Countess of Chester Hospital Inquiry

Lord Markham Excerpts

Tuesday 5th September 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, we have all been appalled at what happened at the Countess of Chester Hospital, and we would also like to extend our sympathy to all those affected, especially those parents of children who were taken from them. Those were losses that we now know that could, and should, have been prevented. I echo the comments of the noble Baroness, Lady Merron, in praise of those doctors who did raise concerns and fought to have them taken seriously. The accounts that we have seen of legitimate concerns either being ignored, or in some cases being actively suppressed, are truly shocking and represent a call to action that we must heed.

The inquiry is welcome, and will cover a lot of important ground, and I will not try to pre-empt their work today. Instead, I want to focus on one aspect where the department could act now without cutting across the work of the inquiry, and that is the role of NHS trust non-executive directors. This is something which the patient safety commissioner also highlighted in her statement on the Letby case. She said of NHS non-executive directors that

“it is vital that they are able to ask the right questions and escalate concerns where needed.”

The relationship between non-executive directors on a board and senior management teams in any organisation involves the delicate balance of responsibilities. Would the Minister agree that NHS trust non-executive directors should see patient safety as a priority responsibility—perhaps the single most important among their broad set of duties? Would he also agree that it is a healthy and positive situation if trust managers feel that they are under scrutiny from their non-executive directors on safety issues and believe that they will be pulled up if they are not fully open with them? We saw in this case claims of management not presenting the full sets of facts to their boards. They must be entirely candid with their non-executive directors and must expect to be challenged; that is the culture we want to see on trust boards, not one of cover-up and misleading.

In this context, could the Minister confirm whether the department will take steps now to reinforce with trust boards the importance of non-executive directors being able to raise safety issues? Importantly, will they be providing non-executive directors with training on how to perform this function effectively, so that they understand the best ways in which to challenge executives where necessary?

As I said at the outset, we welcome the inquiry from these benches, but I hope that the Government will not wait until the inquiry has completed its work to start making changes, and that they will be equally committed to making changes now where these would improve governance, and that the Minister can confirm that they are looking at strengthening the role of non-executive directors on NHS trust boards.

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

I would like to thank the comments, and the spirit of the comments, made by noble Lords. I start by adding my condolences to the parents and families in question. As we all know as parents, it is the most horrible thing we could ever imagine happening to us.

Clearly, the inquiry will find out the full facts of the matter, but at the same time it is important that lessons are learned quickly. To the point of the noble Baroness, Lady Merron, the families will continue to be consulted throughout this time. We would all agree that what happened is unforgivable, and we should praise the doctors for the work that they did and the courage that it took to bring it forward. I am convinced, as mentioned by the noble Lord, Lord Allan, that we need to make sure that we are doing sensible things in the meantime to ensure that we learn those lessons quickly. The foremost responsibility—the first line of defence as I like to call it—is the role of the board and the NEDs.

Speaking to colleagues about this, Chris Whitty was just saying that any sensible statistician and someone with sound common sense should have been able to say that there is something seriously awry here. We must all ensure that the boards are equipped to be able to challenge in the right way. That does take training, but it is important to make very clear to them that their primary duty must, beyond anything else, be the safety of the patients in that hospital. That has to be the first line of defence. There are things that we need to do to help them, including training—and to the noble Baroness’s point, that they are equipped with the records of those people so that it is known whether they are fit and proper people. One of the questions that I have asked, and got answered, is that I know there is a list so that, when you are looking to employ people, you know now whether a person is not a fit and proper person. As happened in this case, people moved on to other trusts in intervening periods, and there must be a mechanism where the trust can annually review, or review even more frequently, whether they are fit and proper through past cases that have just come to light, so that they have the ability to act.

It is our role to arm those boards, and give them the information and training to be that first line of defence. Tragically, we know in this case that first line of defence failed. These actions should bolster that first line of defence, but we also need to look at some of the second lines of defence. Medical examiners are a good way forward. From April 2024, they will now oversee all deaths that have not been put to coroners. I am told that this happens quite regularly already in the hospital setting; the challenge is more in the primary care setting. Along with other lines of defence, there is the duty of candour, allied with the freedom to speak up, so that we are gaining knowledge from the staff and people on the front line. Again, it is clear in this case that, while doctors were very brave in bringing it up, a lid was kept on it for too long. Clearly, we need to do more in terms of that whole approach of them feeling emboldened to speak up.

At the same time, the steps being taken in terms of the Getting It Right First Time programme and the health and safety investigations board and CQC are all good steps in that direction. But what is vital is that we do not, by putting in those central measures, somehow give boards the feeling that the first responsibility does not lie with them. It is the most important job that they can do, and the last thing that any of us would want is the feeling that they do not have to worry so much about that, because there are these other bodies looking into it. Absolutely fundamental to all of this is that they realise that it is their primary duty and that we in the centre are arming them to do that properly.

I hope that gives a good sense of the direction of travel we are going in, and I hope it accords very much with the points made. As to whether we should be going further in terms of registers to make that regulatory, we are absolutely open to that. It is just about trying to work out the practicalities and where the right level is. There are, however, some things, such as making sure this fit and proper persons list is up and running. That is something that we can do very quickly and are doing tomorrow. Clearly, there will be other opportunities for questions that I am taking in a moment. As ever, I will follow up all of this with a detailed reply. Most of all, I want to give a moment’s pause.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare that I am registered with the General Medical Council. I am a doctor and I have been involved in providing some support to the Nuffield review into disagreements in care of critically ill children, which is about to report. As the noble Baroness, Lady Merron, pointed out, this is unbearably and unbelievably terrible. I watched the whole story unfold almost with a sense of disbelief, except the awful thing is that one can believe it happened as it did, with the suppression of the whistleblowers.

That is what I want to pick up from the point made by the noble Lord, Lord Allan: we do not have a senior doctor on every board. The training of a doctor is different from the training of a nurse, a manager or an HR manager. That understanding of statistics is different. When a doctor tries to raise a concern but hits a brick wall, they need to be able to go directly to another doctor on the board to explore what they want to raise and because that other doctor is also subject to the GMC’s requirements. I quote from the GMC’s duties of a doctor:

“You must take prompt action if you think patient safety, dignity or comfort is being compromised”—


“must” being the key word. It was easier for staff to raise issues in the days when there was a senior doctor on the board. It did not always work, but I hope the Government will look at that as an action that could be taken much more rapidly. The GMC also says that doctors must contribute to adverse event recognition.

Again, as has been pointed out, these things have happened before: we had the Robert Francis report into Mid Staffs and the Bristol inquiry into heart surgery. Those people who have been whistleblowers have been traumatised, but nobody has been as completely destroyed as the parents when they know that their child has been killed. Child bereavement is overwhelmingly terrible, but when you know that it was from the action of another person it is even more impossible to come to terms with it.

I hope the Government really will look at whether some urgent intermediate action can be taken, and whether they can have discussions with the GMC so that doctors who are reported to the GMC as being difficult because they are raising concerns are not treated with some of the problems that have arisen, where we have seen doctor suicides and so on when they have been inappropriately referred. I hope the Government will seriously consider whether there needs to be a senior doctor on every board, both in hospital and a provision in the community. Even the appraisal systems that are in place do not seem to be working adequately to protect whistleblowers.

[Lord Markham (Con)]

I thank the noble Baroness for bringing her knowledge and skills to this. Bringing senior doctors very much goes along with the sentiment that we were all trying to express about equipping boards in the right way to be the first line of defence in bringing such things up. I know that many boards have doctors on them, but the noble Baroness raised a very good point; it is something that we should take back. From my point of view, I absolutely see the sense in making sure we do that.

[The Lord Bishop of London]

My Lords, I also declare my interests as noted in the register, specifically as a previous Chief Nursing Officer for England and as a non-executive director of a number of NHS trusts for a number of years. I also extend my sympathy and prayers to those who have been impacted by these awful and unimaginable atrocities.

I join others in welcoming that this is now a statutory inquiry. I also support the points made by the noble Baroness, Lady Merron, particularly around NHS manager regulation. I ask the Minister whether, when the Government look at that regulation, they will consider that it should go beyond the NHS executive, who themselves are managers, so providing external scrutiny.

The NHS has sought to improve patient safety for decades. It has also sought to improve people’s ability to be whistleblowers through a number of reports— I was involved in the publication of some of them. There are policies, guidelines and NHS bodies. A number of policies are even referred to in the Statement, some of which are now up to eight years old. My question to the Minister is whether the review will look at why those policies, procedures and bodies that are already in place, with the aspiration of improving patient safety and enabling people to whistleblow, were not enough to prevent this. The question that goes alongside that is whether the review will look at culture. It is not just about the policies and procedures; what was the culture that enabled this to happen? How might we recognise it and prevent it happening again?

[Lord Markham (Con)]

Again, I thank the right reverend Prelate for the sentiment of her reply. On whether we should be looking at the regulations beyond the executive, all these things are very much in the mix, for want of a better word, to ensure we have the right ones there. On the question of why the bodies that are in place did not catch it, obviously we will learn more as the inquiry goes along, but one of the major things for me when I looked at this was the fact that, because a lot of those cases did not go to a coroner, the medical examiner system was not fully in place at that point, so there was no other set of eyes in all that. I have to believe that if the medical examiners had looked at that they would have picked it up incredibly quickly. The fact that is now being put in place so that everything will have to be overviewed by a medical examiner or a coroner will be a key issue in all this.

