Social Care: Integrated Care Systems

Lord Markham Excerpts

Wednesday 11th January 2023 Lords Chamber

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

ICSs need to include social care fully in planning and strategic decision-making. Local authorities are responsible for social care and have a clearly defined role within ICSs. The Health and Care Act 2022 includes local authorities in its minimum membership requirements for ICBs, giving local government a greater voice in NHS decision-making than ever before. In July 2022, we also published guidance on how ICPs and adult social care providers should work together.

[Baroness Wheeler (Lab)]

I thank the Minister for his response but ICBs and ICSs have been fully operational only since last July—less than six months. The Minister is quite right that, when they were being set up, we argued strongly for the need for effective social care representation in both bodies to ensure that health and social care are integrated and fully embedded in both. However, this just is not happening. The ADASS spring survey found 73% of directors reporting that ICS management has had little impact on local investment in adult social care to date; some even said that ICSs were reducing investment. How does this help ICSs play a key role in their respective areas in, for example, tackling the staffing crisis in both services, prioritising adult social care and producing the urgently needed ICP integrated care strategies, which are due in June?

[Lord Markham (Con)]

First, I think we can all agree on the necessity of making sure that these are integrated and the vital role that social care plays in all this. I must say, my experience from the places I have visited is that they are well integrated, but I will take that point back and would be pleased to look at any particular examples of where we feel that is not the case because, as I think the whole House will agree, it is vital that they are completely integrated.

[Baroness Chisholm of Owlpen (Non-Afl)]

My Lords, I believe that six integrated care boards have been selected as national front-runners on innovations that will help move patients from hospital to their home. Can my noble friend the Minister confirm that these are going ahead, give examples and reassure us that they will be properly monitored, with data being collected? I have just realised that I called the Minister “my noble friend” but, due to my new role, all noble Lords are now my noble friends.

[Lord Markham (Con)]

Replying on behalf of all noble friends, let me say that I am particularly pleased to see this scheme go ahead. Just yesterday, Members of the House were talking about whether we should have full-time contracted dom care people because they know their patients best. That is exactly what these front-runner pilots are designed to do: to try out these new ways of working and heavily invest in areas, which you probably cannot justify on a national level until you know that it really works. Leeds, for instance, is developing a transfer of care hub, while the Northern Care Alliance is focusing on dementia. This is all about seeing what works and then, when we know what works, scaling it up very quickly.

[Lord Laming (CB)]

My Lords, I hope the Minister can assure the House that he has had an opportunity to read the Adult Social Care Committee’s report, which was published in December. The report makes it abundantly clear that the NHS will not achieve its objectives—some might even say its survival—unless social care is integrated at every level and includes the voice of unpaid carers. Can the Minister assure the House that these matters will be taken seriously?

[Lord Markham (Con)]

Absolutely. It strikes me—again, I mentioned this yesterday—that less than 10% of the 13,000 so-called blocked beds contain people who will need to be in social care full-time in future. Most of them need short-term support and, once they have it, will be able to go back to living in their home, which is the best place for them to be.

[Lord Allan of Hallam (LD)]

My Lords, as the Minister has recognised, social care provision is largely in the domain of local authorities. The level of local authority representation on integrated care boards is therefore likely to have an impact on how powerful the social care voice is in integrated care system decision-making. Does the Minister have any information to share with the House about local authority representation across the 42 integrated care boards, including whether it goes beyond the statutory minimum, so that we can understand whether it is sufficient and likely to lead to the step change that I think we all want to see?

[Lord Markham (Con)]

It is, as the noble Lord says, a statutory requirement that the local authorities are represented on the ICBs. In the last few months, I and other Ministers have met and had discussions with all the ICBs. Every ICB is asked to put up a few people. I have had the local authority representative there as one of only three or four people in the meeting—that is key to all of this. They have been critical participants. They are very involved, and it is vital that they remain so.

[Lord Touhig (Lab)]

My Lords, the Government are to be congratulated on amending the Health and Care Act to ensure that responsibility for integrated care systems addresses the needs of children and young people under the age of 25. However, children with special educational needs or disabilities have lifelong problems. How will providers ensure that there will be integrated health and social care for disabled children and their families?

[Lord Markham (Con)]

This is the whole point and the way that we are moving; the real decision-makers running their local areas should be the ICBs. They know their areas and the needs of the people—including people with special needs and learning disabilities—more than anyone. It is absolutely their responsibility to understand the needs in their areas and to ensure that they are provided for under the commissions.

[Lord Polak (Con)]

My Lords, unpaid carers throughout the country are, more than often, working 24/7. The Care Act 2014 requires local authorities to deliver this high-quality care, including support for unpaid carers. How confident are my noble friend the Minister and his department that local authorities will undertake carers’ assessments for unpaid carers?

[Lord Markham (Con)]

From my experience I understand that this is a very important part of their remit and role. As we are all aware, the unpaid carer role is vital and historically has probably not been recognised as much as it should have been.

[Baroness Warwick of Undercliffe (Lab)]

My Lords, following on from the question asked by the noble Lord, Lord Laming, what plans has the Minister to encourage ICSs to embed co-production in the design and delivery of adult social care at the local level?

[Lord Markham (Con)]

Each ICB has a slightly different approach to ensuring that it is there and ensuring the kind of co-production with these front-runners that I talked about earlier. It is about trying to see whether there are new and better ways of doing it. Maybe at another time I can talk to the House in more detail about what those six different pilots are doing. It is about taking the comments that I have heard here over the last few weeks about what works and trying to scale them up.

[Lord Kakkar (CB)]

My Lords, I draw attention to my registered interests. Is the Minister content that the current approach to institutional and professional regulation will foster effective integrated care across institutional boundaries, secondary care, primary care and the broader community?

[Lord Markham (Con)]

Clearly, it is early days. These were set up last summer and we must ensure that they bed in properly and learn. I am confident that that is the right approach, but, as the noble Lord mentioned, we must make sure that regulators in this space ensure that that is the case. It is probably a question for a few months’ time, when we can be sure.

[Baroness Finlay of Llandaff (CB)]

My Lords, according to Hospice UK, of which I am a vice-president, up to half a million people last year had a palliative care phase before they died. In many of those cases, a failure of social care resulted in a breakdown of care in the community and hospital admission. Following on from the question asked by the noble Lord, Lord Touhig, when these patients are seriously ill or disabled children, they need access to respite care during their illness, as well as at the end, with rapidly responsive care. How are the Government monitoring whether the needs of these people are being met and that the timeframe to put in place the social care that they need does not just slip to the point of becoming a meaningless exercise?

[Lord Markham (Con)]

Those monitoring processes are in place, but to give sufficient detail, it is best that I write.

Care Homes: Staffing

Lord Markham Excerpts

Wednesday 11th January 2023 Lords Chamber

[Baroness Pitkeathley]

To ask His Majesty’s Government how they will ensure that care homes where they block-buy places to assist with hospital discharges are adequately staffed.

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

On Monday, this Government announced an additional £200 million of funding for short-term NHS step-down care packages to help ease the pressure on local hospital beds. ICBs will work closely with local authorities to purchase places in care homes and other settings. Using their knowledge, they will commission appropriate beds where there is sufficient capacity, including workforce capacity, to meet patient needs.

[Baroness Pitkeathley (Lab)]

I thank the Minister for that response, although it seems a bit more knee-jerk than it does a coherent strategy and it poses as many questions as it answers. For example, are the Government planning to pay care homes directly to pay recruited staff or to work through ICBs and local authorities only? What rates are to be paid? Will it be more than care workers currently earn, so as to compete with the retail sector? Given that there are 160,000 vacancies in the care workforce currently, where are those workers to come from, without pulling staff away from an already understaffed NHS?

[Lord Markham (Con)]

Before we went ahead with this, we spoke to many care providers to make sure that there was capacity within the system to do it. It was understood that the capacity is there. In fact, there is potential underused capacity of as much as 40,000. We are confident that the staffing is in place and that the care packages are there to really make a difference.

[Lord Bellingham (Con)]

My Lords, is the Minister aware that a lot of homes across Norfolk are complaining that they cannot sponsor more overseas members of staff? At a time when there are not enough locally trained and motivated staff, surely there should be more flexibility for those quality homes that want to sponsor more overseas members of staff.

[Lord Markham (Con)]

Yes, this is absolutely something that we talk to our Home Office colleagues about all the time. I believe that 15,000 people have already come through on this route in the last nine months or so; we are seeing a rate of about 1,500 a month. It is very important and something on which we are focused.

[Lord Watts (Lab)]

My Lords, rather than bringing in people from abroad, would it not be more effective to pay our own people proper wages with proper conditions, so that they want to work in this sector?

