Abuse and Deaths in Secure Mental Health Units

Lord Markham Excerpts

Wednesday 9th November 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, week after week we return to this Chamber to hear of patients dying when their deaths could have been prevented and patients being bullied, dehumanised and abused, and their medical records falsified, in a scandalous breach of patient safety. This cannot continue. In reflecting that it feels as though it is being left to undercover reporters to expose such terrible failings in patient care, will the Minister action a rapid review of mental health in-patient services? What are the Government doing to ensure that patients’ complaints about their care are being taken seriously?

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

I thank the noble Baroness. I first want to apologise for the failings in the care that Christie Harnett, Nadia Sharif and Emily Moore received. My thoughts, and I am sure the thoughts of this whole House, are with their families and friends. The death of any young person is a tragedy, all the more so when they should have been receiving care and support in a safe place.

The Minister in the Commons is looking much more towards a rapid review rather than a public inquiry, as the feeling is that rapid action is needed. We have seen some good examples of that recently, with Dr Bill Kirkup. It is very much at the top of the agenda and I agree with the noble Baroness; this is the third time I have spoken on similar incidents in the short time I have been here. We clearly need to make sure the proper action is in place to identify these issues.

[Baroness Tyler of Enfield (LD)]

My Lords, when this Question was answered in the other place on 3 November, the Minister said that

“staff shortages often contribute to some of the failings we have seen.”—[Official Report, Commons, 3/11/22; col. 1021]

These are some of the most horrific cases of abuse and death in so-called secure mental health units I have ever seen. Can the Minister say what emergency intervention funding will be made available, as happens with maternity services put into special measures, to ensure that every mental health patient in a secure unit is in a safe place?

[Lord Markham (Con)]

I agree, and I have been asking similar questions around whether we should be looking for a special measures-type regime in this space. To be fair to the new CEO, who has come in from 2020, he has set out a plan and progress is being made on many steps. It is the focus of the Minister to see whether that progress is quick enough. We understand that staffing is a key issue. We have increased the number of staff by 24,000 since 2016, and almost 7,000 in the last year alone. Clearly, part of this rapid review needs to be around staffing.

[Baroness Buscombe (Con)]

My Lords, I currently chair the Joint Committee scrutinising the draft mental health Bill. This is an important Bill and is the subject of both Houses on a cross-party basis. We hope to publish our recommendations in the middle of January. Will my noble friend reassure me and the whole House that great care will be taken to consider the recommendations we put to the Government and that an early response will be brought forward in the light of the fact that it is incredibly important that we see this legislation through as soon as possible?

[Lord Markham (Con)]

I thank my noble friend for the work that she and others are doing in this space. I agree that we need to respond rapidly. As I said, this is very high on Minister Caulfield’s agenda, and I assure my noble friend that we will be looking to respond quickly.

[Baroness Berridge (Con)]

My Lords, I am also serving on the Joint Committee mentioned by my noble friend. We received evidence that the highest rate of mortality for those held in custody between 2016 and 2019 was among those held under the Mental Health Act. If you die in a prison or an immigration centre, there will be an independent investigation under the Prisons and Probation Ombudsman, and if you die in police custody, the IOPC will investigate. There is no independent investigation should you die while detained under the Mental Health Act. Is that not a lacuna that the Government could look into in relation to deaths while being detained under the Mental Health Act?

[Lord Markham (Con)]

My noble friend raises a good point. My understanding is that the rapid review that we seek to put in place would involve an independent chair, because independence is key in this area. On the detail of whether that should be the case for every death, I will take back that point and respond to my noble friend.

[Lord Harris of Haringey (Lab)]

My Lords, following on from the noble Baroness, Lady Berridge, until 2015 I chaired the Independent Advisory Panel on Deaths in Custody. As she said, the largest number of deaths in custody were those in secure mental health units. There is no independent arrangement. It is all very well to talk about an independent chair, but, essentially, the assessment is being made by those in the same field—sometimes, indeed, in the same institution. The Government are failing their Article 2 obligations on the right to life. How frequently do the Minister and his colleagues in the department meet the Independent Advisory Panel on Deaths in Custody, and when did they last take note of, and act on, the recommendations it has made?

[Lord Markham (Con)]

I do not have the information to hand on when the last visit was, so I will write to the noble Lord on this. The substance of the question is good: clearly, we cannot have people marking their own homework—for want of a better phrase—in this situation, so I will take back this point. Again, I understand the importance of this; it is vital that these young people, and others in mental health institutes, are supported in the right way. We are spending about £400 million to eradicate dorms, which are often part of the problem, but that is not to say that more does not need to be done.

[Baroness Uddin (Non-Afl)]

My Lords, I declare my interest as a registered social worker. Last year, I had the opportunity to look at mental health services in east London, where the overrepresentation of black and Muslim men is absolutely horrific. Their experiences are vastly different, and there is no recognition of the fact that they are suffering not just bullying but racism and Islamophobia. As the Minister will be aware, the problem is that, as well as cases of bullying, these services are understaffed. More importantly, the staff who are supposed to be supporting these individuals who are very unwell are underqualified and severely underpaid. There is a great deal for us to be concerned about, including underresourcing and staff training. What is the Minister’s department doing about this? Having just announced one set of funds after another, which had no effect at all on the ground in those wards, can the Minister say what the reality is on the ground?

[Lord Markham (Con)]

We are investing, and I understand and agree with the point that training is key to this. We have committed to spend £2.3 billion more in 2023-24 in the mental health arena, exactly around this space. It is something that we are working on, and we understand that we need to ensure that the mental health of all our citizens, whatever their race or colour, is well served and looked after.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, as a member of the committee that the noble Baroness, Lady Buscombe, chairs, may I ask the Minister to especially note what she said about the importance of acting quickly on whatever recommendations come forward? Will he also acknowledge that mental health services, not just in secure institutions but across the country, are under very severe strain and that it is when people get into crisis that they are then put into secure units, often because they have not had the help they need before that crisis arrives? Will he please accept that there is a very serious shortage of mental health provision across the country? It would be interesting to know what real impact the numbers he has been able to tell us about today will have on that.

[Lord Markham (Con)]

As previously mentioned, we are investing to increase the provision—I believe it is £2.3 billion in 2023-24, which is a significant sum. We have increased the workforce by 7,000 in this last year alone, and there are plans to increase it further. Clearly, we need to keep that under review. I agree with the premise that prevention is always better than cure in these instances, and we need to make sure that mental health services, training and support are given at the point of need.

NHS: Discharge to Assess Policy

Lord Markham Excerpts

Tuesday 8th November 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, with the permission of my noble friend Lady Wheeler, and on her behalf, I beg leave to ask the Question standing in her name on the Order Paper.

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

It is vital for carers to be involved in critical decisions regarding their loved ones’ care. The Government will publish shortly new statutory discuss charge guidance, which will include the new statutory requirement to involve carers. NHS bodies and local authorities will be able to use that guidance as a resource to support carers from the point of hospital admission through to post-discharge care and support.

[Baroness Merron (Lab)]

My Lords, today’s State of Caring report from Carers UK paints a bleak picture, with one in two carers still not involved or properly listened to over their loved ones’ discharge from hospital. When will the Government live up to the promise of their Health and Care Act to properly involve both patients and carers in moving from hospital to social care? While there is repeated reference from Ministers to the promise of a £500 million adult social care fund, intended to support the discharge process, when will this reach the front line?

