Health and Care Bill

Lords Hansard - Part 1 & Committee stage
Thursday 13th January 2022 Lords Chamber

Committee (2nd Day)

12:10

Relevant documents: 15th and 16th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee

Clause 3: NHS England mandate: general

Amendment 11

Moved by

[Baroness Thornton]

11: Clause 3, page 2, line 20, at end insert—
“(3A) In section 13G (duty as to reducing inequalities), at end insert—“(2) NHS England must publish guidance about the collection, analysis, reporting and publication of performance data by relevant NHS bodies with respect to factors or indicators relevant to health inequalities.(3) Relevant NHS bodies must have regard to guidance published by NHS England under this section.(4) In this section “relevant NHS bodies” means—(a) NHS England,(b) integrated care boards,(c) integrated care partnerships established under section 116ZA of the Local Government and Public Involvement in Health Act 2007,(d) NHS trusts established under section 25, and(e) NHS foundation trusts.””Member’s explanatory statement
This amendment would give NHS England a statutory duty to publish guidance on how NHS bodies should collect, analyse, report and publish performance data on factors and/or indicators related to health inequalities.

[Baroness Thornton (Lab)]

My Lords, it is a privilege to open this debate on the issue of health inequalities. I am grateful to all noble Lords who have gone through the Bill to ensure that addressing health inequalities is absolutely central. Unless the Bill deals with the kind of inequalities that the pandemic, for example, has brought into sharp relief, it will have failed. Many amendments in this group directly and indirectly address the issue, and I look forward to the many contributions we will hear. This is one area where our NHS may not be among the best in the world. In fact, inequality is often entrenched. Some might argue that, through the famous inverse care law, it even makes things worse. As with other public services, the better-off, with better connections and sharper elbows, get more out of a service than those with less social capital who are already disadvantaged by other factors.

A report published today by the Northern Health Science Alliance, a health and life sciences partnership between the leading NHS trusts, universities and academic health science networks in northern England, says that

“people in ‘left behind’ neighbourhoods are 46 per cent more likely to have died from the virus than those in the rest of England, and 7 per cent more likely to have died of the virus than those living in other deprived areas”

that are not left behind. In left-behind neighbourhoods,

“Men live 3.7 years fewer and women 3 years fewer than the national average,”


and

“men and women can expect to live 7.5 fewer years in good health than their counterparts in the rest of England.”

Tackling the health inequalities facing local authorities of left-behind neighbourhoods and bringing them up to England’s average could add an extra £29.8 billion to the country’s economy each year. The co-chair of the All-Party Parliamentary Group for “Left Behind” Neighbourhoods, the right honourable Dame Diana Johnson, said that:

“Every person in the country deserves to live a long life in good health”,


but this new research demonstrates that this is not currently a reality.

We are all aware of the work of Sir Michael Marmot. In his review, which explored the changes since 2010, he highlighted five policy areas:

“—Give every child the best start in life —Enable all children, young people and adults to maximise their capabilities and have control over their lives —Create fair employment and good work for all —Ensure a healthy standard of living for all —Create and develop healthy and sustainable places and communities”.


The key messages from that review make stark reading. This is one of the strongest:

“The amount of time people spend in poor health has increased across England since 2010. As we reported in 2010, inequalities in poor health harm individuals, families, communities and are expensive to the public purse. They are also unnecessary and can be reduced with the right policies.”


In a note that I think all noble Lords will have received from Crisis and other voluntary organisations, they point out that, as it stands, people who experience the most extreme health inequalities, such as those who are homeless, sex workers, Gypsy, Roma, Travellers, vulnerable non-UK nationals and people with substance misuse issues, encounter significant barriers to accessing and receiving the healthcare that meets their needs. These barriers can include stigma, the lack of a fixed address or ID, fragmented services, the lack of continuity of care because of unstable accommodation, and lack of awareness from healthcare professionals of specific needs.

12:15

These can be reduced by the right policies and the right action. Health inequalities are not inevitable. Evidence shows that a concerted approach, implemented through the NHS and wider policies to address socioeconomic causes of poor health, can make a difference. The most recent national cross-government health inequality strategy was successful in narrowing the life expectancy gap between the most and least deprived communities. But I am afraid it was scrapped in 2010, and since then inequalities have widened as improvements in life expectancy have slowed.

The Bill offers a potential route to strengthen action on health inequalities, and there are three ways to improve the Bill: first, strengthening the existing core of inequalities duties; secondly, boosting the triple aim; and thirdly, ICS structures facilitating greater action on health inequalities. This suite of amendments addresses most of those.

Without doubt, healthcare should have the strongest role in tackling inequality and, in that, the strongest role should be played by public health. It is the part that has not been lucky enough to receive at least some protection from austerity, as the NHS did. Some of the unintended but inevitable consequences of the failure to invest in public health have been seen in the pandemic. Cuts have their consequences, and we have all been suffering them.

We cannot avoid, in a debate about inequalities, reference to the report An Avoidable Crisis, an investigation by my noble friend Lady Lawrence into why black, Asian and minority-ethnic communities were dying at a disproportionate rate during the pandemic. It was immediately apparent that the impact on people’s health was inseparable from economic prospects and experiences of discrimination. She says:

“It will require systemic solutions to systemic problems. It is not enough for policymakers to know that ethnic inequalities exist. We need to honestly confront how inequalities at all levels of society have come to exist and the intersectional impact it has on each ethnic group. This means recognising the interaction of faith, class, gender, disability, sexuality, ethnicity and culture in order to truly understand that no community is ever one homogeneous group.

Only then will we be able to respond effectively. We need bold, joined-up policies and an approach that encompasses tackling ethnic disparities, from housing to employment and health.”

Reducing health inequalities is not an ideological or moral standpoint; it is now well accepted that an unhealthy population is less productive, and there is a loss of economic efficiency and we all lose. The Bill offers us an opportunity to start to remedy that situation.

Those who have been lucky enough to go through the proceedings of the Bill Committee in the Commons will have seen that the Government accept the need to focus on reducing inequalities but claim that this is already a requirement expressed elsewhere in legislation. Because at present this is largely an NHS Bill, many amendments seek to make it a comprehensive health and care Bill. Only when mental health, public health, primary care and community care are all working in collaboration will we actually tackle health inequalities. I beg to move.

[The Deputy Chairman of Committees (Baroness Barker) (LD)]

My Lords, the noble Lord, Lord Howarth of Newport, is taking part remotely in these proceedings and I now call him to speak.

