.

[Lord Walney (CB)]

Is the Minister aware of the findings of the 2015 Kirkup report into neonatal deaths in Morecambe Bay? Among its findings, it concluded that ethnic-minority women were on a number of occasions not given respect and agency by white British midwives, which may have contributed to neonatal deaths. Has that been looked at by the department, and what has been done since?

[Lord Markham (Con)]

I am familiar with that report, and the more recent Kirkup report on east Kent mentions some of the same issues. That is why part of the investment has been in a training programme to make sure that the suitable cultural awareness is there, because the noble Lord is correct that this is an issue.

[Lord Sikka (Lab)]

My Lords, institutionalised racism is a major factor in the higher death rate of black women during childbirth. Numerous surveys have shown that black women are paid far less for their work than their white counterparts, which reduces their access to good food, housing and healthcare. Ethnicity pay gap reporting is a necessary tool for developing policies to tackle institutionalised discrimination. Why are the Government opposed to introducing ethnicity pay gap reporting?

[Lord Markham (Con)]

I do not think I would categorise this in any way in terms of institutionalised racism, and I do not believe that noble Lords would think that of the NHS. Clearly, work needs to be done on helping all ethnic minorities to access health services and on education, because there are many underlying conditions. That is what we are doing now. A few years ago, the numbers were quite a lot worse; black women were five times more likely to die in childbirth, but that figure is now 3.7. A lot more work needs to be done, but we are improving.

[Lord Hamilton of Epsom (Con)]

Does my noble friend accept that the term “institutionalised” is, in the words of the Metropolitan Police Commissioner, “ambiguous”, in that it means different things to different people? Can he define “institutionalised”?

[Lord Markham (Con)]

The point I was trying to make is that I think all noble Lords would agree that the NHS does a fantastic job in addressing and reaching people of all ethnic minorities. That is something we can all support.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, the Minister omitted to answer the first question put to him by my noble friend Lord Hunt of Kings Heath about the frequency with which the task force met and the gap between its last meeting and the moment at which its report was put forward, if I understood the question correctly. Can he answer that now?

[Lord Markham (Con)]

My understanding is that since the task force was set up, which was little more than a year ago, it has had as many as four or five meetings. If that is incorrect, I will correct it. The latest meeting was on 18 April. Again, if noble Lords look at the actions that have come out of it, they will all agree that it is actions that count the most. The task force has been very thorough, and Minister Caulfield is very committed.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Minister has referred a number of times to socio- economic disparities—indeed, the noble Lord, Lord Sikka, referred to the issues of poverty. The MBRRACE report and others have shown the disparity in death rates that sees black women dying in childbirth four times more often than white women. Will the Minister acknowledge for the record that there is a tragic difference here—a higher number of deaths—that cannot be fully accounted for by pre-existing health conditions and socioeconomic disadvantage?

[Lord Markham (Con)]

As I have said, this is a complex area. I do not think we understand all the underlying reasons. Underlying health is a reason, and access is another. What the statistics show is that there is a difference, which is why we are so focused on addressing it and making sure that everyone has excellent standards of maternal care.

Life Expectancy: Pensions, Health and Insurance

Lord Markham Excerpts

Wednesday 26th April 2023 Lords Chamber

[Lord Rooker]

To ask His Majesty’s Government how changes in life expectancy as measured by the Office for National Statistics have affected planning for pensions, health and insurance.

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

The Government consider a range of metrics when determining our approach to pensions, health and insurance, including life expectancy where relevant. We are committed to improving health life expectancy by five years by 2035 and to reducing the gap between areas where it is highest and lowest by 2030. Our major conditions strategy will focus on health conditions that contribute most to morbidity and mortality.

[Lord Rooker (Lab)]

I thank the Minister, but is he aware that Office for National Statistics figures show that life expectancy, which is a key indicator of national health, has stalled in the UK since 2010 for the first time in 120 years? Is he aware that one consequence of this is that over half of families in England cannot get a funeral in less than three weeks, and 17% cannot get one for over a month? Funeral directors are running out of storage space because of what is happening. There are far too many early deaths under this Government, as shown in the report from the Government Actuary’s Department, placed in the Library last week, which states that before the pandemic the UK had the lowest life expectancy of any major European country.