[Lord Markham (Con)]

I welcome the Carers UK report that came out today. It has provided much valued information which will be part of the information that we are using as part of the guidance we will be putting out shortly. It has taken some time because we want to get it right. We have involved NHSE, local authorities and carers, and we are using this report and the Carers UK conference that will take place on Thursday as vital inputs to make sure that we get that guidance out properly. As the report rightly states, the fact that 50% are not getting the guidance and support they need clearly shows that more needs to be done in this space. On the £500 million discharge fund, that has now been agreed, and I understand that that will go out very shortly—in a matter of days.

[Lord Laming (CB)]

My Lords, I am sure the Minister will recognise that any one of us at any time could suddenly have a major caring role thrust upon us —completely unplanned and unexpected. Carers make a huge contribution in our society and to the success of the National Health Service. Can the Minister assure the House that he will do everything he can to ensure that the contribution carers make is recognised and respected and that they are valued?

[Lord Markham (Con)]

I agree. The legislation was put forward by the Government to recognise the vital role that carers have in all this. As we are all aware, there are 5.4 million carers out there, and they make a vital contribution, not only to the health of their loved ones but to the wider economy. Of those, 1.3 million receive the carer’s allowance; that shows how many of them do it completely unpaid. That is why I welcome the legislation, and I hope the guidance will show a big improvement in the way that carers feel that they are valued, because they truly are.

[Baroness Verma (Con)]

My Lords, I declare my interests as in the register. First, carers need respite, so will the Government focus on ensuring that carers’ families are given respite so that they can have some quality of life, which, at the moment, is not readily available to them? Secondly, will my noble friend the Minister please look yet again at the minimum that councils can pay providers for delivering adult social care?

[Lord Markham (Con)]

First, I repeat that the needs of carers, including for a break, some respite, are very much understood. Part of the £292 million fund in 2022-23 is in place to try to give unpaid carers a week’s break. On the second part of the question, I will need to come back to my noble friend in writing.

[The Lord Bishop of Bristol]

My Lords, there are currently more than 160,000 vacancies in the social care sector, and, so often, the work of voluntary carers—relatives—needs the support of the wider social care system. Research from the TUC finds that one in three current care workers is likely to leave in the next few years due to low pay. It is very good to see the Government’s new Made with Care recruitment drive. However, please can the Minister set out what the Government are doing to address the concerns about pay and status in the social care system, particularly given the ongoing cost of living crisis?

[Lord Markham (Con)]

Carers are well valued, and the need to ensure that our social care workers are well valued was the subject of a lengthy debate that your Lordships will remember from a couple of weeks ago. In that, we set out our plans for recruitment—not only domestically but internationally. I am glad to say that, even since then, we have seen a further uptick in the number of people recruited from overseas. Overall, it is understood that this is a vital area as part of the ABCD—which still exists. The “C” for carers is still very much part of this, so we are actively monitoring those recruitment plans and making sure that we are trying to provide every element of support.

[Baroness Pitkeathley (Lab)]

My Lords, I hope the Minister will forgive me for correcting his figures but the figure we generally use for unpaid carers now is nearer 10 million since the pandemic. In view of the truly shocking statistics in the Carers UK report that was published today—I am glad that the Minister said it will inform the department’s policy—have the Government given any consideration to revisiting the carers action plan, which went out of date two years ago, or, better still, reviving the idea of a national carers strategy? The first one was published more than 20 years ago.

[Lord Markham (Con)]

My understanding is that part of the guidance will be informed by making sure that action for carers is there but, when I see the guidance, I will make sure that it covers those elements. I agree, as we all do, with the premise. If the carers action plan is out of date—again, this is legislation that this Government have brought forward to show that we understand the importance of carers—clearly it is something that I will take up.

[Baroness Tyler of Enfield (LD)]

My Lords, the recent survey conducted by Carers UK, which has already been alluded to, found that 63% of carers disagreed that they had been asked about their ability to provide care. Indeed, the report is littered with harrowing examples of carers who felt that the discharge of the person into their care had happened too quickly, as a result of which their condition got worse and they had to go back into hospital. Can the Minister say how the NHS will collect both qualitative and quantitative data at the point of hospital discharge to ensure that undue pressure is not being placed on families?

[Lord Markham (Con)]

As mentioned, the Carers UK report and its findings made for sobering reading. It clearly shows why it was right to delay the guidance until we had that input; again, that will be followed up at the conference on Thursday. I think we all agree on the premise that we want to discharge people into their home quickly because that is the best place they can be, provided that they are medically able to be there. It is then in their home that the assessment takes place. Clearly, that must happen in a timely fashion and with the carer’s involvement but, again, the survey showed that that is not being done quickly enough in many cases. I accept that there are many things we need to learn from this but I think we can all agree on the direction: it is right to discharge people quickly provided that back-up and support are there to ensure that they have what is needed.

[Lord Naseby (Con)]

My Lords, as one who has been a carer in the recent past, I ask my noble friend the Minister to double-check that, before any patient leaves any form of NHS care, they have had a thorough checklist of every conceivable thing, including medicines, vaccination or any other procedure that has been undertaken on that patient.

[Lord Markham (Con)]

My noble friend makes the point well. I agree. It is my understanding that such a checklist exists but I will check that and come back to him.

British Heart Foundation: Tipping Point Report

Lord Markham Excerpts

Tuesday 8th November 2022 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what assessment they have made of the report by the British Heart Foundation, Tipping Point, published on 3 November; and what steps they intend to take in response to the finding that from the beginning of the Covid-19 pandemic to August 2022 there were 30,000 excess deaths involving coronary heart disease in England.

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

This is a detailed report that requires time to be fully considered. NHSE has been monitoring excess deaths and has put in place the cardiovascular disease prevention recovery plan. This prioritises support to help systems, including prevention planning, risk-factor diagnosis, monitoring and management, to recover to pre-pandemic levels; it also tracks progress and ensures that interventions are effectively targeted. The plan includes resources to create CVD prevention leadership roles in every integrated care system from April 2022.

[Baroness Merron (Lab)]

My Lords, British Heart Foundation analysis has found that millions of missing heart patients, both diagnosed and undiagnosed, are struggling to get care for conditions such as high blood pressure. At the same time, modelling by NHS England suggests that a decline in blood pressure management could lead to more than 11,000 extra heart attacks and nearly 17,000 additional strokes in the next three years. What are the Government doing to identify and treat these missing patients? How will they address the backlogs in every part of the system, which are affecting time-critical emergency care?

[Lord Markham (Con)]

It is quite right that blood pressure management or hypertension is a key indicator. That is why we have put in place many points when people’s blood pressure can be measured. Anyone who has had a Covid vaccination recently would have had their blood pressure taken. This can now be performed at—

[Noble Lords]

No!

[Lord Markham (Con)]

I will check on that. I have been told that it is being done as part of that. It is available in a large number of pharmacies now and we have sent out hundreds of thousands of blood pressure monitors, so people can do it from home. It is fully understood that it is a vital part of early monitoring and we have a three-pronged strategy to make sure that we can measure people’s blood pressure at every point of contact.

[Lord Patel (CB)]

My Lords, the report identifies shortcomings in the delivery of primary and community care for patients with cardiac disease, which is a systems failure. I have no doubt that there will be similar findings for patients who suffer from other chronic diseases. Does the Minister agree that it is time to look at a systems change in the delivery of primary and community care, incorporating advances in technology and digital healthcare that would improve access for patients?