--- Later in debate ---

[Lord Markham (Con)]

We absolutely need both. For years, ever since the NHS was founded, we have had international workers. It is a very important part of it now. Of the funding going in—up to £2.8 billion next year and up to £4.7 billion the year after—70% will translate into wages, because this is a staff-based business. That is a huge injection of money into the sector, and it will go into staff, salaries and welfare.

[Lord Allan of Hallam (LD)]

My Lords, we know from surveys by the Association of Directors of Adult Social Services that there is already a shortfall in domiciliary care capacity, such that people are not getting the services they need at home. While additional, funded care home places are welcome, we need to ensure that this does not worsen the domiciliary care situation by drawing staff away from other vital roles. I raised this question on yesterday’s Statement, but I think it important enough to come back to. Will the Government monitor workforce changes to ensure that both residential and domiciliary care capacity benefit from any new funding?

[Lord Markham (Con)]

Since the question yesterday, I have had a chance to talk to colleagues further about domiciliary care and understand its vital role. I talked to one ICB today, which has its own arm’s-length body, set up by the local authority, which does exactly what was suggested by employing domiciliary care staff full-time. They know the patient best and are ready to take them back out of hospital and put them in place. This is central to what we are doing.

[Baroness Browning (Con)]

When people are transferred, either to home or residential care places, part of the delay is caused by the need, quite rightly, for a proper and appropriate assessment of their needs before a transfer is made. What work have the Government done to assess who is going to carry out those proper assessments, either at the hospital or the care home end, and what the likely delay at that stage will be? It is delaying a lot of people now and no doubt will continue to do so.

[Lord Markham (Con)]

That is absolutely right. In our weekly meetings as Ministers, we look at the reason for the delays in terms of the 13,000 beds. That assessment of delay is one of the key criteria that we monitor each week. The best ICBs that I have seen have teams on this—they are absolutely SWAT teams—who make sure that they do it, and measure the time in which they can do it; for example, they have got to have that assessment within 24 hours. When the patient goes in, they have an estimate of the day that they are leaving, which they will target and work towards. The best do that, and the task force is set up to make sure that it is rolled out to all the other places.

[Baroness Andrews (Lab)]

My Lords, the question has been put to the Minister already, but I want to put it again. Has he read the report of the Adult Social Care Select Committee, published in December, which has a raft of challenges and very good ideas on social care? I look forward to discussing it with the Minister. Specifically, does he agree that as long as we characterise adult social care workers as unskilled and pay them, quite often, below the minimum wage, we are never going to build the capacity that we need? That is a huge challenge. If he were to read the report, he would find that what we recommend is so evidently simple: we need a national workforce plan for adult social care, to raise standards, incentives, status and pay.

[Lord Markham (Con)]

I thank the noble Baroness. I think that the House will recall that I have mentioned on a number of occasions that this is a critical part of the workforce plan. What has become clear, even in the short time that I have been at this box, is that social care is a vital cog in the whole chain, so to speak, which goes right back to ambulance wait times and A&E, because if we do not get the flow going out of the system, we have got problems there. So I can assure the noble Baroness that it is key to my thinking, and to all our thinking.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a future member of the NHSE board. I want to ask how we are going to monitor the advancement from care homes back into domiciliary care, in order to ensure that we do not just move the problem from the hospital to care homes so that, very quickly, there are no beds left in care homes to continue this transfer system. In particular, who is going to pay for the residents in those care homes, and for how long?

[Lord Markham (Con)]

The question is absolutely correct: as I said earlier, less than 10% of these 13,000 people need to be in care homes full-time. The danger is often that once you put them there, they remain. That is why the package is focused on stays of up to four weeks, and absolutely making sure that they are monitored through, because it is vital. It is a step-down situation to help people ease from the acute—where they need a bit of extra support—so that, most importantly, they can get back home as soon as possible.

[Lord Young of Norwood Green (Lab)]

My Lords, does the Minister agree that some of the best examples of care are provided by charities and faith-based organisations which pay more than the minimum wage? Is that not an example to be encouraged if we really want to improve the recognition of carers in the care sector?

[Lord Markham (Con)]

Yes, absolutely. I find—and I talk as a businessman of 30-odd years—that by paying people well, you attract and retain the most motivated staff. It is the best way to run an organisation.

[Baroness Tyler of Enfield (LD)]

My Lords, is it not the case that there will be sufficient staff in the social care sector—both care homes and domiciliary care—only when we have a truly integrated approach to workforce planning across both health and social care? Yes, pay will be absolutely critical, but so will progression and career development opportunities, and opportunities for things like joint posts and rotational arrangements between the two sectors. What plans do the Government have to look seriously at this critical workforce issue?

--- Later in debate ---

[Lord Markham (Con)]

Absolutely; it is an integration issue. Noble Lords will have heard me say just yesterday that our plan is for a modular system of development, so that someone in social care has the modules to go on to become a nurse. It is integrated in that way so that it is seen as a career path for all those people. It is fundamental to all our thinking.

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

Lord Markham Excerpts

Wednesday 11th January 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Order and Regulations laid before the House on 11 October and 16 November 2022 be approved.

Relevant document: 15th Report from the Secondary Legislation Scrutiny Committee. Considered in Grand Committee on 9 January.

Motions agreed.

National Health Service Pension Schemes (Member Contributions etc.) (Amendment) (No. 3) Regulations 2022

Lord Markham Excerpts

Wednesday 11th January 2023 Lords Chamber

is foreseen. In light of the criticisms by the SLSC, does the Minister feel that it was the right course of action to not produce an impact assessment? If so, I would be interested to know what assessment the Minister has made of the contribution of these regulations to dealing with the NHS workforce crisis. As we have heard this evening and on many other occasions, one of the many contributors will be getting in place the right terms and conditions—including pensions—if the NHS is to have the workforce that it and we need. I look forward to the Minister’s response.

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

My Lords, I thank noble Lords, particularly the noble Lord, Lord Davies, for bringing this debate today and for reminding me, quite rightly, about learning lessons. I must admit that I have found learning the health brief—which I still continue to try to learn—pretty challenging. Learning the intricacies of tax and pension matters is another dimension that I was not quite expecting in all this—but I will try to repeat what I have learned so far.

The main thing, and a serious point behind the comments from both the noble Lord, Lord Davies, and my noble friend Lady Altmann, is that, to me, it is a sign of the Lords working well that we have this sort of expertise at our disposal. I said in my maiden speech that I wanted to be a different kind of Minister. We have clear expertise tonight, with people all wanting the same thing: to retain doctors, as the noble Baronesses, Lady Masham and Lady Merron, said; and to address the staff shortages that we have, as the noble Lord, Lord Allan, said. These are things that we have to address, and pensions should definitely be part of that workforce analysis.

I would therefore absolutely like to offer that round table that we have talked about. Again, something that I said in my maiden speech was that I have always found it quite strange that we talk across a Chamber; surely, a more productive way is to talk around a table with a cup of tea or coffee and have an exchange of views. So I would definitely like to offer that opportunity to the noble Lords who are interested, so that we can learn from them. I again thank the noble Lord, Lord Davies, for bringing this up, so that we have that opportunity to learn and to try to get it right.

I will tell noble Lords what I think is the premise of what we are trying to do and I will then read my speech, which will probably answer some of the detailed points. I will also endeavour to write with a proper detailed response. As we all have said, we know that what we need to fix is the fact that doctors are voting with their feet. That clearly is the problem and, if we do not try to sort it out, it will just carry on. I am not going to pretend that we have fixed that to date, but we do all understand the problem and I know enough about this subject to understand that a marginal rate of tax of 70% is a clear disincentive to work in that situation.

I have tried to understand ways to address this. The problem is that we know that if we try to address this by changing the whole tax system, it becomes very expensive to change the pension rules for everyone. Understandably, the Treasury has a difficulty about changing the rules for one sector of society and the challenge that might result: the cost of trying to solve the doctors’ situation by changing all the tax rules would be incredibly expensive. The judges’ situation is often used. I believe that the way they get round it is by employers effectively paying them the gross amount, to make sure that they get the same net amount as a result. I appreciate that we would then be paying people who are some of the best-paid workers in the NHS an even larger sum, which, I have to say, sits uncomfortably with me personally, particularly when we are having the understandable pay conversations, disputes and strike actions at the moment.