There is an issue around the culture. I have a quote from a report by Sir Gordon Messenger, which is a perfect example on this and absolutely covers that point. It says that the culture that is set down by these places can often cause these problems. It is clear that, in the case of this hospital, the culture was not right. He said:

“We heard too frequently that poor inter-personal behaviours and attitudes were experienced in the workplace. Although by no means everywhere, acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system, as evidenced by staff surveys and several publicised examples of poor practice. This exists at the micro-level, in individual workplaces, and across sectors, where the enduring lack of parity of esteem, conditions and status between healthcare and social care remains a blight on effective collaborative working”.


That sums up a lot of the problem with the culture. The board, in terms of its training and equipment, is where staff surveys and feedback should act as one of the early warning mechanisms that we should look to put in place.

[Baroness Stuart of Edgbaston (CB)]

My Lords, I reinforce the points made by the noble Lord, Lord Allan, and the noble Baroness, Lady Finlay, about the importance of boards and patient safety being a key factor that they ought to take responsibility for. I will make a wider point. As health is a devolved matter and we are talking about the NHS in England, I urge the Minister to have comparisons of best practice: talk to the devolved Administrations, see what happens in Scotland, Wales and Northern Ireland, both for the way in which we can learn from each other’s experiences but also so we can arrive at common standards that can be accepted across the United Kingdom. Similarly, if any registers are being set up, these should not be confined to just England but should be UK-wide.

[Lord Markham (Con)]

I thank the noble Baroness; that is a good point. We clearly need to be looking at best practice across the board. That is not limited to any one devolved authority, but means learning from each of them and, I think, somehow making sure that hopefully they can learn from the terrible events that have taken place here—so they are putting that in place as well. For me, one of the main failings that we are now putting right is the medical examiners, which I want to make sure are spread out across all the devolved authorities. Clearly it is up to them whether they take it or not, but we should absolutely be making sure that we are cross-fertilising some of those key learnings, so they go both ways.

Tobacco and Related Products (Amendment) (Northern Ireland) Regulations 2023

Lord Markham Excerpts

Tuesday 25th July 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 12 and 29 June be approved.

Relevant document: 45th Report from the Secondary Legislation Scrutiny Committee. Considered in Grand Committee on 24 July.

Motions agreed.

Respiratory Syncytial Virus

Lord Markham Excerpts

Tuesday 25th July 2023 Lords Chamber

[Baroness Ritchie of Downpatrick]

To ask His Majesty’s Government, following advice issued by the Joint Committee on Vaccination and Immunisation on 7 June, whether they are planning to undertake an immunisation programme against respiratory syncytial virus before winter; and if not, what are the barriers to doing so.

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

My Lords, officials are currently developing policy options based on Joint Committee on Vaccination and Immunisation, or JCVI, advice regarding an expanded RSV vaccination programme for infants and older children. While officials are working at speed, challenges such as procurement negotiations, system readiness and delivery capacity mean that a universal programme in time for this winter is not possible. The department is working with partners to mitigate those challenges and to support implementation as soon as possible.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, I thank the Minister for his Answer, albeit a little disappointing. When will that policy position on the introduction of the RSV immunisation programme be submitted to Ministers? When will the business case, including funding priorities, for the introduction of such an RSV immunisation programme be developed and put to the Treasury? Does the Department of Health plan to accept the joint industry offer to work with manufacturers to overcome barriers to rapid implementation?

[Lord Markham (Con)]

I thank the noble Baroness. The issue is that the current jab, palivizumab, is very expensive and lasts for only one month at a time, so it is logistically quite difficult. Promisingly, a new jab, nirsevimab, has just been agreed by the JCVI. It offers six months’ protection, is more effective and is lower in cost, so that is the one we are looking to roll out to more people. At the same time, there is a promising Pfizer jab which can be given to mothers. There are good new vaccines coming along; the issue is whether they are going to be licensed in time for us to be able to use them this winter.

[Baroness Walmsley (LD)]

When immunisation is rolled out, will there be a public information programme to ensure a high level of uptake among people who are eligible for it? In the meantime, in the absence of a test, what advice is being given to people who believe they may have RSV? Should they go to their local pharmacist or to their GP?

[Lord Markham (Con)]

It depends on the type of jab. For instance, the maternal jab can be given to the mother as part of her prenatal check-ups. Either way, if it is for her or for the baby, there will be an education campaign. The other at-risk group is, as I am sure the noble Baroness knows, the over-75s. We are looking at a targeted programme for them as well, which they can go to their GP to find out about.

[Lord Kamall (Con)]

Further to the noble Baroness’s question about public information, we found previously when rolling out vaccines, not just for this but for Covid, that there were certain communities which were difficult to reach or to persuade to take up the vaccine. As an extension to the question from the noble Baroness, what more is being done to encourage people in those communities who are reluctant to be vaccinated to come forward, or to go to meet them in their communities and take the vaccine to them?

[Lord Markham (Con)]

We had this question on MMR just the other day. Some groups are much harder to reach than others. Very young children are the prime at-risk group. There, it is much easier because, naturally, they are seen by their GP and medical staff either prenatally, if it is maternal, or post in terms of the baby check-ups. The group that we are talking more about here is post 75 year-olds, and there those education programmes will be put in place.

[Baroness Wheeler (Lab)]

My Lords, the JCVI advice endorses the vaccine programme for 75 year-olds and for ages above, but we know that evidence shows that there is serious underestimation of RSV infections among older adults and an urgent need to improve testing and treatment of, in particular, those with congenital lung or heart disease or spinal muscular atrophy. What steps are the Government taking to raise awareness among these key groups and to develop information and monitoring systems that identify those most at risk?

[Lord Markham (Con)]

This is where nirsevimab is very promising, in that it gives six months’ protection. The problem with the previous jab is that it needed monthly injections and was only 50% effective. We are talking about 70%-plus effective now, which makes it more practical to have that sort of rollout. To date, we have been looking at the very targeted group of 75 year-olds only, particularly as each course costs £2,000 and has to be given monthly over the winter months. Now that we are opening up to this injection, which is much cheaper and lasts for six months, we can look at a broader range, and then there is a much more general education programme to go with it.

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the Minister comment more generally on vaccine manufacturing in the UK, which comes into play here? During Covid, we learned that having our own vaccine manufacturing capacity was important. Is that the Government’s position going forward?

[Lord Markham (Con)]

The noble Lord is correct. I have two good examples of that, BioNTech and Moderna, where as part of commercial arrangements for us to buy large amounts of Covid vaccines from them they are making investments in UK plants. It will not always be practical, but those examples are billion pound-plus investments which I think we all agree are welcome news.

[Lord Foulkes of Cumnock (Lab Co-op)]

My Lords, following the previous Question, it is great to have a Minister who knows what he is talking about. Does he agree that it is important that we have the same kind of policies in all parts of the United Kingdom in relation to vaccination and immunisation? What discussions is he having with his counterparts in Scotland, Wales and Northern Ireland?

[Lord Markham (Con)]

First, I thank noble Lord. That is the nicest thing anybody has ever said to me; I think I want to go on holiday at this point. This is a devolved matter, but it is something on which we are working very closely with the devolved Administrations. I must admit, as we discussed yesterday, that there is concern about the Northern Ireland Administration. Obviously, the Executive and Assembly not meeting at the moment makes some areas more difficult. We had examples of that yesterday, and we are about to have one in a minute when we talk about the fortification of bread. However, where we can, we are working closely with our colleagues.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, in his initial response to me, the Minister indicated that the policy papers were being drawn up. What policy options are being considered?

[Lord Markham (Con)]

The hope is that there will be two effective and cost-effective vaccines, nirsevimab and the Pfizer maternal jab. Those are much more effective and give longer periods of protection than the current monthly jab—they give six months’ protection. They are open to a mass campaign, particularly for young children, who are the most at-risk group. That allows us to have a negotiation with both parties with some healthy competitive tension so that we can get the best price, because we know that either one will do the job quite well. Where we can reach a successfully negotiated outcome, we hope that will set us up either to do either a year-round programme, if it really is very cost effective, or, if it is still quite expensive, to focus on the winter months, because that is the time when young children are most at risk if they have just been born. Those negotiations are live, and I will be happy to update the House as we learn more.

[The Lord Bishop of Carlisle]

My Lords, I, too, welcome the Minister’s detailed knowledge of this subject. Testing it even further, if I may, can I ask him whether His Majesty’s Government have made any assessment of the usefulness of glycolipid research in countering not only RSV but other viral illnesses, including influenza and Covid-19?

[Lord Markham (Con)]

I fear I might have been taken to the limit of my knowledge. I would like to think I know when to stop and to offer to follow up in writing.

Folic Acid Fortification

Lord Markham Excerpts

Tuesday 25th July 2023 Lords Chamber

[Lord Rooker]

To ask His Majesty’s Government whether it remains their policy to reduce the number of pregnancies affected by neural tube defects through mandatory folic fortification of bread flour.

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

My Lords, the Government remain firmly committed to proceeding with a policy of mandatory fortification of non-wholemeal wheat flour with folic acid to help prevent neural tube defects in foetuses. As I have previously updated noble Lords, this policy is being delivered as part of the wider review of the Bread and Flour Regulations. Having consulted, we are finalising policy decisions; we expect to publish a response this summer and lay new legislation early in 2024, subject to clearances.