[Lord Howarth of Newport (Lab) [V]]

My Lords, Professor Sir Michael Marmot’s work, to which my noble friend just alluded, has shown that health inequalities have widened across England in the last 10 years. The impact of these inequalities has been both exemplified and amplified by Covid-19. I support Amendments 11, 14 and others that address this massively important problem and I fully agree with my noble friend’s analysis.

Health is powerfully influenced by the social, economic and environmental conditions in which people live and work. Place-based and whole systems are therefore vital to improving health and reducing inequalities. This is recognised in the NHS Long Term Plan and the move towards integrated care.

Sir Michael endorsed the findings of the Creative Health report of the All-Party Parliamentary Group on Arts, Health and Well-being, which in 2017 documented over 100 studies on how the arts and creative activities have supported health. In 2019, the World Health Organization’s scoping review of the role of the arts in improving health and well-being provided evidence that creative activities could mitigate the detrimental impact of stressful environments and the negative health impacts of growing up in disadvantaged conditions. Engaging with the arts, the evidence shows, can improve social cohesion and lead to a reduction in social inequalities in deprived areas. It can build skills and mutual support, which can improve social mobility. The positive effects of the arts can make a particular impact on early years development, as is demonstrated in the evidence provided to DCMS by Dr Daisy Fancourt et al in 2020.

Social prescribing, through bringing people together in shared creative activity and voluntary work, helps to build social capital and better health and well-being in deprived communities.

Research by the MARCH network, a UKRI-funded research programme, has shown that the health benefits of engaging with cultural and other community activities are felt by all, regardless of socioeconomic status. We know that there is a social gradient in participation in cultural and community activities and that those living in areas of higher deprivation are less likely to engage in them. However, the MARCH research indicates that when individuals in areas of high deprivation do engage, the mental health and well-being benefits may be particularly great for them, even greater than for those who live in more affluent areas. Therefore, targeted investment in cultural and community opportunities in areas where people are likely to benefit most can help to reduce health inequalities.

For instance, in Manchester, the Natural Cultural Health Service of the Whitworth art gallery is encouraging activities by local residents from diverse backgrounds that promote physical and mental well-being. Contact, a theatre company, supported by the Wellcome Trust, offers a health and well-being space for use by local community groups. Manchester Camerata has moved its base to Pugin’s wonderful Gorton abbey, in a deprived part of the city. Its musicians are working to support people with dementia and the Camerata is providing a resident composer and musician for local schools. Evaluation has shown that encouraging children to express themselves through music-making has raised their confidence and self-esteem, with a positive impact on their schoolwork and all the implications for them and their community that can follow from that.

The Big Noise project, run by Sistema Scotland in Govanhill since 2008, provides free orchestral training to young people. Evaluation has shown positive health outcomes as a result of improved confidence, social and other skills and emotional well-being. Similarly, the Royal Liverpool Philharmonic has run its In Harmony project to improve the life chances of children through music, and since 2009 has benefited 2,500 children in the Everton and Anfield areas of Liverpool.

The cultural and VCSE sectors have a key role to play in reducing health inequalities and should be fully embedded at systems level and in the health decision-making process. Integrated care partnerships provide the gateway to making this happen.

The National Centre for Creative Health, a charity of which I am chair, is currently working in partnership with NHS England in pilot programmes with four ICSs with a specific focus on mitigating health inequalities. We are looking to establish how best to embed creative health into healthcare strategies. We are also hosting a further AHRC-funded research project called Mobilising Cultural and Natural Assets to Combat Health Inequalities. The outputs will support ICSs to maximise the potential of the arts and natural assets in improving health and reducing inequalities.

I hope the Minister will assure us that the Government recognise the indispensable role of the arts and culture, as well as engagement with nature, in mitigating health inequalities, and that the system created by the Bill—designed, I hope, with an unambiguous purpose to reduce health inequalities—will fully embrace such non- clinical approaches.

[Lord Patel (CB)]

My Lords, I thank the noble Baroness, Lady Thornton, for introducing this group of amendments. My name is attached to her amendments, and I have some amendments in my name; I thank noble Lords who have added their names. I will speak in particular to Amendments 11 and 14 but what the noble Baroness, Lady Thornton, said applies to other amendments, and I agree with them and have added my name to them.

Covid-19 has exposed and exacerbated existing health inequalities in England, and the Government have committed to “levelling up” the country. Progress on national NHS commitments related to reducing health inequalities has been slow in recent years, and NHS England has urged local systems to accelerate action to tackle health inequalities after the pandemic. A step change is clearly needed, yet the Bill’s current provisions on health inequalities amount to no more than the same: transposing existing inequality duties from CCGs to the new NHS ICBs.

One area where there is clearly scope for improvement is strengthening reporting on health inequalities. There is currently no explicit requirement for NHS England to publish national guidance about which performance data and indicators relevant to health inequalities should be collected, analysed and reported on by NHS bodies. The NHS’s current system oversight framework, as a means to define national priorities and monitor the overall performance of local systems, also includes little in the way of concrete measures on health inequalities, with those that are included being focused primarily on shorter-term Covid-19-related equity impacts.

The amendment in the name of the noble Baroness, Lady Thornton, addresses this. It would require NHS England to publish guidance on collecting, analysing, reporting and publishing data on all factors or indicators relevant to health inequalities. I hope the Government will commit to considering this amendment in order to drive more action on inequalities and enable better tracking of progress across different areas.

The only thing I would add to this is the NHS Priorities and Operational Planning Guidance that was published by NHS England just before Christmas—in fact, on 24 December; it could not be much nearer to Christmas. On page 6 of this, as one of the priorities for 2022-23, NHS England asks local health systems to:

“Continue to develop our approach to population health management, prevent ill-health and address health inequalities—using data and analytics to redesign care pathways and measure outcomes with a focus on improving access and health equity for underserved communities.”


It also states that in delivering all the NHS’s priorities, it intends to maintain the

“focus on … tackling health inequalities by redoubling our efforts on the five priority areas”—

already mentioned by the noble Baroness—

“set out in guidance in March 2021.”

It reiterates that ICSs will take a lead role in tackling health inequalities and notes:

“Improved data collection and reporting will drive a better understanding of local health inequalities in access to, experience of and outcomes from healthcare services, by informing the development of action plans to narrow the health inequalities gap. ICBs, once established, and trust board performance packs are therefore expected to be disaggregated by deprivation and ethnicity.”


On page 29 onwards there are further details about this.

12:30

Amendment 11, in the name of the noble Baroness, Lady Thornton, to which I have added my name, therefore goes with the grain of current policy and would help support these efforts and put this in the legislation. Arguably, it will not be possible to do this effectively without more consistent guidance and clarity around how to measure progress on inequalities, which is what the amendment seeks to do. I am led to believe that NHS England might be supportive of this and clearly thinks it is needed to spur action.