[Lord Markham (Con)]

Yes, we all agree that prevention is better than cure. One of the few benefits of Covid was that millions of people downloaded the NHS app. People are using that for self-diagnosis now, in exactly the way that has been mentioned. In October alone, 500,000 people used the app for self-diagnosis, the healthy heart blood pressure MoT and diabetes checking. That is part of this and it is all part of our five-year healthier life plan, which, as mentioned, is very much focused on MoTs from age 40 onwards, so that we can diagnose these problems early. Our focus should absolutely be on prevention rather than cure.

[Lord Balfe (Con)]

My Lords, will the Minister look at any connection between vaccinations and worsening heart disease—in other words, the extent to which the vaccination itself might contribute to worsening a heart condition?

[Lord Markham (Con)]

My understanding is that that is something for in-depth research, which I do not have at my fingertips. I will inquire and write back to the noble Lord.

[Lord Scriven (LD)]

My Lords, following on with prevention, prevention measures lead to fewer premature deaths from heart disease, yet this Government have slashed the public health grant by 24%, on a real terms per-person basis, since 2015-16. Some of the largest reductions over this period were in stop-smoking services and tobacco control, which fell by 41% in real terms. Do the Government not understand that decimating public health budgets means more heart disease and premature deaths?

[Lord Markham (Con)]

We are at the forefront of trying to encourage healthier eating, as per the sugary drinks levy and through product placement in shops. We have been at the forefront of anti-drinking and anti-smoking initiatives and are very much in favour of the smoke-free agenda. These are all key elements of our five-year healthier life plan. It takes these things into account because, as I say, prevention really is better than cure.

[Baroness Browning (Con)]

Would my noble friend the Minister consider that, in the same way that people check their own bodies for the possibility of cancer developing, they should be trained to take their pulse regularly to check for atrial fibrillation? It is sometimes described as a disease that nobody notices until something dramatic happens, and it can lead to stroke and pulmonary embolisms, which can cause heart attacks.

[Lord Markham (Con)]

Yes, the more that we can educate people to self-diagnose and take a stake in their own health, the better. Again, many of us now have Fitbits, Apple watches and so on, which can be vital early-warning indicators.

[Lord Sikka (Lab)]

My Lords, austerity kills: 334,000 people have died from it in the period from 2012 to 2019. The Government publish monthly statistics on GDP, inflation, wages and much more. However, we do not get monthly data on excess deaths attributable to government policies. Will the Minister provide this information every month? Secondly, can he ensure that the impact assessment accompanying each Bill shows the human cost arising from that Bill?

[Lord Markham (Con)]

The House will agree that we provide some very detailed information on excess deaths. That is quite sufficient at this time.

[Lord McColl of Dulwich (Con)]

My Lords, does the Minister agree that, when we talk about increasing mortality, there is a very obvious cause for this? Some 40 million people in this country are obese and moving inevitably to very premature deaths from a variety of very unpleasant diseases. This could be prevented if they had one fewer meal per day.

[Lord Markham (Con)]

My noble friend is referring to the healthy eating agenda, which we very much support. It is a key component of health and enjoyment of life. The more we can do in that department, the better. We have taken some very solid steps on sugary drinks and, more recently, on the product placement guidelines, to show that that is central to our beliefs.

[Baroness Masham of Ilton (CB)]

My Lords, how much research is being done on Covid-19, specifically on long Covid and heart disease? Who would collect the data?

[Lord Markham (Con)]

I believe that extensive, detailed research is being done in those areas under the overall guidance of Sir Chris Whitty. We will share this when we have the results.

[Lord Aberdare (CB)]

My Lords, what assessment has been made of how many extra deaths could have been prevented by faster access to defibrillators? What steps are the Government taking to increase the availability of defibrillators, particularly in the light of the current severe supply problems affecting them and their parts?

[Lord Markham (Con)]

I am afraid I do not have information on the number of deaths. I will investigate this. I can say that I am sure that we have all seen a great increase in the number of defibrillators and we very much encourage this.

[Lord Hunt of Kings Heath (Lab)]

My Lords, that is very kind of the Minister. May I take him back to his response to his noble friend about vaccination? Would he, none the less, tell the House that the Government are absolutely convinced that the Covid and flu vaccinations have brought huge benefits?

[Lord Markham (Con)]

I thank the noble Lord for giving me the opportunity to state this. I should have done so the first time around, so that is appreciated. As he says, vaccinations have brought huge benefits. We can all be proud to be the leading country on rolling them out, seeing the benefits that have come from it all.

Ambulances

Lord Markham Excerpts

Thursday 3rd November 2022 Lords Chamber

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

My Lords, I am pleased to respond to this short debate. I reassure the right reverend Prelate the Bishop of London that ambulances are an utmost priority for this Government. We are absolutely committed to supporting the ambulance service to ensure that people receive the treatment that they need when they need it. However, as many noble Lords have noted, our ambulance services have faced unprecedented pressure since the pandemic, so I totally agree with the point that this is a whole-system issue, as the right reverend Prelate and the noble Baroness, Lady Merron, mentioned, and a “beds and backlog” issue, as the noble Baroness, Lady Brinton, mentioned. We all have similar variants on that. The plan for patients is still valid and is being reviewed by the current team. It is always being worked on and updated.

To directly address the point of the whole-system issue, or flow, some work that I have done has shown that the biggest predictor of ambulance wait times and handover times is bed occupancy. We all know that bed occupancy, which can be as high as 95%, with about 10% of our beds being taken up by Covid, is very much the issue. That is the first priority. Obviously, the Covid and flu vaccination programmes are important parts of that, but the £500 million adult social care fund to remove the 13% of bed blocking is vital to this.

I assure all the speakers who have mentioned it that the question of how the spend is allocated has been the subject of much debate, because we want to make sure that it really is targeted in the right place. Again, as a data hound, I wanted to make sure that we really were spending it in the best place. How it is spent now has been agreed, and that should be seen very quickly in the system.

The other issue regarding bed occupancy is, as the noble Baroness, Lady Brinton, mentioned, the 7,000 new beds. I am a big believer in the use of virtual wards, but I will get that breakdown so that we understand exactly what that situation is. I have been very much at the forefront of making sure that those 7,000 beds are targeted at the areas of most need, which is vital in all of this.

I think we all agree that dealing with the flow to create the space for A&E patients is the central issue. Primary care is a part of it too. That is why the 50 million increase in appointments is a vital part, as mentioned by the right reverend Prelate the Bishop of London and the noble Baronesses, Lady Merron and Lady Brinton. I will get the specific information on pharmacies as well.

On the workforce plan, work is being done on that right now. We are working from the 2020 NHS People Plan, and I will update the House as we get more information.

Central to the whole issue of ambulance handovers is, as I like to call it, the flow—the whole-system issue. It is only when we resolve bed occupancy and the flow into adult social care that we will have the free flow through the whole system and the reduction in handover times.

Response times were brought up by all the speakers. A lot of that is about managing the calls to achieve the right outcome. Yes, it means more call handlers, as was pointed out, so we are increasing the number of 999 call handlers to 2,500 and 111 call handlers to 4,800. I take the point made by the noble Baroness, Lady Brinton, about paying tribute to the work they are doing and the impact they make.

It is also about making sure that the call is navigated correctly. I was made aware of the fact—maybe this was known already—that 50% of 999 calls do not result in a conveyance to hospital. That says to me that there is a lot more we should be doing to help people in their home, such as picking up people from a fall and making sure that we go out quickly to their care homes. The thought is: in those instances, is an ambulance staffed with three people the best sort of response vehicle when someone needs help being put back on their feet? Maybe that is a much better place for us to use quick-response paramedic motorcycle-type people. This is very much at the top of our agenda. It is something that I was speaking to the NHS chair about just this week and something that I am going to do personally in terms of visits.