[Lord Markham (Con)]

I am aware that there has been a similar phenomenon across all the G7 western nations. Life expectancy has been plateauing for the last few years, and the only country to buck that trend is Japan. A lot of this is to do with obesity, which I know noble Lords regard as a very important issue. While we are improving issues such as alcohol intake, the impact of obesity on healthy lifestyles is an important factor that we will need to tackle.

[Lord Allan of Hallam (LD)]

My Lords, as well as falls in overall life expectancy, there have been significant falls in disability-free life expectancy, as shown in the recent ONS figures. Can the Minister describe the steps his department is taking to understand why more people are acquiring long-term conditions earlier in their lives, and to ensure that health and social care services are geared up to meet that extra demand?

--- Later in debate ---

[Lord Markham (Con)]

This goes very much to our strategy of improving healthy life expectancy by five years by 2035. “Healthy” is a key component of that, taking the major conditions strategy and looking at the six major causes of death—cancers, heart disease, respiratory issues, dementia, and mental health and musculoskeletal issues—and what we can do on each one to improve lifestyles.

[Lord Forsyth of Drumlean (Con)]

My Lords, considering inflationary pay demands in the health service, has my noble friend given enough emphasis to the benefits provided in the form of final salary index-linked pensions? Is there not a conflict between being concerned about inflation and knowing that you will be protected? How long is it possible to sustain such a system?

[Lord Markham (Con)]

I know that my health brief is broad but including pensions and insurance in it is quite a challenge. Like other noble Lords, I am very aware of the impact of inflation on the final salary scheme and on lifestyles, and of the fact that not many employers can afford the schemes any more—apart from, dare I say it, government. That has an impact. However, I am happy to meet my noble friend to go through this in further detail.

[Lord Winston (Lab)]

My Lords, the Government have made a pledge that they know perfectly well they cannot keep. There is no way that this massive morbidity will be reduced: obesity is not the answer. If he looks carefully, he will see what the Science and Technology Committee—chaired by the noble Lord, Lord Patel, who may want to comment—showed: that it is clearly due to deprivation in poorer parts of the country, which leads to a much shorter life. The Government need to deal with this holistically; it is not the problem of the Department of Health and Social Care but a much wider issue.

[Lord Markham (Con)]

As ever, there are multiple factors at play. That is what the Office for Health Improvement and Disparities is all about: making sure that we are tackling this in exactly the holistic way the noble Lord mentioned, going back to all the major conditions that are causes of death and tackling each one by one. The 10 million cancer screenings save 10,000 lives a year, and our breast cancer screenings save 1,300 lives. There is a lot to do but a lot that we are doing already.

[Lord Patel (CB)]

My Lords, in his introductory remarks, the Minister quoted the Government’s ambition to extend healthy life expectancy by five years by 2035. Can he put some numbers to it? What age are we talking about?

[Lord Markham (Con)]

My understanding is that people are predicted to live a healthy life until around age 63. It is about looking at that aspect as well; it is not just about the length of life but how well we live it.

[Lord Robathan (Con)]

My Lords, last week, the Institute for Government issued a paper that said that every obesity strategy since the first one, in 1992, had failed. It also pointed out that taxes would have to rise to deal with the epidemic in obesity and type 2 diabetes. Can the Government bring together a decent strategy to help all the people who are overweight, so that they live longer and we have a healthier society?

[Lord Markham (Con)]

My noble friend is correct: it is a key issue. There have been successes such as the sugar tax levy, which has reduced sugar consumption by about 40%. But clearly, you need only to look at the statistics to see that all western nations, including the UK, are facing this problem. It is a challenge that we have to attack. We can learn a lot in this space from Japan, where employers and the whole society are very much involved in the healthy lifestyles of their workers and people.

[Baroness Merron (Lab)]

My Lords, life expectancy for those with a learning disability is particularly shocking: only four in 10 live to see their 65th birthday, nearly half of their reported deaths are avoidable, and those living in the north-west and the Midlands are at greater risk. What action are the Government taking to address the specific barriers faced by people with learning disabilities in getting access to the timely, quality healthcare which could perhaps extend their life expectancy?