I turn very briefly to Amendment 14, which relates to the “triple aim”. I strongly support Amendment 14 —in the name of the noble Baroness, Lady Thornton, and others—which aims to extend this. To send a clearer signal about the importance of narrowing inequalities, the triple aim should be extended so that it explicitly references the need for organisations to consider the impact of their decisions on efforts to reduce inequalities.

The Government so far have argued that addressing inequalities is already implicit in the first aspect of the triple aim—the requirement to consider the effects of decisions on the health and well-being of the population. It has clearly not been obvious to many experts and charities scrutinising the Bill. However, if it is the Government’s intention to ensure that the reduction of inequalities is prioritised, they should make this explicit in the Bill.

[Lord Young of Cookham (Con)]

My Lords, this is my first contribution to the debate on the Bill and, listening to earlier exchanges, it struck me how many were being made by those who had either run the NHS as administrators or, indeed, as Ministers. I can join that happy band. I was a Health Minister in 1979 and put on the statute book the Health Services Act 1980, abolishing area health authorities. Nostalgia has overcome me, as phrases I used 40 years ago about streamlining the structure and making it more efficient have been recycled in debates on this Bill.

My first piece of health legislation followed the appointment of commissioners to run the Lambeth, Southwark and Lewisham Area Health Authority which was breaking its cash limits and behaving illegally. Unfortunately, our suspension was also illegal, and I had to pilot through the other place the National Health Service (Invalid Direction) Bill, with much hilarity at my expense from the Opposition. So, more than 40 years later, it is good to join in another debate about NHS reorganisation. Today’s debate about inequality was actually raised 40 years ago: noble Lords may remember the Black report on inequalities in health. I was rereading it last night and it struck me how many of the 37 recommendations made 40 years ago are still relevant today.

Mine is the lead name on four amendments, but I plan to say very little on Amendment 66 and leave it to the noble Lords, Lord Rennard and Lord Faulkner, to make the case for a specific reference to smoking as a key factor in reducing health inequalities.

As we have heard, the Bill gives integrated care boards a responsibility to reduce inequalities in access to health services and in health service outcomes. The biggest cause of inequalities are factors such as smoking, obesity and alcohol, particularly smoking, which is responsible for half the difference in life expectancy between the richest and poorest in society—an issue that was raised an hour ago during Oral Questions. Others will say more about the imperatives of tackling these hazards to health.

I will focus instead on Amendment 152 in my name and will also speak briefly to Amendments 156 and 157. These amendments are supported by the noble Lord, Lord Shipley, who will focus on housing and why legislation is necessary, and by the noble Baronesses, Lady Neuberger and Lady Watkins. I am grateful to Crisis, the homeless charity, for its briefing.

I commend the Government’s welcome commitment to tackle health inequalities and hope the forthcoming White Paper on levelling up will have a strong section on this, following the recent report of the Public Services Select Committee, chaired by the noble Baroness, Lady Armstrong. I hope that will put flesh on the bone of what risks becoming more of a slogan rather than a policy, meaning different things to different people. I hope the levelling up White Paper will directly address inequalities in health.

As the Secretary of State for Health has said recently, we must tackle the “disease of disparity”, and these amendments highlight the experiences of those groups who are undoubtedly at the worst end of that disease. In current NHS policy and documents, these groups are referred to as “inclusion health populations”—a term used to highlight the need for health services to overcome the social exclusion and marginalisation that many people face, resulting in dire consequences for their health. That group includes rough sleepers, Gypsy, Roma and Traveller communities, vulnerable non-UK nationals and people with substance misuse issues.

These people develop health conditions usually seen in people in their 70s and 80s up to 40 years earlier, and often die from them. Tragically, the average age of death among people experiencing homelessness is 46 for men and 42 for women. Clearly, these are not health outcomes we should accept for anyone. The solutions exist, and chime very well with what the Health and Care Bill seeks to do. However, it currently does not go far enough.

The Bill places a welcome emphasis on integrated services. To tackle the health injustices for people who are socially excluded, we need holistic, integrated health services to meet their needs, and we need them everywhere. They do exist in some places; they are also referred to as “inclusion health services” and they have a significantly positive impact. For example, Pathway, the leading health charity for inclusion health, has helped 11 hospitals in the UK create multidisciplinary teams of doctors, nurses, social care professionals and housing workers. These teams support over 4,000 patients every year who are homeless, with very positive outcomes. An audit of Pathway’s services in 2017 showed a 37% reduction in A&E attendances, a 66% reduction in hospital admissions and an 11% reduction in bed days. However, despite these successful services, inclusion health services are not currently commissioned at the scale required, and access to them is a postcode lottery. King’s College London found that 56.5% of homelessness projects in England do not have a specialist GP inclusion health service in their area—hence the amendments on best practice.

During my time as a Housing Minister, I saw the impact of social exclusion on people, including how not having a stable home to live in is devastating for people’s physical and mental health. Therefore, working closely with expert organisations across these sectors including Crisis, Pathway, St Mungo’s and many others, we want to amend the Bill to ensure a strategic focus in the new systems being set up to help the most socially excluded in our society.

The amendments introduce two important and necessary changes. The first would place a duty on integrated care partnerships to have due regard to the need to improve health outcomes for inclusion health populations when they create their healthcare strategies. Placing a duty on partnerships will make it clear that inclusion health is a strategic focus, and that should follow through and be reflected in the resourcing and commissioning decisions of integrated care boards. I do not regard the requirement to “have regard to” as an onerous imposition.

The second change would make clear the importance on health outcomes of having a stable home. It would mean that, in addition to the partnership having to consider health and social care in its strategic integration arrangements, it would also need to consider housing. This possible change would make clear that housing is on a par with health and social care services. The noble Lord, Lord Shipley, will say more about this.

With the advent of the Everyone In scheme in March last year, which sought to provide safe accommodation for those who without it would have continued to sleep rough, we saw how critical it is for people to have a place of their own. We need to build on that success and prevent rough sleepers drifting back on to our streets. My amendment legislates to ensure that health, social care and housing services continue to work more closely together to consistently support people who too often fall through the gaps between these services.

These amendments are firmly within the scope of the Bill. They will complement and strengthen its welcome aims to integrate health services across the whole system and tackle health inequalities. The amendments are neither overly prescriptive nor bureaucratic; their aims are simple. I look forward to my noble friend the Minister’s reply.

