Ultra-processed Food

Lord Markham Excerpts

Tuesday 18th July 2023 Lords Chamber

[Baroness Boycott]

To ask His Majesty’s Government what assessment they have made of the latest research into the effects of ultra-processed food on the mental and physical health of children and adults; and whether they plan to introduce any further restrictions on these foodstuffs.

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

The Scientific Advisory Committee on Nutrition did not find evidence for a causal link between ultra-processed food and mental and physical health. It is unclear whether ultra-processed foods are inherently unhealthy, or whether it is more that those foods are typically high in calories, saturated fat, salt, and sugar. Therefore, the Government’s priority is continued action to reduce the consumption of foods high in calories, salt, sugar and saturated fat.

[Baroness Boycott (CB)]

I thank the noble Lord for his Answer, but I beg to disagree. The latest scientific evidence indeed shows that ultra-processed food, which is, in essence, not really food given that ordinary foodstuffs have been put through industrial processes that render them chemically different from what they were when they began, has had a massive impact on the nation’s health, especially in the past 30 years. Some 66% of our diet is ultra-processed food, and 16% of everything we eat every day goes to our brain. It seems to be no coincidence that instances of heart disease, cancer, obesity and many other illnesses, as well as mental illnesses, might have something to do with the food that we are eating, the fuel that we are putting in our cars. No noble Lord in this House would put Coca-Cola in his Rolls-Royce and expect it to do its best. I beg the Government to come back and have another look. I would be very happy to set up a meeting for the Minister with the newest experts in neuroscientific research to see whether we can take this forward.

[Lord Markham (Con)]

First, I thank the noble Baroness for the work she does and has done in this space for a number of years. The problem is the definition of “ultra-processed food”. It includes things such as wholemeal bread, baked beans and cereal. It is not a helpful definition. There are certain ultra-processed foods which are high in fat, salt and sugar. We completely agree that those things are bad for us and that we should do everything we can to discourage people from eating them. The label “ultra-processed food” is not helpful.

[Baroness Manzoor (Con)]

My noble friend will know that one-third of baby and infant foods contain ultra-processed food which, in effect, is leading to obesity, and he will know that obesity can lead to cardiac problems and hypertension in later life, which costs the NHS significant sums of money. There is evidence in recent research that firms’ marketing is providing misleading information. What are the Government doing to ensure that this aspect, particularly with baby and infant food, is better regulated?

[Lord Markham (Con)]

I thank my noble friend. We are focused on the sugar, salt and saturated fat content. It is not the fact that food is called ultra-processed, per se. We would not discourage people from eating whole- meal bread, but wholemeal bread is considered to be a processed food. The action we are taking is for a reduction in sugar, salt and saturated fat.

[Lord Brooke of Alverthorpe (Lab)]

The Minister is focusing on reducing fats, salt and sugar in meals. When are the Government going to reduce those elements in school meals for children?

[Lord Markham (Con)]

Absolutely. That is why we are at the highest level of free school meals for children ever. More than a third of children are now receiving free school meals, including all infant schoolchildren. The noble Lord is correct that a healthy start to life is vital, and if we can make sure that children are getting a good, nutritionally balanced school meal, that is a good start to life.

[Lord Allan of Hallam (LD)]

My Lords, as the Online Safety Bill works its way through this House, we see how interventionist the Government can be in the interests of public health and well-being when they put their mind to it. Learning from that effort, does the Minister agree that the phrase “legal but harmful” is quite an accurate description of some of the kinds of ultra-processed food that are sold and marketed in the UK?

[Lord Markham (Con)]

Absolutely. Some of the foods are not healthy at all, and we totally want to discourage them. We have taken a lot of steps in that space. The whole product positioning strategy, whereby you cannot now put such foods in places where there will be so called pester-power influences, is beginning to have an effect. We are already seeing healthier foods outgrowing non-healthy foods from that. Those sorts of actions were modelled to show that they were effective for 96% of the things that we are trying to target to reduce in terms of calories.

[Lord Krebs (CB)]

My Lords, I declare my interests as listed in the register and I hate to disagree with my noble friend Lady Boycott but, on this occasion, I do. Does the Minister agree with the conclusions of the nutritional advisory committee of the five Nordic countries, published on 20 June 2023? It says:

“The … committee’s view is that the current categorization of foods as ultra-processed foods does not add to the already existing food classifications and recommendations”.


Does he also agree with the Brazilian scientists who coined the notion of ultra-processed food when they say that their classification is a good way to understand the food system, but not individual foods?

[Lord Markham (Con)]

Yes, the noble Lord is absolutely correct and makes the point that I have been trying to make but far more eloquently; I thank him. That is precisely the point. Some ultra-processed foods are very unhealthy and we should be doing everything we can to discourage them. Others, such as wholemeal bread or baked beans, are totally fine.

[Lord Hannan of Kingsclere (Con)]

My Lords, I am very grateful for my noble friend’s reply to the noble Lord, Lord Krebs. The definition of ultra-processed foods to which I think noble Lords on all sides are referring comes from the recent book, Ultra-Processed People. It is food that is

“wrapped in plastic and has …one ingredient that you wouldn’t find in your kitchen”.

I suspect that is true of the contents of almost all of our cupboards, including, as my noble friend the Ministers says, sliced wholemeal bread. Is it not time that we stood up against moral panic, focused on the actual empirical data and followed the science?

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[Lord Markham (Con)]

I thank my noble friend; that was excellently put. Again, it is the content of the food that matters and not what it is called.

[Baroness Merron (Lab)]

My Lords, to follow on from the Minister’s comments about the definition of ultra-processed foods, can he confirm what work is taking place to nail down a definition and, upon this definition, will the Government carry out the research that scientists believe to be necessary?

[Lord Markham (Con)]

As I have said, the fact that something is processed is not a helpful definition. I would recommend that we focus all our activity on the contents of the foods—whether they are high in saturated fat, sugar or salt—and not on whether they are processed.

[Baroness Jenkin of Kennington (Con)]

My Lords, will my noble friend the Minister let us know what assessment the Government have made of food industry links with the Scientific Advisory Committee on Nutrition and whether this might have influenced the evidence and recommendations of the review?

[Lord Markham (Con)]

On any advisory body you clearly want to get experts in the field. Necessarily, they will often be experts from companies as well. It is vital that they abide by the principles of conduct in public life and make sure they declare any conflicts. As such, we are content that we have a proper expert panel.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, may I take the Minister back to the question from my noble friend Lord Brooke, who asked about the content of school meals? The Minister replied that school meals are a good thing and more people should have them, with which I do not suppose anybody would want to disagree. However, I did not hear him say in what way the Government are ensuring that the content of those school meals is appropriate and free from salt, sugar and fat in the way that my noble friend Lord Brooke was asking for.

[Lord Markham (Con)]

My understanding is that those guidelines are there; it is absolutely the right question. The Department for Education, working with the Department of Health, makes sure that a nutritionally balanced diet is there. There is also a joint DfE/DHSE programme in respect of nursery milk and fresh fruit and vegetables for young children, to give them a good start in life.

[Lord Forsyth of Drumlean (Con)]

My Lords, is it not the solution to this problem not to ban things but to improve education so that people understand what they are eating and make rational and clear choices? Is it not the case that many of these processed foods are bought by people because they are cheaper? If we could encourage people in schools to learn what used to be called domestic science—cooking skills and so on—so they can use fresh ingredients, then we would advance this case far more effectively than by banning things.

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[Lord Markham (Con)]

I absolutely agree with my noble friend about education and teaching people how to cook a decent meal. The other crucial thing is the industry reformulating foods to take out sugar and fat content. That is where some of the restrictions are working. Advertising and product placement really do work, so if you make it harder, the industry is incentivised to take sugar and fat out of those meals to make them healthier so that they can still be marketed.

National Health Service (Performers Lists) (England) (Amendment) Regulations 2023

Lord Markham Excerpts

Thursday 13th July 2023 Lords Chamber

I am sure that the Minister has got the message that while there is no issue with the actual changes, there are many issues with the way in which the regulations have been dealt with. There are great concerns that they may not deliver the impact that the Government seek and, indeed, we all seek—that is, improvement to access to dental care.

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

I thank noble Lords for their contributions and the noble Lord, Lord Hunt, for bringing this topic before us today. As noble Lords know, I have an interest in this case in that my wife is an overseas dentist, which means I can trump the website search by the noble Lord, Lord Allan, and say that I have filled in these forms myself.

Overall, I am glad that there seem to be shared goals in that we all want to increase the supply base of doctors, dentists and opticians—in this case, the focus is particularly on dentists. Clearly, we all want to maintain high standards and remove unnecessary red tape. That is what we are trying to do here.

I do not think anyone is going to pretend that this alone will be a massive thing. I liken it to Team GB cycling—noble Lords have probably heard me use that example before—where you are looking at 1% and 2% changes and sensible things at the margin that will accumulate over time. The noble Baroness, Lady Merron, asked about some of the July 2022 changes. The noble Lord, Lord Hunt, mentioned the changes to the UDAs and those earlier changes. Each of those on its own will not make a massive change, but the accumulation of all those things will begin to have an impact. That is why it is so difficult to do an impact analysis on any one individual measure, because we are trying to combine all those things to make it into the right space for people to want to do this.

I think we all agree that it seems strange not to trust that the Scottish, Welsh or Northern Ireland NHS has gone through a process good enough that we would automatically use it. It is sensible that we trust them and their standards but have a case to verify afterwards if we need to. I do not know whether it will be reciprocal. I argue that we should do it regardless, because it has to be to our benefit that we are as inviting as possible. I would not be surprised if they follow suit. Funnily enough, if they do not, it might be to our advantage through a narrow NHS England lens and making sure that we have the easiest approach to work and practice.

The other main point is where I really have a personal interest. I hope it will add some colour to the thinking behind this, albeit with a sample size of one. Please take this as an anecdotal experience rather than as a massive data analysis. I have seen that you go through a very thorough GDC process. That is something that I filled out in the context of my wife when we did all this. She had practised and had her own practice in Madrid for about 15 years and was very experienced. She went through a very thorough GDC process to make sure that she was eligible to practise here. She then practised in Manchester and Liverpool at some very high-end private clinics.

We then decided to move to Surrey. She saw that there were a number of jobs on offer that wanted people with private registration, but that it would be helpful if they had NHS as well, because a number of clinics have a hybrid model whereby they will offer both NHS and private treatment. She went down that process and I was involved in it. Eventually, she came to the conclusion that she was doing a hell of a lot of hard work. There was a two-year process and all sorts of courses she needed to take—it was very much a checklist of things to do—so she thought, “Do I really need to do this? I have plenty of private practice anyway”. In the end, she concluded that there was no point. I grant that this is a sample size of one, but I think we can all see that, if someone has been practising for many years to a very high level and can continue doing that, but suddenly there is a load of red tape in the way of becoming an NHS dentist, eventually they would say that it is not worth it. That is what this approach is all about.

It is also about accepting that you need judgment; you cannot put down any hard and fast rules, as was questioned, because every case is going to be different. Part of the problem now is that it is almost a tick-box exercise when looking at their experience. That is what this is designed to do. If a dentist has worked in the private sector or overseas for 10 to 15 years and can show evidence of the different types of treatment they have done, you can be pretty confident—by all means, meet them and talk to them—that they can do that at the NHS level. Those are the judgment calls that they make, and that is where we are coming from.

Community Health Services: Waiting Lists

Lord Markham Excerpts

Wednesday 12th July 2023 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what recent assessment they have made of current levels of waiting lists and times for community health services for (1) children and young people, and (2) adults.

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

We regularly monitor community health services’ waiting lists and recognise the variability between the number of people waiting and the time on waiting lists across services in local areas. We are committed to reducing waiting lists; that is why the NHS Long Term Workforce Plan sets commitments to grow the community workforce, with increases in training places for district nurses and allied health professionals and a renewed focus on retaining our existing staff.