What we are trying to do in all of this—we are not there yet—is at least get to a situation whereby if it is penal for someone to be receiving this as part of their pension, they can receive it as part of their pay instead, at which point they will be paying the marginal rate of tax, be it 40% or 45%. There will be flexibility and choice: I can either have it in my pension pot, or my personal circumstances mean that if I trip over one of the many different allowances rules and it starts to penalise me and I am disincentivised to work, I can at least get it back in my salary, my pay packet, and get it back that way round instead. That is the principle of what we are trying to do in all of this, so when we come to our round table, that is the approach I plan to bring.

On the statutory instrument itself and the regret Motion, I take on board the point made by the noble Baroness, Lady Merron, and I will take that away. I believe that in this circumstance, the regret Motion is less about this per se—because if we were to vote this down, it would make the problem even worse, because all it is doing is extending the situation to March 2023—and really saying that we do not think it goes far enough. That is slightly different; correct me if I am wrong, but I do not believe noble Lords are actually saying here that they disagree with the SI per se and want it to fall. So, it is not a regret Motion, but we are using this as an opportunity, absolutely in the right way because it means that we brought it to the Floor and had a debate, we got a proper conversation and dialogue and a round table to try to fix the problem. This SI in itself helps but definitely does not fix the whole problem.

So that is the direction we are trying to come from. The proposals I have had the officials explain to me are trying to increase flexibility so that people can dip in and dip out, they can step out completely for a while and then start working again if that suits their lifestyle, and restart the clock in terms of their pension and everything else like that. They can take some of their pension and come back to it afterwards. They are trying to solve those sorts of problems, obviously removing the hour cap and trying to solve things about the abatement hours, all on the principle that we know it is a very valuable pension scheme that many of us wish we had the opportunity to be part of, but it is not quite working properly in the way we need it to. The CPI disconnect, as I understand it, is one of the clear issues there. I understand the issues around what the scheme pays: I must admit it was an education for me to hear that, if we are talking about interest rates of 12.5%, clearly that needs to be understood further as well.

I hope noble Lords can see from my response tonight that I very much appreciate the noble Lord, Lord Davies, tabling his Motion because it allows us to discuss this properly. At the department, we know that this is an issue we need to face, because otherwise doctors will continue to vote with their feet and it can be only to our detriment and the health service’s detriment if we do not fix it. With that in mind, I hope I have picked up most of the questions and, as I say, I will write in detail and offer that round table. I hope noble Lords understand why I do not support the regret Motion and I hope, on the basis of the conversation we have had tonight, that while I very much appreciate that this has been brought for us to talk about and set up the round table, the noble Lord will feel able to withdraw.

Excess Deaths in Private Homes

Lord Markham Excerpts

Tuesday 10th January 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what is their assessment of the reasons behind ONS figures showing excess deaths in private homes in England and Wales in the week ending 23 December 2022 were 37.5 per cent higher than the five-year average for the same period.

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

My Lords, while the detailed assessment is not yet available, it is likely that a combination of factors has contributed to an increase in the number of deaths at home, including high flu prevalence, the ongoing challenge of Covid-19, and health conditions such as heart disease and diabetes. On 12 January, the Office for Health Improvement and Disparities will update its excess deaths report, providing further insight into causes that have contributed to excess deaths.

[Baroness Merron (Lab)]

My Lords, while a patient may choose to die at home, the spike in home deaths rings considerable alarm bells. Analysis suggests that record ambulance and emergency delays could be the explanation for a significant number of many more sudden deaths that are occurring at home. Can the Minister point to any government analysis, whether published or ongoing, to explain this unexpected increase in home deaths and a potential link with these delays? If there is no such analysis, how will the Government know how to overcome this shocking state of affairs?

[Lord Markham (Con)]

I thank the noble Baroness. This is an important question, and I had the opportunity to speak to Sir Chris Whitty on this very subject this morning. The statistics show that, over the course of the year, home deaths have increased by about 22%—a lot of that through personal choice, because it was happening over the summer and earlier in the year. Sir Chris told me that a lot of factors are in play at the moment. Flu is a clear example. There were about 1,000 more deaths in the week mentioned than would normally be expected. The cold snap came early, creating more cardiovascular deaths. However, clearly, the challenges are also a component part, which is why we made yesterday’s announcements about the further measures.

[Lord Allan of Hallam (LD)]

My Lords, we are fortunate to have in the Office for National Statistics a source of trusted data to inform our policy deliberations. It provided essential data about excess deaths during the pandemic, and we should equally reflect on what this data says about the health of our nation post-pandemic. There is clearly a range of potential factors that could have led to the excess deaths, as the Minister has outlined, but it is really in the public interest to test all those hypotheses and establish any causality. Can the Minister commit the department to carrying out research, such as the noble Baroness, Lady Merron, asked for, into any potential link between the pressures that we know about on the ambulance service and the excess deaths at home?

[Lord Markham (Con)]

Again, I spoke further to Sir Chris Whitty exactly on this. He writes an annual report on this. We will be doing so in the same way and looking at all the factors.

[Lord Stirrup (CB)]

Can the Minister tell the House what happened to cancer diagnosis and referral times during the course of 2022, and what the prognosis is for these crucial measures over the coming year? If he does not have the statistics to hand, can he write to me and place a record in the Library?

[Lord Markham (Con)]

I will happily provide the detail on that. We all know about the 62-day challenge. That has been the focus of Ministers ensuring that we are bearing down on that number, so that an increasing proportion are treated within that period.

[Lord Hannan of Kingsclere (Con)]

My Lords, some of these numbers plainly reflect the diagnoses and the treatments that did not happen during the pandemic, as my noble friend the Minister has suggested. Given that we now know that the OECD country with the lowest excess death figure during those two years was Sweden, does my noble friend the Minister believe that, knowing what we now know, we would have locked down?

[Lord Markham (Con)]

My noble friend makes a challenging point. This will be a subject of the inquiry, on which I look forward to hearing more.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister agree that one of the elements here may be the lack of support to family carers, who are often the element most involved in providing care at the last stages of life, and in particular the lack of willingness to engage with family carers, who are the people who know most about the condition? I have lost count of the number of family carers who have said to me, “They just didn’t want to know my side of this element.”

[Lord Markham (Con)]

I thank the noble Baroness. We have spoken before about this in the House. I agree with the general point that family carers, probably more than anyone, have great knowledge to bear, and so absolutely that should be an important component.

[Lord Dobbs (Con)]

My Lords, it is blindingly obvious that lockdown has had a huge impact on the number of excess deaths. Indeed, many people warned of that consequence at the time. I will put it politely: at that time, the Government showed a deep lack of interest in the points being made. We are now talking about excess deaths in the hundreds of thousands, quite apart from the extraordinary impact that it has had on mental health, particularly for young people. Could he please promise that the Government will take every step, and then go a step further, to ensure that the inquiry into this by the noble and learned Baroness, Lady Hallett, deals with what we got wrong as well as the many things that we got right, to make sure that we are properly prepared for a future challenge if it should ever arise?

[Lord Markham (Con)]

I totally agree with my noble friend. We all know that it was an unprecedented time, and we learned lessons all the way through: we were much more resistant to locking down as time went on, for all the good reasons mentioned by my noble friend. Yes, that absolutely needs to be a key feature of the report.

[Lord Laming (CB)]

My Lords, the Minister will agree that a very important point in all of this has been the restrictions now in force on primary healthcare services and domiciliary services. We have left housebound people to their fate for a great deal of this time. Is the Minister willing to look at these matters?

[Lord Markham (Con)]

It is a whole-system issue, as I have often mentioned in this House, that takes into account some of the elements of home care, and very much the social care and dom care elements. We know that that is very much a factor in the 13,000 beds that we need to free up through things such as dom care, so yes.

[Lord Scriven (LD)]

My Lords, excess deaths started to rise in June of last year—at the same time, interestingly, as long waits on trolleys in A&Es started. These have got worse as A&E trolley waits have increased. What did Professor Whitty say about that statistic? If nothing, will there be a review into the waits on trolleys in A&E as a possible cause of excess deaths?

[Lord Markham (Con)]

This whole area is all about the number of beds and the occupancy. This analysis was done around the October plan for patients, where we said that we were going to put in 7,000 beds and a £500 million discharge fund. What was clear, as per the announcement yesterday, was that the high level of Covid beds—9,500—and the over 5,000 flu beds were far more than any of us estimated. That increased bed occupancy means that we have had to look to increase supply again and at the number of discharges to social care. That is the root cause of the problem. That is why we acted again yesterday to provide even more care in those places.

[Lord Davies of Brixton (Lab)]

My Lords, although my noble friend quite rightly emphasised the particularly concerning figures in a particular week, this is a reflection of a longer-term trend that has taken place. Does he accept that a particular concern is the high number of non-Covid-related deaths during the last summer? Normally, you expect to see a dip during the summer, and it simply did not take place this time. Is he seized with the urgency of dealing with this issue?