[Baroness Greengross (CB)]

My Lords, in October last year, during the debate on the Ageing: Science, Technology and Healthy Living report, the Minister, the noble Lord, Lord Kamall, confirmed that the Government maintain their commitment to ensuring that people live at least five extra healthy and independent years of life. A practical first step towards achieving that goal would be to ensure that tackling health inequalities is a priority in this legislation, and the amendments in this group seek to achieve that. We know that health inequality is a problem that has been getting worse, and we need to tackle it as an emergency. I support the amendments in the group calling for NHS England, NHS trusts and the integrated care strategy to collect relevant information and data, as well as to take the necessary action to prevent health inequalities and improve healthy living.

In 2010, as we know, Sir Michael Marmot published his report on health equity, finding that social position determined people’s health outcomes and that people at the lower end of the social gradient had worse health. At the time, the report recommended that the focus on improving this should not be targeted just at those from the most disadvantaged parts of the country but should take a universal approach to improving health outcomes, which is very much needed. The report highlighted the economic benefits of addressing health inequalities. In particular, it raised the issue of lost productivity, increased spending on welfare and lost tax revenues due to people having to leave work as a result of poor health.

Just before the pandemic, in 2020, Sir Michael Marmot did his 10-year review, and we know how alarming the findings of that report were. For the first time, life expectancy had stalled in the UK. In the poorest 10% in England, the life expectancy of women actually declined between 2010 and 2012 and between 2016 and 2018. Mortality rates for people between 45 and 49 years old increased, and in many cases those were deaths of despair, due to suicide or substance abuse. That is terrible news. The level of child poverty has also increased in the UK to 22%—compare that with Norway, for example, where child poverty is 10%. That is also alarming. The number of years lived in poor health across England has increased and continues to be worse in the poorest parts of the country.

We hear much about the so-called levelling-up agenda from the Government. One finds it hard not to dismiss it as little more than a glib and somewhat trite slogan, because there is little to back it up in real policy to try to address issues such as health inequality. However, I am an optimist and I see the Bill as a step towards trying to address these challenges. But to do this effectively we must have a better understanding of the drivers of health inequality. We must have plans at a local and national level to address those drivers. This group of amendments offers some solutions to start addressing health inequalities through this legislation. I look forward very much to the Minister’s response to these amendments and to hearing his view on how the Bill is going to achieve the Government’s goal of people living at least five extra healthy and independent years of life.

12:45

[Baroness Tyler of Enfield (LD)]

My Lords, my name is attached to six amendments in this extremely important group. I should like first to turn to Amendment 14 in the name of the noble Baroness, Lady Thornton, to which my name is attached. Other noble Lords have expressed support for amending the triple aim to explicitly include health inequalities, and I add my voice to that call. The examples given by the noble Lord, Lord Patel, and others about the real-life causes and impacts of health inequalities show just how important it is that we strengthen the Bill.

I would like briefly to highlight the specific impact of mental health inequalities, which are pervasive and deeply embedded. As the noble Lord, Lord Crisp, said in our debate on Tuesday, mental illness itself causes inequality. People with severe mental illness live, on average, between 15 and 20 years less than the general population. Black people are more than four times as likely as white people to be detained under the Mental Health Act. There are higher rates of suicide in the LGBT community, yet many in that community do not, or feel that they cannot, seek healthcare because of fear of discrimination. People with a learning disability often suffer with significantly worse physical and mental health than the general population.

The Centre for Mental Health Research has shown that it is often groups of people with the poorest mental health who have the greatest difficulty accessing healthcare that meets their needs and produces good outcomes for them. Unless an ICB is focused on which groups of people have the poorest health in the first place and understands why that is the case, it will, frankly, struggle to reduce the inequalities flowing from that.

Amendment 14 would amend the triple aim duties specifically for NHS England. Amendments 94, 185 and 186 in the name of the noble Lord, Lord Patel, to which I have attached my name, would replicate that explicit inclusion in the triple aim for integrated care boards, NHS trusts and NHS foundation trusts.

As the noble Lord, Lord Young, has said on health inequalities, regarding them as implied in the first element of the triple aim—to consider the impact of decisions on the health and well-being of the population—does not, in my view, get us any further than where we are today. Given the statistics that I have outlined and the fact, as we have heard, that the pandemic has made things a lot worse, we clearly need to go further.

I turn now to Amendment 65, regarding the role of local health systems. It seeks to strengthen the health inequality duty placed on integrated care boards by giving them a requirement to

“implement systems to identify and monitor inequalities in physical and mental health between different groups of people within the population”

of their area. As things stand, the provisions in the Bill will ensure that NHS organisations are required to address inequalities in a similar way to how CCGs currently do it. But we need to see more ambition. The provisions would be strengthened and not merely transferred. The current requirement to “have regard to” is not enough. Local health systems have a central role to play in addressing health inequalities. They are ideally positioned to understand the challenges in their areas and, to use the jargon—for which I apologise —co-produce local solutions with communities. The development of integrated care systems gives us a new opportunity for local areas to take population health and place-based approaches, so that the vulnerable groups who have been referred to do not fall through gaps.

There is a lot about health inequalities that we do not know; we suspect, but we just do not have the data. Amendment 65 proposes that the Bill includes clearer and more direct requirements for integrated care boards to focus efforts on identifying and monitoring those inequalities. Currently, the quantity and quality of data collected is inadequate for it to be fully disaggregated against the different protected characteristics and provide a real insight into the inequalities that exist. That is why I have attached my name to Amendment 61 in the name of my noble friend Lady Walmsley, which I strongly support.

Robust information and data are prerequisites for any action. Improved data collection—both on health services and on wider inequalities in the area—will lead to a far better assessment of what needs to be done, particularly in areas such as public mental health and the local NHS workforce. I will quote one statistic about GPs. A GP working in a practice serving the most deprived patients will, on average, be responsible for the care of almost 10% more patients than a GP serving a more affluent area. This simply cannot be right.

I will end by quoting from work we have already heard about—the work of Professor Sir Michael Marmot. It needs no introduction. He has demonstrated that efforts to address health inequalities will benefit society as a whole. The NHS Long Term Plan states:

“While we cannot treat our way out of inequalities, the NHS can ensure that action to drive down health inequalities is central to everything we do.”


I urge the Government to ensure that the Bill does just that.

[Lord Desai (Non-Afl)]

My Lords, as an NHS patient but not an expert, I will say one small thing about inequalities. Given the way in which the NHS is structured, with no money paid up front and with excess demand and inadequate supplies because of budget shortages, it is forced to allocate treatment by queuing—and queuing, obviously, means that people have to wait.