[Baroness Merron (Lab)]

My Lords, long waits have a more severe effect on children because delays in assessment and treatment have a knock-on effect on their communication skills, social and educational development and mental well-being. With over 37% of children and young people on waiting lists for community health services for more than 18 weeks, compared to under 16% of adults, when will the Government address this ever-widening gap and what steps are they taking to prevent a disproportionate impact on vulnerable families both now and in the long term?

[Lord Markham (Con)]

The noble Baroness is correct about the urgency for young people; I have personal experience of this as well. We are taking steps by piloting nine early language and support services for all children focused on exactly what the noble Baroness mentioned. There is £70 million behind that pilot, with the intention being that we learn lessons from that and roll it out quickly.

[Baroness Manzoor (Con)]

My Lords, my noble friend will know that a number of surveys have identified that over half a million adults are waiting for adult care assessments. The normal waiting time is 28 days, but for some it is, sadly, significantly longer, which has a disproportionate effect on some of the most vulnerable. What action are the Government taking to reduce it?

[Lord Markham (Con)]

We are starting to see a blue- print which is beginning to work. The highest waiting list for adults is related to musculoskeletal issues. Since we put an improvement framework in place, 91% of people are now being seen within 12 weeks—a big improvement. We are moving to self-referral also, and digital therapeutics beyond that. There is a road map in place that we need to apply across other areas.

[Lord Allan of Hallam (LD)]

My Lords, within the published data for wait times in community health services, we see that some people face very long waits for home oxygen assessments, including some waiting for over a year. Given that home oxygen is key for many with respiratory conditions staying out of hospital, will the Minister prioritise looking into why we are seeing these delays, and ensure those who need home oxygen do not face unnecessary waits?

[Lord Markham (Con)]

As noble Lords probably know, we published this data for the first time in March, so it is only now we are getting the data that we can truly work on it. It sets out 35 different areas where we understand those waiting lists for the first time, so we know which ones to prioritise—home oxygen being clearly one of those.

[Baroness Finlay of Llandaff (CB)]

My Lords, with a staff absence rate of 5.6% overall for NHS community staff, which is equivalent to 75,000 staff, what are the Government doing to address this high level of sickness, including mental health sickness? Without the staff, the services cannot be provided. Can the Minister also explain what is being done to target those who have particular training in looking after children, given that in some areas the waiting lists for children are incredibly high, particularly for mental health services for children in the community?

[Lord Markham (Con)]

The noble Baroness is correct: absenteeism is often an example, in the same way as poor retention is, of problems in the wider workplace and the pressures that people have to face now. That is why the long-term workforce plan, which I think was welcomed by all noble Lords, looks to tackle every aspect: recruiting more staff so the pressures on individuals are reduced; making sure we have training and retention plans in place; and the necessary skills training in each area, including that of young people.

[The Lord Bishop of Southwell and Nottingham]

My Lords, in a recent survey of the Association of Directors of Adult Social Services, over 90% agreed that unpaid carers are now coming forward with an increased level of need, with directors ranking burnout as the number one reason for the increasing carer breakdown over the past year. Unpaid carers are clearly bearing the brunt of shortages in health and social care support, so can the Minister say what the Government can do to help more with unpaid carers?

[Lord Markham (Con)]

We all agree that unpaid carers are the backbone and hidden army behind a lot of what we see. We have made some good moves in that direction. We have the set-up for leave, so that they can have time away and a reduction in stress. We are setting up payment for them, albeit we all accept that there is such a hidden army we need to do more.

[Baroness Ritchie of Downpatrick (Lab)]

My Lords, recent research has found that almost three in five disabled children seeking physical and talking therapies are waiting more than 12 months for appointments, which is totally unacceptable? How do the Government plan to address such a large backlog and improve opportunities for disabled children? Perhaps the Minister can elucidate on that particular area.

[Lord Markham (Con)]

Unfortunately, as we know, we have a backlog in quite a few areas, often as a consequence of the pandemic and the period when we could not see as many people as we would have liked to. I wish I could say there was a quick solution; we all recognise the long-term solution is the long-term workforce plan, where we need to address the vacancies and have more staff to increase the output and supply. We are putting in a record investment of £2.4 billion behind this, but I freely admit it is not an overnight solution.

[Baroness Browning (Con)]

My Lords, I draw attention to my interest in the register and my association with the Alzheimer’s Society. My noble friend will know that, when asked, most people will say that when they die, they would like to die at home in their own bed. There is one group of people for whom there seems to be no structured plan to make that possible, and that is for people with dementia and Alzheimer’s. They are cared for at home until the end of their life, but the end of their life very often ends up in a hospital ward—the most inappropriate place for somebody with dementia, unless there is a genuine medical need to be there. Could my noble friend look to see if we can put together a structured plan that would be of help to families in planning the end of life of close relatives? I particularly do not mean something that follows the way the Liverpool care pathway was put together.

[Lord Markham (Con)]

I thank my noble friend. This was actually a conversation of a big task force summit that we had just last week. We commented that a lot of people have pregnancy plans, for instance, which might say that they want to have birth planned at home; a lot of people will have “Do not resuscitate” plans; what we do not have enough of are frailty plans, which say, “I don’t want to go into hospital. I’d rather be cared for at home. I know it might mean that I don’t live for quite as long, but that’s my preference”. I think there is a whole debate that we need to have to start to move towards that, and to make sure we have that support in the community to do it as well.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, is the Minister aware of the spare capacity of therapists in the private sector, some of them specialising in the mental health of children? As we have such long waiting lists for children and mental health, why is that not being used?

[Lord Markham (Con)]

The noble Lord is correct, and my understanding is that we are looking to use the independent sector more and more. I will check and verify this, as it was from the briefing probably about three or four months ago, but my belief is that about 51% of the physiotherapy that we use is from the private sector. I absolutely agree with the noble Lord that we need to use the independent sector more and more in these situations—something pioneered by the noble Lord, Lord Reid, over there.

[Lord Patel (CB)]

My Lords, every day, about seven children will develop cancer; eight out of 10 will survive more than five years with modern care, but these children who survive require long-term community care, both for their families and themselves. Would the Minister agree that the integrated care pathways developed by integrated care systems should improve community care for cancer-surviving children?

[Lord Markham (Con)]

Yes; our whole direction of travel, as noble Lords are aware, is putting more and more power in the hands of the local integrated care boards. Going into the detail of it, the whole workforce plan moves a lot of the emphasis away from treatment in hospitals into care in the community—primary and prevention. This is a direction of travel that I think we all agree on, which is why we are putting more resources behind it, albeit that these things take time.

Healthcare (International Arrangements) (EU Exit) Regulations 2023

Lord Markham Excerpts

Wednesday 12th July 2023 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 5 June be approved. Considered in Grand Committee on 5 July.

Motion agreed.

Healthcare (International Arrangements) (EU Exit) Regulations 2023

Lord Markham Excerpts

Wednesday 5th July 2023 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Healthcare (International Arrangements) (EU Exit) Regulations 2023.

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

My Lords, reciprocal healthcare arrangements enable UK residents to access healthcare when they live, study, work or travel abroad. They not only provide an added safeguard for our residents when they travel but support those with long-term pre-existing conditions to avoid them facing expensive insurance premia or funding private treatment. This is why the UK Government are proud to have concluded healthcare arrangements that provide our residents with greater access to healthcare in countries across the world, such as with the European Union, Switzerland and our overseas territories.

Last year, we amended our primary legislation that enabled the implementation of comprehensive reciprocal healthcare arrangements in the European Economic Area and Switzerland. Thanks to the Health and Care Act, which noble Lords played a crucial role in scrutinising, the UK can now implement comprehensive healthcare arrangements with countries around the world—not just in Europe—where it will be to the benefit of the UK. This means that we can implement arrangements that include the reimbursement of costs and exchange of data, such as the one we have with the European Union, across a wider geographical area where it is in the interest of the UK to do so. Overall, extending arrangements offers potential benefit for all UK residents, providing them with greater reassurance when travelling and deepening diplomatic ties with our international partners.

Following the amendments to our primary legislation, secondary legislation is now necessary to continue implementing our existing reciprocal healthcare arrangements, as well as future ones. I am pleased to introduce the regulations to the Committee. They will replace implementation regulations made under our former primary legislation, the geographical scope of which was limited to the European Economic Area and Switzerland.

While these regulations remain substantively similar to the regulations they replace, they also provide the necessary legal framework to implement any future arrangements with countries around the world. They work by conferring functions on the NHS Business Services Authority and local health boards across the UK to give effect to our existing healthcare arrangements. For example, they enable the NHS Business Services Authority to make payments, process applications and provide information to the public, including issuing the global health insurance card.

The regulations also confer functions on Welsh and Scottish local health boards so that they can deliver planned treatment provisions within our arrangements, which is an area of devolved competence. Until a Northern Ireland Executive are in place, we will save our existing implementation regulations to ensure that planned treatment can be delivered across the UK according to our obligations under the reciprocal healthcare arrangements that we have with the EU, EEA states and Switzerland. We have worked closely with the devolved Administrations in the drafting of the regulations and they have confirmed, through a formal consultation, that they are content.

We have included a Schedule to these regulations, which consolidates all the healthcare arrangements that the UK currently has with countries and territories around the world. It includes not only our arrangements with the European Union, which contain reimbursement provisions, but our existing international arrangements, where no money is exchanged and where the cost of treatment is waived, with countries such as Australia and New Zealand. To add a new country or territory to the Schedule, it must be amended by affirmative statutory instrument, providing noble Lords with the opportunity to scrutinise the implementation of any new arrangements.

The regulations enable the Secretary of State to make payments outside of an arrangement only when there are exceptional circumstances to justify the payment and only in countries or territories where a reciprocal healthcare arrangement with the UK is in place. Having this power means that we can support UK residents when they face difficulties and extraordinary situations when accessing healthcare abroad is critical. This will be accompanied by a policy framework, which we have developed and consulted on publicly. The framework will guide exceptional payment decisions while providing adequate flexibility for the Secretary of State to assess cases individually.

Finally, I take this opportunity to reassure your Lordships on concerns which were raised previously in the House about the interaction of reciprocal healthcare and trade. I reiterate that these regulations are not about trade deals or privatising the NHS; they are about implementing reciprocal healthcare arrangements and supporting UK residents to access healthcare abroad.

I am happy to bring forward this legislation today. These regulations are crucial to honour our current commitments and obligations under our existing healthcare arrangements, and to continue supporting the people who depend on these arrangements to access the healthcare they need while abroad. I beg to move.

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[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his introduction to the SI and the other noble Lords who have spoken to it. For the record, we wanted to look very closely at it, given the discussions, commitments and reassurances made last year by the Government and the then Health Minister, the noble Baroness, Lady Penn, about the Government’s policy intentions on reciprocal health agreements during the passage of what is now the Health and Care Act.

We had strong concerns that any provisions under the Act which reflected post-Brexit arrangements should be confined to the implementation of reciprocal healthcare arrangements, not to the negotiation of international health agreements which could be used for wider and different purposes, such as the privatisation of parts of healthcare. The Healthcare (European Economic Area and Switzerland Arrangements) Act 2019 included explicit constraints to make such agreements on the powers of Secretary of State in this regard. We also had concerns that the new arrangements should not change the definition of future reciprocal healthcare agreements.

Reassurance from the Government that the purpose of the 2019 Act was not to implement trade deals and that reciprocal healthcare agreements do not relate to the commissioning and provision of services for the NHS were very welcome. We are therefore content that the SI properly reflects this; I thank the Minister for his reassurances in his opening remarks. We are also pleased that the affirmative procedure ensures that Parliament is able to be kept up to date with developments and that these issues are properly debated.

The Explanatory Memorandum is very helpful. I look forward to the Minister’s response to the issues raised by the noble Lord, Lord Allan, about scope, because they are important.