[Lord Markham (Con)]

As noble Lords are aware, we have been putting significant investment into mental health; from memory, there has been a £2 billion-plus increase over the last year. In recognition that learning disability is an issue we particularly need to tackle, as the noble Baroness is aware, we are putting investment into schools so they can identify it early on. Some 35% of schools now have the right educational leads in this space, and the figure will rise to 50% next year. It is a big improvement, but do we need to do more? Absolutely.

[Baroness Cumberlege (Con)]

My Lords, my noble friend will be aware that for many years, the UK has enjoyed increases in life expectancy but now we are getting reports that the rate of increase is declining. What plans—I have given my noble friend notice of this question—do the Government have to reverse this trend?

[Lord Markham (Con)]

My noble friend, whom I thank for that question, has characterised this issue in exactly the right way. Life expectancy is still increasing, but not at the rate it was. That is why the major conditions strategy was launched. I can give one example: cancer is one of the six major killers, and we are seeing 20% more cancer patients this year than we were pre-pandemic. So there are improvements in this space, and that is what the major conditions strategy is all about; but clearly, the record investment we are putting in needs to show that sort of output.

[Baroness Wheatcroft (CB)]

My Lords, the Minister’s ambition to increase life expectancy is not being helped by the current wave of doctors strikes, with extended waiting lists certainly bringing down life expectancy rates in some quarters. Can he tell the House why he and other Ministers will not get round the table now, with no preconditions, to discuss how this might be brought to a speedy end?

[Lord Markham (Con)]

The noble Baroness is absolutely correct: any strike action is regrettable, and we have a part to play, as do the unions, in trying to make sure that we reach a sensible place. We feel we have done that for nurses and ambulance drivers with the Agenda for Change, and clearly, we want to do the same for doctors. I think all noble Lords can agree that we do not want the impact on patients and healthy outcomes that strikes cause.

Long Covid

Lord Markham Excerpts

Tuesday 25th April 2023 Lords Chamber

[The Earl of Clancarty]

To ask His Majesty’s Government what steps they will take to support those suffering from long Covid.

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

We are committed to supporting people experiencing long-term effects of Covid-19. We have invested £314 million in long Covid care, establishing 90 specialised services for adults and 14 services for children and young people across England. These direct people with long Covid conditions into care pathways that provide appropriate support, treatment and rehabilitation. Furthermore, we have invested £50 million in research to better understand long Covid and how to treat it.

[The Earl of Clancarty (CB)]

My Lords, with ONS data now showing more than 2 million people affected by long Covid, is it not high time that this condition was properly addressed in the workplace, as asked for by Long Covid Support and the TUC? Will the Government specify long Covid as a disability under the Equality Act 2010, as other conditions have been? Will they recognise long Covid as an occupational disease for all front-line workers? This is surely the least we can do for those who risked their lives to protect ours and those who continue to work in an unsafe environment.

--- Later in debate ---

[Lord Markham (Con)]

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

[Lord Hunt of Kings Heath (Lab)]

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

[Lord Markham (Con)]

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

[Baroness Bull (CB)]

My Lords, the Minister will know that evidence shows that the risk of long Covid increases with each subsequent reinfection, and that most adults were last vaccinated in the autumn, which means that their immunity is waning and that they are vulnerable to new infection. For many, this will be their second or even third case of Covid. Given that the living with Covid strategy is to manage Covid like other respiratory illnesses, what consideration have the Government given to adopting a similar vaccination strategy as they do for flu, in that those not eligible for free vaccinations could be offered the option to buy a vaccination? Have the Government made any assessment of the impact that such a strategy would have on the number of reinfections and therefore the rates of people suffering with long Covid?

[Lord Markham (Con)]

I thank the noble Baroness. I think we all accept that this is a complex area where, naturally, we are being guided by the science. Our vaccination strategy has been focused on the highest-risk groups. On allowing other people to pay over and above, as with flu, I think it is best that I come back in correspondence.

[Lord Borwick (Con)]

My Lords, in the statistics for long Covid, are any particular professions overrepresented among sufferers?