On the use of 111, unfortunately I had experience of that this week when my four year-old son was up all night throwing up and I was a distressed parent. My wife, like any mother would, was saying, “Should we be taking him to hospital? Should we be ringing 999?” We called 111 between midnight and 1 am. It took me a while to get through, so I am not saying it was a perfect experience, but when I spoke to them and they were able to put me in touch with a local doctor who could support me and get us through, that was key to helping us and stopped us going into A&E or clogging up 999.

Having the right people to deal with the problem in the right way is the best approach. It ensures that when there is an absolute emergency and you are into your golden hour, so to speak, the focus is really on having the right people. I shall not pretend that we have got it all right now but, believe me, it is very much at the top of the agenda. The investment in the ambulance fleet—we are talking about £20 million per year—is about making sure that we have the right type of vehicles to sort out the right situation, while ensuring that this is all overseen by a national ambulance co-ordination centre so that we really are responding in the correct way to each type of call and triaging, as mentioned.

I have mentioned the 15 trusts and 45% delays before; these were also mentioned by the noble Baroness, Lady Merron. I am very much into what the action plan is to address each of those. It is at the top of my agenda when I meet my NHS colleagues and I will give an update on where we are with that plan and our actions. To me, that is all part of an exercise to identify best practice and then roll it out across the system. As part of that, we have just kicked off a winter improvement collaboration programme that is about trying to identify those best practices and roll them out. That is the £450 million fund we are using; we have already used it to fund 120 trusts to create capacity in the system, such as in Leicester, north Bristol and Grimsby, so that we have those wait areas and can increase the capacity in the system. I am personally visiting some of the new system control centres in Maidstone next week, so that we can see what good really looks like and ensure that we are managing it as well as possible.

In addition, within the ambulance services themselves, we have put £150 million of increased funding into the system for these measures. It includes a lot of support, because a lot of these calls are from people who have mental health issues, so making sure that we have mental health-trained paramedics is a key part of this as well. These are all parts of the plan for patients, which is very much alive in all of this. However, as mentioned in the Question of the right reverend Prelate the Bishop of London and by the noble Baroness, Lady Merron, industrial action will clearly have an impact on everything we are trying to do here.

I note at this point that we have made the pay increases recommended by the pay review body at all points but I accept that if people are balloting to strike, there are clearly things we need to understand about why they feel the need to do that. It is premature to predict the outcome of the ballot at this time. We know that there is a range of options on the ballot, be it strike, work to rule or no strike, across three unions nationally and regionally. We are working on a number of contingency plans but, until we know the exact shape it will take, we cannot put those in place. Public and patient safety will come first and foremost; I know that is a view the ambulance staff share, which again is a point made by the noble Baroness, Lady Merron. When the ballot results are known, the NHS will sit down with the unions and staff to agree an approach with this in mind. They will agree the safe level of cover, which is foremost in all our minds, and then deploy our contingency plans around this safe level.

I hope I have managed to cover most of the points raised before I run out of time and sum up. Again, I will go over my notes to make sure that I follow up on any points I may have missed. I accept that this is an issue of key focus. I hope that the plans I have gone through this afternoon give a sense of what we are doing in this vital area. First and foremost, it is the whole-system issue, as mentioned by all the speakers today.

We recognise the pressures that the ambulance service and the wider NHS are facing. We continue to work closely with NHS England to ensure that patients receive the help they need when they need it. With that, I once again pay tribute to the right reverend Prelate the Bishop of London for securing this important debate. I know that we have a meeting soon, where I look forward to discussing this further.

NHS: Nurses

Lord Markham Excerpts

Tuesday 1st November 2022 Lords Chamber

[Lord Clark of Windermere]

To ask His Majesty’s Government what discussions they have had with the Nuffield Trust further to their research finding, published on 30 September, that more than 40,000 nurses have left the NHS in England in the past year.

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

We welcome the Nuffield Trust publication and the spirit in which its analysis was conducted. Leaver numbers should be seen in the context of overall growth in the workplace. We are more than half way to delivering on our commitment to have 50,000 more NHS nurses by 2024, with nurse numbers more than 29,000 higher in August 2022 than in September 2019 and more than 9,100 higher than in August 2021.

[Lord Clark of Windermere (Lab)]

I thank the Minister for his Answer, but I think his figures are a little out of date now. A record number of nurses left the profession last year, and we are now 46,000 nurses short. These figures show that the Government’s plans for nurse recruitment are inadequate. Retention of staff is the key. In view of the fact that nurses have seen their pay fall by 20% in recent years, will HMG not rectify this and give nurses the pay they deserve?

[Lord Markham (Con)]

With respect, the numbers I quoted are up to date. They take into account the overall increase. We saw 36,000 leavers and 45,000 starters in the last year, so that is an overall growth of 9,000, which shows that the work we are doing to encourage people into the profession is working.

[Baroness Chisholm of Owlpen (Con)]

My Lords, I know how much I, the noble Baroness, Lady Watkins, and the right reverend Prelate the Bishop of London enjoyed our nursing careers; we all trained at the same place. Is there not some way in which we can encourage students to come forward to this fantastic profession so that we can make sure we have a sustainable domestic workforce here in this country?

[Lord Markham (Con)]

I totally agree. I am proud to say that we have 72,000 nurses and 9,000 midwives in training at the moment. There is no cap on the number of people who can join the programme, so that is very much the spirit of what we are trying to do. Key to that was a £5,000 grant each year for nurses to attract them into the profession. It is working.

[Baroness Brinton (LD)]

My Lords, the comment about the figures by the noble Lord, Lord Clark, was entirely accurate. The Minister gave us the truth, which is that the net increase is 9,000, whereas the manifesto promise of 2019 was for 50,000 extra. Does this explain why the Royal College of Nursing reported last week that 75% of shifts did not have the planned number of nurses? When will the NHS see 50,000 extra, on top of the 2019 figures?

[Lord Markham (Con)]

To be very clear, today, there are 29,000 extra, over the 2019 figures. That is more than half way towards the figure of 50,000. I will quite happily write to noble Lords so that they can see the figures clearly in black and white, but I can assure the House that we are talking about increases in nurse numbers. We have achieved a 29,000 increase on the 2019 levels.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a registered nurse and would like to follow on from the noble Baroness, Lady Chisholm. We must grow our domestic workforce in nursing. I do not dispute the figures the Minister has given, but any nurse earning more than £27,000 who trained recently is now repaying 9% towards their student loan, on top of the 20% tax they are paying. I accept that they get a £5,000 bursary a year, but they work extraordinarily long hours compared with ordinary students. It really is essential that we find a way to retain those young nurses who have just trained by doing a debt write-off of their loan after five or six years.

[Lord Markham (Con)]

I totally agree that retention and attracting people into the profession are key. I like to think that we are looking at all these things in the round, taking into account the £5,000 grant, the service they are giving, and their conditions and pay going forward. As ever, this is a moving feast, for want of a better term, so we will keep looking at it to make sure we continue to both attract and retain the domestic and international staff numbers.

[Lord Turnberg (Lab)]

My Lords, have the Government made any assessment of the reasons why so many nurses are wanting to leave, and, if so, what remedies are being suggested by them?