We recognise that the regulations are vital to implement international healthcare agreements following our exit from the EU. Reciprocal healthcare agreements support people to access healthcare in the listed countries. Those faced with the stress and worry of a healthcare emergency abroad will rightly expect suitable arrangements to be in place where possible. That is particularly true of people with a disability, those who are older or who live with a pre-existing or chronic health condition.

The amendments to the Act allow the Government to implement more complex agreements with the ability to make financial reimbursement at cost, as the UK currently does with many EEA countries, and confer further powers on the Secretary of State. Can the Minister outline further details about the Government’s plans for other international healthcare co-operation outside the EEA and Switzerland and what these plans might look like?

From our understanding of the SI, we think that payments can be made only if both the following conditions are met: the healthcare treatment is in a country with which we have an international healthcare agreement, and the Secretary of State considers that exceptional circumstances justify the payment. Can the Minister explain the Government’s thinking on what would constitute exceptional circumstances and how the policy framework might work? What guidance is being issued by the NHS Business Services Authority, which has certain administrative functions conferred on it through the SI?

The public consultation on the policy has just closed but we understand that the results and an analysis of it will be published this month. An early indication of the timetable and results would be welcome.

On the role of the NHS BSA, can the Minister provide more detail on the work currently undertaken to establish and maintain the public information and advice service on healthcare provision under relevant healthcare agreements, as set out in the SI? Again, the noble Lord, Lord Allan, mentioned this important function. The importance of transparency has been underlined. It will be crucial in the future to help people understand how reciprocal healthcare agreements work and can be accessed, to ensure they are doing all the right things to be properly covered, and to make claims, as the noble Baroness, Lady McIntosh, said.

I look forward to hearing answers to the questions about the issue of EHIC and GHIC. Specifically, can the Minister update the House on how the transfer from EHIC to GHIC has worked and whether any complications have been experienced—for example, the impact of the non-application to the UK of the EU cross-border healthcare directive, which enabled UK patients to pay for qualifying private healthcare in Europe and to receive reimbursement up to the amount that the treatment would cost the NHS? UK travellers can now no longer seek reimbursement, and I wondered if there had been any instances where the lack of awareness of that has caused problems—for example, for patients needing kidney dialysis where reimbursement for private treatment has not been allowed.

I appreciate that the Minister might need to come back to me on that. I think we are about to have a vote, but I look forward to his response.

[Lord Markham (Con)]

I will try my best, potential votes notwithstanding. I thank noble Lords for their contributions to today’s debate and for the generally received welcome. To try to answer them in turn, on the point made by the noble Baroness, Lady McIntosh of Pickering, I believe the arrangements made with the EFTA countries were signed on 30 June 2023. The expectation is that they will become operational by the middle of 2024—saved by the bell.

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[The Deputy Chairman of Committees (Lord Duncan of Springbank) (Con)]

My Lords, I understand that another vote is coming, so I do not think there is any point in having another few minutes of the Minister—fun though that may be. Shall we twiddle our thumbs until the next vote?

[Lord Markham (Con)]

Unless I can finish before then.

[The Deputy Chairman of Committees (Lord Duncan of Springbank) (Con)]

Unless the Minister can finish in the next two minutes.

[Lord Markham (Con)]

Perhaps.

[The Deputy Chairman of Committees (Lord Duncan of Springbank) (Con)]

I will leave it in the Minister’s hands.

[Lord Markham (Con)]

I am happy to try. We will see. I will write a detailed letter after all this, so noble Lords can decide, when the bell rings, whether they want me back for more. That was a nice break in terms of being able to get some—

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[Lord Markham (Con)]

I guess it is probably easier if I recap. On the question asked by the noble Baroness, Lady McIntosh, on the EFTA countries, the situation was that they were indeed under EHIC, but under the Brexit arrangements they effectively fell out. These arrangements mean that they have signed, so they are back in again and will be covered there.

As regards how it works, first, as I believe the noble Baroness got salmonella at a Conservative event, I apologise on behalf of the ex-CEO of the Conservative Party. The way the system should work in most cases is that you can show your GHIC—or your EHIC, which is still valid—and, in most cases, state-to-state paperwork and payment should be made on that basis rather than you having to pay personally. Unfortunately, there are examples where you have to do that. That might be just because a hospital is not fully aware of it at the time. However, there is also an NHS Business Services Authority hotline that you can ring, which can help you through all of it.

On the questions from the noble Lord, Lord Naseby, there is no reciprocal arrangement with the Cayman Islands and the Pitcairn Islands at the moment. There is a quota system, whereby the Cayman Islands and the Pitcairn Islands—he did not mention the latter but it is another example of the same situation—are allowed to send a number of their residents to us each year and they pay on a fully costed basis. However, there is no reciprocal arrangement; it is just on a pay-as-you-go basis. However, I clearly understand the issue, given the desirability of the Cayman Islands; I personally volunteer for a ministerial mission to negotiate there—with help from all sides, clearly.

On the question from the noble Lord, Lord Allan, about the GHIC rather than the EHIC, it is indeed clearly an aspirational ambition. However, there are additional countries—I think I already mentioned Australia, New Zealand and Montenegro—so it is an E-plus; maybe it does not quite deserve a “G” at the front of it yet, but clearly that is the direction of travel.

NHS: Doctors’ Strikes

Lord Markham Excerpts

Wednesday 5th July 2023 Lords Chamber

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

My Lords, the Government have been clear that we want to resolve the strikes by doctors. We negotiated in good faith with the BMA’s junior doctors committee in May. The Government stand ready to meet junior doctors again if they move from their unreasonable ask of a 35% pay rise this year. We also want to open negotiations with consultants. We encourage unions to come to the negotiating table rather than proceeding with strike action.

[The Lord Bishop of Exeter]

I thank the Minister for his response. I am sure that today, on the 75th anniversary of the founding of the National Health Service, he will want to join me and all Members of this House in paying warm tribute to the hard-working nurses and clinicians in our NHS. All that underlines and underscores the urgency of settling this dispute. What consideration have His Majesty’s Government given to the request of the BMA to use ACAS to resolve this dispute?

[Lord Markham (Con)]

First, I absolutely echo the sentiment about the 75th anniversary and the hard work of all our doctors, nurses, dentists and medical staff. Clearly, we want to find a negotiated solution. I think we showed in the case of the nurses and Agenda for Change that we have a framework and the ability to find a solution between ourselves as parties. That is why we encourage them to please stop the strike action so that we can have a sensible conversation.

[Lord Dubs (Lab)]

My Lords, I join in wishing the National Health Service a happy 75th birthday—especially as, 75 years ago today, I was a teenager in Stockport Infirmary. Despite my efforts at persuading the consultant, he would not throw a party to celebrate the occasion. This dispute is dragging on, and there are some suspicions voiced in the papers that the Government do not mind too much, because on the whole they want to cut back on the health service—their heart and soul is not with the health service. Could the Minister reject that by demonstrating a greater willingness to negotiate with the doctors?

[Lord Markham (Con)]

I can totally reject that by pointing to the record spend we are putting in this area and the fact that, just on Monday, we launched the long-term workforce plan, with a £2.4 billion investment in expanding the workforce to make sure we are set fair for the next 75 years. We absolutely want to resolve the strike by all means possible.

[Lord Sherbourne of Didsbury (Con)]

My Lords, is my noble friend aware that, apparently, in the consultants’ strike, consultants are not obliged to tell their hospital whether they will be striking; nor is it possible for the hospital to ask whether they are striking. Is not the result of this that the BMA is going to impose maximum dislocation on hospitals, damaging patients’ interests?

[Lord Markham (Con)]

Clearly, that is the last thing anyone wants. I trust all the medics who, first and foremost, care about patient safety to inform their local management so that they can make sure that the correct processes are in place to ensure that patient safety is looked after.

[Lord Allan of Hallam (LD)]

My Lords, yesterday, we discussed the Government’s plans to increase the number of doctors in training. But does the Minister accept that junior doctors are facing real challenges in dealing with the rising costs of living on their current pay rates, especially in their early years? Is this need to retain trainee doctors part of the Government’s submission to the independent review body, so that we do not end up bringing in more trainee doctors at year 1 only to lose them at years 6, 7 and 8?

[Lord Markham (Con)]

Yes, of course, the noble Lord is absolutely correct; retention is key in all this. That is looking at all aspects of the package and work conditions and everything around those. That is what the workforce plan addresses, I hope, because recruitment and retention are key.

[Lord Stirrup (CB)]

My Lords, pay is the headline issue in this dispute, but behind it lies a wholesale collapse of morale within the NHS workforce, and that is about much more than just remuneration. The NHS Long Term Workforce Plan addresses some important issues but by no means all of them. Does the Minister not think that the morale issue, which is so crucial to the future of the NHS, will be better attacked through the kind of radical approach suggested by Sajid Javid than the “evolution” proposed by the Health Secretary?

[Lord Markham (Con)]

I think the morale of doctors is best approached by a number of measures. As I said yesterday, there is not one silver bullet. There are a number of things: clearly, pay is important; pensions are very important, and we have addressed those, and so are working conditions. I was at Whipps Cross Hospital, one of the new hospitals, last week. The morale boost to staff there, knowing they are getting a new hospital, is massive. All those features are vital to improving morale.

[Baroness Merron (Lab)]

My Lords, in celebrating the 75th anniversary of the NHS, I too pay tribute to all NHS staff. It is therefore highly regrettable that the Government are currently presiding over the largest amount of industrial unrest in the history of the National Health Service, with doctors’ leaders warning that the strike action could last until 2025. With that in mind, what is the Government’s assessment of the impact of their failures to resolve NHS disputes?

[Lord Markham (Con)]

As we have seen, it is having an impact, regrettably. We saw that from 14 to 17 June: almost 100,000 appointments were lost during that strike. We are now looking to cover that up. That is why we are firm in our conviction that we want to resolve this situation. These sorts of things are not good for anyone. We have a formula that worked; we have managed to do this with nurses and the Agenda for Change unions, which make up the vast majority of the health service. Our hope is that we can sit down and have sensible conversations and do the same with doctors and consultants.

[Lord Naseby (Con)]

My Lords, I thank my noble friend for his ingenuity and the work he has put in since taking over this role. All we hear of pay rises is that they should be 12%, 19%, 39% or whatever. Has the time not come for a slightly different approach? We should calculate the capital cost of whatever sections of the health service claim they have lost, pay them that cost and then revert to the normal process of review bodies.

[Lord Markham (Con)]

I thank my noble friend for his kind words. We are willing to look at all solutions. We have to balance the salary wishes of doctors with making sure that we keep the money in front-line services. Everyone is aware that pay rises of 35% would eat heavily into what we can do and afford on the front line. We need to get that balance right.

[Lord Clark of Windermere (Lab)]

My Lords, one of the greatest concerns of individuals working in the NHS is lack of confidence about the future. The real problem is retention. I understand that there is a massive shortfall of staff. Will the Minister tell us how big that shortfall is and what the Government are doing to make it up?

[Lord Markham (Con)]

The noble Lord is absolutely correct; that is why I was delighted, as I think all sides of the House were, by the launch of the NHS Long Term Workforce Plan. As Amanda Pritchard, the CEO of the NHS, said, it was a “truly historic” moment for the NHS; it absolutely recognises that staff are the backbone of it all and that we need to do everything to recruit and retain them. Retention is all about professional development and all those things that make up staff morale.

[Lord Bethell (Con)]

I congratulate all noble Lords who joined me this morning on the five-kilometre fun run in celebration of the 75th anniversary of the NHS. It was a tremendous event and all those involved greatly enjoyed themselves. With that in mind, will my noble friend explain what the NHS is doing today to reduce the incredible pressures on doctors and nurses from the huge amount of sickness in the country and what it is doing to make Britain healthier in order to reduce those pressures?