[Lord Rooker (Lab)]

I remind the Minister that it is now 35 weeks since the consultation on the Bread and Flour Regulations closed. The last time they were reviewed, in 2013, the Government’s decision was announced within 20 weeks of the closure. It is now four years since the Government consulted on fortification of bread flour with folic acid, and it will be two years this September since they made their seminal decision actually to do it. So, we have just lost another two years, which means another 300 babies born with lifelong illnesses, and 1,600 terminations.

When will we get some action? We have lost two years since the previous decision, when it was announced that we were going forward. The Minister has already indicated—he was clever to do so—in answer to the previous Question that he has a problem with Northern Ireland. It is a pity that the noble Lord, Lord Dodds, is not here, because then we would get the facts on Northern Ireland. If that is the excuse, it will not be good enough.

[Lord Markham (Con)]

I first thank the noble Lord, Lord Rooker, for his tireless and passionate campaigning on this issue, which he is right to do. As I have learned, the situation is complex. We had 369 consultation responses, and more than 13,000 different SKU items—products containing flour—will be affected. We are not just talking about bread; pizza, lasagne, cakes and sauces are all affected, so you have to change the labelling of all those. We are trying to bring them all on board in a sensible manner, and to get this right quickly. We believe that a lot of people will voluntarily take this up much quicker. When you are talking about changing labels on the 22 billion items that are sold each year, you obviously need to look at how to do that practically and within a reasonable timeframe.

[Lord Cormack (Con)]

My Lords, my noble friend was right to acknowledge the indefatigable campaigning of the noble Lord, Lord Rooker, but will he please not rely upon these government phrases “shortly”, “in due course” and “soon”? Perhaps he could tell us which of those comes first. We feel that we are being fobbed off and that the delay is inordinate. He talked about early 2024, but will it really be early 2024? According to me, January is early 2024.

[Lord Markham (Con)]

I thank my noble friend, and I agree. I hate the words “in due course” because they mean “whenever”. While I freely admit to using words such as “soon” and “imminent”, “in due course” is not a term I use, and I understand the point being made. The consultation will be published late in the summer. It is a complex area, and I have said that I want to get personally involved now; I want to make sure that we get the balance right between the many competing interests. The legislation is planned for early 2024. All I can do on my side is to undertake to push that forward as much as possible.

[Lord Allan of Hallam (LD)]

My Lords, the Minister said in reply to a previous question that a lot of the industry is already voluntarily adding folic acid to bread and other foodstuffs. Of course, “a lot” is a well-known scientific term for “more than a little”. I invite the Minister to offer us a more precise figure. Does the department know what percentage of bread and similar products are currently fortified on a voluntary basis? If not, could it carry out a survey so that we can have that number?

[Lord Markham (Con)]

Probably the best thing to do is for me to give the noble Lord the detailed information we do have and try to find out more. I am told that “a lot” means the majority of bread products, but I will give the noble Lord a more precise answer.

[Baroness Hayman (CB)]

I ask the Minister not to be too downhearted about the complexities he faces, according to the department. In the more than 30 years since the MRC’s ground-breaking research on this subject, more than 80 countries have managed to fortify their flour. Not one has reported adverse effects; not one has withdrawn that fortification. As I have said before, I had four young children when this evidence first came out; I now have four grandchildren the same age and, honestly, I do not want to stay here until I have great-grandchildren. So can we have some action soon?

[Lord Markham (Con)]

Yes, the noble Baroness is correct, and the point made by the noble Lord, Lord Rooker—that each year’s delay involves another 200 or so babies—was very well made. The beauty of this process is that it makes me shine a light on this issue, so I will be working on quite hard on it.

[Baroness Merron (Lab)]

My Lords, the last time this issue was raised in the Chamber, the Minister put delays down to co-ordination with the devolved Administrations and consultation with the EU due to Northern Ireland—which he referred to in the previous Question—before allowing industry to get on board. Just yesterday, noble Lords debated two statutory instruments that apply to the devolved Administrations, including one specific to Northern Ireland. Can the Minister explain why timely co-ordination across the nations has been possible on tobacco products and pharmacies but not on folic acid in flour, in respect of which time is obviously of the essence, given the importance of the neural health of babies?

[Lord Markham (Con)]

I thank the noble Baroness for that question; as I am rapidly learning, this is a complicated area. For the benefit of noble Lords who were not present yesterday, the tobacco arrangements are part of the Windsor agreement, so we passed primary legislation to allow us to make those changes. On the items before us, which involve secondary legislation, my understanding—if I am wrong, I will make a correction in writing—is that the co-operation of each of the devolved authorities is needed. That is why we are not able to proceed in Northern Ireland without its involvement. The plan is that we will go forward with GB-only measures if we have to. For obvious reasons, we would prefer not to do that; we want Northern Ireland to benefit from these changes as well but, as I have learned, it is a complex area.

[Lord Balfe (Con)]

My Lords, when I became president of the British Dietetic Association—the dieticians’ trade union—this was one of its priorities. When I stood down five years later it was still a priority. My noble friend Lord Rooker has pursued this relentlessly, but what we are overlooking, I am afraid, is that every year more and more babies are born with this defect. Some 80 countries have managed it; what has impeded us for such a long time? I echo my noble friend Lord Cormack’s question: will “early” next year really be early?

[Lord Markham (Con)]

As I have said, there are complications. The MHRA, for instance, has raised concerns about the side-effects of certain folic acid levels in respect of anti-epilepsy drugs. We are going through various medical areas and checking that we do not have unintended consequences, and these are some of the issues that have been taking time to deal with. I am not trying to give excuses, but to allow noble Lords to understand some of the complexities involved. As I have mentioned, the plan is very much to lay legislation in early 2024. We then have to give notice periods to the EU and the World Trade Organization, so, in order to achieve complete transparency for noble Lords, I am afraid there will be a two-year implementation timeframe from then. But rest assured that I will be pushing hard on this.

[Baroness Walmsley (LD)]

My Lords, we have heard that there are millions of products, but also that some manufacturers have implemented this policy voluntarily. Industry has had years of notice that this is going to happen. Surely it is for the Government to legislate and industry to comply.

[Lord Markham (Con)]

Yes, and as I have said, a lot of companies are doing that. What we are really talking about is a backstop for “edge” products that are not fast-moving. There are a lot of products out there already, so relabelling takes some time. I would hope and expect to see most of this implemented pretty quickly, as soon as we get into the new year.

As I am out of time and this will probably be the last thing I say, I wish everyone a happy Summer Recess.

Human Medicines (Amendment Relating to Original Pack Dispensing) (England and Wales and Scotland) Regulations 2023

Lord Markham Excerpts

Monday 24th July 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Human Medicines (Amendment Relating to Original Pack Dispensing) (England and Wales and Scotland) Regulations 2023.

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

I am grateful to be here today, as is right, to debate such an important issue. The Human Medicines Regulations 2012—the HMRs—set out when medicines need to be prescription only and requirements for pharmacists selling or supplying prescription-only medicines. This SI will make two amendments to the HMRs to enable original-pack dispensing of medicine—OPD—and to require whole-pack dispensing of medicines containing valproate.

The first amendment, on OPD, is to enable pharmacists and pharmacy staff under their supervision the flexibility to dispense up to 10% more or less of the medicine compared to the quantity prescribed if it means that the medicine can be dispensed in the manufacturer’s original packaging. The second amendment requires medicines containing valproate always to be dispensed in the manufacturer’s original packaging, supplying a quantity as close to the quantity prescribed as possible, with exceptions in specific circumstances when the prescribed quantity must be dispensed.

The aims of enabling OPD and requiring whole-pack dispensing of medicines containing valproate are to increase patient safety by ensuring that patients receive the necessary information that is included on, as well as inside, the manufacturer’s original packaging about the safe and effective use of a product. A further aim of OPD is to support efficiencies in community pharmacies.

The Human Medicines Regulations require that a pharmacy may not sell or supply prescription-only medicine except in accordance with a prescription given by an appropriate practitioner. Currently, we interpret dispensing

“in accordance with a prescription”

to mean that pharmacists must supply the exact quantity of medicine prescribed, with a few exceptions where it is practically impossible or very difficult to split the original pack. This means that, where the quantity prescribed on a prescription is not equal to or multiples of a pack size, pharmacy staff need to split the manufacturer’s original pack. In order to dispense the prescribed quantity, the medicine may be supplied in a plain dispensing box or bottle or in the manufacturer’s original packaging but with some taken out. In the case of tablets and capsules, this usually means snipping the strip of medicines.

When supplying in plain dispensing packaging, pharmacies look to provide patient information leaflets but this may not always happen. Patients certainly will not receive or have the opportunity to read the safety information printed on the manufacturer’s original packaging. Further, they may get a collection of snipped strips in a plain dispensing box, which makes it difficult to know whether they have taken their tablet that day or how many tablets they have left and therefore when they need to reorder their medicines. Where patients get the manufacturer’s original pack but with some tablets taken out, and where any tamper-evident seal is broken, they may be concerned that their medicines have been interfered with.

In the case of medicines containing valproate, these amendments will mean that they must always be dispensed in whole packs in the manufacturer’s original packaging, regardless of the conditions that we set around other products for original package dispensing. The requirement is that the nearest number of whole packs to the quantity prescribed—either rounding up or down—will be supplied so that the patient receives only the manufacturer’s complete original packs. These must not subsequently be repackaged into plain dispensing packaging.