[Lord Markham (Con)]

The Nuffield study was very interesting: of the reasons for people leaving, 43% said retirement, 22% said it was for personal reasons, and 18% said it was due to too much pressure. Again, in quoting those figures I accept that there is work we need to do on this. Clearly, 18% leaving due to too much pressure is something we rightly need to be concerned about. I know that is why we set up the 40 mental health and well-being hubs with a £45 million investment, to look at whether we can address some of those pressures. Most of all, though, I completely agree that we need to recruit as many nurses as we can so that we have as big a supply as possible to ensure that we continue to relieve any pressures that exist.

[Lord Kamall (Con)]

My Lords—

[Lord Kamall (Con)]

I apologise to the noble Lord but it is some time since I have spoken in this part of the House. Given that it was Black History Month last month, does my noble friend the Minister agree that we owe a great deal of gratitude to immigrants from the Commonwealth who helped to save our public services after the war? Now that we have left the EU, can he also assure us that we will no longer give priority to mostly white Europeans over mostly non-white non-Europeans, and treat all equally when we want to recruit health and care staff from abroad?

[Lord Markham (Con)]

I totally agree. My noble friend rightly states that we have had a fine tradition, right back to the beginning of the NHS, of recruiting people from all over the world, predominantly the Commonwealth. I am also delighted to say that, since we moved the cap on visas from people all round the world in 2019, the number of those who have joined has gone up from 25,000 a year to 48,000 a year. That is almost double the number and very much the result of what my noble friend said about making sure that we are welcoming people into the profession from all over the world.

[Lord Patel (CB)]

My Lords, shortages of NHS staff, whether they be nurses, physiotherapists, doctors, dentists or community nurses, results in poor service. What plans do the Government have to make primary and community care more sustainable in the long term?

[Lord Markham (Con)]

The plans are very much those that we are doing, which I believe are successful. As mentioned before, it is not just that the number of nurses has gone up by 29,000; we have seen significant increases in doctors and the other medical professions as well. We should remember that we have 200,000 more people working now within the profession than in 2010. That is not to say that we will rest on our laurels; I completely agree that we need to carry on expanding supply to ensure that we properly meet the demand.

[Baroness Merron (Lab)]

My Lords, given that the Minister has previously stressed that nurses should rely on the vocational appeal of their work for their rewards, how does this square with the reasons that he acknowledged exist as to why a record 40,000 nurses left the NHS in the past year alone?

[Lord Markham (Con)]

I am very aware of the Nuffield figures but that 40,000 includes people who have gone back into other parts of the nursing profession. The actual net number as cited by Nuffield is a 27,000 reduction, which is why we have had the growth. However, we should ensure that it is as attractive a profession as possible for people to work and progress in. That is very much what I would like to see.

[Lord Lilley (Con)]

My Lords, can my noble friend explain why we none the less turn away every year more than 20,000 applicants for nursing courses? Why does there appear to be a de facto limit on recruitment at universities for nursing, whereas they are allowed to take an unlimited number for media studies, PPE and other less worthy disciplines?

[Lord Markham (Con)]

I have been assured by officials that there is not a cap, so my only thought would be that, if people are turned down, it is perhaps because they may not have the necessary qualifications. I will check that and, if I am wrong, I will reassure the noble Lord, but my understanding is that there is no cap, and the more the merrier.

Nursing: Recruitment

Lord Markham Excerpts

Wednesday 26th October 2022 Lords Chamber

[Baroness Merron]

To ask His Majesty’s Government what progress they have made towards meeting their target of recruiting 50,000 extra nurses by 2024.

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

This Government are committed to delivering 50,000 more nurses and putting the NHS on to a sustainable long-term workforce supply. We have set up a comprehensive work programme to improve nurse retention, support return to practice, diversify our training pipeline and ethically recruit nurses internationally. We are over half way towards meeting the commitment, with nursing numbers over 29,000 higher in July 2022—our latest available data point—than the September 2019 starting point for this commitment.

[Baroness Merron (Lab)]

My Lords, recent analysis shows that there are over 50,000 registered nurse vacances across all settings in England alone. What assessment have the Government made of the impact of current vacancy rates on patient safety? What is the Minister’s response to the warning of the Chief Nursing Officer that the Government’s pledge for additional nurses, even if it is reached, will not be enough?

[Lord Markham (Con)]

We appreciate that recruitment is an ongoing process, and while I think the whole House would agree a 29,000 increase is a good record—up 9,000 in the last year alone—we cannot rest on our laurels. Vacancies of 50,000 is partially a function of a full-employment economy, which I think we would all support. We are showing that our recruitment is working and, as I say, we are over half way towards our target of 50,000 more nurses.

[Baroness Harding of Winscombe (Con)]

My Lords, a few months ago, the Secretary of State but two said that the NHS long-term workforce strategy would include numerical assessment of both supply and demand of nurses and other clinical professionals but that publishing those details would depend on cross-government agreement. There was broad agreement in this House, in June, that those numbers should be published. Could my noble friend the Minister put on record his support for publishing NHS workforce supply and demand numbers? If he does not feel able to, could he explain how we will know whether 50,000 is the right number of nurses?

[Lord Markham (Con)]

There is a long-term workforce strategy plan being put together, as I think we know, and that builds on the NHS people plan of 2020, which has seen this increase in numbers. I will find out where we are with that, and the details behind that, and write to my noble friend.

[Baroness Symons of Vernham Dean (Lab)]

My Lords, what advice would the Minister give to a senior staff nurse, working in theatre, and at the top of her pay band, alongside agency nurses who are paid two to three times as much as she is for a 10-hour shift? Should she leave the NHS and become an agency nurse herself, or should she vote to strike, as she may well be asked to by her union?

[Lord Markham (Con)]

I would hope and trust that such a respected person would see this position as the vocation that it is and the support that they give. We accept that there are some agency workers being used in this space, because obviously, in terms of safety, we need to make sure we cover that number of people. The whole recruitment plan—which, again, we are on target to achieve—is all about making sure we have enough nurses so that we do not have to use agency workers.

[Baroness Brinton (LD)]

My Lords, following on from the question from the noble Baroness, Lady Harding, can I ask the Minister if there are plans to increase the number of student nursing places at universities and student apprenticeships over at least the next decade? While there is a short-term crisis, there is also a longer-term sustainability crisis, especially with current demographics.

[Lord Markham (Con)]

The noble Baroness is correct that this is a long-term pipeline. We have 72,000 nurses in training at the moment. To be clear, there is no cap at all on student places. We are seeking to increase them as much as possible, and we put a £5,000-a-year grant in so that trainee nurses could enjoy superior levels of financial support than other students. The fact that we have a pipeline of 72,000 shows that this is working, but that pipeline is not capped, so if we can get more people in, we definitely want to do that.

[Lord Turnberg (Lab)]

No matter how many nurses we try to recruit, we never seem to catch up with the rate of loss. What are the Government doing to help retention of nurses? We must try to encourage them and support them to stay. What plans are there to do that, and what plans have the Government got to bring back nurses who have left or retired?

[Lord Markham (Con)]

First, we are actually exceeding the number of leavers. There were 36,000 people who left last year and 45,000 who joined—a net increase of 9,000. That is not to say that we do not want to retain people. I absolutely accept the premise that we do, which is why we have a retention programme in place to ensure that we are able to do so. We also have a restart programme to help people who have left to get back into nursing in a quick and easy way. Overall, the main point here is that the number of joiners is exceeding the number of leavers. We are more than catching the number up; we are exceeding it.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a nurse and the co-editor of the WHO report, State of the World’s Nursing. It is true that we have 9,000 additional nurses, but of the 48,000 who in the last year joined the register for the whole UK—for the four countries, not just England—more than half had trained overseas. Those nurses are very welcome here, but it illustrates that we are not encouraging people who wish to go into nursing to do so, beyond the 72,000 the Minister referred to. That is very much to do with student finance and the lack of apprenticeship opportunities for older people who want to go into the profession. Can the Minister look into increasing those opportunities?