[Lord Markham (Con)]

As my noble friend says, wellness is about a lot more than treatment in hospitals. That is why I was so pleased by the long-term workforce plan, which recognises the importance of primary care and, especially, prevention—the use of our whole wellness through social prescribing and keeping fit through things such as fun runs, which is important for keeping people and staff well. As part of that, we are working on the technology front, because a lot of the frustration of doctors is that they spend so much time not seeing patients but filling in paperwork and forms. Earlier this week, I saw all the changes Chelsea and Westminster Hospital is making so that doctors can be where they want to be—in front of patients and caring for them.

NHS Long-term Workforce Plan

Lord Markham Excerpts

Tuesday 4th July 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I shall try not to be too grudging, as we have been calling for this plan for so long. I start by recognising the enormous amount of work that has gone into this from people working in the NHS and the department over a very long period, but the reality is that the plan is too late for those who are waiting for treatment today and are unable to get it, because the investment was not made in the workforce years ago for it to be available now on the front line. However, the plan certainly is substantive and there is much to welcome in it, looking forward. There are several areas where I hope the Minister can explain the Government’s thinking further.

First and perhaps most importantly, we need a similar, sister plan for the social care workforce. As we have discussed many times across these Benches, health and care work in symbiosis and both have seen too little supply to meet demand in recent years. Can the Minister confirm that the Government have no plans to further reduce capacity in social care by acceding to some of the requests from his political colleagues to limit visas being made available for essential social care staff? Can he say when the Government intend to release a sister plan to the NHS plan dealing with the social care workforce?

The plan also depends on ambitious productivity gains, and these will require certain things to be put in place. First, we need technology that will make life easier rather than more difficult for staff. Will the Minister explain what work is being done to understand how front-line staff in the NHS actually experience the technology they are being provided with, to ensure that we are not setting them back? Technology, when implemented well, leads to productivity increases, but technology poorly implemented can simply add to the frustrations of staff and make their jobs more difficult.

Another key factor in productivity is good management. This is a much less fashionable area to comment on than additional doctors and nurses, but the evidence seems to suggest that the National Health Service is actually quite lean in terms of its management. Will the Minister comment on what is in the plan to boost management capacity so that we can make savings on that other kind of consultant, the management consultant? Far too much is still being spent on externalising management expertise rather than building capacity within the service.

The final area I want to comment on is retention. The plan has hard numbers and new targets for getting new people into training but is much less precise on how we can improve staff retention over the long term. This is of course, quite importantly, a matter of pay and working conditions across all grades of staff. I invite the Minister to comment on some of the press stories we have seen saying that there seems to be some reluctance on the part of the Prime Minister to implement pay review body recommendations in full, something that he himself has said we should rely on to resolve issues particularly around junior doctors. Certainly, understanding that pay is important and that review body recommendations are going to be respected is critical for retention.

We can see that the Government have looked very closely at the specific factors that discourage senior doctors, in particular, from staying on as they approach retirement age. I suggest to the Minister that similarly detailed work needs to be done to understand the precise factors that are leading more junior staff at earlier stages in their career to leave the profession. Similar attention must be paid to resolving those specific issues if we are to address the retention problem.

One way we can motivate staff to stay on is through continuous professional development and retraining into more highly skilled roles, yet training opportunities can be constrained by the capacity of those delivering it. Can the Minister assure us that training opportunities will be provided for existing staff as well as new staff, so that we do not end up holding back Peter in order to train Paul? It will be net negative if we lose staff from the existing workforce through missed training opportunities as we bring in new staff. More generally, is there an understanding of how we are going to build up that capacity for training existing and new staff?

When I was younger, I had a teacher who would often write on my essays, “Okay as far as it goes”. This would annoy me, but with the benefit of wisdom and age I have to concede that it was often fair and accurate. Today, we might say that this plan, into which I know a huge amount of work has gone, is okay as far as it goes. We can be confident that it will really make a difference only if it is delivered in full, and in particular if there is a sister plan for the social care workforce and a real effort made on staff retention. I hope the Minister will comment on some of those aspects.

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

I thank noble Lords. Before I answer their points, and while I shall not repeat the Statement, it would be remiss of me not to repeat one thing, which is about Lord Kerslake’s passing. Lord Kerslake inducted me into government many years ago when I was a non-exec director at the Ministry of Housing, as it was then, and I always found him a very wise head and a very kind man. I am sure that condolences go from all of us, and particularly from me.

I welcome the constructive responses from the opposite Benches. As we have said, a huge amount of work has gone into this plan from some 60 organisations, including royal colleges, and it is an NHS document. I must admit that while I will take the description from the noble Lord, Lord Allan, of “Okay as far as it goes”, I prefer the description of Amanda Prichard:

“This is a truly historic day for the NHS”.


On a personal note, I am very glad not to have to answer about how quickly it is coming any longer.

On the detailed comments, the noble Baroness, Lady Merron, said that this is a living document, with the two-year update, and that is a critical part. I agree with her that this is going to be effective only if it is a live document that we continue to review, amend and improve as time goes on. On the quality management of staff, this comes to the point about retention. There is no silver bullet, as we know. I liken it to the approach we see in the cycling, in the Tour de France, with Team Sky: there are lots of little things that you have to do and it is the collective effect of putting those things together which really makes the difference.

Clearly, pay is an important element of that; the point of view of the pay review body is clearly going to be very important; clearly, pensions are a big move; clearly, professional development is a big part of it, not just for new staff but absolutely for existing staff as well. It is also about the conditions that people work in; it is not just the culture and leadership but the place they work in as well. That is why I am pleased that the capital parts of this are seen as very important in driving the right culture and environment that people want to work in: these are key to retention and driving productivity. The new hospital programme is a very important part of that, and so is the capital programme generally.

Equally, technology is a key part of this, as mentioned before, and that includes front-line staff. Just on Friday, I was at Chelsea and Westminster, where they showed me at first hand how they found the databases they were using really helpful, with basic patient tracking, making sure they were following them through the whole care pathway and managing their whole journey, so to speak. They were using it and enjoying it, if that is the right word, and that was key.

The point about NHS management and leadership is very important; this plan looks at the medical side, but we all know that leadership is so important for the effectiveness of hospitals and a key part of this.

The noble Baroness mentioned the focus on hospitals. Clearly, hospitals are a very important part of this, but underlying that is a key shift towards primary care and prevention. If you delve into the details of the numbers, you will see that the level of people who need to be trained for primary care is going up and that they are becoming a bigger proportion of the workforce. I think we all agree that that should be the direction of travel. To deliver that, we will need to look at the capital estate behind this and make sure that we have the GP surgeries and everything else in the right places.

I turn to social care. The increase in medically trained people can only be a good thing for social care and the sector as a whole. However, social care is not included here. It is difficult. We can make an NHS plan because we are the employer behind the NHS; whereas there are hundreds, if not thousands, of different employers in social care so it is not for us to make that plan. However, it is for us to make sure that we increase the supply of medically trained people, as set out in this plan. We know how important international workers are to that; we recognise that and the importance of visas. Notwithstanding that, the value of this plan is that, eventually, it will reduce our dependence on the need to recruit internationally. We will see it go from about 25% of recruitment, as currently, to about 10% because we are increasing the supply base and the pool of people who can do that, rather than making a change on the visa front.

As ever, I have tried to cover most of the points raised in the time available. I will follow up in writing on the rest, but I conclude by welcoming this report.

--- Later in debate ---

[Lord Markham (Con)]

I thank my noble friend. Dentists were pointed out in particular because so many of them go on to work not in the NHS but in private care settings. It is out for consultation, but I think that was the thinking behind it. For instance, even after five years, 93% of doctors are still registered and working in the health service; that is a lot lower in the dentist space. We are putting investment into that group and it is clearly perfectly reasonable to expect a return on that by a certain time.

[Lord Watts (Lab)]

My Lords, the Minister has set out the aims and objectives of the plan, which we all welcome, but does he understand that, unless we fix the care system at the same time, this plan is bound to fail? It could make it even worse, with staff moving from the NHS and away from care services. How will joined-up government address the problem of under- recruitment and low morale in the care service, which will make this plan either succeed or fail?

[Lord Markham (Con)]

I would like to think, as I mentioned before, that increasing the supply and training of the whole medical profession would help the whole sector. This is quite close to my heart; as I have mentioned before, my mum became a nurse later on in life and went through an apprentice-type route, for want of a better phrase. Having different entry points is a very positive thing. I sincerely hope that people going into a social care environment will see that as a building block to onward career progression and that it will set them up to take further qualifications later on in life, if they wish, in the nursing profession. We are looking to expand the whole sector, and the general belief is that that will benefit both social care and the NHS.

[The Deputy Speaker (Baroness McIntosh of Hudnall) (Lab)]

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

[Baroness Brinton (LD) [V]]

My Lords, while this NHS plan is welcome, can the Minister say whether this Government will undertake to commit to the plan and, crucially, to its funding and not change the number of education and training places, as happened last year and in too many previous years, causing chaos in planning for doctors, nurses and allied healthcare professionals? On hospital training places for junior doctors after they have finished their medical school courses, last year 790 medical graduates could not begin their junior doctor in-hospital training because the NHS did not have enough placements. Given that university medical school places are already capped and highly competitive, this is a complete waste of newly qualified medical graduates.

[Lord Markham (Con)]

It is absolutely a pipeline; some people might say, “Why are you not doing more earlier in this plan?”, but, as the noble Baroness says, there is no point training a lot of people at the university end if you do not have junior doctor places later in the system. That is why we are trying to get a sensible ramp-up so that we can build capacity into those places, recognising the point that the noble Baroness makes. On the numbers in the plan, we have set down £2.4 billion for the first five years of training and development, but the point about it being a live plan is that we will update it every two years. Given the data—this is an NHS document, not a Department of Health one—I would expect those numbers to change, as I would be amazed if we got it spot on first time. The whole point about making this an NHS living document that we can use and which updates is that we can all stick to the plan.

[The Lord Bishop of Exeter]

My Lords, we on these Benches very much welcome this workforce plan, in particular the expansion of places for training with a range of clinicians and the shift of gaze towards community care and prevention. Our anxiety very much mirrors that of the noble Baroness, Lady Merron, and the noble Lord, Lord Allan of Hallam. We notice that page 23 of the report says:

“This Plan is predicated on access to social care services remaining broadly in line with current levels or improving”.


That is a jolly big assumption given that the Care Quality Commission report tells us that there are vacancies of 10.7% in adult social care and of 13.2% in the home care services. Without an equivalent plan for social care, in our view this admirable workforce plan is unsustainable, so will His Majesty’s Government publish an equivalent plan for social care?

[Lord Markham (Con)]

As I mentioned previously, the NHS plan is something that we or the NHS can publish, being the employer. With there being hundreds, if not thousands, of employers in social care, it is clearly a different situation. What we can do is make sure that we put the investment into the sector, so that there is pull through in the number of places. Over the next few years, we are looking at an increase of up to £7 billion, which is about 20%. We know that, of that £7 billion, around 65% to 70% flows through to staffing and wages. We are seeing a massive investment on our side, which we are looking to lots of employers to fulfil. By increasing the number of medically trained people, we will be increasing the supply base to fulfil that demand.

[Baroness Harding of Winscombe (Con)]

My Lords, I too thank and commend my noble friend the Minister, the Secretary of State and the leadership of the NHS for producing an extremely good plan. It is historic, not because it is the first time such a plan has been written but because it is the first time in 20 years such a plan has been published. The Minister has commented a couple of times that this is a living plan—one that will be updated at least every two years. Could he confirm that those updates will be published every two years, and that this House will be able to debate and discuss them?