Further to the consultation responses, an exception is being included: pharmacists will be able to make an exception to whole-pack dispensing of medicines containing valproate on an individual patient basis where a risk assessment is in place that refers to the need for different packaging, such as a monitored dosage system, and where processes are in place to ensure the supply of patient information leaflets. The risk assessment might identify that the patient needs different packaging to support them taking their medication. Otherwise, while dispensing in original packs may support increased access to patient information, there is a danger that it may undermine measures being taken to support individual patients to take their medicine appropriately.

Amendments to the HMRs for OPD will enable pharmacists, or pharmacy staff under their supervision, to dispense 10% more or less of the medicine compared to the quantity prescribed if it means that they can dispense the medicine in the manufacturer’s original packaging. However, judgment by the responsible pharmacist will remain a critical part of the process; for instance, there are some prescriptions, such as a course of steroids or antibiotics, where a decision may need to be made to supply the exact quantity prescribed.

It is important to note that OPD will not apply to controlled drugs, which are medicines that have further legal controls on top of those that apply to all prescription-only medicines. This is because they may cause serious problems, such as dependence and harm, if they are not taken as intended by the prescriber or are diverted for other uses. Furthermore, OPD does not apply where a medicine is in a form that is not practicable to dispense in the exact quantity ordered, where there is an integral means of application, where splitting the packaging could adversely affect the medicine, such as inhalers, or where the packaging is keeping the medicine sterile.

Although the flexibility of 10% will not enable all medicines to be dispensed in manufacturers’ original packs, it will deal with the issue of whether a month’s supply is 28 days or 30 days and multiples. For example, if a prescription is for 28 days but the pack has 30 tablets, the 10% flexibly enables the full pack to be supplied and vice versa.

The amendments for OPD will apply across Great Britain and are enabling, so pharmacists can decide whether they utilise OPD 10% flexibilities. A transitional provision has been included so the flexibility to dispense up to 10% more or less does not automatically apply in NHS pharmaceutical services in England and Wales. This will allow these administrations to decide how they want to apply this in their respective NHS services. In Scotland, the OPD 10% flexibility will apply immediately.

The amendments will directly contribute to the overarching objective of safeguarding public health by improving patient safety. Ensuring that patients receive the necessary information included in and on the manufacturer’s original packaging will support them taking their medicine safely and effectively. More patients will receive their medication with any tamper-evident seal intact, which reduces concerns that someone has somehow interfered with the medicine. This amendment will lead to a reduction in the use of plain dispensing packaging so that patients will stop getting lots of small “snips” from a blister strip, which we know will make it easier for them to manage their supply and supports compliance as it makes it easier for patients to identify whether they have taken their tablet that day.

OPD is a commitment in the community pharmacy contractual framework 2019-2024 to support efficiencies for pharmacies. This will help pharmacists and their staff become more efficient as the number of times that they have to snip blisters, repackage medicines and source extra patient information leaflets are reduced, freeing up their time for other tasks such as providing clinical services to patients.

Both OPD and expanding hub-and-spoke dispensing arrangements are recognised in the primary care recovery plan, published in May 2023. The NHS long-term workforce plan, published in June 2023, highlights hub-and-spoke arrangements alongside the greater use of automation, which would be facilitated by OPD. These plans recognise OPD and hub-and-spoke arrangements as important foundations in the transformation of community pharmacy that, together, aim to facilitate the greater use of automation in order to increase efficiency and free up pharmacists and their staff to be able to provide more clinical interventions.

The benefits of OPD will be synergistic with the benefits of expanding hub-and-spoke arrangements, which we are also progressing and which will need separate further legislative amendments. Hub-and-spoke arrangements are where parts of the dispensing process are undertaken in separate pharmacy premises. Typically, there are many spoke pharmacies to one hub pharmacy. The concept is that the simple, routine aspects of assembling prescriptions can take place on a large scale in a hub that usually makes use of automated processes.

--- Later in debate ---

With that, as this is the last SI—certainly the last health and social care SI—for us to discuss before the summer, I wish the Minister, his officials, the Whip and all noble Lords a very enjoyable and happy Recess.

[Lord Markham (Con)]

As ever, I thank noble Lords for their constructive comments and general welcoming of the proposals.

On the points made by the noble Lord, Lord Dodds, unfortunately, we do not have the power. It is one of those bizarre situations whereby the Windsor agreement enabled us to follow what is happening in the EU but, for other matters such as these, it requires the involvement of the Northern Ireland Executive and Northern Ireland Assembly where we instigate moves from this side. It is a concern; I am concerned. We have all welcomed the benefits here today as an example, but they are benefits that Northern Ireland obviously will not receive.

One of the things that I am responsible for in the department are the rule changes that are happening. It is a general concern in Northern Ireland. We will talk about this in the new year but there are some very exciting medicine developments, for instance point-of-care medicines. We see as one of the benefits that we can get on and move quickly in those areas. It is a concern that we may, again, have to do them as GB-only if there is no functioning Northern Ireland Executive and Assembly. I have met Northern Ireland Office Ministers to express this concern; they are aware of it. From their point of view, they are doing everything they can to try to get the Northern Ireland Executive and Assembly up and running, but I appreciate that these are complex issues. I know that that is not an ideal response but that is the position that we find ourselves in at the moment.

On the other points, I appreciate the welcome given to these regulations and, in particular, the impact assessment. I will directly, for the benefit of Hansard, thank the team for it. It is appreciated. As has been said, there is incredible attention to detail in it. I am impressed by the attention to detail shown by the noble Lord, Lord Allan; I wonder how he is going to occupy himself over the Recess without impact assessments. Seriously, these are a set of well-thought-out, sensible arrangements and, as has been said, are an exemplar of how we should be doing these things.

On the question about savings, my understanding is that they will be seen by pharmacists themselves and people in their stores. They will be getting paid and they will be keeping it in the system, so to speak. This will help their viability, which the noble Lord, Lord Allan, mentioned.

The point on extra training and checks is well made. I know that that is being kept under review. It is a good point that we need to make sure that it is diarised formally so that we can assess it, particularly in terms of risk assessment. How it was explained to me is that we are talking more about where a person has many medications so it is better for them to have a blister pack-type format and they may not be of child-bearing age so making sure that they can take the correct medicine each day outweighs the risk of side effects for an unborn baby. That is one of the examples that have been described to me of where a logical case can be seen.

Noble Lords might be aware that there is also concern about potential fathers taking valproate pre-conception and how that can have an impact. This is primarily a concern for women of child-bearing age but potentially for males as well, hence the suggestion about the packaging.

As ever, I will respond in writing, but I am not aware that this will specifically impact GPs because they will continue to prescribe in the same way. It will be for pharmacists to use their judgment to make sure that they round up or down for the packaging or dispensing, in the case of valproate in its original form. I repeat that I will write in detail but, off the top of my head, I do not think it will have an impact on GPs.

The wider point is that this should help pharmacists in a lot of their processes. The need to sometimes make judgment calls means that they will obviously need to apply a bit more intelligence but, on balance, we believe that those cases will be isolated enough to be outweighed by the benefits of whole packaging. In response to the points made earlier, that is exactly the sort of thing we should consider when we review it all. As the noble Baroness, Lady Merron, mentioned, the whole point is to free up some pharmacy time so that pharmacists can spend it where they want to on patient care.

I will happily follow up in detailed writing on all the questions. I thank noble Lords for their input; as ever, it was a very interesting debate. I echo the wishes for a happy recess; personally, I cannot wait. Although I will be doing a lot of hospital visits, as I mentioned, it will indeed be lovely. On that note, I commend the regulations to the Committee.

Motion agreed.

Tobacco and Related Products (Amendment) (Northern Ireland) Regulations 2023

Lord Markham Excerpts

Monday 24th July 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Tobacco and Related Products (Amendment) (Northern Ireland) Regulations 2023.

Relevant document: 45th Report from the Secondary Legislation Scrutiny Committee

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

My Lords, the purpose of this instrument is to implement the EU Commission delegated directive (EU) 2022/2100 of 29 June 2022, which amends directive 2014/40/EU—the tobacco products directive—to withdraw certain exemptions in respect of heated tobacco products placed on the Northern Ireland market.

The instrument amends the Tobacco and Related Products Regulations 2016—the TRPR—in relation to Northern Ireland. The regulations will apply to producers, suppliers, retailers and wholesalers that produce or supply heated tobacco products for consumption in Northern Ireland. Subject to the regulations being approved by Parliament, they are due to come into force on 23 October 2023.

The regulations apply to Northern Ireland only and are made for the purposes of dealing with matters arising from the Windsor Framework. The SI implements a change so that, from 23 October 2023, heated tobacco products can no longer have a characterising flavour, such as menthol, vanilla and fruit flavours. This is not a ban on heated tobacco, but it will limit the flavours available. A characterising flavour ban is already in place for cigarettes and hand-rolling tobacco in the TRPR.

We do not need to make changes in light of the Commission delegated directive’s requirement for heated tobacco products to contain health warnings and information messages if they combust. If heated tobacco products that involve a combustion process were placed on the UK market, they would be regulated as tobacco products for smoking and subject to existing regulations in the TRPR that require these products to contain a combined health warning and information message. There are currently no heated tobacco products on the GB or Northern Ireland markets that involve a combustion process and, as such, they are subject to the labelling requirements applicable to smokeless tobacco products.