[Lord Markham (Con)]

I am definitely seized with the urgency. I was able to speak to Sir Chris Whitty about a number of those, including last summer. The heatwave was a factor then: we had over 2,500 excess deaths caused by the heatwave over those couple of weeks. There were multiple factors. You have heard me say, again from Sir Chris Whitty, that cardiovascular disease is a real concern: for those three years that people missed going to their primary care appointments, they did not get their blood pressure checked in the same way, and we did not get the early warning indicators. That is another thing that you will hear me talk further about, so that we can get ahead of the curve, because those are the areas of excess death that we risk in future.

[Lord McColl of Dulwich (Con)]

My Lords, have we not forgotten something? When we blame all sorts of factors for these excess deaths, have we forgotten that there are 44 million people in this country suffering from the disease called obesity and all the complications that arise from that? This means that these people are moving inevitably to a premature death from a variety of very unpleasant diseases.

[Lord Markham (Con)]

My noble friend makes a good point that prevention is a key part of this agenda, as is the role that we all take in our individual health and well-being. Obesity is included as a key part of this as well. We need a four-pronged approach that tackles the things that we as individuals need to address as well, to make our own lifestyles healthier.

NHS Winter Pressures

Lord Markham Excerpts

Tuesday 10th January 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, we welcome the fact that the Government are making a Statement, as it is abundantly clear to everyone that we have a crisis on our hands, and we on these Benches have been calling for this to be recognised as a national major incident. In that context, will the Minister clarify the status of the NHS recovery forum that was announced with great fanfare last week? Was it a one-off, or will it be meeting regularly and taking ownership of this crisis? If it is not the NHS recovery forum, what group within government will be taking us through the rest of the winter? This requires daily, serious leadership at the highest levels in government.

I have three questions on the specific measures outlined in the Statement. First, the Government have told us about the block-booking of care home beds, which should provide some immediate relief for hospitals, but they are much less clear on how they plan to increase domiciliary care so that people who can and should be in their own homes do not get stuck in care homes unnecessarily. The last thing we want to do is to move people out of one inappropriate care setting into another one, and domiciliary care remains the key to providing the best care for the vast majority of people who need neither hospital nor permanent care home residency. Can the Minister offer us any assurances on what the Government intend to do about domiciliary care provision?

Secondly, the Statement referred to the new NHS system control centres that will be in each integrated care board area, and which are a welcome development. There is published information about the data that will go into these new centres, but no information about what the centres themselves will make available to the public. Does the Minister agree that it would be helpful for people to know much more about the pressures on the NHS in their local area through these NHS system control centres publishing regular updates with as much information as they can provide to help patients make informed choices, with full knowledge of where the blockages are in the system?

Finally, the Statement referred to the use of artificial intelligence systems to help release patients sooner and track their progress through hospitals. There have been recent press reports about Welsh hospitals using tools developed by a British company called Faculty AI to improve patient discharges. Can the Minister add any insights into how these and similar technologies are going to be tested and deployed in England? I know that nothing is a silver bullet, but the reports suggest that they could make a significant difference to discharging people more efficiently and quickly. If that is so, we do not need to wait to deploy these technologies, and should be getting on with it.

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

My Lords, I thank noble Lords for their comments. As I mentioned in answering the previous Question, this is a reflection, from our part, of trying to understand the situation. We did some plans in October and looked at demand and supply, and that led us to make the announcements about the 7,000 extra beds and the £500 million adult social care discharge fund. It was clear to us that the bed occupancy issue was going to be at those danger points, and that was the plan.

Then, of course, as with any plan, you amend and review it all the time. Over the last few weeks of December, with the onset of flu beforehand, it became clear that we had higher levels of bed occupancy than we had planned for at that time because we had 7,000 or so extra beds taken up by flu while, at the same time, still requiring higher levels of Covid care than planned. It became clear from all this that the bed occupancy levels were still too high to be comfortable. This was causing the knock-on impact on the flow across the whole system, backing right up into the A&E wait times. That is why, very responsibly, we looked at the latest data, planned, and realised that we needed to do more. That was very much the components of the plan.

In answer to the point from the noble Baroness, Lady Merron, some of those short-term measures were about bringing in extra adult social care funding packages and, candidly, looking within every area of our budgets at what we really needed to spend over the rest of the year and at what we could prioritise. We managed to make some in-year savings through reducing headcount, particularly in admin and central areas, and then looked to redeploy that to make sure it was going to the front line.

As well as that, we looked at things such as the expandable modular space. This goes back to the flight control systems, which I would recommend to anyone. It is well worth a visit to Maidstone, where you will see what we plan for the longer term and what we are looking to do across the system in time for next winter. It became very clear there that, because it has the data, it can manage demand and supply. It sees the incoming from the ambulances; it sees the bed situation; it sees those people who are getting close to be ready for discharge. It is working with clinicians to say, “Actually, we’ve got some incoming and we need to free up that space. Let’s get the social care places ready. Let’s have transport ready and clean the bed quickly.” It is absolutely those micro-improvements and the Team Sky cycling-type approach that address it. AI comes in very much as part of that; you can speed up the flow all the time. It is not silver bullet stuff, but it is about looking at those micro-improvements as you go through it. That is very much the background to all this.

Dom care is an important aspect of that as well. I went through the stats with the team today, which said that of the 13,000 people ready for discharge, probably only 3% should require social care in the long term, and the other 97% should be in a home environment. Some of them might need a few weeks, which is where those care packages come in, and a lot of them need dom care, but 97% of them should not be in care going forward. That is why we need to focus these things towards that. That is the thinking behind this.

The modular space is an important component of this. Look at Maidstone again; it has looked very carefully at the patient flows and at where you can have same-day emergency care and get people out again so that they never have to go into a hospital. But you need extra space to do that. We have made this available so that the hospitals can decide where they most need that expandable space—whether it is pre-A&E, when they are finished in A&E and waiting in a decent space for a bed to come free, or step-down or discharge areas. It is about providing that flexibility and putting it in place quickly for them all.

What we were trying to do here was show flexibility and be fleet of foot to be able to course correct as time goes on; to put our hands up and notice when things were difficult and more challenging because bed occupancy was higher than expected—as I say, due to flu, Covid and other factors—and put in the measures to address them. That is exactly what we are doing in the short term.

In the longer term, next year—not that many people would say that nine or 10 months away is the longer term—we need to make sure that adult social care has further funding, as the House has heard me say many times. There will be a substantial increase next year, up to £1.7 billion, and a substantial increase the year after, of up to 20%. With flight control systems, expandable modular care and the rollout of virtual wards, we have a number of things that, on their own, are not a silver bullet, but, by putting them all together, you will start to get the changes and improvements that we expect to see. I say unashamedly that, if there are other facilities in the independent sector that we can make use of, be it making more use of pharmacies or expanding virtual wards, then we should do so.

I am sure there will be more questions as we go on in this debate, but I hope your Lordships can see that we have tried to respond to the challenges through a range of measures that we believe will make a difference. At the same time, we must be open to the need to do more; we will need to add more things and course correct as time goes on.

[Lord Patel (CB)]

The Minister may not agree, but the NHS is in crisis. He may say that the situation is “challenging”, but it could not be more challenging. Although infection rates related to Covid, flu and other infections may have exacerbated the situation, the genesis of the crisis is not of today’s making. It has been in the making for years. It is related to lack of capacity. Does he agree that the emergency measures now being put in place are not likely to work? If they are not likely to work, what is plan B? Importantly, what is the long-term plan to ensure that this does not continue into the spring, summer or next winter?

[Lord Markham (Con)]

I absolutely think these measures will improve the situation; I would not be putting them forward if I did not believe that. At the same time, just as we put out plans in October and are amending them now, I will continue to amend our plans. I think that is a flexible, responsible approach: you have a plan, you adapt that plan, you invest and you continue to improve. That is what we will continue to see and do; we will see those improvements go through this year and into the next.

[Lord Grade of Yarmouth (Non-Afl)]

My Lords, my noble friend the Minister mentioned pharmacies in his response, which clearly demonstrated a complete lack of understanding of the crisis that is going on in the independent pharmacy sector. They are closing at an alarming rate, yet they are the front line of the NHS, with record numbers of people coming to see them for free medical advice because they cannot get in to see their GP. There is a very serious crisis in the independent pharmacy sector, which is vital for healthcare. I have had many meetings, I have had letters, and I have got a campaign going in the media. It is clear from the responses that the department does not have a clue about the extent of the crisis and the closure of these independent pharmacies. Something needs to be done before they all close.