[Lord Markham (Con)]

That is absolutely my understanding. For it to be a living document, people clearly need to have input and to be able to debate it in exactly the way we are doing here today.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I remind the House of my membership of the GMC Council. The GMC has warmly welcomed the plan and its role in the expansion of medical education, the development of physician and anaesthesia associates, and the apprenticeship programme. I want to follow on from the point made by the noble Baroness, Lady Brinton. The key point the GMC has made is that it is absolutely essential that there are sufficient clinical and educational supervisors, particularly for the F1 grade—newly qualified doctors going into postgraduate training. NHS trusts will have to release more of their doctors to provide this. Is the department in touch with and talking to the chief executives of NHS trusts to ensure that, as the pipeline develops, there will be sufficient clinical supervision? This is essential in order to get the quality of doctors that we need.

[Lord Markham (Con)]

The noble Lord is correct that it is essential. I emphasise that this is an NHS document, and the whole point is that it does not look to go “zoom” on recruitment. There is absolutely the understanding that this is a pipeline that has to be built brick by brick. There is no point front-loading the number of university places if, as the noble Lord mentions, there is no follow-up behind it in clinicians. The plan has been developed from the bottom up, including with clinicians and the trusts. There is an understanding that they need to build their own part of the pipeline towards this as well.

[Lord Jackson of Peterborough (Con)]

I welcome this ambitious and comprehensive workforce plan and I concur with other noble Lords on the issue of social care. On the specific issue of medical school places, while I strongly welcome and commend the Government for responding to the campaign of many people—including Policy Exchange and its excellent Double Vision report, published earlier this year—my concern is the waste of resources and the talents of those thousands of A-level students who do not get university places to study medicine. While I welcome the focus on degree apprenticeships and the regionalisation of medical education, is there any chance that we could speed up the process? Another eight years to double the number of medical places is an awfully long time—it is almost the equivalent of two Parliaments.

[Lord Markham (Con)]

As for the A-level point and those people not being able to go on to universities, that is what the different routes are about. The different pathways that we are talking about include nursing associate training places, which we want to see increased to 10,000, and similarly with physician associates. While we all understand that having a university education is a fantastic medical grounding, there are many other ways to get there. I am sure we all have very good examples of fantastic clinicians who did not have a degree.

[Lord Harris of Haringey (Lab)]

I refer to my interest as chair of the General Dental Council. I welcome not only the whole document but the specific commitment within it to increase the number of dental training places by 40% by the beginning of the next decade. Does the Minister accept that simply increasing the number of dentists will not solve the problems of NHS dentistry if dentists decide that it is more lucrative for them to practise privately rather than through the NHS? This is only part of the process. If the solution to dealing with the problems of NHS dentistry is to essentially create a tied class of dentists who have trained and are therefore expected to work in the NHS, I am not sure that this will be sufficient.

I also raise a more general point which is nothing to do with dentistry specifically. Could the Minister tell the House what proportion in any one year of the number of people entering the workforce are expected to go into the NHS? My calculation suggests that they are expecting the figure to go up from 10% of those entering the workforce to 15%. What will incentivise that, and will it be addressed through the various pay processes that we have already referred to?

[Lord Markham (Con)]

I thank the noble Lord for the work he does as chair of the GDC. He will know that this is something that is quite close to my heart, given that my better half is a dentist. I completely agree that it is about far more than just the training places. I think the House has heard me discuss this before, but if we are serious about dentists who have been in practice for 10 years setting up their own clinic, maybe in an NHS Digital desert, we must give them guidance and support, as it is quite an ask to do that. We plan to produce and publish a dental plan in the not-too-distant future, in which I hope and trust that a lot of these points will be covered.

The noble Lord is correct; I do not know the exact maths behind it, but we spend roughly 12% of our economy on the health sector and so it is not surprising that roughly that number would be expected to go into the NHS workforce. In some ways, that shows the magnitude of everything we are talking about today. Probably one in eight of all people leaving school will end up in this sector—that really is a number worth thinking about and pondering over. As we all agree, it shows why this plan is timely and why it must be a living document that is continually adjusted as we go forward.

[Lord Young of Norwood Green (Lab)]

My Lords, I welcome this historic document. I concur with some of the concerns expressed by my noble friend on the Front Bench. Nevertheless, I believe it to be very significant. It addresses many important areas, such as apprenticeships and training, all of which I welcome. I could carp and say that we will check against delivery, and of course we need to. I hope we will have a proper debate on this plan at some stage, and I would welcome an assurance from the Minister on this. It merits a much longer debate; it is probably one of the most important issues that this House has discussed.

I am interested in dentistry because I recently visited my local dentist—a man of principle who converted a private practice into an NHS practice. I always get him to do my teeth, and he cleaned and scraped them and did all the necessary things, and he then took X-rays. I went to the desk to pay and the charge was £28.50— I could not get a plumber to come out for those prices.

If you do not reward NHS dentists—that dentist’s son and daughter are both practising dentists—they will inevitably go into private practice. If we are serious —I believe we are—about doing something, of course we have to look at the charges. I do not want to end on a negative note. I agree with those who have said that this is one of the most important issues that this House has discussed in a long time, and I welcome the Government’s actions.

[Lord Markham (Con)]

I thank the noble Lord. He is quite right to say that we need to check against delivery and he is quite right to hold us to account on that. Personally, I am happy to commit whatever time we need to debate this because I completely agree on how important it is. As I say, it is quite sobering when you think about the figures: as we said, we expect one in eight school leavers to go and work in this sector, so we almost cannot spend too much time on that.

As I say, the dental plan will be published shortly, and making sure that the balance is right, and that it is seen as an attractive option to be an NHS dentist versus working in the private sector, is absolutely an important part of that as well.

[Baroness Watkins of Tavistock (CB)]

My Lords, I very much welcome this plan and in particular the fact that we will start to deliver more homegrown healthcare workers; in fact, the WHO has applauded us for these moves because there is such an international shortage, not because overseas workers are not welcome here.

I want to ask one question. I very much support the concept of apprenticeships, but professional workers on registers, be that nursing, medicine, physiotherapy or paramedicine, expect apprenticeships to be degree-level apprenticeships, accepting that the entire workforce will not be graduates but that registered clinicians should be. Can the Minister please clarify that issue?

[Lord Markham (Con)]

I thank the noble Baroness. The whole idea of the apprenticeship is that the standard that you are training to is absolutely the same, albeit obviously you are getting there via a different route. However, as regards the capability, training and knowledge of that person, clearly, whichever route they have come from, they need to be at that same required level. That is why the royal colleges have been such an important part in the development of this whole plan.

Mental Health In-patient Services: Improving Safety

Lord Markham Excerpts

Monday 3rd July 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, I am grateful to have an opportunity to discuss mental health provision, and my comments will very much follow on from those of the noble Baroness, Lady Merron. We are also interested in the Government’s latest thinking about the draft mental health Bill. Now that the workforce plan is out—we will discuss it tomorrow—our new refrain may be, “When will the Government get on with the mental health Bill?”. It is long overdue, and a huge amount of work has gone in that is clearly fundamental to trying to deal with some of the structural issues.

Turning to some of the issues raised in the Statement, I first want to ask about people’s journeys when they are in need of mental health support. The Statement said that 111 will now provide mental health advice, which is very welcome, but can I ask the Minister for his thoughts on what is happening in primary care? My understanding is that at the moment mental health nursing provision is not a requirement of all general practices—some offer it and others do not. Can the Minister, who I know cares about joined-up, seamless services, give us some insights into the Government’s thinking on ensuring that people who present with mental health problems to general practice—which is the first port of call for many of them, before they even get to 111 or 999—see more consistency of support available at that level?

Thinking about the review—a major part of what is in the Statement—a significant proportion of providers of mental health in-patient services are private sector, which has been the case for some time. Can the Minister confirm that they will be included in the review and comment on whether the inspectorate’s powers will be applied equally to the private and public sectors? That is critical to understanding what is happening in all settings.

Will the Minister also talk a little about the input the review may get from related services? Again, we know that the police, local authorities and accident and emergency departments often pick up the pieces where mental health provision has not been made available. Can the Minister assure us that the review will also look at all those other parties to this journey of care that people require? Can he also comment on the data questions? I have seen evidence from freedom of information requests to the Office for National Statistics asking about deaths of people in mental health in-patient settings. My understanding is that the data is not recorded consistently. If we are to have a review and to understand what is happening in the mental health sector, it would be helpful to know what measures the Government will take to improve the consistency of data collection so that, when someone unfortunately suffers a tragic incident, we know where they were at the time and have the data available to build up the national pattern.

The final issue I want to ask for the Minister’s comments on is out-of-area placements. Will he acknowledge that it remains a serious issue that many people with serious mental health conditions are able to get treatment only in places that are far from home and therefore far from their families and support networks? I note from the Statement that the Government are providing three new hospitals. This is of course welcome, but I hope the Minister will also be able to confirm that there is a locality-based strategy, with the Government thinking hard about matching local facilities to local need so that we can end the situation in which people at a time of extreme distress are sent very far away from home, which can only add to the crisis they are facing.

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

I thank noble Lords for their questions and their general welcome for the Statement. On timing, we had hoped that doing it on a non-statutory basis would have been sufficient. The advantage is that you get the results that much quicker; you can often get them within a year, versus three years. We have many examples of where it has worked quite well, such as the Kirkup report. To answer the question of why it is taking so long, in the first place we had hoped that doing it on a statutory basis would not have been necessary. There was a course correction in January, when we were not getting the response we needed and not enough staff were making themselves accessible. There was some improvement at that point, but it was felt by the chair that it was not sufficient, hence the decision now.

We believe that we can build on the work that has been done so far, so we are not starting again from zero. However, there are some lessons. On a number of occasions, trusts and staff have responded well to a non-statutory inquiry, but we have learned from this that sometimes it needs to have the teeth of a statutory inquiry so that it is taken seriously enough. Somehow, there was an impression that, because the inquiry was not statutory, it was not seen as serious enough to trigger that. There is a key lesson to learn from all of that.

How we can seek to restore confidence is absolutely the right question to be asking. We believe that the additional investment of £2.3 billion that we are putting into this space is a key part of that, and the increase of 27,000 staff is another. We are learning from the reviews that we are doing, and we are quickly learning from the rapid review. We are working fast, so I cannot give an exact date for those results. We asked for it to be a rapid review so that we could get on with it and make the most of the findings.

The other key part of this is the Healthcare Safety Investigation Branch. We are asking it to look into a number of questions, one of those being out-of-area in-patients and the impact that has. I think we all agree that it is best if people can have in-patient services locally. That is one of the key parts that it will be asked to review. On the timing of that review, it will start in October and should be able to conclude within a year. We should get results back quite quickly.

On the timing of the mental health Bill, we are working through the parliamentary calendar now. We do not know the timings yet, but the scheduling is being looked at.

The noble Baroness mentioned the prevention agenda. I completely agree that care in the community and the training of staff in GP settings and schools are vital to this. As noble Lords have heard me say at the Dispatch Box before, we are making good progress: about 35% of schools are trained up in mental health support. Last year it was only 24% and next year we think we will be pushing 50%. Those are big increases, but I freely accept that 50% is not 100%. A lot of progress is being made in that area but we accept that a lot more needs to be done.

As for the private sector being included in the review, I have every reason to think that it should be and that there should be equal powers, but I will check that. I am talking off the top of my head now as it seems perfectly sensible, but I will come back properly on that.

I will do likewise with the comments on the recording of and use of data. Again, one of the rapid review findings was that we do not have enough real-time data. That is very much the direction of travel but, again, I will come back with more detail. As ever, noble Lords will know that I like to bring all these things together in a lengthy letter where I hope I am able to cover any points I did not cover here.

There are steps in the right direction, and the investment I talked about is another step in the right direction. I completely agree with the emphasis that it is vital we restore confidence in this area.

--- Later in debate ---

[Baroness Buscombe (Con)]

A question is coming. I was accompanied by a brilliant consultant, Julia Riley. She has not even had a cursory note of thanks from those civil servants. Could the Minister therefore please respond by giving a little more detail on the timing? Could he also let me know whether there has been any progress on developing that particular app? I would also like to know about the implementation of safe places, where people can go when they are in crisis.