A full impact assessment has not been prepared for this instrument because the costs involved for business fall below the threshold for producing one.

Heated tobacco products on the UK market are produced and manufactured outside the UK by the tobacco industry. The characterising flavour ban will limit the products it can produce and supply to the Northern Ireland market and may impact on profits, in what is a relatively small market for the industry in Northern Ireland.

The DHSC has communicated with the tobacco industry, Northern Ireland retail representatives and enforcement agencies regarding the proposed changes. There is no significant impact on the public sector. Each district council in Northern Ireland will enforce the new requirements. They are not expected to be a significant burden on district councils, given the low use of heated tobacco products in Northern Ireland.

I am content to bring forward this legislation today. These regulations allow us to honour our current commitments under the Windsor Framework and will have limited impact on Northern Ireland business. I commend these regulations to the Committee.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, I thank the Minister for his presentation of the statutory instrument. I have to declare an interest: I am a member of the Secondary Legislation Scrutiny Committee, and we discussed this SI. There was no dissent from it and there was general support, but we drew it to the attention of your Lordships’ House.

I am a supporter of the Windsor Framework, and any shilly-shallying around it can lead to uncertainty in Northern Ireland. It is important that we and the people of Northern Ireland, particularly businesses, can avail themselves of the economic opportunities in relation to access to the UK internal market and the EU single market.

--- Later in debate ---

[Baroness Merron (Lab)]

I start by thanking the Minister for introducing these regulations, which we welcome, and expressing my appreciation for the way he set out their application, the summary of which is that, from October, it will be illegal in Northern Ireland to produce or sell heated tobacco products that have what is called a “characterising flavour”. As the Minister explained, this change is happening because of the requirements of the Windsor Framework and in response to a policy change implemented by the EU—more of that later.

With regard to heated tobacco products, unsurprisingly, some in the tobacco industry have claimed that they are less harmful than conventional smoking. Has the Minister had time to review the analysis by the University of Bath, which has shown that most of the studies referred to in order to back up said claim were either affiliated with or funded by the tobacco industry? Surely that raises a considerable flag. Conversely, the European Respiratory Society has pointed to independent research showing that heated tobacco products emit substantial levels of toxicity as well as other irritant substances. Although the use of these harmful products is said to be very low in Northern Ireland, they are increasingly being marketed, without evidence, as a healthier alternative to smoking.

On that point, I would like to pursue the questions that have been asked by noble Lords in the course of this debate about whether there are plans to adopt similar legislation here so that there is parity between England and Northern Ireland; and whether there have been discussions with the other devolved Administrations in order to ensure that there is parity in legislation and, therefore, not the problems across borders that have been described. The noble Lord, Lord Dodds, explored this matter extremely well. I was particularly taken with the obvious practical example that somebody can purchase a product here and take it to Northern Ireland. What is the implication of that? That is going to happen all the time; it is just a fact. I am sure that all noble Lords will be interested to hear the Minister’s response on that.

Have the Government made any assessment of the prevalence of heated tobacco product use across the rest of the United Kingdom, principally in England, along with the wider health implications of such use? Perhaps the Minister could also outline what action his department is taking to combat the increased marketing of such products—marketing that is often underpinned by spurious tobacco industry-backed research, as I referred to earlier.

As was spoken to by the noble Baroness, Lady Ritchie, and the noble Lord, Lord Allan, can the Minister set out how the Government will assist Northern Ireland in the implementation of the ban, particularly given the possibility of illegal importation from England? It certainly seems strange—this point has come out in the debate—that, following the implementation of the draft regulations, there will be more stringent legislation in place to clamp down on heated tobacco products in Northern Ireland than in the rest of the United Kingdom. Can the Minister assist us in trying to understand how that will help? Are the Government considering implementing a ban on these products in their tobacco control plan, which was promised by the end of 2021? That leads me to the question of when—indeed, whether—we will ever see it published?

I want briefly to highlight concerns in relation to children and young people in particular. I note that the Secondary Legislation Scrutiny Committee referred to the fact that it was in the light of increased sales volumes among under-25s that the EU amended its legislation on heated tobacco products. In this regard, the Health and Social Care Committee in the other place recently took evidence from not only health experts but the industry. It made for interesting reading. The committee heard evidence that the topic of conversation for young people in the playground was often the different flavours that they were trying, such as

“Gummy Bear, Slushy and … Unicorn Milk and Unicorn Frappé”.

This was also referred to by the noble Lord, Lord Allan. These are different flavourings that are clearly not aimed at an adult audience. While we are talking about vanilla and other flavours in heated tobacco products, does the Minister agree that it will not be long before we see them being extended to products that are deliberately constructed to be attractive to children to get them to take up smoking? What is the strategy to deal with this?

It is absolutely crucial, in dealing with tobacco control and ensuring that we reduce harm to the health of people of all ages, that we look ahead. I hope that these regulations and the debate around them, including noble Lords’ contributions, will again alert the Minister to the need to anticipate future developments in tobacco products, not just in Northern Ireland but across the whole of the United Kingdom.

[Lord Markham (Con)]

I thank noble Lords for their contributions. As ever, they showed that there are interesting intricacies in every part of health; it is one of my key learnings over the past nine or 10 months that I have been in this role.

I want to clear up one thing. I admit that there was a bit of confusion on my part, as well. As the noble Lord, Lord Allan, said, we are not talking about vapes here—we are talking about heated tobacco. There is a heated tobacco stick, which basically heats to temperatures lower than that of a cigarette and releases an aerosol. I am sorry if noble Lords knew that already, but I thought that was worth clarifying. Because of that, this product is used by a very small number of people. It is estimated that less than 0.5% of smokers use this product; if you apply that to the population, it is 0.065%. I hope that this gives some sort of clarification behind our decision, when we talk about whether we did an impact assessment, because we are talking about very small numbers being involved here.

--- Later in debate ---

[Baroness Ritchie of Downpatrick (Lab)]

I thank the Minister for giving way. In relation to what he said about the transport of these substances, I indicated the issue of regulation, as did the noble Lord, Lord Allan. In the past, during our troubled history, cigarettes were used as a form of smuggling, and also used as contraband by paramilitary organisations. The Minister says there is only minor use of these cartridges, for want of a better description—but I have seen them sold along with cigarettes in locked-up containers in shops, and young people purchasing them, particularly the fruit-flavoured ones. If they do not have access to that, how will they be able to get them? What mitigation and control measures will be put in place to prevent them becoming like contraband and being abused by erstwhile paramilitary organisations?

[Lord Markham (Con)]

I thank the noble Baroness for that remark. I think that I probably need to give that a detailed response as well. The point I was trying to make was that these heated tobacco products are a very small part of the market to begin with and the flavoured versions are even smaller again. While the noble Baroness is correct that that potential is there, the amount is very small indeed, but I will give her a detailed response on that.

I have tried to answer the specific points raised; as I say, I will follow up in more detail in writing. We have to honour the regulations set out by our commitments under the Windsor Framework agreement. With that, I commend these regulations to the Committee.

Motion agreed.

Stroke Care

Lord Markham Excerpts

Monday 24th July 2023 Lords Chamber

[Baroness Wheeler]

To ask His Majesty’s Government how they are ensuring that integrated care systems across England implement recommended best practice in stroke care in line with the updated National Clinical Guideline for Stroke, published in April.

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

The National Clinical Guideline for Stroke, published in April 2023, is an initiative of the intercollegiate stroke working party made up of representatives from the professional bodies involved in stroke care. National regional SQuIRe managers, who are responsible for managing stroke services, are working with integrated stroke delivery networks and newly formed integrated care systems to implement the NHS integrated community stroke service and improve the provision of community-based stroke rehabilitation.

[Baroness Wheeler (Lab)]

My Lords, the update of the national stroke guidelines is welcome, particularly its now UK-wide remit, with one of its major changes being significant expansion in the number of patients eligible for thrombolysis and thrombectomy. Given that both these powerful clot-busting interventions are most effective the faster they are used following a stroke, what assessment has been made of the impact of the current NHS delays in the expansion of their respective uses and how will the Government ensure that ICSs address the huge regional variations in both thrombectomy and in the vital post-stroke rehabilitation in hospital and at home that is so necessary?

[Lord Markham (Con)]

First, I thank the noble Baroness for the work that she does in this area; I know that it is very close to her heart. I have set up a meeting with the NHS COO David Sloman and with Sarah-Jane Marsh, and would be delighted if the noble Baroness would like to join me. The benefit of these sessions is always the shining of a light on areas.

It is vital that people are seen within the first hour; currently 59% of people are, which is an improvement on the last couple of years when the figure was 55%. However, we would all agree that we want that number to be as high as possible. The SQuIRe managers’ job is to make sure that all the different integrated care boards are delivering best practice in each area.

[Baroness Manzoor (Con)]

My Lords, what role will NHS England play in first collecting information, monitoring it, evaluating it and disseminating it across the UK to ensure best practice, and how often does it undertake to do this?

[Lord Markham (Con)]

I thank my noble friend. The NHS delivery plan set out in January 2023 was trying to set out the best practice in this area. It is then the job of the SQuIRe managers to make sure that that is implemented in each area. One example is that they are trialling having videos in ambulances in certain areas so that paramedics can speak to stroke experts. We all know that getting patients to the right place quickly is vital, so I hope that that is another example of best practice that we can roll out.