There is a fallacy that somehow the poor have more time than the rich. In my experience it would improve matters immensely if, when appointments are given, there was less delay in the patient seeing the person whom they are supposed to see. I know that, right now, there are standard regulations that cover these matters, so that people end up waiting three hours. I have done that. But my time is not as valuable as that of someone poorer. You do not measure the value of your time by your income. So it would improve matters if the allocation of services were made using communication devices. This would waste less of patients’ time and help them better access services.

[The Lord Bishop of Carlisle]

My Lords, I will speak on behalf of my noble friend the right reverend Prelate the Bishop of London. She has added her name to Amendment 65, and we on these Benches support the other amendments in this group that seek to reduce health inequalities. As we have heard, these amendments would help to ensure that the Bill does not forget the underserved and disadvantaged in our society, many of whom have been mentioned already.

In the Christian and Jewish faiths, there is a Biblical concept—shalom—which embodies a sense of flourishing, generosity and abundance. Shalom can be summarised as experiencing wholeness, or a state of being without gaps. This is reflected in the World Health Organization’s definition of health, which is about not only the absence of disease but mental, physical and social well-being. It is a vision for individuals and for the whole of society. Our efforts to design a more holistic health service are, in effect, aimed at achieving that sort of shalom. We see this clearly in the decision made to place 42 integrated care systems across the country. What is not yet apparent is the relationship of these systems and boards to the wider community.

This Bill must seek to involve local communities—and not just professionals—in the reduction of health inequalities. These amendments highlight the monitoring of both physical and mental inequalities, take account of the experiences of young people and children and place more emphasis on the strength of local interventions to help reduce and prevent health inequalities. I commend them wholeheartedly to your Lordships’ House and to the Minister.

[Lord Rennard (LD)]

My Lords, I rise in support of these amendments, in particular Amendment 66 in my name and those of the noble Lords, Lord Young of Cookham and Lord Faulkner of Worcester.

This amendment would expand the duties of integrated care boards. We want them to exercise their functions with respect to reducing inequalities relating to

“modifiable risk factors, such as smoking.”

Our aim is to help the Government achieve their manifesto commitments to reduce health inequality, level up and increase healthy life expectancy by five years by 2035. This amendment would mean that integrated care boards would have a responsibility to reduce inequalities in access to health services and the outcomes achieved. They would also be responsible, in consultation with partners such as local health and well-being boards, for drafting joint five-year plans to explain how they would discharge their responsibilities, including those to reduce inequalities.

At present, there are significant inequalities in both patient access to health services and in the outcomes achieved. The biggest causes of inequalities in health outcomes are behavioural risk factors, such as smoking, obesity and alcohol. As the noble Lord, Lord Young of Cookham, said, smoking alone is responsible for half the difference in life expectancy between the richest and poorest in society. It is a greater source of health inequality than social position and it remains the leading cause of premature death in this country.

We all hope that the integrated care systems will contribute significantly to reducing inequalities in smoking and other behavioural issues, but they are likely to succeed only if addressing such modifiable risk factors becomes a core function of the NHS, working in collaboration with local authorities. Amendment 66 would ensure this.

The difference in healthy life expectancy between those living in the most and least deprived areas of England is around 19 years for both men and women—in other words, almost two decades. Let us look at one place in particular. As measured by the index of multiple deprivation, Blackpool is, sadly, top of the table of the most deprived local districts in the country. Over the last decade it has consistently had one of the highest smoking rates in the country, at over 20%. Most distressingly, more than 20% of mothers in Blackpool are smokers at the time they give birth. So our amendment is needed because the recently published NHS inequalities strategy—which is impressive in parts—does not address the behavioural causes of health inequalities. In fact, it says nothing about them at all.

The Government’s inequality strategy sets out five clinical areas that are crucial to improving health outcomes for the poorest 20% in society. They are chronic respiratory disease, serious mental illness, early cancer diagnosis, maternity and—last but not least—identifying people with high blood pressure who need to be pre-treated to prevent heart attacks and strokes. In all these areas, behavioural factors such as smoking, obesity and alcohol very significantly increase the dangers to health. If appropriate action is taken, it can greatly improve patient outcomes and, at the same time, reduce pressure on our NHS.

To take just one example, chronic respiratory disease is caused primarily by smoking. It is estimated that smoking is responsible for 90% of chronic obstructive pulmonary disease, but one-third of patients diagnosed with COPD carry on smoking. There is nothing in the NHS England inequalities strategy about this, and no target for reducing smoking rates among those with chronic respiratory disease. Yet stopping smoking is the most effective and cost-effective treatment. Only by quitting smoking can those with COPD prevent further decline in lung function.

Smoking, obesity and alcohol are also causally linked to cancer and hypertension. People with mental health conditions die on average 10 to 20 years earlier than the general population. Smoking is the single largest factor in this shocking difference. The question we must therefore ask today is this: given that modifiable behaviour risk factors are core to all five identified clinical focus areas, why are they not included in the NHS England inequality strategy? Perhaps it is because the Government do not see addressing these population-level health risk factors as a core responsibility of the NHS.

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Could it be that the Government are leaving the responsibility for such issues to local government despite knowing that local authorities have greatly diminished resources at the same time as they face considerably increasing costs to fund activities for which they have legal obligations? Addressing modifiable risk factors should be core business for the NHS and local authorities working together. At every level, we need to recognise that funding activities such as smoking cessation services extends people’s lives, improves their quality of life and saves the NHS significant sums of money in the long run.

Amendment 66 therefore seeks to make smoking and other modifiable risk factors to health the responsibility of integrated care systems and local authorities, which must work together if we are to improve public health, with all the benefits that follow, including helping to protect our NHS.

[Baroness Watkins of Tavistock (CB)]

My Lords, I am delighted to speak to this group of amendments, which I support; I am particularly delighted to speak to Amendment 156, as one of its co-sponsors. I very much support the comments of the noble Lord, Lord Young, who has highlighted the appalling health disparities faced by people who are the most socially excluded. I, too, ask the Government to recognise how amending the Bill in the way proposed would help them to realise their ambitions in this area.

We know that the level of ill health among people who would be considered under inclusion health is significant. We have heard the shamefully low average age of death for people experiencing homelessness in England and Wales. We also know that the life expectancy of Gypsy, Roma and Traveller communities is around 10 to 12 years fewer than that of the general population, although one study has found that this gap can be as high as 28 years. This disparity in life expectancy clearly demonstrates the devastating impact of extreme social exclusion.