[Lord Markham (Con)]

I thank my noble friend for her tireless work in this space. We believe that a number of constructive points were made in the committee report, which I know Maria Caulfield is working on and looking to get a timely response to. Maybe that is something on which we can meet up and discuss later.

[Baroness Uddin (Non-Afl)]

My Lords, I raise the issue of the mental well-being of men from black and Asian backgrounds. I particularly raise the issue of the care they are receiving at the hands of very poorly qualified, untrained, unsympathetic people, who do not adequately understand the complexity not just of mental health and well-being but the way that they should be operating. They are not working in tandem with the families, which is one of the requirements. There have been suggestions from a number of community organisations that black and Asian men are four times more likely to be detained, and sometimes it is more than likely that there has not been any consultation with their families, which is one of the prerequisites. Can the Minister assure this House that any formal forward-thinking and examination of these issues is looking at the disproportionality of the effects and the causes of very poor services, particularly for men from black and Asian minority backgrounds?

[Lord Markham (Con)]

Yes, we are very aware of the points made very well by the noble Baroness, including some of the stats on the community treatment orders and the fact, I believe, that if you are a black male, you are eight times more likely to be detained. I know that that led to some of the recommendations from the pre-legislative scrutiny committee. I can give an undertaking that that will be fundamental to what we are trying to do here.

[Baroness Watkins of Tavistock (CB)]

My Lords, I welcome the Statement, but I will raise two issues. First, it seems that several different bodies will look at what the problem is, yet the ombudsman has just said that it is absolutely imperative that

“The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like”.


Could the Minister comment on how that will be considered in tandem with the proposals outlined in the Statement?

Secondly, will the proposals look at a safe staffing model for all in-patient mental health services? In fact, in-patient services are really looking after only those people who have severe mental health problems; they are almost the equivalent of an intensive care unit in a general hospital. Increasingly, staff do not have time for proper continuity of handover when they leave shifts, and that needs to be examined. It is relatively easy to describe somebody’s blood pressure and blood stats in an intensive care unit as you hand over in a general area, but to describe the complexities you have been working with, for example with somebody who has severe schizophrenia and is deluded and paranoid, takes a good 10 minutes in a handover. I would welcome the Minister’s comments on how we will look at ensuring that that is considered when measuring safe staffing.

[Lord Markham (Con)]

I thank the noble Baroness. The points she rightly makes are exactly what we believe is the remit of the new HSSIB review starting from October. One of the specific points is about developing safe therapeutic staffing models for all mental health in-patient services. I think and hope that the exact points raised by the noble Baroness will be addressed by the review.

[Lord Bradley (Lab)]

My Lords, the Government’s draft mental health Bill proposes—and I and the Joint Committee support this—the banning of prisons as a place of safety and the transfer of patients within 28 days of the mental health assessment to a safe mental health secure unit. Will the Minister ensure that this is included in the national review, so that there are sufficient local safe secure facilities to implement the 28-day recommendation and that these patients are cared for in genuine places of safety?

[Lord Markham (Con)]

I understand the concern brought, quite rightly, by the noble Lord. It would be best for me to write on that, so that I can give the specific position and he can have the detail he requires.

[Baroness Berridge (Con)]

My Lords, I am a member of the Joint Committee. We heard compelling evidence from the Independent Advisory Panel on Deaths in Custody that, although there is always an inquest into an unexplained death, there is the unique situation where if you die detained, in effect, by the state but in a secure mental health institution—as opposed to a prison, police cell or immigration detention centre—there is no independent investigative body to investigate the circumstances around your death. Given that this independent inquiry will look at a series of deaths over 20 years, will it be within its remit to look at whether or not, had there been some kind of independent investigation of those deaths, the themes and problems faced by the trust might have been spotted earlier?

[Lord Markham (Con)]

We see that as being very much in the remit of the Health Services Safety Investigations Body. In fact, the first thing we are asking it to do is to consider how we can learn from those unfortunate deaths, where they have taken place, in terms of their care. The intention is that it will report back. It will start in October and will report back on that within a year, so that we can get some rapid findings.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the Minister return to the contribution from the noble Baroness, Lady Watkins? I note that the HSSIB has been asked to look at and develop a safe staffing model for in-patient services, but I re-emphasise the point made by the noble Baroness: you cannot look at in-patient services only; you have to look at the whole spectrum. Surely, he accepts that. For instance, with young people, the huge waiting times for CAMHS services, which eventually lead to some of them being out-of-area placements, is shocking. Surely, HSSIB should be looking at the whole picture. Can he also say how this will relate to the workforce plan? In other words, will the conclusions of HSSIB’s report go forward into the workforce plan, so that for the future we are developing enough people in the mental health field?

[Lord Markham (Con)]

As I am sure the noble Lord is aware, the second thing that the HSSIB is being asked to look at is exactly the point about how people are cared for as in-patients and how we can improve that approach. On staffing—again, we will debate this more tomorrow night following the Statement repeat—it is vital that there is a feedback loop in terms of the long-term workforce plan. That feedback loop, as I am sure noble Lords are aware, is built into it, so that when new data comes along, as will potentially be the case with the HSSIB, there is a way for that to feed back in again.

[Lord Harris of Haringey (Lab)]

My Lords, I will follow on from the point made by the noble Baroness, Lady Berridge. Until 2015, I chaired the Independent Advisory Panel on Deaths in Custody, which covered the more high-profile areas of deaths in police and prison custody. However, the largest number of deaths under the care of the state was in mental health institutions. The noble Baroness, Lady Berridge, asked about independent investigations and the Minister said that the review will look at what lessons can be drawn. The point is, however, that over the last 20 to 30 years, there have not been independent investigations into the individual deaths, so how will there be an evidence base to decide whether proper lessons were drawn at the time and whether those were acted on?

Secondly, my noble friend Lord Hunt of Kings Heath talked about the difficulties with CAMHS. There is a gulf at age 18 between people being treated under CAMHS and then going into adult mental health services. What are the Government doing to bridge that gap? People who may have received some support from CAMHS then lose it when they go into the adult sector.

Finally—I know I should not ask three questions, but I want to—one of the striking things about the number of deaths that occurred in mental health institutions is that many arose from physical causes. It was not about people committing suicide or their mental health crisis; it was the fact that in a hospital, a place of medical provision, they were not getting adequate physical healthcare. What are the Government doing about that?

[Lord Markham (Con)]

I thank the noble Lord for his commitment in this area over the years. With regard to the first question about past evidence, clearly the HSSIB will be looking at what evidence exists. As the noble Lord said, some investigations go back 30 years, so there will not always be circumstances where it can pick out that evidence, unfortunately. However, where there is that information, we are trying to make sure that we pull it out and learn from it. That is very much the direction of travel. Clearly, if part of the HSSIB’s findings is that we need to make sure that every death in such circumstances is investigated under a certain pathway, then I am sure that will come into its recommendations. In terms of the other questions, I think it is best that I write to the noble Lord, if I may.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Statement includes a number of themes which it is expected the new Health Services Safety Investigations Body will consider. Not included in that list, however, is the growing role of private provision in NHS mental health care services. This is something that patient groups and others are expressing considerable concerns about. Take, for example, the Priory, where the Care Quality Commission reported that the number of deaths at its sites rose nearly 50% from 2017 to 2020. One of those was the tragic death of 23 year-old Matthew Caseby. An inquest jury concluded that his death was contributed to by neglect, and the coroner issued a prevention of future death report because of continuing risks.

The Priory Group earns more than £400 million from the NHS, and much more from social services. It is now owned by a Dutch private equity firm after it was sold by its former owner at a loss and is financed by a sale and leaseback deal of 35 properties with rents subjected to annual inflation-based escalators. Through the mechanisms in this Statement or others, are the Government going to consider the risks presented by private ownership—particularly private equity ownership—of mental health care services?

[Lord Markham (Con)]

As noble Lords are aware from some of my previous answers, I think the key thing is the quality of output rather than the ownership of an institution. Around the House, we have very good examples of where we believe the Government need the help of the independent sector to increase supply and capacity. That always needs to be done with the right quality of regulatory regime, and that is what we have put in place. From my point of view, I am always going to be looking at the quality of the output and not the ownership of a company.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, on the Minister’s last observation, I think there are a number of noble Lords here who would say that the quality of the output has not been that great from some private providers. It is just an observation.

However, the question I want to ask will take us back to the original observations by the noble Baroness, Lady Buscombe—I was also a member of the Joint Committee. The Minister gave a very brief reply to her questions about what has happened to the many recommendations, the vast amount of evidence and a great deal of hard work that went into producing that report. He even mentioned that it was going to be responded to in a “timely” manner. I think the moment for that has passed. Will the Minister have another go at explaining what has happened to the report and when there will be a response to it?

[Lord Markham (Con)]

I am afraid I do not have the timing of a response on that. Minister Caulfield is very engaged in this area. A number of things have been mentioned. I mentioned the community treatment orders, where we are very mindful of the point made earlier by the noble Baroness, Lady Uddin, about black males being eight times more likely to be given one, and the recommendation that they should be abolished altogether. Those recommendations are very much in our thinking and our knowledge base. I know that Maria Caulfield is working on them, but I am afraid I cannot give the noble Baroness an exact time yet.

Lung Cancer: Screening

Lord Markham Excerpts

Monday 26th June 2023 Lords Chamber

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

My Lords, with the leave of the House I shall now repeat a Statement made earlier in the other place by my right honourable friend Steve Barclay, the Secretary of State.

“With permission, I would like to make a Statement on our national lung cancer screening programme for England. Around a quarter of patients who develop lung cancer are non-smokers. We all remember our much-missed friend and colleague, the former Member for Old Bexley and Sidcup, James Brokenshire. He campaigned tirelessly to promote lung cancer screening and was the first MP to raise a debate on this in Parliament. His wife Cathy is continuing the brilliant work that he started in partnership with the Roy Castle Lung Cancer Foundation.

In 2018, after returning to work following his initial diagnosis and treatment, James told this House that the Government should commit to a national screening programme and use the pilot to support its implementation. As I am sure many colleagues in the Chamber will recall, he said:

‘If we want to see a step change in survival rates—to see people living through rather than dying from lung cancer—now is the time to be bold.’—[Official Report, Commons, 26/4/18; col. 1136.]


Despite being a non-smoker, James knew that the biggest cause of lung cancer was smoking and that the most deprived communities had the highest number of smokers. That is why I am delighted that today the Prime Minister and I have announced targeted lung cancer screening programmes at a national level, building on our pilot, which will be targeted at those who smoke or have smoked in the past.

Lung cancer takes almost 35,000 lives across the UK every year—more than any other cancer. Often, patients do not have any discernible symptoms of lung cancer until it is well advanced; in fact, 40% of cases present at A&E. Since its launch in 2019, and even with the pandemic making screening more difficult, our pilot programme has already given 2,000 lung cancer patients in deprived English areas an earlier diagnosis. That matters because when cancer is caught at an early stage, NHS England states that patients are nearly 20 times more likely to get at least five years more of life to spend with their families.

We all know that smoking is the leading cause of lung cancer. It is responsible for almost three quarters of cases, and in deprived areas people are four times more likely to have smoked. We have deployed mobile lung trucks equipped with scanners to busy car parks in 43 deprived areas across England. Before the pandemic, patients from those areas had poor early diagnosis rates, with only a third of cases caught at stage one or two. To put that in context, while a majority of patients diagnosed at stage one and two get to spend at least five more years with their children and grandchildren, less than one in 20 of those diagnosed at stage four are as fortunate. Thanks to our targeted programme, three quarters of lung cancer cases in those communities are now caught at stage one and two.