[The Lord Bishop of St Albans]

My Lords, these guidelines are very encouraging, and all who work on them should be congratulated. As we keep hearing, the essence is speed if we are to treat effectively, yet this is particularly difficult in rural areas, especially remote rural areas. What additional help is being given to integrated care boards’ care systems to ensure that our rural integrated care boards can deliver these guidelines, which are so vital?

[Lord Markham (Con)]

The job of each integrated care board and the regional SQuIRe managers within it is to make sure that they are catering for the needs of their area. Clearly, rural areas present more challenges in terms of speed of access to the relevant stroke services. At the same time, there has been a rollout of the integrated stroke networks that can perform the clot-busting treatments to make sure that we have more of them located in the right places.

[Lord Allan of Hallam (LD)]

My Lords, we are fortunate to have the Sentinel Stroke National Audit Programme—SSNAP—to help us monitor compliance with the national guideline. In its very good easy access report for the first quarter of this year, it tells us that three out of five stroke patients are not taken to a stroke unit immediately and it calls for urgent action in this area. What are the Government doing to make sure that stroke patients are immediately admitted to stroke units in line with that guideline?

[Lord Markham (Con)]

The noble Lord is absolutely correct. As mentioned, speed to the right place is vital; videos in ambulances are one way of communicating ahead and speaking to the paramedics so that they are ready to receive them, which is really important. The latest data I have seen is that 92% of people are now sent straight to the stroke ward on arrival, which sounds promising but is somewhat at odds with the Sentinel figure he mentioned. I will find out more about that and get back to the noble Lord.

[Lord Woodley (Lab)]

I speak with experience, having seen my wife suffer a very serious stroke more than a decade ago. As the right reverend Prelate said, speed is of the essence. Not one but two ambulances arrived within 15 minutes and she was in hospital within 25 minutes; they saved her life at Chester County Hospital. Does the Minister agree that things have got worse and worse over the last decade and that, unfortunately, people are dying?

[Lord Markham (Con)]

I agree that last winter was particularly difficult; as we all know, ambulance wait times were too long, which undoubtedly caused issues. We have a recovery plan for the emergency services and have invested more in ambulances, but it is all about flow, which we have spoken about many times in this House, and making sure that people can get to where they need to be as soon as possible.

[Lord Kamall (Con)]

My Lords, I will take this opportunity to ask my noble friend a more general question about guidelines. I am sure he receives correspondence about parts of the NHS not meeting guidelines, not only on strokes but on other issues. What are the Government and the NHS doing to make sure that, where there are guidelines, they are followed through and adopted by ICSs and medical practitioners right across the system?

[Lord Markham (Con)]

I thank my noble friend. As we all agree, there are always two steps involved: setting out the guidelines that we believe are best practice and making sure that they are then implemented. ICBs have that responsibility and regional managers look into them. As I think I have mentioned before, each Minister personally takes charge of six or seven ICBs—I will visit a few of them in the next few weeks during Recess—so we can make sure that they are really delivering on the ground.

[Lord Scriven (LD)]

My Lords, the Getting It Right First Time report has shown that 29 recommendations are needed for strokes and its wider programme has shown what works in the healthcare system to improve care and save lives. What levers do the Government have when integrated care boards do not implement best practice to save lives and improve health in an area?

[Lord Markham (Con)]

There are a number of things. For want of a better phrase, we have a tier rating for the different trusts and hospitals and they can be put into the equivalent of special measures—that is not the right term, but the noble Lord knows what I am referring to. Ultimately, the NHS and Ministers also have the ability to hire and fire, as we know that leadership is vital in all these areas.

[Lord Kakkar (CB)]

My Lords, I draw noble Lords’ attention to my registered interests. It is clearly important that stroke networks are properly supported to deliver clinical care efficiently and effectively but, beyond the capacity to do that, there must also be ongoing capacity to participate in further research and development and to provide the opportunity for appropriate clinical evaluation of innovations that will yet further improve outcomes for those suffering ischemic stroke. Is the Minister content that there is sufficient support for that activity in stroke networks?

[Lord Markham (Con)]

A lot of good work is being done. AI is often used to analyse brain scans very quickly in a lot of these centres that the noble Lord mentions. One of the very good things about trusts is that they have a lot of independence to develop their own initiatives, but sometimes the challenge—which I have really taken up—is getting that innovation adopted widely. I and the Secretary of State are great believers in that but, candidly, we need to work harder on it.

[Lord Sikka (Lab)]

My Lords, I invite the Minister to visit A&E departments and note the chronic lack of resources and capacity. I will give a personal example. I took my son to the local A&E as he had some life-threatening issues. We arrived at 12.13 pm on a Wednesday and a bed was found at 2.30 am the next morning; no spare bed could be found in any of the adjacent hospitals at all. When was the last time the Minister visited an A&E department and what did he notice?

[Lord Markham (Con)]

In the last few weeks, I have been in A&E departments most weeks. Over the Recess, I will be visiting another 15 or so hospitals—I cannot remember the exact number, but it is a big one. That will be to see the A&E and the new hospital programme that I am responsible for. I agree with the noble Lord that there is nothing like visiting a place to really understand the problems and get on top of them.

Emergency Healthcare (Public Services Committee Report)

Lord Markham Excerpts

Thursday 20th July 2023 Grand Committee

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

First, I add my thanks to the noble Baroness, Lady Armstrong, and all the contributors to the report. It was a thoughtful and constructive report, just as today’s debate has been. I thank noble Lords for that.

Probably one of the benefits of debating the report now, a few months later, is that we have had an opportunity to learn some of the lessons from last winter. I will try to reflect those in my reply. We have also had the opportunity to take on board the evidence from the committee’s report and, as the noble Baroness, Lady Merron, mentioned, the NAO—and, I hope, to reflect quite a few examples of best practice, which I will try to take your Lordships through.

As has featured so much in this debate, I completely agree that this is all about flow. I will try to respond by talking through the flow, because we all agree that that is the vital component.

Of course, the first step of the journey in terms of the flow, as a few noble Lords have said, is demand. We know that as many as 50% of the people going into A&E do not need to be seen there. To me, the first step is how we manage demand and make sure that we treat people in the right place. Of course, that comes in two parts, the first of which is making sure we have sufficient primary care in place, because we know people that often turn up in A&E because they feel that they cannot get the necessary GP appointment. The emphasis we are putting on our primary care recovery plan is very much part of that, as is the direction of travel for the long-term workforce plan—investing much more in primary care and prevention, and having that emphasis versus treatment in hospitals, which is the wrong end of the telescope to be always looking through.

Also we want people to use 111. There will be a complete reset of 111, seeing it as a real navigation tool. Again, as noble Lords have heard me mention a number of times, when we relaunch the app in September, that will be a very important feature, so that people can use the 111 app to establish whether they really need to go to A&E, or whether there is a better place for them to be treated. The other side of this is to establish whether it is appropriate for someone to call 999 and whether they need to be conveyed to A&E. It is about having the right treatment in the right places, and it is all about the “falls” ambulance service, which it is now the responsibility of every ICB to supply. We know that sometimes, you can rectify the situation there and then, set someone right and make sure they are okay, and they do not need to be conveyed to hospital.

It is also about making sure that we have experienced mental health handlers in ambulance services and somebody in the control centre trained in mental health who can help. As for steps in the right direction, we are starting to see the numbers being conveyed go down, which is of course what we want. Whereas 58% of people were being conveyed to A&E a couple of years ago, the current figure is 52%. Clearly, there is more that can be done.

The point that the noble Baroness, Lady Morris, and the noble Lord, Lord Allan, made about the risk-averse nature was absolutely spot on. I shall not pretend that we have proper answers to that, but we need to have a grown-up conversation about it, because we all have very good examples to give. The hope is that the 111 navigation I referred to can help to address that issue, but the human attitude to risk is also a factor.

I turn now to the supply side, response and the ambulances themselves. We are putting more resources into 999, and we are investing in 800 new ambulances. A vital part of that is the discharge hubs for ambulances, so that they are not waiting in the car park with their patients and can instead get back out on the road as quickly as possible. As we know, that is all part of the UEC plan.

Crucial in all this and in managing flows—this links to the point made by the noble Lord, Lord Allan, about data and process improvement—are the flight control systems. As I think I have mentioned before, one of the first hospital visits I ever did was to Maidstone, where they had a fantastic flight control system, managing everything in real time. You knew whether the ambulance was there and whether a person was likely to need a bed; the system looked straightaway at finding that bed and managing the person through the system. What impressed me was that it addressed head-on the often risk-averse nature of clinicians. Amanda Pritchard herself explained the situation to me. She said, “If I were a doctor talking to you, Nick, I’d be saying, ‘I’m pretty happy with how you’re doing, but I’m just going to keep you in one more night to be sure.’” However, when that clinician is armed with real-time data and knows that ambulances are coming and there are people with much greater need of a bed than me, they can make the clinical decision that I am 99% probably going to be fine, and another patient needs that ambulance much more. That is an example of real-time data being used by clinicians, and we are rolling that out as we speak to make sure that it is in place for the winter in 16 trusts. I know that 16 is not 120, but it is a good first step towards that, and I hope we will see improvement.

Carrying on in the flow journey and coming to the beds themselves, we are on target to have a real increase of 5,000 beds in place for the key winter period, as per the question from the noble Lord, Lord Allan. In addition, 10,000 virtual ward beds will be available, with the intention of treating about 50,000 patients per month. That will strengthen everything we are trying to do in terms of the back door, the flow and, as mentioned by many noble Lords, the social care element.