It is clear to me that the health and social care system has a significant role to play in tackling the health inequalities experienced by these groups. These amendments would facilitate crucial progress towards that and encourage social enterprise involvement to reach the most socially excluded individuals. We have seen examples of this at the relatively new Plymouth dentistry school, where the training clinic has been set up as a social enterprise to serve some of the poorest people in Plymouth.

In relation to Amendment 156 in particular, we know that NHS services must be integrated with wider services to reflect how people’s lives work. A main aim of the Bill is integration, yet integration could not be more important for the groups that experience the most complex needs and require very effective, co-ordinated care. As I know from my time in nursing, there has been a historic lack of integration between housing, health and social care, yet housing is fundamental to reducing health inequalities. Without integration across these different systems, people will continue to develop acutely poor health.

People who experience social exclusion, and extreme health inequalities as a result, often fall through the gaps in the provision of primary and secondary care, mental health and substance misuse services, health and social care, and even health and wider systems, such as housing. For example, we know that people experiencing homelessness attend A&E six times as often as people with a home, are admitted to hospital four times as often, and stay three times as long. One study has found that homeless people attend A&E 60 times more than the general population. This has tragic results for the individual and also places incredible strain on our healthcare system.

We must act to alleviate the pressures on the NHS where we can. Severe and multiple disadvantage is conservatively estimated to cost society more than £10 billion a year. It is clear that the cost of doing nothing is too high, both to the individual suffering severe health inequalities and to the NHS. This amendment would help address these issues by ensuring that housing is considered by integrated care partnerships. It is non-mandatory, therefore speaking to the Government’s aims of enabling local decision-making and flexibility, but would ensure that partnerships think of the important role that housing plays by providing a stable place from which people can then engage with wider health services. A wide range of expert organisations are supportive of this amendment and related Amendments 152 and 157, including Crisis, Social Enterprise UK, Doctors of the World, and Friends, Families and Travellers.

The NHS must work effectively for all who are entitled to use it, including those who need it most. If we get access and outcomes right for the most marginalised in our society—those who experience the poorest health —we will likely get access and outcomes right for everyone. That is why I call on the Government to support the amendments in this group.

[The Lord Bishop of St Albans]

My Lords, Amendments 68 and 95 are in my name. I declare my role as president of the Rural Coalition. I support the broad drift of these amendments, which engage with the important issue of reducing inequalities.

Rural health and social care has often presented challenges in terms of proximity to services, the types of services available within a local area and the demographics of rural areas. It is complicated. Rural areas have a higher proportion of older residents, which is always a greater burden on healthcare services compared with areas with younger populations.

Furthermore, a variety of issues that feed into rural health and social care are beyond the remit of the Bill. In March 2017, Defra produced its Rural Proofing practical guidance to help policymakers assess the impact of policies on rural areas. At the time, this was a welcome initiative to ensure that rural interests were being adequately considered and, to quote the report, that

“these areas receive fair and equitable policy outcomes.”

Unfortunately, concerns have since grown among rural groups that this guidance has become a sort of bureaucratic box-ticking exercise in Whitehall that does not take into account the complexities of rural life.

Funding allocations are often the result of specific metrics or formulas, many of which disadvantage rural communities. For example, a 2021 report by the Rural Services Network, Towards the UK Shared Prosperity Fund, highlighted how many of the post-Brexit levelling-up funds disadvantaged poor rural areas due to way in which they measured poverty. The Department for Transport’s own 2017 statistics showed that, on average, travel from rural areas to either a GP or hospital was 40% longer by car and 94% longer via public transport when compared with travel in urban locations.

Further, 2017 figures from Rural England highlighted the higher rates of delayed transfer of care from hospitals in rural areas: 19.2 cases per 100,000 compared with 13 per 100,000 in urban locations. Analysis by the RSN has shown that, when compared with predominately urban areas, rural local authorities received significantly less grant funding per head to pay for services such as social care and public health responsibilities, in spite of the fact that they generally deal with older populations. Other problems include limited intensive care capacity in rural areas, the loss of local services through amalgamations, the relatively few specialist medical staff in rural areas, and the general staff shortage and retention issues facing rurality.

It is commendable that the Government have legislated in this Bill to introduce a duty on integrated care boards to reduce inequalities between patients with respect to their ability to access health services. My amendments would extend this principle and reduce those health inequalities with respect to where someone lives, whether it is an urban or rural area, and place a duty on ICBs to co-operate with each other for the purpose of reducing healthcare access inequalities. In effect, this is a statutory rural-proofing requirement.

This duty to consider rural access when reducing inequalities extends to co-operation between ICBs because rural areas often exist on the periphery of a large geographical region where patients in one area may reside closer to crucial services in a neighbouring board. Naturally, rural areas lack the economies of scale of urban areas, and greater cross-ICB co-operation will be required to utilise joint resources most effectively when delivering different services to rural areas that fall within border zones of ICBs.

One area where a collaborative approach between ICBs will be crucial for rural areas in the near future is the current reorganisation of non-emergency patient transport by NHS England, which will shift to ICBs shortly. Although rural areas undoubtedly are being considered as part of this re-organisation, patient transport is already a rural inequality that needs addressing. Putting rural proofing with respect to health care on a statutory footing presents a more concrete way to implement the existing rural-proofing guidance. The need for co-operation between administrative areas and for overall plans to be rural proofed will become more essential, particularly for secondary health services, if teams of specialist clinicians become increasingly consolidated in ever fewer locations.

Can the Minister outline how the Government intend to reduce the inequalities in healthcare access and funding that many rural areas face, and how they will effectively ensure that ICBs adequately rural proof their plans in line with the Government’s own guidance?

[Lord Faulkner of Worcester (Lab)]

My Lords, I am very pleased to follow all noble Lords in supporting all the amendments in this group. I congratulate my noble friend Lady Thornton on the way in which she introduced the debate when moving Amendment 11. I will speak briefly to Amendment 66, which was tabled by the noble Lord, Lord Young of Cookham, and signed by the noble Lord, Lord Rennard, and me.

It was enjoyable listening to the noble Lord, Lord Young, taking a voyage down memory lane to more than 40 years ago, when he was a Health Minister. He could perhaps have added that we would have become a smoke-free country rather earlier, had his advice and proposals for tobacco control been accepted at the time, and had he not been removed from health on the instruction of Sir Denis Thatcher and given another role in government. He is and remains a pioneer, and I am delighted to be behind him with his amendments; we shall come to other smoking amendments later.