[Lord Markham (Con)]

I wholeheartedly agree with my noble friend that the pharmacies are the front line. We realise that they have been underutilised in the past. Actually, the plan of using them more for patients will put more funding their way, which I hope will support them, just as allocating Covid vaccinations to many pharmacies provided support. I hope my noble friend will see that this plan should add to the viability of a number of pharmacies by putting more business their way. They are a crucial part of the front line.

[Lord Turnberg (Lab)]

My Lords, this focus on the number of hospital beds may be at the wrong end. It is much more fruitful to think about why staff are so dissatisfied and unhappy that they wish to leave and do so in droves. We have to do more to improve the morale of the nursing and medical professions and, in particular, those who work in the community—the care workers. We are losing them in great numbers; they are not coping. The reason is partly their pay, and we must pay them a reasonable rate, but it is also that they are completely disillusioned as people do not take them seriously. They do not have a professional qualification or a proper training programme. They do not have the possibility of career progression. We must do more to encourage them and ensure that they have a satisfactory career. If we do, we could possibly get more patients out of those beds that were building up, and perhaps help reduce the queues of ambulances.

[Lord Markham (Con)]

I agree that we need a whole-system approach. Workforce is a key part of that, including the adult social care workforce. Again, as all noble Lords did, I welcome the advent of the agreement to do a workforce plan, which needs to take all these factors into account. We need to make sure that it is an attractive place to work, and that people see it as a career progression—and that it is modular so that you can start in social care and, if you want to, progress into other parts of the health service.

[Baroness Brinton (LD)]

My Lords, I declare my interest as a vice-president of the LGA and vice-chair of the All-Party Group on Adult Social Care. Nearly three years ago, the Government created Nightingale hospitals, which were much vaunted and had millions spent on them. Virtually all of them were useless because there was no staffing available for them at short notice. I listened to the question from the noble Baroness, Lady Merron, about the short, medium and long-term workforce plan. We are now in emergency time: there are 160,000 social care vacancies and 40,000 nursing vacancies, which includes those in social care. How is this unblocking of beds going to be staffed and by when?

[Lord Markham (Con)]

Obviously, prior to this, we were in touch with the adult social care sector to make sure that there was that capacity within the system for it. We have been assured that the capacity exists, but we wholeheartedly agree that we need to recruit the staff to fill those vacancies, which is why we have taken measures to recruit internationally as well as in the domestic recruitment programme. Those are all key components of the longer-term plan to solve this issue.

[Lord Kakkar (CB)]

My Lords, I remind noble Lords of my declared interest as chairman of the King’s Fund. The Statement made yesterday in the other place refers to a primary care recovery plan. It is well recognised that the hospital system is not sustainable if primary care cannot discharge its important gatekeeper function. Is the Minister able to confirm that, as part of that plan, there will be a radical review of options that might be adopted to ensure that primary care can deliver its important function?

[Lord Markham (Con)]

Yes, this is very much the focus of my colleague Minister O’Brien. I think it is understood that as many as half of the people who turn to up to A&E could have been looked after by the primary care system, so a lot of the pressures caused are as a result of that. It is absolutely a whole-system problem; many of the issues at the front end are about the GPs and at the back end they are about adult social care, which is why we need to address the whole system.

[Lord Balfe (Con)]

My Lords, last month, I had the dubious privilege of staying at one of the Minister’s hospitals. I was struck by the sclerotic way in which decisions were taken. It seems that the whole premium is on safety rather than looking after the patient. I would ask that the department looks into the way in which decisions are made, because I found far too often that a decision was made on the basis of what was safest. The multidisciplinary team, as it was called, was basically there to deflect anyone who wanted to do anything very adventurous. Will the Minister start looking, maybe in selected hospitals, at ways in which the decision-making and care process can be speeded up and made less sclerotic?

[Lord Markham (Con)]

I have seen very good examples of where that works. You have clinicians in the room with the data—the management and bed information. They make decisions according to the flow and number of people who they see are going to need a bed from the ambulances and the A&E situation, and the number who are ready to release. You have clinicians united with the information to make good decisions. Those are the best. The idea with the longer-term plan is to make sure those “best” have the tools in terms of the flight control system and have management processes in place so that they can adopt and follow best practice. It is key to what we are looking to make sure we have in place in time for next year, as the noble Baroness, Lady Merron, mentioned.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Minister replied to my Written Question on 5 January about commercial companies promoting strep A tests. The Answer said that these are “not currently recommended” by NICE

“for individuals aged five years old and over … with a sore throat”

and that UKHSA is conducting a

“bedside review of existing antigen-based lateral flow devices”

to

“identify the tests that are most likely to perform well”.

Given that, can the Minister explain why I have a number of emails from DAM Health headed “Concerned about strep A? Order your home test kit today. Only £12.99 per test kit. Quick and reliable results within minutes”? Can the Minister truly put his hand on his heart and say there is sufficient regulation and oversight of private testing companies, and indeed the broader private health sector? Is it not profiteering from the crisis in the NHS, potentially damaging the NHS and putting more pressure on NHS services?

[Lord Markham (Con)]

First, I declare an interest in this space. As many noble Lords will know, I set up a Covid testing company which never did any business towards the Government; I am very pleased to say that it served only the private sector. I am disposing of it as part of my obligations as a Minister. As the question relates to testing, I am quite keen to put that on the record.

Secondly, I would say “absolutely”. Dare I say it, but the reason my company was so successful is that we set the very highest standards according to the regulators. That is why we were able to win the crème de la crème—the Formula 1s and Wimbledons of the world. I cannot speak for other companies which may not be taking that high level of support, but there is absolutely a role for the regulator to make sure that only effective tests are marketed and those which are not effective should not.

[Baroness Armstrong of Hill Top (Lab)]

My Lords, I wonder whether the Minister—I hate to say this—will recognise that, too often, it feels that the Government have no institutional memory, have no ability to learn from what has happened in the past and keep trying to reinvent the wheel while the wheels are spinning away long before they get anywhere near. The King’s Fund recently published a report on how the last Labour Government brought down waiting lists. That report shows that you do not just have to shout about it; you have to put in place all the different steps, including the right financial flow.

From all that has been said today, it is clear that the right flow is to encourage more people into social care work and encourage and enable them to do more serious, high-level work like urine testing. The Government have not even begun to think about this. Until financial support for the whole flow and the financial incentives to change the things the Government need to change are there, and that is understood by Ministers, we will not get it. It is not enough to say, “We’re putting another £15 million or £50 million into this, that or the other”, without making sure that you know how it is going to be spent and that people are going to be there to deliver it.

[Lord Markham (Con)]

I have said before in this Chamber —and I will say it again—that we should be learning all lessons. I like to think that, three months into my role, I am learning some of those lessons. The noble Baroness will see that we have taken some backwards steps on the use of the independent sector, which, again, was pioneered 15 or 20 years ago, but hopefully we will move forward again. I unashamedly say that we can learn from those things. I have spoken to some colleagues from the noble Baroness’s side of the House, and will continue to, because I will adopt anything that works, and I agree that payment by results is one of those things. We can speak after these questions; my door is definitely open on those matters.

[Baroness Jolly (LD)]

My Lords, I have the privilege to chair the NHS national community nursing plan clinical reference group. We meet on a regular basis and look at how community nurses can keep people out of hospital and get people home from hospital. We have heard very little about that today. Can I have five or 10 minutes with the Minister at some stage to bring him up to speed on the work that is going on?

[Lord Markham (Con)]

As with my answer to the previous question, I look forward to that meeting and learning everything we can. I will repeat the statistics on that subject that struck me most: of those 13,000 people who are fit to be discharged, we think that only 3% need to be in social care in the long term; 97% could be at home, which is the best and most cost-effective place for them. We need to ensure that the support is in place to ensure that that option exists.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a nurse and as a new appointment to the NHS England board as a non-executive director. There are two things missing from this discussion. First, there has been no reference to people waiting for mental health support. How can we ensure that people in mental health crisis are moved rapidly out of busy A&Es to be supported in quieter environments? There is a very good example across the road, at St Thomas’ Hospital, which is helping the A&E. Secondly, it is high time that we seriously consider giving full-time contracts to care workers in domiciliary services, because, as soon as somebody goes into hospital, the care worker’s hours are cut and, although they know that individual, they very rarely get reallocated to them when they are transferred back out of hospital. The lack of continuity of care often results in readmission, so what will the Minister do to ensure that, in the way that the noble Lord, Lord Turnberg, just outlined, we improve the lot of those particular care workers?