Targeted lung cancer checks work. They provide a lifeline for thousands of families. We need to build on that progress, which is why we will expand the programme so that anyone in England between the ages of 55 and 74 who is at high risk of developing lung cancer will be eligible for free screening, following the UK National Screening Committee’s recommendation that it will save lives. It will be the UK’s first and Europe’s second national lung cancer screening programme. If results match our existing screening—there is no reason to think that they will not—when fully implemented the programme will catch 8,000 to 9,000 people’s lung cancer at an earlier stage each year. That means that each and every year around 16 people in every English constituency will be alive five years after their diagnosis who would not have been without the steps we are taking today. That means more Christmases or religious festivals with the whole family sitting around the table.

Alongside screening to detect conditions earlier, we are investing in technology to speed up diagnosis. We are investing £123 million in AI tools such as Veye Chest, which allows radiologists to review lung X-rays 40% faster. That means that suspicious X-rays are followed up sooner and patients begin treatment more quickly.

How will our lung cancer screening programme work? It will use GP records to identify current or ex-smokers between the ages of 55 and 74 who are at a high risk of developing lung cancer, assessed through telephone interviews. Anyone deemed high risk will be referred for a scan and will be invited for further scans every two years until they are 75.

Even if they are not deemed at high risk of lung cancer, every smoker who is assessed will be directed towards support for quitting because, despite smoking in England being at its lowest rate on record, tobacco remains the single largest cause of preventable death. By 2030, we want fewer than 5% of the population to smoke. That is why in April we announced a robust set of measures to help people ditch smoking for good, with one million smokers being encouraged to swap cigarettes for vapes in a world-first national scheme. All pregnant women will be offered financial incentives to stop smoking, and HMRC is cracking down on criminals who profit from selling counterfeit cigarettes on the black market.

The lung cancer screening programme has been a game changer for many patients: delivering earlier diagnoses, tackling health inequalities and saving lives. We are taking a similar approach to tackle obesity, the second biggest cause of cancer across the UK. The pilot we announced earlier this month will ensure that patients in England are at the front of the queue for innovative treatments by delivering them away from hospital in community settings. Together, this shows our direction of travel on prevention, which is focused on early detection of conditions through screening and better use of technology to speed up diagnosis and then treatment, because identifying and treating conditions early is best for patient outcomes and for ensuring a more sustainable NHS for the next 75 years. I commend this Statement to the House.”

--- Later in debate ---

[Lord Allan of Hallam (LD)]

My Lords, I would like to follow the noble Baroness, Lady Merron, in welcoming the Government’s acceptance of the National Screening Committee’s recommendation to introduce a targeted lung cancer screening programme, and echo her tribute to the late James Brokenshire, whom I dealt with in a previous capacity when he was a Minister advocating for child safety online. I found him to be very effective; a firm Minister who was also very pleasant to deal with—the most effective model for all of us.

The new programme is especially welcome as a step towards addressing the glaring health inequalities we face in the United Kingdom. I hope the Minister will reassure us that sufficient data will be collected in order to understand whether it is having the kind of impact the Government intend, as he outlined in the Statement.

I hope the Minister can also provide more information about how it can be delivered, given that we already have dire shortages in capacity to deliver diagnostic tests. This shortfall is reflected in today’s report from the King’s Fund, which shows a serious gap in CT and MRI scanner capacity between the UK and comparable countries. When can we expect to see investment from the Government in additional scanners, to bring us up to something more like the international mean? As well as the lack of machines, we do not have sufficient people to operate them or to assess the test results. I invite the Minister to refresh his formula for when we may see the long-awaited NHS workforce plan, including the element that relates to radiologists, perhaps updating it from “shortly” to “in the next week”, as it surely has to come before the 75th<sup>anniversary of the NHS on 5 July.

The concern we continually have with announcements of new services by the NHS in the current context is that they will come at the expense of existing services; the noble Baroness, Lady Merron, also referred to this. I believe this is a rational and reasonable concern to have, given the evidence of missed targets and unacceptable wait times that is all around us. I hope the Minister can give us further assurances that, as the Government will the end of catching more cancers earlier, they will also be willing to will the means to deliver on this promise.

Anyone with eyes in their head can see that vaping is being cynically promoted to young teenagers; it is all around us in high street shops and in the evidence from the litter around schools. The Statement refers to the role of vaping as a tool to help existing smokers give up their harmful habit, but there is increasing evidence that vaping is creating new nicotine addicts, with associated risks. The Australian Government have found that young people who vape are three times as likely to take up smoking, and they have plans to bring in a range of measures to suppress vaping among young non-smokers. Can the Minister explain what assessment the UK Government have made of the Australian evidence of vaping leading to higher smoking prevalence among young people, and are the UK Government considering similar measures to reduce vaping use here? It took us five years to follow Australia in introducing plain packaging for cigarettes. I hope we can follow faster here, on vaping.

The new screening programme is welcome, but it must be properly resourced with both machines and people. I hope the Minister can give us some insights into how that will happen, and at the same time explain what action the Government intend to take to reduce vaping among non-smokers, so that we do not end up creating a new wave of people who are at risk of lung cancer.</sup>

[Lord Markham (Con)]

I will start with a small correction to the Statement. It should have said:

“We are investing £123 million in AI tools such as Veye Chest, which allows radiologists to review lung”


scans, not X-rays. I do not whether the etiquette is that I should have said that during the Statement. I repeated the Statement verbatim because I was told I should, but the correct word is “scans”.

I thank both the noble Baroness and the noble Lord for their comments and support. I too had the pleasure of working with James Brokenshire, and I realise what an effective and kind person he was. Like others, I am delighted that we are making these positive steps today and welcome the constructive and supportive comments.

Regarding trying to show that we are matching the will with the means on MRI scanners, that is exactly what the 100-plus CDCs are all about. It is a recognition that we do not have the same diagnostic capability, as highlighted by the King’s Fund report. That is what the investment in those centres is all about. My understanding is that about four million tests have already been done, so we are looking to match that. We will need 184 radiographers and 75 radiologists to do this work, but the other big support will be the use of AI. We are seeing some promising technology, which will help to a large degree. I am glad to say that a lot of this will be set out in the long-term workforce plan in the coming days—a new formulation. In other words, pretty soon.

In terms of the comments about screening being targeted at those most in need, that is where I have been most pleased by the pilots. Use of the mobile trucks really made a difference in those areas most in need. It really made a difference in the most deprived areas, which, as the noble Baroness, Lady Merron, mentioned, have higher levels of smoking. I am glad that it is targeting those areas.

Can we work to hasten the timetable? I think we would all like to but what we are trying to do here is to put down plans that we are confident we can hit. To answer the money question, it is £1 billion of extra investment during that time and that increases over time so that by the end it is about £270 million extra per annum.

What does that mean in terms of the Dr Khan responses? As I mentioned, we are committed to the smoking cessation results. As part of that we are considering all the points in the Khan review. I think we all accept that vaping is much better than smoking. We are very much trying to encourage vaping over smoking. But you have to be careful of the side-effects of that. As we have seen, vaping can be used in a somewhat cynical way—to borrow the phrase—with young people. More work undoubtedly needs to be done in that space but it is recognised that there needs to be a balance. I think I will need to come back in writing on air quality and cystic fibrosis.

I have tried to cover the points at this stage and look forward to further questions.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I have two questions. My first question is about the timeframe and the role of GPs. The Statement says that, using GP records, current and ex-smokers aged 55 to 74 will be assessed by telephone interviews. Will that require resources from GPs? We all know that there are many different computer systems so where are the resources going to come from? Specifically on GPs, I can well imagine at many GP surgeries tomorrow morning at that terrible time of 8.30 am as everyone frantically tries to hit the dial button that a lot of people will be asking for a scan. Have GPs been equipped to handle that? Do they know what to say and how to manage that kind of scenario?

My other question follows on from the questions about the Khan review. That said that we are grossly underfunding things. Mass media campaigns in particular are funded at 90% under what is needed, while other services are about 50% underfunded. Surely we have to stop these cases happening. Can we see a commitment from the Government within some sort of timeframe to say that we are going to put more money into this?

[Lord Markham (Con)]

I thank the noble Baroness. In terms of identifying the smokers, the telephone is just one way of doing it. The hope is that using the digital data and the app means that more of these things will be on people’s records and identified with them. As ever with these things, electronic means will be the best way to do that, albeit those telephone resources in terms of supporting the GPs are very much part of the plan. It is understood that GPs have a large burden at the moment.

There is not a lot more to add about the Khan review. The ambition is still there to be smoke-free by 2035 and investment has gone behind that. The best example of that, as has been mentioned, is people swapping cigarettes for vapes as one means to do it. Undoubtedly, a lot more needs to be done in that direction as well.

[Lord Kennedy of Southwark (Lab Co-op)]

My Lords, I join noble Lords in paying tribute to James Brokenshire. I met him a few times, and it was a tragedy when he lost his life after a brave fight. I also pay tribute to the work his wife continues to do in his name.

This progress is to be welcomed, but can I say—if nobody else is going to come in—that cancer takes many forms? One area of cancer where we need to make much more progress is that of brain tumours and glioblastomas. We all remember our dear friend Tessa Jowell, who died on 12 May 2018 of a brain tumour. My brother John was a cab driver. Many people would not know my brother; he was just a cheeky, funny London cab driver who had a view on everything and who was loved by his family. He died on 26 March this year at 57, having fought a brain tumour for nearly three years. Our dear friend Baroness McDonagh was mentioned in the other place today. She died on 24 June at 61. She was my friend for 42 years; I met her when I was 18.

It is devastating. There has been no progress in this area of cancer treatment. There are quite clear inequalities, partly because only about 3,500 people a year get glioblastomas, so there are not huge numbers. There is no research, no trials and no hope—it is a death sentence. That cannot continue. We are no further than we were 30 years ago in this area. What happened today is brilliant, and I think there is now an 85% survival rate for breast cancer and that the rate for bowel cancer is 55%. However, brain tumours are virtually a death sentence. We have to improve that. It is an outrage that people can die so young from them and that there is no hope.

I do not expect an answer from the Minister today; I just want to put down a marker that I and other colleagues here and in the other place will keep mentioning this. I refer all colleagues here to the wonderful speech made by my honourable friend Siobhain McDonagh MP—my friend Margaret’s sister—when she talked about her sister and the treatment she had to undergo. I saw Margaret about three or four days before she died; it is a real tragedy, as is my brother’s case. I hope we can all work together and with the cancer charities, and that we can get some research done, put some money in and improve the situation. It cannot carry on.

[Lord Markham (Con)]

I thank the noble Lord, Lord Kennedy, and I am sorry for the loss of his brother. I agree with his sentiment that while this is good news today and is welcomed by all, it shows that this is a journey and that we need to do more in lots more areas. I take on that point and say, from our point of view, that we agree that we must work together to make further progress.

[Baroness Merron (Lab)]

Could I give the Minister another opportunity to pick up on the key point I raised? We very much welcome the improved diagnosis rates—and my noble friend Lord Kennedy makes a very pertinent point that, of course, we are talking not just about one cancer. I thank him for sharing his views and feelings with your Lordships’ House. That takes me to my reminder to the Minister: I asked about matching improvements in diagnosis with improved access to treatment; otherwise, we are leaving people diagnosed but not matching it by giving them the treatment they need in a timely manner. Could the Minister assist with that point?

[Lord Markham (Con)]

I am sorry; I was answering in a generic format in terms of the new CDCs. The noble Baroness is quite right that diagnosis is one thing—and we all know that the early stages are key—but you then have to follow that up with treatment. Of course, the good news is that if you can detect cancer in people at the earlier stages, they need less treatment. The resources I mentioned, in terms of what is being spent on the programme, take into account the treatment required as well.

Of the people being identified at this stage, only 1.4% from the pilot were then positive and needed treatment, thankfully. Obviously, those resources are in place. There is a second interesting category of people—about 17% or so—who are fine but we want to make sure that what has been noticed is in an okay state.