Amendment 66 would require integrated care boards to address the leading preventable causes of sickness and death, particularly smoking. The Bill as drafted fails to get to the root causes of health inequalities and will have only a limited effect. Our amendment would correct this oversight as far as smoking is concerned. In 2019, there were 5.7 million smokers in England, one in seven of the adult population. As the noble Lord, Lord Rennard, said, in England smoking is the leading cause of premature death, killing over 70,000 people a year and leaving 30 times as many suffering from serious smoking-related disease and disability.

13:15

As Sir Chris Whitty, the Chief Medical Officer, said in a lecture on public health at Gresham College last May, smoking is likely to have killed more people in 2020 than Covid-19, but unlike Covid-19, smoking kills on the same scale every year, and will go on doing for many years without robust action to correct this. It is worth pointing out that he also said that one in five people who die from cancer will die from lung cancer, and

“the reason that people like me get very concerned and very upset about it is that this cancer is almost entirely caused for profit. The great majority who die of this cancer … die so that a small number of companies make profits from the people who they have addicted in young ages, and then keep addicted to something which they know will kill them. So lung cancer is unfortunately still a very major problem”

that exists almost entirely because of smoking for profit.

While overall smoking rates have fallen significantly over the last 20 years, the difference in smoking rates between the most disadvantaged group and the general population has become more pronounced: the inequality has widened. This includes people with mental health conditions, pregnant women, those in routine and manual occupations, and those living in social housing. There is a real risk that people from these groups will be left behind as we move towards a smoke-free 2030.

Given current trends in smoking, Cancer Research UK has estimated that we will miss the smoke-free 2030 target by seven years, and the most deprived quintile will not reach the target until the mid-2040s. This amendment will help to ensure that this prediction does not become reality. The Government announced their ambition to make England smoke-free by 2030 in the 2019 prevention Green Paper. However, in the two years since, we have seen no sign of the “bold action” that the Government acknowledged is needed to achieve the 2030 ambition.

In December 2020, the Government announced that a new tobacco control plan would be published in July 2021 to deliver that ambition. This did not happen and last month, the Minister, the noble Lord, Lord Kamall, told Parliament that publication had slipped to 2022, with no date specified. With only eight years left until 2030, there is an urgent need for action to back up the Government’s rhetoric. This Bill is a great opportunity to get us on track to deliver a smoke-free 2030, and to tackle the severe health inequalities plaguing our society. I urge the Government not to squander this opportunity and to accept this amendment, along with the other amendments on smoking which we will come to later in Committee.

[Lord Shipley (LD)]

My Lords, now that we are in Committee, I remind the House of my interest as a vice-president of the Local Government Association. I rise to speak to Amendments 152, 156 and 157, to which I am a signatory. I will not repeat all the excellent points made by the noble Lord, Lord Young of Cookham, and others, but I hope the Government will accept that what is being proposed is central to the success of this Bill, and that is because the NHS does not exist in a vacuum.

We know that prevention and early treatment of people’s ill-health will help them, reduce demand for hospital beds and lead to a more efficient use of public resources. We know well enough that poor housing contributes to poor health. These amendments to Clause 21 present an opportunity for the Government to demonstrate their commitment to truly tackling health inequalities and, in particular, to ending rough sleeping, by the end of this Parliament in 2024. As the noble Lord, Lord Young, and others have clearly laid out, the beneficial impact on a range of groups experiencing social exclusion and poor health outcomes would be significant. That means that there must be integrated approaches between housing, health and social care at the point when integrated care partnerships create their healthcare strategies.

Research shows that an average local authority might have around 1,400 people a year experiencing multiple disadvantage, including support needs around mental and physical health, homelessness and contact with the criminal justice system. Around 58,000 people a year experience the most severe disadvantage. It is therefore essential that local integrated care partnerships consider all the ways in which health intersects with housing.

I was concerned to read recently that in July last year 77% of women leaving our largest women’s prison became homeless. Homelessness inevitably leads to poor health. As Professor Dame Carol Black’s recent review of drugs highlighted, unless housing and housing support needs are addressed, the health service will fail to improve people’s health consistently, regardless of how effective the commissioned health services may be.

We know this approach works. The Government’s welcome effort to vaccinate people who were homeless went alongside a push for not only GP registration but provision of emergency accommodation. This acknowledged the need to bring together support into housing alongside access to basic health services. Indeed, we have seen the Government revisit this approach just before Christmas, with the Protect and Vaccinate scheme. Since the Government have recognised the need for this integrated approach, I cannot see why they would object to these amendments that would help continue it.

Amendments 152, 156, 157 and others seek to make our NHS systems more effective in the delivery of services to the most excluded and marginalised in our society. As it stands, people are forced to attempt to navigate a siloed and fragmented health service that does not adequately address their complex health needs. For example, one patient with alcohol and other addictions, supported by Changing Lives, could not access mental health services until after his alcohol addiction was addressed. However, with the right support from Changing Lives’ inclusion health approach, this patient is now managing abstinence from alcohol and engaging with mental health support. Crucially, his experiences highlight the challenges in addressing substance misuse in isolation, without making support available to address mental ill-health at the same time.

The Government may argue that it will be sufficient to address these concerns in guidance, but I hope they do not. I acknowledge that guidance would be beneficial in ensuring that approaches to inclusion health populations are considered within integrated care systems. However, without legislation, tackling inclusion health would become nice to do rather than something that must be done.

A recent example of this is Covid-19 vaccine uptake among people who were homeless. We know that where inclusion health services existed, there was a concerted effort to ensure good vaccine uptake, but without these specialist services we simply do not know how effective vaccination programmes have been. The only data available from July 2021 show vaccination rates to be substantially lower among people who were homeless compared to the general population.

I am aware that commissioning strategies and services for inclusion health populations is already on the agenda of some integrated care systems, but we need all integrated care systems to play their part. Guidance will not be effective enough to ensure the provision of specialist support everywhere, not just in some places.

In conclusion, the level of complexity of the marginalised and excluded experience can be met only by embedding inclusion health throughout the health and care system at the highest levels. Legislation is the most secure way to achieve this. Otherwise, there will continue to be a postcode lottery in access to the right healthcare services for these groups, resulting in that “disease of disparity” the Secretary of State wants to address.

[Lord Kakkar (CB)]

My Lords, I first join other noble Lords in thanking the noble Baroness, Lady Thornton, for the thoughtful way in which she introduced this group of amendments. I support Amendment 14, in the noble Baroness’s name, and Amendments 65, 94, 186 and 195 in the name of my noble friend Lord Patel. This is a vital group of amendments, as your Lordships have already heard, because it is focused on inequalities. Clearly, no society, Government or Parliament can tolerate the inequalities that we see in both clinical outcomes and access to healthcare that have remained despite our remarkable healthcare system and the NHS. It is for that reason that it is absolutely right that, in the opportunity afforded by this Bill, inequalities are properly addressed.