[Lord Markham (Con)]

I thank my noble friend. We do not capture statistics in that way—I had a chance to ask the department quickly a few minutes ago—but I will inquire to see whether we can find out more on that. Obviously, some occupations, such as working in the health service, lend themselves more to it, because you are more likely to catch Covid, which is why how we look after our own staff is of paramount importance. On the wider point, I will come back to my noble friend.

[The Senior Deputy Speaker (Lord Gardiner of Kimble)]

My Lords, the noble Baroness, Lady Brinton, is taking part remotely.

[Baroness Brinton (LD) [V]]

My Lords, 2 million people currently reporting symptoms of long Covid is a shocking 3.1% of the population, with over a million people having had it for at least one year. There are some very successful models for assessment and treatment, but some clinics still assume that long Covid is like ME/chronic fatigue and do not investigate for microclots and heart and lung problems. Why is there not a gold standard for assessments and treatment of long Covid in England as there is in a number of other countries, including Scotland?

[Lord Markham (Con)]

I thank the noble Baroness. My understanding is that the 90 specialist adult centres and 14 specialist children’s centres have care pathways which they are supposed to adhere to. Therefore, I hope that the instances which the noble Baroness brings up are the exception, but I am happy to investigate because I think we all agree that a consistent care pathway is vital in this space.

[Baroness Merron (Lab)]

My Lords, despite the provisions that the Minister has outlined, the reality is that just a fraction of the people who have long Covid are seen and supported. What steps are being taken to ensure that GPs recognise long Covid in those who do not self-label as having the condition, and how will the Minister respond to the data that shows inadequate access to specialised health services?

[Lord Markham (Con)]

As I say, the data that I have been working with indicate that 80% are seen within eight weeks, which I think most noble Lords would agree is a pretty good statistic. My understanding is that GPs are fully briefed on referrals and disability types. It is clearly important that people who are suffering in the long term make sure that they get treatment.

[The Lord Bishop of London]

My Lords, the advice of the DWP and DHSC is that, if those impacted by long Covid are unable to work, they will be able to access financial assistance through schemes such as PIP. However, in practice, as the noble Baroness said, there is a lack of recognition of long Covid among GPs and PIP assessors. What steps are the Government taking to make sure that more long Covid sufferers are identified and able to access financial support?

[Lord Markham (Con)]

They are absolutely part of the prescribed path. I know from my DWP colleagues that it is part of the training that those people should be supported with personal independence payments. As of January, more than 4,000 people were being treated and receiving payments in this way. It is fundamental that they get access to those payments going forward.

[Lord Patel (CB)]

My Lords, two things are important in the long-term management of patients with long Covid. The first is epidemiological studies, and I am glad that the Government are backing with £50 million the NIHR to do such studies. The second is finding cures. Interestingly, the molecular studies carried out by Oxford show that there might be mitochondrial dysfunction, which leads to a loss of energy production and therefore fatigue. A drug that has entered its phase 2 trial sounds promising, so we must also support molecular science to find a cure for this condition.

[Lord Markham (Con)]

I thank the noble Lord and applaud the research work that has been done. As I said, we have invested £50 million on top of the £118 million for Covid research. Just as we were one of the front-runners in developing the Covid vaccine, with AstraZeneca, it is very much our ambition to be a front-runner in developing cures for long Covid.

[Lord Allan of Hallam (LD)]

My Lords—

[Lord Dobbs (Con)]

It is this side. Thank you for giving way; I appreciate it. So far, 223,738 people have died from Covid and it has cost this country between £310 billion and £410 billion. Last month, in a Written Question, I asked the Government what they thought were the origins of Covid. The Answer that came back, which was not a reply at all, was that they fully supported the World Health Organization’s study into its origins. But that is an organisation that once speculated that Covid might have come into China on a package of frozen food. The World Health Organization has achieved very little since, and Nature magazine has just revealed that it has “quietly shelved” its second scientific investigation into Covid’s origins. Why do the Government appear so uninterested in the origins of a disease that has cost us so much? Why did it happen, where is it going and how are we going to prevent a second epidemic causing the same sort of chaos that came from Covid?

[Lord Markham (Con)]

We are interested, and the Covid inquiry is all about finding out the origins and learning the lessons. I, among others, am very keen to hear that.

If I am allowed to, I am happy to take the question that was not allowed in. Okay, I am not—I tried.