[Lord Markham (Con)]

Indeed, and towards that aim we have set up the nursing associate role, which is a stepping-stone to allow people to ease in and have qualifications on the way to becoming a fully trained nurse. The overall point I make, as before, is that by putting in a £5,000-a-year grant for student nurses, we are recruiting the numbers. I reiterate that 72,000 is a big pipeline but also that it is an uncapped pipeline. The more we can attract, the merrier—whether domestically or, as in the fine tradition of the NHS, from overseas sources.

[Baroness Walmsley (LD)]

My Lords, is the Minister aware that the percentage of nurse vacancies is much higher in community care than in any other part of the sector? What is the department doing to ensure not only that we have enough nurses but that they are in the right places?

[Lord Markham (Con)]

That is an excellent point. One thing I probably should have said is that the number of 36,000 leavers includes people who have left NHS trusts and gone into community care, working in GP surgeries. We do not catch that number who come back in again, so the real number is less than 36,000, but the basic premise of the question—making sure we are attracting nurses to the right place—is absolutely the right one. I believe that is the plan in place, but I will check on that and make sure we are doing as requested.

[Baroness Masham of Ilton (CB)]

My Lords, would it be possible to make it quicker and cheaper to get visas to bring to the UK nurses from across the world who would like to work here? We can never have enough nurses without them, can we?

[Lord Markham (Con)]

I totally agree with the approach. I have declared a personal interest before in that my wife is a dentist from the Dominican Republic who came in exactly that way, so I completely support the intent.

[Lord Brownlow of Shurlock Row (Con)]

My Lords, I raised the subject of agency nurses in my maiden speech. In the private sector, it is quite common that if you receive training by an employer and leave within a certain period of time, you repay the cost of that training. If nurses qualify and then transfer to become an agency nurse and rip off hospital trusts, as we heard earlier from the noble Baroness opposite, should they repay the costs of the training they have been given?

[Lord Markham (Con)]

I do not think I can quite agree with the words “rip off”, but I get the sentiment. As I am sure we all have, I have been involved in industries where, if your employer pays for your training and you do not return the contract—for want of a better word—or investment by giving a few years’ commitment to do it, there should be some sort of clawback. I understand the approach, but right now my focus is on making sure we get as many people into training as possible.

Water Fluoridation (Consultation) (England) Regulations 2022

Lord Markham Excerpts

Wednesday 26th October 2022 Lords Chamber

Moved by

[Lord Markham]

That the draft Regulations laid before the House on 20 July be approved. Considered in Grand Committee on 25 October

Motions agreed.

Maternity and Neonatal Services

Lord Markham Excerpts

Tuesday 25th October 2022 Lords Chamber

[Baroness Cumberlege (Con)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and, in so doing, I declare that I am remunerated for chairing the independent maternity review.

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

I am grateful to Dr Kirkup for this report. Our intention is to review the recommendations alongside existing work to improve maternity outcomes, including the recommendations from Donna Ockenden’s final report. With NHS England, we have established an independent working group chaired by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists that we will use to support our considerations.

[Baroness Cumberlege (Con)]

My Lords, I thank my noble friend for that reply. Does he agree that as this has been a series of maternity tragedies across England, we must do all we can to prevent further disasters? Will he, with NHS England, introduce a maternity signalling system that identifies units providing poor care before they cause widespread harm?

[Lord Markham (Con)]

I thank my noble friend. I agree. This was captured in recommendation 1 by Dr Kirkup about having early warning indicators in place. That is what we have set up in the maternity quality surveillance framework, which has the oversight in this area and can escalate concerns and effectively report to the national maternity safety surveillance and concerns group, which can then put the trust into special measures.

[Baroness Blackstone (Lab)]

My Lords, I declare an interest as the chair of the trustees of the Royal College of Obstetricians and Gynaecologists. I am aware that the Government have allocated an extra £200 million for maternity services over the last couple of years, but according to the Health and Social Care Select Committee this is not nearly enough. It recommends up to £350 million for staffing alone. Do the Government accept that, above all, more funding is needed now for multi-professional training and to support programmes to improve clinical practice? If so, can the Minister say how much funding the Government are prepared to allocate and when?

[Lord Markham (Con)]

I agree. We are putting the money into the training programmes. We have actually put £95 million on top of the £127 million investment into this area. As ever though, what is most important is outcomes not investment. Alongside the tragic instances we have seen, we have seen a reduction in stillbirth of 19% since 2010, a reduction in neonatal mortality over 24 weeks of 36%, and a reduction in maternal mortality of 17%. Alongside these tragic findings of individual trusts, we have an improving picture of maternity care overall.

[Baroness Brinton (LD)]

My Lords, in yesterday’s Statement on Dr Kirkup’s report, the Minister told us that 23 hospitals are in maternity safety support programmes—special measures—and that, while four are coming out, another 10 are due to go in. Can he assure the House that extra resources, including extra supervision, will be there to ensure that mothers and babies in those hospitals are absolutely safe?

[Lord Markham (Con)]

Yes. Resourcing the special measures programme—for want of a better name—is vital to all of us. I am pleased to see in the case of East Kent that, of the 67 special measures recommended, it has now passed 65 and the two remaining ones will be completed by the end of November.

[Lord Patel (CB)]

My Lords, this is the most recent of several reports identifying failures of maternity units in England. The CQC identified 40 maternity units that had failing safety standards. Bill Kirkup has not only produced a brilliant report but identified the way forward, by developing a matrix of standards of safety and outcomes that would apply to all maternity units to make them all high calibre, high standard and safe. Will the Minister agree that, by meeting Bill Kirkup, Ministers could ask him to identify the areas to draw up these standards? Because time is short, if the Minister agrees I will be happy to meet him to enlarge further.

[Lord Markham (Con)]

I agree about wanting to implement the recommendations. My colleague Dr Johnson, the Minister in the other House, already met with Dr Kirkup this week. We also undertook to come back in the next four to six months with where we are on each of the recommendations. I will bring that back to the House then.

[Lord Lansley (Con)]

My noble friend referred to the first recommendation for the prompt establishment of a taskforce to develop maternity and neonatal outcome measures. It is over a decade since we introduced the NHS outcomes framework but, far too often, it is not used as the basis for accountability inside the National Health Service. Will he say whether that first recommendation will be acted on immediately?

[Lord Markham (Con)]

As I mentioned before, we have already put this in place with the maternity quality surveillance framework. At the same time, if we feel that more needs to be done, it will be included in my review of the recommendations and report back to the House in four to six months.

[Baroness Andrews (Lab)]

My Lords, one of the significant things about this devastating report is that it does not deal with a list of one-off recommendations, as previous reports have. It deals with systemic issues that mean that the whole service is challenged. One of those, as we have already heard, is the difficulty in identifying risks. The other is why we do not hear what families are saying, which is clearly an issue in preventable deaths. One of the specific recommendations is that the Government should now bring forward a Bill that would place a duty on public bodies not to deny or deflect or conceal information from families. That should be a priority. Will the noble Lord take that back to his senior Ministers and get them to acknowledge it?

[Lord Markham (Con)]

We all acknowledge a duty of candour. That should be fundamental to the leadership and to everyone in every trust. In this case, I was pleased to see the trust completely accept the findings and its failings and apologise unreservedly. That is something we need to make sure that all trusts do. We have the framework in place to do that but, if we do not, we will not hesitate to act further to ensure that it is.