We have started to see the impact of all the things we are talking about. The investment that we are putting into social care is starting to have an impact. As for discharge, right now, we are seeing 2,300 fewer beds blocked, for want of a better word. There is still some way to go; as noble Lords will remember, the target is 13,000, but there has been progress towards that. Our action in terms of the extra money is about learning the lesson around getting the discharge fund out early, instead of suddenly getting to January and thinking, “Oh, we’ve got a problem”. A lot of the social care providers have talked about getting it out early so that they can then plan in advance. Those are all things that we are doing towards that aim. Of course, as many noble Lords have mentioned, underpinning all this is the long-term workforce plan, to make sure that we have cover in the appropriate areas.

Best practice more generally was mentioned in the report and by many noble Lords, and I agree that it is often an issue. We do not have a problem with pilots—I am sure that many noble Lords have heard the quip that the NHS has more pilots than British Airways—but the issue is adoption. I have mentioned a couple of examples of that. We now have tiering in place. The performance of hospitals in each area of UEC is looked at and specific plans are put in place with the leadership to address the tiering. There has been some good progress there, but I agree that, of all the things we need to do, that is definitely a work in progress. On that note, the noble Lord, Lord Allan, will be pleased to know that I am spending the summer visiting hospitals. After the last couple of weeks and those coming up, I will have notched up another 15 or 20 on my visit list. I am definitely trying to get out there.

I really appreciated the thoughtful contribution of the noble Baroness, Lady Bennett. She talked about the environmental impact, and I must admit that it made me think about it in a different way. The NHS recognises that it has a role to play in this. I want to give her a proper response because I was struck by what she said and appreciated her sharing that.

The noble Baroness, Lady Armstrong, mentioned the publication of figures on 12-hour waits. We have been publishing them since February 2023, but there is an understanding of the need for complete transparency in this, as mentioned by the noble Lord, Lord Allan. I know that this is something we are trying to achieve.

The right reverend Prelate the Bishop of St Albans mentioned the rural response. We are looking at each ICB to make sure that they are responding with plans that look after all the needs of their area and where they need more help. We know that it is often hard to recruit people to some of those areas, so there is the possibility of these special incentive payments in order to recruit people to them. As ever, if I run out of time and do not manage to answer everything, I will follow up with a detailed letter.

“Frequent flyers” have been mentioned a couple of times. I saw a very good example the other day of one of the best practices we want to roll out. Redhill is taking its top 1% of “frequent flyers” and getting upstream with them by proactively going out to visit, screen and check them. That has resulted in them needing 30% less treatment. What struck me, and as noble Lords have mentioned, is that one of the first experiences I had as NED in DLUHC’s forerunner was the troubled families programme, which I thought was an excellent example of trying to look holistically at the problem. I wonder—I am wondering out loud with your Lordships—whether we need to look at that more holistic approach for some of these cases; that is one of my takeaways.

As for the NAO report on the NHP, I am still very confident about the 40 new hospitals. The NAO report talked about the original list of 40 but ignored the fact that we have brought in the RAC hospitals. It says that of the original list of 40, we are committing to only 32 by 2030. That is absolutely correct, because we have brought in the RAC hospitals on top of that which were not previously on the list. It is 40—but it is not the same 40 hospitals. That is what the NHP was pointing out, but I think all of us here today would agree that the RAC hospitals were clearly the priority which should have been brought into the list.

The £150 million is new and is a separate part of the budget which I look after as part of the whole capital programme. It will be subject to bids from the hospitals, which need to make sure that they have the revenue to do it.

To conclude on the question on the assessment: yes, I do think there will be improvements next year. Is it going to be challenging? In all honesty, I think it will. I am not going to pretend that there will be one leap and we will be there, but we have a number of measures in place through which we will see step-by-step improvement next year, and, I hope, reflect a lot of the points made in today’s debate on the report.

MMR Vaccine

Lord Markham Excerpts

Thursday 20th July 2023 Lords Chamber

[Baroness Twycross]

To ask His Majesty’s Government what further steps they will take to work with schools to encourage greater take up of the MMR vaccine among pupils.

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

The UK Health Security Agency is closely engaging with the Department for Education to boost uptake of the MMR vaccine, especially in areas with lower uptake. Earlier this month a messaging campaign to the education sector encouraged uptake among pupils, and an NHS England national MMR call/recall campaign between September 2022 and February 2023 reached approximately 940,000 parents and guardians and resulted in the delivery of over 160,000 vaccinations.

[Baroness Twycross (Lab)]

My Lords, I declare an interest as chair of the London Resilience Forum and as someone who contracted viral encephalitis as a child, albeit from mumps, not measles. Measles in children can cause death or serious disability. The increase in measles breakouts comes as research finds that the number of nurses in schools has dropped by 35%, with some local authorities scrapping the role altogether. Does the Minister believe that the decline in school nurses has contributed to falling MMR take-up in schools? Have the Department for Education and the Department of Health and Social Care set a joint target to achieve an uplift in the take-up of MMR, and what is it?

[Lord Markham (Con)]

I do not necessarily believe that that is the reason for the reduction. What we saw during Covid, as with so many things, was a couple of years when people were not attending school so much and were not attending GP surgeries for their vaccinations. That is why we have had a series of catch-up campaigns, which are working. We are getting there, but clearly there is a long way to go.

[Baroness Blackwood of North Oxford (Con)]

My Lords, we learned from Covid that high-uptake vaccine programmes can be effectively delivered only with a firm foundation of high-quality data and surveillance. The UK measles and rubella elimination strategy set out by UKHSA commits to a target of rigorous case investigation and the testing of over 80% of suspected cases with an oral fluid test. Can the Minister update the House on our performance on surveillance so that we can get on top of falling vaccination rates?

[Lord Markham (Con)]

I thank my noble friend. I was speaking to the senior epidemiologist at UKHSA just this morning about this. My noble friend is right to point out the concerns in this area. On exactly where we are on oral fluid testing, I will need to write to her.

[The Lord Speaker (Lord McFall of Alcluith)]

My Lords, the noble Baroness, Lady Brinton, is participating remotely.

--- Later in debate ---

[Baroness Brinton (LD) [V]]

My Lords, the NHS says that susceptibility is not just among the under-twos; it is particularly high among 19 to 25 year-olds whose parents were affected by the unfounded Wakefield stories two decades ago, and many may still not be vaccinated. What is the NHS doing to reach this cohort, including at further education colleges and universities, to ensure that they are fully vaccinated before they start their own families? Catching measles when pregnant can cause miscarriage, stillbirth, premature birth and low birth weight.

[Lord Markham (Con)]

The noble Baroness is correct. The unfortunate Wakefield effect had quite an impact on that cohort of people, so the campaigns have been targeted particularly at specific communities in particular areas. Outreach campaigns are being done as part of that, looking at every area where it can be done. Sometimes that involves looking at colleges and sometimes it involves going specifically to community centres themselves.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, the Minister referred to outreach campaigns in relation to the take-up of MMR. Will that extend to children who are disabled and who are forced to be off school for certain periods of time to ensure that they are able to access their MMR vaccines?

[Lord Markham (Con)]

Yes. This whole campaign is looking particularly at hard-to-reach communities. The concern is particularly in London. Whereas we have about 85% take-up across England as a whole, in London it is around 75%, so that is where the particular outreach is. That also involves looking at children who are not able to go to school or who are home-schooled.

[Baroness Manzoor (Con)]

My Lords, I welcome the catch-up campaigns that the Government are running. They are very welcome. I particularly note the campaign in London. As the Minister will know, there is variation across the country. The WHO stipulates that 95% is the target reach, yet we are at 89%. So how are those hard-to-reach communities, particularly the ethnic-minority communities, being targeted? The uptake is slightly lower in those particular areas.

[Lord Markham (Con)]

There are two main approaches. If a child is under 11, we would prefer to have a parent present, for obvious reasons—because it involves a vaccination—so that is normally done through the primary care system, through nurses. Post 11, because you do not need the parent there, that is where schools really come into effect. In particular, there is a school-age assisted immunisation providers programme that goes into every school in a particular area, targets it and speaks to every child to see whether they have had their vaccination—and they can give it on the spot if they have not.

[Lord Allan of Hallam (LD)]

My Lords, does the Minister agree that the experience of both the MMR and Covid vaccination programmes shows that vaccine hesitancy is actually a very complex problem with multiple factors? Given the importance of high vaccination rates for public health, are the Government commissioning any research from academic experts in misinformation and disinformation so that we can understand what kinds of government campaigns will work and which ones will not and will only reinforce vaccine hesitancy?

[Lord Markham (Con)]

The noble Lord is correct about trying to make sure that we learn the lessons from all these areas. The approach that they have been responding to so far is very much “horses for courses”. In the last six months alone, they have had four different types of campaign. We do not have the results from those campaigns yet, but the point is a very good one and I will make sure that we get those results from the research and share them.

[Lord Kirkhope of Harrogate (Con)]

My Lords, as my noble friend has referred to, it is very important that young people, children, get vaccinations when they are due, but the current government campaign to encourage adults to have a shingles jab, and indeed other areas, seems to point out—I have heard this from GPs—that the fact that adults are not now taking boosters for things such as tetanus, and other areas where vaccination is so important, means that there is a gap. Does my noble friend not think that we ought to do more to encourage adults to take up vaccinations, renewals and boosters where appropriate to safeguard their health?