[Lord Markham (Con)]

First, I welcome the noble Baroness to the NHS England board, with high expectation of the value that she will add to it. I am very interested to understand her point further; I will speak to Minister Whately about that and respond to the noble Baroness in writing. Where people have knowledge of a patient at home, they can add that to their care when they come back out again.

[Lord Lansley (Con)]

My Lords, one of the lessons we learned, sometimes very painfully, during the earlier stages of the pandemic was the importance of working with, and often through, local government to tackle some of these issues. The same is true now. Would my noble friend explain how the NHS will use discharge funding and purchase social care provision? Will integrated care boards do that locally with local government, which has been managing social care purchasing for decades?

[Lord Markham (Con)]

I thank my noble friend. The best ICBs that I have seen have the local authority as part of their board and their decision-making on a day in, day out basis. One of the best control systems that I saw in an ICB actually had the local authority social care people in the room making the decisions with them, so they are a key element in all of this. On purchasing and funding, they are very much a strong player.

[Lord Watts (Lab)]

The Government have spent 13 years cutting the number of beds and they are now reversing that and starting to increase it, which is welcome. The other thing that they have done is to constrain pay in the NHS and social care. They have an opportunity to do something about that. Why are they not taking the opportunity to boost pay in both those sectors to address some of the problems that we face?

[Lord Markham (Con)]

I welcome what I hope, over the past few days, has been better mood music—let me put it that way—in this space. I hope from the different things that we see that we will get closer towards a landing zone where we can reach agreement going forward. We know from both sides that neither side wants to be in this dispute. My hope very much is that constructively—with good will on both sides, which we are seeing—we will find a way forward.

National Health Service (NHS Payment Scheme—Consultation) (No. 2) Regulations 2022

Lord Markham Excerpts

Monday 9th January 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the National Health Service (NHS Payment Scheme—Consultation) (No. 2) Regulations 2022.

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

My Lords, I start by wishing everyone a happy new year and welcoming the noble Lord, Lord Allan of Hallam, to his position. It gives me great pleasure to speak in this debate and I welcome the opportunity to discuss these draft regulations.

The Health and Care Act 2022 marks an important step in the Government’s ambitious health and care agenda. Noble Lords will be fully aware of how wide-ranging a piece of legislation it is. I think we can all agree with its overall objectives; making it easier for health and care organisations to provide joined-up care is vital.

With the introduction of integrated care systems came the opportunity to review how the financial frameworks in the NHS worked and tailor them to make them consistent with the new integrated approach. The Health and Care Act replaces the NHS national tariff payment system with the NHS payment scheme by inserting new Sections 114A to 114F into the Health and Social Care Act 2012. As with the tariff, the NHS payment scheme will set rules around how commissioners establish the amount to pay providers for healthcare for the NHS. It does not set the amount of money available but intends to make sure that available resources are used as effectively and efficiently as possible.

Before a new payment scheme can be published, NHS England has a duty under the Health and Social Care Act 2012 to consult on the proposals for the new scheme, as it did with the tariff. NHS England is required to consult each integrated care board, each relevant provider and other such persons it considers appropriate. It opened the consultation on the proposals for the 2023 to 2025 payment scheme on 23 December 2022, which is scheduled to close on Friday 27 January 2023.

This brings me to the purpose of these regulations, which is relevant to how those consulted respond and what this means for NHS England. The purpose of this SI is to set these objection percentage thresholds at 66%, which will be reached if the requisite percentage of either integrated care boards or providers object. I believe this is a proportionate level to ensure that a qualified majority can require NHS England to reconsider its proposals, while minor objections cannot stop them. I also consider laying these regulations to be a relatively administrative process. The objection percentages are not changing compared to previous consultations on the tariff; we are maintaining the status quo with 66%. I commend these regulations to the Committee.

[Lord Patel (CB)]

My Lords, I thank the Minister for his comments. I too wish everybody a happy new year. My question is quite simple, and it reflects the discussions we had during the debate on the Act that we passed: is 66%, which is two-thirds, too high a level for the objections? It is a higher order to achieve than, let us say, 60%.

While we await the tariff, I reiterate, so that it is on record, that the important bit is not the level at which the trusts and ICSs can object but how the tariff will vary according to the needs of the population. When we had the debate, we focused on existing inequalities in health and how to minimise and reduce them. One way of doing that is to address the needs of the population who have greater need in healthcare, and therefore the tariff needs to be different. It is a high order to require 66% of ICSs, trusts or providers to object.

I would like the Minister to confirm that the tariffs will reflect the need for the levelling-up agenda to improve healthcare, particularly in more deprived populations, and to comment on why 66%, which is two-thirds, was chosen.

--- Later in debate ---

[Lord Markham (Con)]

I thank noble Lords for their contributions to the debate. A number of issues were raised which, as ever, shows the diligence of noble Lords, particularly as I believe none were raised in the other place—so good for us. Let me try to address them.

Most of the comments were around whether 66% is the right threshold. My understanding is that it was kept at 66% because that is what historically the number has been, so it was decided to continue with that for reasons of continuity. At the same time, I accept the point that the consequences now in terms of it no longer being a Competition and Markets Authority review are not so high. To my mind, the real question is: what circumstances have we seen where it has fallen between 50% and 66%? Clearly, no one would ever say we should have a threshold of less than 50%, but should it be somewhere between those figures?

I think I need to give the disaggregated figures to be able to give a specific answer. I have aggregated the responses where generally there were much larger majorities. Looking at the last three years, for instance, in 2019-20, the figure for those responding positively was 66%, so right on the threshold; it was 78% in 2021 and 77% in 2021-22. So those figures are fairly high. However, if I may, I will come back with the disaggregated figures, because it is only those that give the real data.

The noble Lord is correct that the idea behind having the ICSs involved in these is very much to try to set them around local needs, to make sure that they are understanding that and reflecting some of the inequalities that might exist in their local area.

To address to some extent the point about ministerial or political input, obviously having those thresholds set does not stop Ministers being involved in the decision and seeing that, even if it is a lower threshold, the point raised about particular local circumstances can mean that something needs to be overruled. Funnily enough, it was something we have been talking about in terms of Ministers today. The Secretary of State was saying that with the procurement function, while it is seen by a lot of people as a bit dry and boring, you actually have tremendous buying power and can move the needle very significantly, whether in getting economies of scale in terms of purchasing and purchasing power, incentivising innovation or buying British—which is exactly the point that the noble Baroness, Lady Merron, made. I know that is very much understood by the current ministerial team. I cannot speak historically, but that is very much on our agenda at the moment.

On reviewing this legislation going forward, to look at how well it has worked, I am happy to commit to making sure that we have a further opportunity to reflect on the findings. We would probably need to give it at least a year, maybe more, but we can then have an opportunity to see whether the system has worked in the way we hoped. By definition, that works only if there is then some sort of transparency in terms of the feedback, so that noble Lords can see it and reflect on it. I am happy to take that on; I think it is a wise way forward.

With that in mind, and if I can come back with the detail on those percentages, I will welcome my new year’s gift—may those gifts keep flowing, but I suspect maybe they will not. I appreciate the input from noble Lords today. I hope that we will feel that we have struck the right balance going forward and, crucially, that we are getting the local input we need to set the right process going forward.

Motion agreed.

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

Lord Markham Excerpts

Monday 9th January 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Dentists, Dental Care Professionals, Nurses, Nursing Associates and Midwives (International Registrations) Order 2022.

Relevant document: 15th Report from the Secondary Legislation Scrutiny Committee

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

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

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

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

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

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

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

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

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

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

[Lord Hunt of Kings Heath (Lab)]

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

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

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

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


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

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

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


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

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


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

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

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

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


which is really wasteful of their abilities.

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

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I thank the Minister for bringing this order before us. On these Benches, as across your Lordships’ House, these changes are welcomed as sensible and as part of a suite of measures that we will continue to consider. Certainly, the increased flexibility that they bring to the work of the General Dental Council and the Nursing and Midwifery Council by amending the registration and examination processes and procedures so that they are as effective and practical as possible is very welcome. This is about harnessing the capacity and meeting the standards that are needed so that we can ensure that we have the right professionals in place. The noble Lord, Lord Patel, raised important points that I hope the Minister will consider on how the practicalities of this need to be done.

I am grateful to my noble friend Lord Harris, who laid out what the order does but also what it does not do—in our deliberations it is important that we understand that. I noted his comment that there was no ministerial claim that this will solve a workforce crisis, but, as my noble friend Lord Hunt said, we have a challenge in getting a workforce in place to provide the services that we need. In that regard, it is important that we consider the changes today in the current context of the health system in the United Kingdom.