[Baroness Finlay of Llandaff (CB)]

My Lords, this alarmingly clear report flags up flawed teamworking as a major failing throughout. That also reflects previous reports. It also points out the unintended adverse consequences of using the phrase “normal births”, which should perhaps be replaced by “safe births”. Will the Government consider the problem of teamworking? Although there already is a joint group between the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, there also needs to be commissioning guidance to make sure that services are commissioned only when there is joint education and training, audit, and co-production of guidance with parents who have experience of the unit.

[Lord Markham (Con)]

Again, we agree with Dr Kirkup’s third recommendation that teamwork is vital in all this. Some £26 million has been invested in maternity teamwork training, and a core curriculum has been set up for professionals in this area. Strong leadership has been established, with two national maternity safety champions and a number of regional and local maternity safety champions. We believe that we have the framework in place for these independent working groups but, as we review these recommendations, if we find they are inadequate we will not hesitate to act further. We will bring this back to you in the four-to-six-month timeframe when we report on the recommendations.

[Baroness Hussein-Ece (LD)]

My Lords, the duty of candour has been in place for some years now, but there still seems an ingrained culture of denial and blame deep-rooted within these services. This is the third such report since 2015 and one of its central tenets is that women are just not listened to and are ignored, resulting in terrible deaths and disabilities for so many children. Can the Minister give us his assurance that the duty of candour and listening to women will be at the heart of the Government’s response?

[Lord Markham (Con)]

Yes.

[Baroness Merron (Lab)]

My Lords, Dr Kirkup’s extraordinary report cites a lack of junior staff and, critically, a shortage of midwifery leadership as contributing to the tragedies at East Kent. In the absence of a comprehensive workforce strategy from the Government, and more midwives leaving than joining, what is being done right now to tackle the considerable number of midwifery vacancies that the NHS is suffering? It currently stands at well over 2,000.

[Lord Markham (Con)]

The number of midwives has been stable over the last four years. We have seen a slight decline over the last year, which is why we have a training and recruitment programme to recruit 1,200 more midwives. In my main point, I echo the comments that Dr Kirkup made: working under pressure is no excuse for staff being rude and aggressive. While we want to recruit the extra numbers, I think that the whole House agrees that there is no excuse for what happened at East Kent.

Water Fluoridation (Consultation) (England) Regulations 2022

Lord Markham Excerpts

Tuesday 25th October 2022 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Water Fluoridation (Consultation) (England) Regulations 2022.

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

My Lords, in moving that these regulations be approved, I shall also speak to the Health and Care Act 2022 regulations.

The water fluoridation provisions of the Health and Care Act will come into force on 1 November, and in doing so will transfer the power to initiate new schemes, or to vary or terminate existing schemes, from local authorities to the Secretary of State. Public consultation will continue to be an important aspect of proposals, and the focus of today’s debate is the draft consultation regulations, which set out the process that any future consultations must follow. We know that some have strong feelings on the subject of water fluoridation and consultations relating to it, and we were keen to gather public opinion before laying these draft regulations. We therefore launched a public consultation on 8 April, which ran until 3 June 2022, seeking views on whether future water fluoridation consultations should be restricted only to those affected locally and bodies with an interest, as has previously been the case, or whether they should now be open to all, given the shift of responsibility from local authorities to central government.

We received 1,228 responses; 94% came from individuals and 6% from organisations. The majority of respondents favoured a consultation which is open to all. The draft regulations do not therefore restrict those who can respond to any future consultation. However, we understand that it is those living, working and studying in the areas in question who are directly affected, which is why the regulations also provide for consideration to be given, as part of the decision-making process, to whether those who may be particularly affected by any future proposals should be given additional weight.

Although public opinion and the extent of support for a water fluoridation proposal will continue to be important, consultations are not referendums. It is right that regulations provide for a range of other factors to be taken into account when considering a water fluoridation proposal. This includes, but is not limited to, the strength of evidence underpinning any arguments made by respondents. It is right that due regard is given to those arguments that are properly supported by sound evidence.

We are committed to scientific evidence surrounding water fluoridation underpinning any proposal. The department continues to review scientific papers published both in this country and internationally as part of the continuous monitoring of the evidence—including those on the epidemiology and toxicology of water fluoridation —and every four years the department will continue to publish a summary report on our knowledge, in line with the Secretary of State’s responsibility for monitoring the effects of the water fluoridation arrangements on the health of the populations served by schemes. I provide assurance that, if the balance of evidence in favour of water fluoridation as a public health measure were to change, a review of the current water fluoridation policy would take place.

Another important element in deciding to proceed with a water fluoridation proposal is the cost-benefit analysis of such proposals. Any new proposal will have to demonstrate that the benefit to health will represent good value for the investment of public money proposed.

We want more of the country to benefit from water fluoridation, and many noble Lords may be aware that yesterday we announced, subject to the outcome of this debate and future consultations, that funding has been secured to begin expansion across the north-east into Northumberland, County Durham, Sunderland, South Tyneside and Teesside, including Redcar and Cleveland, Stockton-on-Tees, Darlington and Middlesbrough. I know that the local authorities in these areas are strong supporters of water fluoridation. In accordance with the regulations we are debating, we will hold a public consultation on this proposal next year. This expansion would enable an additional 1.6 million people to benefit from water fluoridation, which will help to reduce the level of tooth decay in the area and over time will reduce the number of children who need to be admitted to hospital for tooth extractions.

I turn now to the draft Health and Care Act 2022 (Further Consequential Amendments) Regulations 2022, starting with mandatory training on learning disability and autism. People with a learning disability and autistic people experience poorer health outcomes in comparison to the general population. There is a need to address the significant and persistent health disparities faced by this group of people. That is why the Government have introduced, from 1 July 2022, a requirement in the Health and Care Act for CQC-registered service providers to ensure that their employees receive specific training on learning disability and autism. Introducing mandatory training on learning disability and autism is intended to ensure that health and social care employees have the skills and knowledge to provide safe, compassionate and informed care. The Act also creates a duty for the Secretary of State to publish a code of practice which will outline how to meet the new requirement on mandatory training. The code of practice is being developed and we expect to publish a draft for consultation early next year.

The consequential amendment proposed today seeks to remove the requirement for the Care Quality Commission to issue statutory guidance about the mandatory training requirement, by amending Section 23(1) of the 2008 Act. This carve-out clause should have been applied during the passage of the Health and Care Bill. If the Act is left unchanged, registered service providers will have two sets of guidance: statutory guidance issued by the Care Quality Commission and, subsequently, the code of practice issued by the Secretary of State. Removing the requirement for the CQC to issue statutory guidance will mean that registered providers will have a single source of guidance once the code of practice is published. The Care Quality Commission has agreed to keep all its statutory guidance, which was published on 1 July 2022, available to registered service providers until the code of practice is published.

Lastly, I turn to virginity testing and hymenoplasty. Safeguarding vulnerable women and girls is a top priority for the Government, which is why we were one of the first countries in the world to ban virginity testing and hymenoplasty. Virginity testing and hymenoplasty have no scientific merit or clinical indication and are a violation of human rights. These degrading and intrusive acts have an adverse impact on women and girls’ physical, psychological and social well-being. They can lead to extreme psychological trauma in the victim, including anxiety, depression, post-traumatic stress disorder and suicide, and physical trauma including damage to the hymen and vaginal wall, bleeding, infection and sexual difficulties. As such, we are proud that the Health and Care Act 2022 made carrying out, offering, and aiding and abetting virginity testing and hymenoplasty illegal.