I am going to grab my notes to make sure I am referring exactly to the right term at this stage. I apologise; about 1.7% have nodules, which is not a problem per se, but it is a problem if those are growing. The idea is that we will be getting those people back in for frequent scans on a three- to six-monthly basis and using AI technology to see whether or not the nodules are growing. If they are not growing, it is not a problem, but we then keep up the frequency of scans. Obviously, if they are growing, that would be a concern at the early stages, and that would then move them into the treatment category.

The other 80% or so of people fortunately will not have any concerns from the scan at all. At that stage, they will be put into this continual programme, where they will be reviewed every couple of years to make sure that we keep on top of it. I hope that this shows that this is a well thought-out, entwined service, with the idea being that for the 1.4% who are identified as needing cancer treatment, the treatment is there to back them up.

NHS Procurement: Palantir Contract

Lord Markham Excerpts

Thursday 22nd June 2023 Lords Chamber

[Baroness Brinton]

To ask His Majesty’s Government, in light of the contract awarded to Palantir, what plans it has to ensure that NHS contracts are procured through a public and transparent tender system as outlined in the Procurement Bill.

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

All NHS contracts are procured using correct procedures. This is a new transition contract with Palantir, with new and improved contract terms, including robust exit and transition schedules to support transition from Palantir to the new federated data platform supplier. This contract includes additional terms, such as termination for convenience and a six-month break clause. The contract was procured by a compliant and transparent direct award tender process, using a Crown Commercial Service framework agreement.

[Baroness Brinton (LD)]

My Lords, it is not the first closed contract used that way, particularly for Palantir, since 2020. Ministers deliberately excluded the NHS from the new rules in the Procurement Bill, giving the Secretary of State for Health the powers to create regulations, resulting in untransparent closed contracts such as the £24 million Palantir contract just granted. Unlike every other public body and government department, senior NHS leaders are excluded from any restrictions when they move to providers, as happened last year when two senior staff moved to Palantir. These NHS practices are the exact opposite of what the Government hope to achieve in the Procurement Bill. Will Ministers please reconsider bringing the NHS under the Procurement Bill?

[Lord Markham (Con)]

This was a very sensible move to ensure that the tender process we are going through at the moment allows us to transition to whoever wins the federated data platform. That is a sensible way to do it. It was done according to the Crown Office pre-tendering framework agreement, which is very transparent and well set out. It is normal in these situations that, when you need transition arrangements, you do not want hospitals left in the lurch. You need a transition so that, whoever wins the new bid, hospitals are safe in the meantime.

[Lord Berkeley (Lab)]

My Lords, it is quite easy to invent rules to get away from competitive tender and do direct awards. It goes back to the Horizon Post Office scandal, which is still there 30 years on. Why is this contract exempt from competitive tendering? What is the benefit? Given that the Procurement Bill requires it, why are the Government not doing it?

[Lord Markham (Con)]

As I said, there is a very clear benefit. We are going through the process of a very large £500 million contract for a data platform that will be key to the NHS. Everyone agrees on the importance of data in health work, but we want to make sure that we have an open process so that suppliers have a chance to win the contract. In any circumstance, you need to make sure that transition arrangements are in place; otherwise, the current supplier is the one most likely to win—if there is a concern about ongoing procedures. By having a transition arrangement in place—clearly, transition can work only with the current supplier—you are making sure that there is an open process for new bidders to come in.

[Lord Fox (LD)]

My Lords, the reason the Minster is able to call this contract “sensible” is that it follows on from a contract given to Palantir that was already granted without tender. This is compounding one after another. To return to my noble friend’s original point, can the Minister tell your Lordships’ House why all other public services will be subject to a Procurement Bill that hopes to deliver transparency, fairness and ethical purchasing, yet his department is exempting itself from the Bill?

[Lord Markham (Con)]

This went through the long-term plan in 2019, and the idea behind it all—it was debated a lot as the Health and Care Act went through—was to provide an approach which allows the flexibility in place here. What we are doing here is very good: I do not think anyone would want to see hospitals left in the lurch and the impact that would have on waiting lists. This makes sure that we have a robust situation in place so that we have an open tender, which we are going through the process of right now to get the best solution for the NHS—something which I think we all want.

[Lord Lansley (Con)]

My Lords, my noble friend will recall that the review led by the noble Lord, Lord Carter of Coles, and followed up by Professor Briggs with the Getting it Right First Time programme, has made significant improvements in how the NHS procures its services. During the debates on the Procurement Bill—I hope my noble friend will say that this will indeed be taken up in the NHS—we talked about the promotion of innovation through public procurement. I wonder whether the Getting it Right First Time programme could be a mechanism for that, by bringing evidence-based innovation to the attention of procurement managers across the NHS.

[Lord Markham (Con)]

I thank my noble friend. This is absolutely about enabling innovation: the data platform is there so that providers can use it to innovate. We all hear about AI, and AI depends on data. This puts in place a data platform that AI can use. It can also be used for scheduling appointments—currently done in 32 hospitals—and for the dynamic discharge of waiting lists. All those applications can work in place only if we have an open tender process, which is exactly what we are doing here, while making sure that transitions are in place so that no hospital is left in the lurch in the meantime.

[Lord Alton of Liverpool (CB)]

My Lords, one of the issues raised during the passage of the Procurement Bill and, certainly, in the context of transparency, efficiency and getting value for money, was the keeping of some 118 million items of PPE in storage in the People’s Republic of China, at a cost of millions of pounds to British taxpayers. I have also raised this directly with the Minister. Can he give us an update as to what has happened to those items? Will they stay in storage? Are we continuing to pay and, if so, at what cost, or are we going to dispose of them? What lessons have we learned from that?

[Lord Markham (Con)]

As I said in a previous Answer, we are in the process of disposing of those contracts. On many occasions, it is easy to look with hindsight. Noble Lords may remember that, at the time, there was a massive rush and countries were gazumping each other to get hold of PPE. It was very much the feeling of this House, and all the people in the UK, that we had to desperately contract suppliers to do it. Did we make mistakes? Yes. Were we right on more than 90% of occasions? Absolutely. To keep the front line going, we needed to order more than 9 billion essential items, and we did so using the very system that we are talking about here in respect of Palantir. There are circumstances—Covid is a prime example—where it is appropriate to do those sorts of direct awards. That notwithstanding, I think we all fundamentally agree that an open, transparent and competitive tendering process will always be preferable.

[Baroness Hayman of Ullock (Lab)]

My Lords, the £25 million contract awarded this week is a drop in the ocean compared with the £480 million that is on its way. The scope of the federated data platform is vague, but there is no doubt that the data it stores will be both vast and sensitive, so it is vital that any procurement process is fair and transparent and enables the public to engage with it so that the system works as intended. However, 48% of adults, when asked, said that they were likely to opt out if it was introduced and run by a private company. This would have a catastrophic impact on the quality of NHS data, which is an extremely valuable resource. Do the Government recognise this as a risk? How will they ensure that we have public faith in the process?

[Lord Markham (Con)]

The noble Baroness is correct: public confidence is vital, particularly in the case of data, where we are concerned about privacy. We are arranging a briefing of noble Lords so that everyone can have the opportunity to understand what we are talking about here, which is almost like the plumbing of the system. The NHS maintains primacy of use—it is the only organisation allowed to use it—and privacy will be maintained at all times. It is much better to think of whoever wins this contract—we do not know who they are—as just the technology provider, like Microsoft, for instance. We use private sector companies for technology all the time. The key thing is that the provider is protected. That is the NHS, and no one else can get access.

[Lord Clement-Jones (LD)]

My Lords, the Minister talked about the plumbing, but is it not the case that, with this further contract, which has had no tendering, Palantir’s Foundry system is further embedded in the federated data platform of the NHS, and what we are effectively seeing is what the Doctors’ Association UK calls a “monopoly lock-in” that is therefore a shoe-in for the award of the next contract?

--- Later in debate ---

[Lord Markham (Con)]

Actually, it is the opposite. It absolutely lets bidders know that, when we are assessing who the best bidder is, we are looking only at who is the best provider. We do not need to have any concerns at all about continuity or risks because we are giving them plenty of time to get their new contract and systems in place. We do not need to worry about any services being lost in the meantime.

[Baroness Boycott (CB)]

My Lords, Palantir is a data analytical company. It wants our data. In cases where it has been in business with other people, it has used that data and sold it under the surveillance capital model. Is the Minister absolutely confident that we are safe in entrusting all of the NHS’s data to an American company? It seems to me that that is not in the best interests of a not-for-profit organisation such as the NHS.

[Lord Markham (Con)]

Yes. I really appreciate having this opportunity to state categorically that the NHS will remain the data user here. The data controller will remain in place for each individual institution; sometimes it is the GP and sometimes it is the hospital. Fundamentally, everyone’s data will be allowed to be used only by the NHS in these circumstances. There are no circumstances in which Palantir—or any other supplier should it win—will have access to see individuals’ data.

[Lord Davies of Brixton (Lab)]

My Lords, health service data is incredibly valuable. The Minister should, and probably does, understand the sensitivity of Palantir in this context. The Minister said that the quality of the contract was the only criterion. Where does price come into it? How can we build in protections against predatory pricing by the sitting tenants of contracts, who create an effective monopoly?

[Lord Markham (Con)]

I think I said that we wanted the best supplier to win; I will check and correct the record if I mentioned quality only. Quality is very important because the contract has to be good, of course, but the price has to be right as well. There are a number of criteria. Again, we will hold a session so will be able to take noble Lords through the whole process. I am confident that, at the end of that process, people will feel confident that we have reached a decision on the best supplier across all the criteria.

[Lord Wallace of Saltaire (LD)]

My Lords, press coverage of this contract has indicated that an alternative British consortium was prepared for this contract. Can the Government confirm whether they examined alternative bidders, in particular British ones, given that the issue of trust in the use of data is an important one? As the noble Baroness remarked, trust in Palantir as a supplier is absent from substantial chunks of the NHS.

[Lord Markham (Con)]

Again, it is important to say that the whole point of this transition arrangement was to allow us to have an open bidding process across loads of suppliers, knowing that, when they were able to put their solution in place, their transition arrangements were in place. That opened up the field to British suppliers and suppliers from around the world. We have had an open process, which has been going on for a number of months now and continues. We expect a contract award around autumn time and I can assure the noble Lord that we have looked at a whole range of suppliers to make sure that we get the best outcome.

[Lord Allan of Hallam (LD)]

My Lords, can the Minister confirm something that he said in a previous answer: namely, that whoever wins the federated data platform contract will not have the right to use any NHS data outside the terms of that contract? Secondly, assuming that the current provider, Palantir, does not get the contract, will the NHS put in place by the end of this transition period procedures to ensure that all the data and access that Palantir had is removed safely so that there is no ongoing situation?

[Lord Markham (Con)]

I thank the noble Lord for giving me an opportunity to clarify that absolutely. The answer is yes on both counts. If Palantir is not successful in winning the contract, no data will remain on its systems; it will be transferred over completely and, as the noble Lord says, whoever ends up winning the contract will be allowed to use that data only in an NHS context—that is, in no other context at all.

[Lord Fox (LD)]

My Lords, can the Minister clarify when he expects the large contract of nearly £500 million to be awarded?

[Lord Markham (Con)]

Round about autumn time. Currently, we think that the contract will be awarded in September and then finalised. The new database should in place by April. Having this transition arrangement until June gives us a safety net to make sure that everything is in place.

[Lord Davies of Brixton (Lab)]

My Lords, I welcome the opportunity of a meeting to discuss data security. Can the Minister say whether it is anticipated that that security will go beyond what is currently being established in legislation going through Parliament? If it will be stronger, why are the other protections not stronger?

[Lord Markham (Con)]

I am sorry; I am not sure that I completely followed the question. It is fundamental here that everyone’s data is strongly protected in the best possible terms. As I say, we will arrange in the next few weeks a meeting where we can answer all the questions that noble Lords have and have the experts in the room as well.