It is important to say that, sadly, in 2021 alone, 2,000 dentists and over 7,000 nurses quit the NHS. There are more than 46,000 empty nursing posts across hospitals, mental health, community care and other services, which means that one in 10 nursing roles is unfilled across the service overall. As we have spoken about many times in your Lordships’ House, the number of NHS dental practices fell by more than 1,200 in the five years before the pandemic, and there are 800 fewer midwives than just three years ago. That is the context in which we are discussing this.

I turn specifically to the order. If, as expected, the GDC begins recouping costs incurred around international registration, including charging applicants more to take the overseas registration exam, could the Minister give an indication of what effect this might have on the number of dentists operating in the UK? I am sure he understands that, given the number of dental deserts that we already face, we cannot afford to lose the capacity of any further dental professionals.

As well as the overseas registration exam, non-EEA dentists also have to go through the performers list validation by experience process to practise here. The Minister will be aware that stakeholders expressed concern about dentists’ PLVEs being disrupted—for example, by being endlessly rearranged or cancelled—and that that is acting as something of a deterrent to working here. Can the Minister confirm whether there is recognition of that difficulty, and whether the department is looking at what needs to be done to make the process as coherent and smoothly run as possible?

In the other place, the Minister of State committed to write further on the breakdown of positive and negative responses to the consultation that was carried out. Can the Minister of State’s response be made available to Members of your Lordships’ House so that we might also better know what stakeholders were thinking when they responded to the consultation on these changes?

The Government’s Explanatory Memorandum states that policy changes that the regulations make following this order

“may potentially impact international applicants and existing registrants with different protected characteristics, particularly with regards to age, sex and race”

but does not provide detail on what that impact might be. Can the Minister offer any insight into this, if the department has correctly forecast what the regulators are planning?

As we have discussed today, the intent of the order is that there will be changes to application processes and so on. Can the Minister indicate what plans there are to review and audit changes to ensure that there is consistency of decision-making, fair treatment of all applicants and the achievement of the right standards?

In conclusion, while we all support the substance of the order, I hope the Minister can give an assurance that its impact and implementation will not be beset with logistical hitches and unforeseen consequences, because we are keen to ensure that changes are made to deliver the right result to get the workforce more into place than it has been hitherto. I look forward to hearing what the Minister has to say about how the order may assist that, if not entirely cure it.

[Lord Markham (Con)]

I thank noble Lords for their contributions to the debate. I shall attempt to answer the questions set. As ever, I will happily follow up in detail afterwards.

I accept the premise that no one believes that this is a silver bullet that answers all the issues around recruitment and workforce needs. At the same time, I think there is a belief that this is one of many things that can, hopefully, help increase access at the end of the day. I reiterate our commitment to independence, in answer to the question from the noble Lord, Lord Hunt. That is fundamental to this issue and, hopefully, something that the noble Lord, Lord Harris, has recognised through this process.

Probably the point I would like to devote most time to is the one about the DCP register. I must admit that it is something I brought up specifically and wanted to go around the houses on. I absolutely understand the issue: are we cutting off our nose to spite our face? On the equivalence argument—our dentists cannot apply overseas—part of that, as it was described to me, was also the feeling that even in the UK our dentists cannot use the DCP route, so to speak, in that they might be a qualified dentist but want to use some other qualifications, rather than be a dentist. So it was felt that there was no consistency there either.

Hospital Beds: Social Care

Lord Markham Excerpts

Monday 19th December 2022 Lords Chamber

[Lord Dubs]

To ask His Majesty’s Government what assessment they have made of the number of hospital beds currently occupied by patients who could be discharged to their own homes or to residential care if social care support were available.

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

There are around 13,000 people in hospital who do not meet the clinical criteria to reside, including, but not limited to, people waiting to go home and people awaiting access to residential care. We constantly look to reduce these delayed discharges to ease flow in the system, and we have provided a £500 million discharge fund to support people to be discharged at the right time, to the right place and with the right support.

[Lord Dubs (Lab)]

My Lords, I am grateful to the Minister for answering the Question. Does he understand that many of us will think it is a complete disgrace that, for a long time now, hospital beds have been blocked by people who could be discharged into the community or residential care? These people would be better off and have a decent quality of life. Should we not be making this a high priority, instead of saying that we are planning to do this? We have heard that for so long.

[Lord Markham (Con)]

It absolutely is a high priority. Noble Lords have heard me say many times that the key to the whole system is flow through the system, to relieve times in A&E and ambulance wait times. That flow depends on us discharging the 13% of beds that are currently held up. That is why we put the £500 million discharge fund in place and will put £2.8 billion of funding next year, and £4.7 billion the year after, to solve exactly this problem.

[Baroness Berridge (Con)]

My Lords, I currently serve on the Joint Committee that is scrutinising the mental health Bill. Could my noble friend the Minister outline whether that 13,000 includes those who are perhaps in secure mental health beds, awaiting discharge? That of course causes backlogs, and not only into A&E: currently, some of those people could be being held in a police cell, which is not an ideal place if you need admission for assessment to a mental health bed.

[Lord Markham (Con)]

I will happily write on the detail, but, yes, it includes everyone who could be provided a space, either in a care home or a mental health home, and those who are fit to go home but need domiciliary care.

[Baroness Brinton (LD)]

My Lords, Our Plan for Patients, which was published at the end of September, says:

“This winter, the NHS will open up the equivalent of 7,000 beds so that every hospital has space to see and treat patients more quickly.”


Winter is clearly here, so how many of those virtual beds are in operation now?

[Lord Markham (Con)]

I thank the noble Baroness. She is absolutely right that the target of 7,000 beds is a key part of this. All Ministers have been talking about it with every ICB over the last few days to see exactly where they are on the target for both real beds and virtual beds. I will happily provide exact information on the target, but I know that we are making good progress.

[Baroness Merron (Lab)]

My Lords, an estimated one in four hospital beds is occupied by people living with dementia. Many of the admissions would have been avoidable if they had had better community support. Of course, their stay in hospital is typically twice as long as those of other people who are over the age of 65. Does the Minister acknowledge that those dementia patients need to be discharged to a place of their own, or their carer’s, choosing, after a holistic assessment? What steps are the Government taking to ensure that this happens, so that people with dementia do not experience discharges that are inappropriate and unsafe?

[Lord Markham (Con)]

I thank the noble Baroness. We are all seeing different shapes and forms of describing how we need a local care system set up by the integrated care boards that can have an overview of all the needs in their area. That is exactly what we are doing, and exactly what the Patricia Hewitt review is reviewing. It will give advice on how best to do that by looking at the best needs of mental health care patients, or any other kind of patient, to make sure that the proper institutions and places are set up to give them the up-front support so that, as the noble Baroness said, they never need to go to hospital in the first place.

[Lord Patel (CB)]

My Lords, while recognising the current problems caused by bed blockages in NHS hospitals due to capacity and social care issues, does the Minister agree with the report from the Health Foundation, which, looking ahead, suggests that, because of changing demography and disease patterns in future, we will require between 25,000 and 40,000 more beds in the NHS if we are going to cope with the pressures on both the NHS and social care? What plans do the Government have to address that?

[Lord Markham (Con)]

We are absolutely aware that we need long-term plans and forecasts. That is also one of the things that the healthcare workforce plan will take into account: it will look at exactly where the capacity needs to be on a regional basis going forward so that we have the right number of hospital beds and social care places for an elderly and growing demographic in terms of age groups.

[Lord Turnberg (Lab)]

My Lords, is it not the case that patients are stuck in hospital because social care staff are leaving in droves? They are leaving because they are not respected, not given a career and not paid sufficiently. Should we not be doing something about retaining these vital social care staff?

[Lord Markham (Con)]

The number of care workers is key to all this and I delighted to say that the latest data shows that we are back to the levels of April 2021. Too many people have left, but we have managed to fill the gaps with the international recruitment fund and other measures. We all agree that we need to progress that further, but we are now making the increases that are needed in this space.

[The Lord Bishop of London]

My Lords, we have heard how important a sustainable workforce is, both in social care and healthcare. Can the Minister tell us what the Government are doing to listen to the concerns of health and social care workers about patient safety and their own working conditions at this time?

[Lord Markham (Con)]

Clearly, if we are going to retain and recruit the key staff in this area, it has got to be a good career, and that means that we must listen to their concerns. I know that Minister Whately is talking to and visiting them all, so it is a key part of the plan. As I say, the fact that we are managing to grow the workforce again shows, I think, that we getting on top of it—but absolutely we need to keep close and make sure it is a good place to work.