As these are new offences, certain changes to other legislation are necessary to protect vulnerable groups. The Scottish Government have requested a change to be made to the Foster Children (Scotland) Act 1984, which contains a list of matters which disqualify a person from fostering a child in Scotland. The consequential amendments proposed today would add to that list the conviction of an offence of virginity testing or hymenoplasty in relation to a child. The change would also flow through to assessments by adoption agencies in Scotland under The Adoption Agencies (Scotland) Regulations 2009 in relation to the suitability of prospective adopters.

The 2009 regulations require those suitability assessments to be carried out by reference to a range of information, including whether the prospective adopter or any member of their household has been disqualified or prohibited from keeping a foster child under the 1984 Act. This change would have the effect of disqualifying or enabling the disqualification of individuals convicted of virginity testing or hymenoplasty offences from fostering or adopting in Scotland.

Similar changes were made to English and Welsh law in negative regulations under the Health and Care Act 2022. Scottish provisions on this matter are set out in primary legislation requiring an affirmative procedure. It was unfortunate that we were not able to make this amendment in the Health and Care Bill, as the need for the change was not identified during the Bill’s passage, but the priority is to put in place these restrictions now. This change will help to protect girls and young women from so-called honour-based abuse.

[Lord Reay (Con)]

My Lords, I have spoken previously in the House in Committee and at Second Reading of the Health and Care Bill about how the Government’s water fluoridation policy is considered to be misguided by numerous eminent scientists in the UK and overseas, including government advisers. They warn that fluoridation causes a variety of health ailments, including damage to the foetal brain. I hope to offer my noble friend the Minister some constructive comments on how to improve the water fluoridation consultation process, which is unsatisfactory and inadequate in many respects.

First, the consultation should be more prescriptive as to the minimum level of publicity required from the Secretary of State to promote the policy. The current framework gives scope for minimal effective publicity, as the media requirement is merely defined as that which the Secretary of State considers appropriate. In comparison, in the case of public health initiatives concerning Covid, the NHS has texted those patients registered and sent letters to relevant individuals based on their ages. The same has applied to screening tests for various cancers. In addition to the NHS database, local authorities have council taxpayer databases and electoral register databases, which could be used for public information notifications. It is particularly straightforward to do that on a locality-by-locality basis, as would apply for fluoridation schemes. There could also be a specification for notices in local papers and in the national press.

Secondly, the consultation period is quite short, given that the public are expected to gather information and evidence, analyse data, review scientific evidence, carry out cost-benefit exercises and marshal arguments on a variety of aspects of a given scheme. Six months would be a more reasonable period.

Thirdly, no objective process is stipulated whereby the Secretary of State can realistically assess

“the extent of support for the proposal”

under Regulation 5(1)(a). What about the extent of opposition to the proposal? There should be a requirement for independent public opinion-polling and also canvassing of the views of parish, borough, city and county councillors. A local referendum should be considered. It stands to reason that, if a local proposal is to have any real democratic legitimacy, the view of a majority of the local populace should not be overridden.

Fourthly, it is difficult to see how the Secretary of State can gauge the cogency of arguments, ethical considerations or scientific evidence without being guided by a panel of relevant experts. These should be recruited independently from the Department of Health, by nominations from bodies such as the royal institutes or other professional bodies for engineers, statisticians, accountants, economists, scientific research bodies, toxicologists, ethicists and the like. They should be similar to commissions of inquiry or standing advisory bodies, chaired by legally qualified personnel.

Fifthly, Regulation 5(1)(b) should prescribe that particular weight should be given to representations made by individuals who would be affected by the proposal. Conversely, it is difficult to see why any weight should be given to anybody with an economic interest in favour of a proposal, because a public interest health policy should not promote private economic interests.

Sixthly, as far as “capital and operating costs” are concerned, in Regulation 5(1)(c), the relevant costs are the full range of costs, including establishment costs, insurance costs, admin costs, consultation costs, any extra security costs, extra wear and tear or corrosion costs, monitoring costs, safety training costs, additional computer software costs and many others. A narrow compass on these costs would generate some very misleading results.

On Regulation 5(1)(c), it is no good looking at the above costs in isolation: there has to be a comparative cost-benefit analysis, taking into account a range of alternative options such as no scheme, a lesser or more targeted scheme, alternative dental preventive health schemes such as providing fluoride via milk or tablets or topically, public education or in-school training, and so forth. This should include an analysis of the successful Childsmile programme in Scotland, which, through education and dentist visits to schools has been shown to reduce tooth decay in children.

--- Later in debate ---

With those comments, I welcome the regulations and thank the Minister.

[Lord Markham (Con)]

I thank your Lordships for your contributions today. First, as the noble Lord, Lord Hunt, said, the principle has been decided in previous debates, and the debate today has been about the consultation and the implementation. As for the comments made by the noble Baronesses, Lady Brinton and Lady Merron, there is strong evidence in favour, as illustrated by the Australian dentist cited by the noble Baroness, Lady Brinton. As the noble Lord, Lord Hunt, said, we must at all times be driven foremost by the medical evidence, so I agree that the highest stakeholder in this process should be the science.

At the same time, the noble Lord, Lord Reay, makes good points about ensuring that the consultation is properly done, so I completely hear his comments about making sure it is well publicised so everyone has the opportunity to contribute to the debate, ensuring that sufficient time is given so that everyone has a chance to submit their piece, and having proper experts assess the consultations. I think we could also all agree as a principle that private, commercial interests should not be a factor that people can use. I hope those are items on which we could all agree.

On the point about health research and different cases emerging all the time, as noble Lords will be aware, under these provisions we have committed to publish the latest evidence every four years so that if things change, we are able to change with them. I hope that will give the safeguards and make sure that we are always led by the science and the medical evidence, as the noble Lord, Lord Hunt, said.

On the points about learning disability, virginity and hymenoplasty, I welcome the thanks; it was before my time, but I know that it was very much a team effort. My understanding is that it was very much the Lords working at its best, with cross-partisanship.

A very good point was raised on the foster parent household definition. I have just phoned a friend, but I am not sure my friend has given me the answer. I understand the point that you can often have an elder—a household member who might not actually live there but who can be hugely influential—so I will come back in writing on that. It was a well-made point.

I hope I have covered all the points raised in this debate. Again, I thank noble Lords for their contributions and trust that we have been able to answer them, apart from the household point, which I will come back on in writing.

I am glad to see that we mostly agree on the benefits of water fluoridation. The regulations reflect the consultation responses from the public and will not restrict those who want to respond to future public consultations on water fluoridation schemes.

I trust that my answers have provided reassurance that removing the requirement for the CQC to issue statutory guidance on mandatory learning disability and autism training will not leave service providers without clear guidance. I trust that they have also provided reassurance that amending the Foster Children (Scotland) Act 1984 will help protect children being fostered and adopted in Scotland from virginity testing and hymenoplasty.

Finally, on a personal note, reflecting on the 10 debates and speeches I have done today, it is with pleasure that I feel I am playing a small part in doing something very good here. I thank all noble Lords for their contributions.

Motion agreed.

Health and Care Act 2022 (Further Consequential Amendments) Regulations 2022

Lord Markham Excerpts

Tuesday 25th October 2022 Grand Committee

Moved by

[Lord Markham]

That the Grand Committee do consider the Health and Care Act 2022 (Further Consequential Amendments) Regulations 2022.

Motion agreed.