[Lord Markham (Con)]

Yes. That is where we really see UKHSA coming into its own in terms of taking an intelligence-led approach. The concern came from its modelling: its epidemiologists brought this up as a concern, which led to the alert going out on 14 July. Likewise, it is looking into other categories and, where there are those concerns, it will come out and suggest such outreach programmes.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I refer to the question asked earlier by the noble Lord, Lord Young, about the high level of absence of children from school at the moment; I believe the present figure is in the order of 24%. What special steps are being taken there, where the appeal to the school will not make any difference yet we have to try to get to the homes of the individual parents?

[Lord Markham (Con)]

As mentioned, there are outreach programmes, particularly for home-schooled children or children who are not there. There are also programmes in community centres, with the idea of trying to pick them up in as many places as possible. Obviously, there is concern about certain communities that are harder to reach than others. That is particularly the case in London, as I mentioned earlier. That is where we are trying to specifically target those community centres with outreach work.

[Baroness Bennett of Manor Castle (GP)]

My Lords, in April the UK Health Security Agency’s director of public health told the Health and Social Care Committee in the other place that the workload for delivering vaccines now falls disproportionately on general practices—particularly after the 2012 NHS reforms—and that this is one of the weaknesses we are trying to put back together.

In that context, the Minister may be aware of the issue around the quality and outcomes framework payment to GPs. GP practices in deprived areas are missing out on payments for delivering vaccines that could help them deliver more vaccines because it is extremely difficult for them to register the patients whom they have tried to contact multiple times when those patients do not respond. So, the GPs are missing out on payments they need to be able to reach those difficult-to-reach patients.

[Lord Markham (Con)]

I am sorry, I am not quite sure what the question was there. Clearly, we need to make sure that the system is working in terms of making sure that the payments are there so the doctors can follow up. If the noble Baroness would like to follow up with me, so that I can fully understand it, I will get her a response.

Food: Two-For-One Offers

Lord Markham Excerpts

Wednesday 19th July 2023 Lords Chamber

[Baroness Walmsley]

To ask His Majesty’s Government on the basis of what health evidence, if any, they have postponed the planned ban on two-for-one offers for foods high in fat, salt and sugar.

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

The volume price promotion restrictions have been delayed for two years while we prioritise the implementation of the location restrictions. This is the most impactful policy for reducing children’s calorie consumption, and accounts for 96% of the expected health benefits of the promotions policy. Kantar data suggests that it is working. The evidence suggests that this will have the biggest impact on tackling obesity.

[Baroness Walmsley (LD)]

I thank the Minister for his reply, but according to the Food Foundation’s most recent Broken Plate report, the most deprived 20% of families would have to spend half of their disposable income on food to comply with the Government’s healthy diet advice. Bearing that in mind, why are the Government continuing to allow retailers to sell HFSS foods, which can make people ill, at a discount? Do the government really want to encourage people to buy cheap food that could, in the end, kill them?

[Lord Markham (Con)]

First, I thank the noble Baroness for her tireless work in this space. I think we have shown that our restrictions are absolutely placed to inform and educate people so that they can have a healthy diet. I mentioned what we have done on location—the so-called pester power avoidance. It is estimated that these measures will reduce calorific intake by 96%. That is the prize that we are looking at here.

[Lord Rooker (Lab)]

My Lords, can the Minister confirm that the Secretary of State for Health actually believes in public health policy, because his recent speech at the Centre for Policy Studies—I watched all of it—indicates he does not?

[Lord Markham (Con)]

He definitely does. He was very much behind these measures. Just look at what we are doing in the smoking space, through the swapping out of cigarettes for vapes—another example of where we are taking action. As I mentioned, the evidence from Kantar suggests that it is working.

[Lord Naseby (Con)]

My Lords, if a product is marketed legally in the United Kingdom, why should His Majesty’s Government feel they have to interfere at all with the marketing of that product? I understand the point about education and totally accept it, but is it not wrong for His Majesty’s Government to restrict what is a legally marketed product?

[Lord Markham (Con)]

We are trying to educate, inform and nudge. The best example of all is encouraging the industry to reformulate its foods to be healthier. At this point, I am glad to say that, since we introduced these restrictions, Mars, Galaxy, Bounty and Snickers have reformulated, and even Mr Kipling’s Deliciously Good cakes are compliant.

[Lord Allan of Hallam (LD)]

My Lords, next week it will be three years since the Government committed to legislate to end the promotion of high-fat, salt and sugar foods by volume. Would a reasonable person think that this commitment has been met when the legislation has been passed but not implemented, and will not be for another couple of years?

[Lord Markham (Con)]

As I mentioned, the key is giving industry time to adjust so that it can reformulate. We would all agree that, if you can get the same taste but it is a lot healthier, with less fat, salt and sugar, that must be a good outcome. The examples that I just gave show that, and it is working.

[Baroness Boycott (CB)]

The NHS Food Scanner is promoting to children a number of ultra-processed food items. Do the Government not think that this is quite perverse given the new knowledge about what exactly ultra-processed food means? It is not just about the sugars, salts and fat but about the chemical destruction and reformulation of foodstuffs into something else.

[Lord Markham (Con)]

As I mentioned in answer to a Question on ultra-processed food yesterday, as a definition that is not particularly helpful because wholemeal bread, baked beans and cereals are all examples of ultra-processed food. The real point is the content of the food, and that is what our regulations should look to.

[Baroness Merron (Lab)]

My Lords, when the anti-obesity strategy was published, this ban was said to be supporting food affordability, citing evidence that multi-buy offers such as “buy one, get one free” increase the amount that people spend on foods by around 20% but often on foods high in fat, sugar and salt. With the Government now making the opposite argument to support this postponement, do they no longer stand by the evidence? Would a ban on these deals make it easier or harder for those who are struggling to get by?

[Lord Markham (Con)]

As we have mentioned before, our general direction of travel is to educate, reformulate and give people the best chances through having choices, and a good start in life through the fresh fruit and vegetables that we have in schools. Those are the things that will really make the difference.

[Lord Lansley (Con)]

Does my noble friend the Minister recall, on that exact point about access to fresh fruit and vegetables, the very successful scheme that we pioneered about 12 years ago with the Association of Convenience Stores so that corner shops would carry fresh fruit and vegetables close to the till and make them accessible, with us carrying the risk of wastage? That led to a significant increase in corner shops selling fresh fruit and vegetables.

[Lord Markham (Con)]

To me, that is a great example of how working in co-operation to allow people to make the right choices is the best way. For instance, 78% of shoppers have said that they are in favour of not having unhealthy items at the till because they know that they give in to pester power. That is why this has been focus of what we have done.

[Baroness Bull (CB)]

My Lords, notwithstanding the interesting “legal but harmful” point made by the noble Lord, Lord Naseby, I think that most of the House would agree that reducing high-fat, sugar and salt content is a good idea. However, the Minister has at least twice mentioned reduction of calories. Does he acknowledge and recognise that while one way to address obesity is calorie reduction, it is not an appropriate message for everybody and it certainly is not the sole cause of obesity across this country?

[Lord Markham (Con)]

The noble Baroness is correct; this is a complicated area, and a number of measures need to be taken. The best thing is the promotion of healthy foods, and the fresh fruit and veg initiatives that we have talked about today are perfect examples of that.

[Lord Dubs (Lab)]

My Lords, some years ago, the British-Irish Parliamentary Assembly looked at obesity in children, during the course of which we went to Amsterdam to look at what was going on there. Two of the things that were very enlightening were educating children in schools and educating pregnant mothers. What about that?

[Lord Markham (Con)]

I am aware of the Amsterdam initiative. Off the back of that, the OECD said that there were four main strands to what countries should be doing: first, information and education, such as the good examples I spoke about; secondly, increasing healthy choices through the reformulation of foods, which again is something we are doing; thirdly, the modifying of costs—the sugar tax, which has reduced sugar consumption by as much as 40%, is a perfect example of that; and, fourthly, restrictions on where product placement should take place. I am absolutely familiar with the initiative in Amsterdam, and am pleased to see that we have taken action on a lot of those things.

[Lord Brooke of Alverthorpe (Lab)]

Is the Minister not ashamed about what has happened to children’s health while the Conservatives have been in power since 2010? We have more obese children than ever before, and a plethora of policies which would work if implemented, yet so many are delayed. Will the Minister give a commitment to go back and look at the regulations governing children’s school meals? They were changed in 2014, with permission granted to give children more sugar. The Government were reviewing this in 2019 and 2020, but that stopped because of Covid. Will the Minister give a commitment again to start a review? Even if they cannot implement it, the next Government could.

[Lord Markham (Con)]

The noble Lord is correct: good school meals are fundamental to all of this. My understanding is that the review is something that the Government are looking to do, but I will happily provide more details on what the plan is.

[Lord Morse (CB)]

My Lords, can I just test with the Minister whether there is still a commitment to the policy of banning two-for-one promotions? If there is, is there an effective deal going on with the food producers that they will change certain processes if this ban continues to be pushed backwards and effectively talked out of effect?

[Lord Markham (Con)]

There is absolutely the commitment for October 2025. The tactic behind that is to give industry the time to make its food healthier. That is exactly what it is doing in the examples I mentioned, including the Deliciously Good cakes. It is good to see industry respond in that way.