[Lord Kirkhope of Harrogate (Con)]

Does my noble friend agree that there are main concerns in some hospitals that dialysis patients are having to be retained in hospital over the Christmas period because of their deep concerns about transport arrangements, partly through the threatened ambulance strikes but also in other ways? Is this not another problem with regard to the bed blocking that we are looking at at the moment?

[Lord Markham (Con)]

The best hospital trusts I have seen have got that absolutely organised. We see a difference in different trusts between as low as 6% bed blocking for social care and over 30%. That depends somewhat on local demography and the amount of care homes, but also on how quickly they can arrange transport, and that is what the best ones are doing, so that cases such as the ones brought up by my noble friend do not exist.

[Lord Laming (CB)]

My Lords, the report from the Adult Social Care Committee that was published just a few days ago—which I commend most warmly to the Minister—highlights that in the past 10 years there has been a 29% real-terms reduction in local government spending power. This is despite the increase in the population during that period. Can the Minister assure the House that the Government are taking seriously the reality of life in social care?

[Lord Markham (Con)]

I thank the noble Lord. Yes, we are, and I think that is shown by the investment we are putting into place. As I say, that will be up to £2.8 billion next year and up to £4.7 billion the year after, which will be a 22% increase. That shows that we are very serious about this.

[Baroness Tyler of Enfield (LD)]

My Lords, we have already heard about the crisis in the social care workforce. NHS leaders are calling on the Government to introduce a new national minimum care worker wage of at least £10.50 an hour to stem the flow of social care staff to other sectors. Can the Minister say what plans they have to introduce such a minimum wage, which could hardly be said to be stoking inflation at that level?

[Lord Markham (Con)]

Of course, the noble Baroness is aware that it is the third parties, whether it be the local authorities or the private sector, that employ them. But what we have done in terms of setting the national living wage, which I believe is around that amount, is exactly making sure that there is a minimum amount that these people can get. About 65% of the funding going into the system goes through to wages, so the £2.8 billion increase next year will flow largely into wages and salaries.

[Baroness Pitkeathley (Lab)]

Every one of the interventions we hear about points to the inadequacy of the social care system and every one of the interventions that the Minister makes, however well intentioned—and I do not dispute that they are well intentioned—concerns piecemeal reforms. Will the Government ever accept that the only thing that is going to solve this ongoing problem, which is only going to get worse, is a wholesale reform of the social care system?

[Lord Markham (Con)]

There are a lot of questions that we need to answer in this space—I absolutely accept that—and lots of things that need long-term thought. I think and hope that noble Lords are starting to see that thinking emerge. A lot more needs to be done at the moment, but I think that we accept that this is a long-term issue that needs to be resolved with help from all sides of the House.

Plastics: Health Research

Lord Markham Excerpts

Monday 19th December 2022 Lords Chamber

[Baroness Meacher]

To ask His Majesty’s Government what plans they have to fund research into the health impact of plastic through a new National Plastic Health Impact Research Fund.

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

The Government are funding a broad portfolio of research in this area through UK Research and Innovation and the National Institute for Health and Care Research; both funders welcome applications for research into any aspect of human health. Since 2018 the Government have committed over £100 million for research and development and innovation support, to tackle the issues that arise from plastic waste.

[Baroness Meacher (CB)]

My Lords, I thank the Minister for his reply and assurance that the private sector and trusts and others are investing in this area. But when almost four-fifths of people in this country have plastic particles in their blood, which means most of us in this Chamber if you think about it, and when these particles are associated with cancer, diabetes and other, serious, chronic illnesses, does the Minister accept that this really is a priority? Does he accept that a proportion of the Government’s R&D spending—we suggest 0.1%, which is hardly great—should be allocated as a priority to investigating the impact of plastic particles on human health, and how to tackle the problem?

[Lord Markham (Con)]

I have had the opportunity to speak to the chief scientific officer in this space, so I am guided by the science here, and I have also heard the impact from the Food Standards Authority, which considers it unlikely that the presence of plastic particles in food would cause harm. Further research in this space will be reporting in March 2023, but currently there is limited evidence to suggest that there is any harm.

[Viscount Colville of Culross (CB)]

My Lords, the Environment Act includes the power to be able to charge for single-use items, including plastics, to reduce consumer consumption. Can the Minister tell the House whether or not the Government intend to use this power and, if so, when?

[Lord Markham (Con)]

I am mindful that my brief as Health Minister is fairly large but maybe not quite that large. But I note that in this space we have already replaced plastic bags, very successfully introduced a usage charge, and reduced consumption by 95% in the main supermarkets, so that is a tool that we know works. But currently there is limited evidence suggesting that it is a health hazard.

[Lord Allan of Hallam (LD)]

My Lords, while the global production of plastics continues to grow, the literature tells us that there is still very limited information about their long-term health effects. As we are trying to shift behaviour so that people and businesses reduce their use of plastic, for a variety of reasons, would the Minister agree that more research into the health effects would be helpful to support that public awareness effort?

[Lord Markham (Con)]

We have set up a research fund; as I say, £100 million has been spent around plastic waste in the last few years. Again, I have spoken to the chief scientific officers on exactly this, and if there are good research proposals in this space, they are ready to look, assess and commission them if they will be valuable here.

[Baroness Merron (Lab)]

My Lords, air pollution is the largest environmental risk to public health. Can the Minister say what assessment has been made of the contribution to that risk by the burning of plastic in landfill?

[Lord Markham (Con)]

Again, my understanding from the science is that that is not a concern here. The presence of nanoparticles in the bloodstream has not caused concern to date. However, again, if there are good research proposals in this space, that is exactly what the research council was set up to look at.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Minister has said a number of times that there is limited evidence, yet we know, as the noble Baroness, Lady Meacher, said, that there are microplastics in our blood. There is evidence that nanoplastics cause change and inflammation in skin and lung cells, and plastics also contain additives, including bisphenol A, phthalates and polychlorinated biphenyls, which are endocrine disruptors and alter reproductive activity. Is a lack of knowledge, in the light of the Government’s supposed attachment to the precautionary principle, an excuse for not acting while all these risks are clearly evident?

[Lord Markham (Con)]

Again, the research bodies are very happy to look at any good proposals. The only place I would disagree with this is on whether you would want to ring-fence a certain amount to a space when you do not know whether there is a health risk there. Therefore, if there are good research proposals, we are definitely ready to take that forward. I will caution against some of the quotes where they are based on a sample size of 22 people, in terms of the common-sense study. That is why we place caution on this, but if there are good research proposals, I say: absolutely, please bring them forward.

[Lord St John of Bletso (CB)]

My Lords, while welcoming the plastic packaging tax in April this year, I noted an alarming OECD report recently that plastic waste entering the oceans is set to treble in the next 40 years. What are our Government doing to fund credible plastic alternatives so as to mitigate the problems at source?

[Lord Markham (Con)]

I understand that this is part of the £500 million Blue Planet Fund that we put in place to help developing countries support the marine environment, and we are a contracting party to the OSPAR convention to participate in marine-limited monitoring programmes.

[Lord Kamall (Con)]

As the Department of Health and Social Care moves towards prevention, is my noble friend the Minister aware of initiatives within the National Health Service and across the health and care system to reduce the use of plastic across our system?

[Lord Markham (Con)]

I thank my noble friend. Yes, the NHS is committed to a 10% reduction in clinical single usage by 2045, and these plans are set out in the NHS long-term plan document, Delivering a “Net Zero” National Health Service.

[Lord Harris of Haringey (Lab)]

My Lords, the Minister has said several times that there is no credible evidence that this is harmful. I just ask him to contemplate whether it really can be good for the human body to be pumped full of foreign material in this way. Would he have given the same answer in respect of smoking, which, when it was first promulgated and mass-marketed, was also seen as beneficial to health?

[Lord Markham (Con)]

The phrase I used was that there is “limited evidence” in this space. I reiterate that if a good research proposal is put forward, funds are available there. The only point of difference on this is that I do not believe we should ring-fence a definite amount each year when the evidence does not yet exist that it is a health risk.

[Lord Patel (CB)]

My Lords, the Minister suggested that his scientific advisors told him that there was no evidence. Finding “no evidence” does not scientifically prove that there is no evidence. It has been said several times that if a scientific proposal was put forward, it would be looked at. Accepting that plastic pollution is a problem, should the NIHR not put out tenders inviting research proposals?

[Lord Markham (Con)]

Again, my wording was “limited evidence”. There are many demands. It feels as though every day I am up here being asked to spend money on something else. As a responsible Minister, I must prioritise spend in areas where it is needed. At the moment, I am being guided by the science, which tells me that there is very limited evidence in this space. If a good proposal is put forward, we will welcome it and look into it. Until then, this is not good use of public money.