More worrying is that, despite this country’s substantial investment in healthcare and the development of health systems over the past 70 years, these disparities in outcomes and access to healthcare described geographically and across different ethnicities and socioeconomic groups have continued to grow. That is despite all the success we have seen more broadly in delivering healthcare, addressing prevention and improving treatments.

It is also right to recognise that inequalities in outcomes and access to healthcare are best addressed at the local level. Through a focus on integration in not only the capacity of services but the capacity to integrate the development of policy and its execution across healthcare and through local government and the other elements of the state—education, employment, housing and so on—we will have the greatest opportunity to address social determinants of health. There has probably been no other health Bill presented to this Parliament since the creation of the NHS that provides the greatest opportunity to take that combined and collective approach.

It is therefore quite right that one turns attention to the triple aim. This is a laudable addition to the Bill, with an absolutely appropriate focus on promoting health and well-being, ensuring access to quality care for all citizens and ensuring the appropriate and effective utilisation of healthcare resources. Why not add to that triple aim a fourth clear objective to address issues of inequality? The triple aim does not mandate action, but it provides the context in which a framework should be developed locally, cognisant of the healthcare needs of the local population. An ideal framework would ensure that we drive collaboration and co-operation as required to focus activity and the allocation of resource and establish a local vision and determination to address health inequalities.

To fail to take this opportunity would be disappointing and, quite frankly, unacceptable. As we have heard in this excellent debate, if we fail to address these inequalities not only will they have a continuing and profound impact on health outcomes and access to healthcare for large numbers of our fellow citizens, but there are broader societal and economic consequences of continuing to accept inequalities in healthcare. I hope that, in answering this debate, the Minister will be able to confirm that Her Majesty’s Government are prepared to consider this issue and will put inequalities the heart of this Bill in the triple aim—becoming a quadruple aim—and will ensure that, at a local level, data collection and reporting become a primary focus of healthcare systems.

[Baroness Harding of Winscombe (Con)]

My Lords, I begin by declaring my interest as the recently departed chair of NHS Improvement. I support these amendments, especially those that seek to extend the triple aim, such as Amendments 14, 65 and 94, as the noble Lord, Lord Kakkar, just set out so eloquently. It seems there is no disagreement in the Committee about the importance of addressing health inequalities. Anyone who has lived through the past two years can see that plainly and clearly, as Covid has so cruelly highlighted the health inequalities in this country. The question is how we make sure this Bill genuinely tackles the issue that we all agree about so passionately. Why is it important, as just set out by the noble Lord, Lord Kakkar, to put the duty to address health inequalities in the Bill?

13:30

I want to make as my contribution a short story about a visit that I made recently in my capacity as chair of NHS Improvement with the noble Lord, Lord Mawson, to north-west Surrey last summer. We visited the team from the NHS trust, Ashford and St Peter’s, as well as the local authority and a number of local community organisations. There was a moment in that visit when the medical director of the trust, a cardiac surgeon, said that he had had an epiphany: the NHS was not the most important actor in addressing health inequalities. He said that had hit him like a train; he had realised that he and his trust, by far the biggest organisation in the integrated care system and the largest employer with the most money, needed to play a supporting role rather than the prime-moving, main acting role. That was a huge culture shift for him and for the trust that he was part of. Over the course of the last couple of years, it has led them to do some small but hugely important things, such as relocating their physiotherapy clinics to gyms, which means that people get more into the habit of exercising when their NHS treatment ends. That requires the NHS to be subservient to the local authorities, voluntary organisations and private sector partners in their integrated system. If we are really to address health inequalities, that requires change from our beloved NHS.

The system that I am describing is one of our very best but they would openly admit that they are still in the early stages of that change, which is why it is so important that we put this in the legislation. I know that the Minister and the Secretary of State care deeply and passionately about addressing health inequalities; both have been very public about their commitment. I urge them to hear the spirit of the cross- party agreement in this Committee today and accept the amendments.

[Baroness Pitkeathley (Lab)]

My Lords, I support all the amendments in his group but particularly Amendment 68, in the name of the right reverend Prelate the Bishop of St Albans, about health inequalities faced by those living in rural areas. When you live in a rural area, it is often difficult physically to access a GP practice—if you do not have a car, try getting a bus in a rural area whose timetable coincides with the opening hours of your surgery—and to access health information if your internet is not up to scratch. There are many rural areas where connectivity still leaves a great deal to be desired. Pharmacies, too, can be difficult to access; although some run outreach services, they are by no means universal.

In rural areas, the important non-clinical services mentioned by my noble friend Lord Howarth are largely dependent on the voluntary sector. During the pandemic, when village halls, with their plethora of exercise, dance, art and social support services, were closed, many older people in rural areas were cut off completely, with disastrous effects on their mental health.

The problems of delivering social care in rural areas are also well known. When care workers are paid for home visits only for the time when they are in the home and not for travelling time—time that will of course be extended by the spread-out nature of those visits—it is no wonder that many private and voluntary agencies are handing back social care contracts to local authorities because they simply cannot deliver them.

Poverty, the underlying cause of inequality, is more widespread in rural areas than is often acknowledged. Escaping to the country is a nice idea, but unless you recognise the particular inequalities faced by country residents, it is not as you see it on the television. Moving as a couple approaching retirement is a different picture when one—usually the husband, both the gardener and the driver—dies, leaving an isolated widow in declining health. The cost of fuel is also more acute in rural areas, and you will find many older people who may own a nice-looking cottage having to choose between heating and eating, with consequential effects on their health and future dependency.

I very much hope that when the Minister replies, he will emphasise that when integrated care boards are considering the provision of services for the purposes of achieving equality of access for patients, they will consider those living in all parts of the board’s area.

[Lord Scriven (LD)]

My Lords, this is my first intervention on the Bill. I draw the Committee’s attention to my relevant interests in the register, namely as a vice-president of the Local Government Association and a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust.

I support this suite of amendments—particularly Amendments 11, 14, 65, 94, 186 and 195—which explicitly puts the issue of health inequalities in the Bill and makes it central to the aims of the NHS. It also deals with reporting and holding people to account for helping to reduce health inequalities.

The reason for my support is simple. I speak as a former NHS manager who, as a rookie many years ago, in the very early 1980s, was on the general management trainee scheme. For the first three months, our aim was just to go around. I remember asking the very naive question: “Who’s responsible for quality?” I expected the person who was showing me around to say, “Everyone”, but he said, “Follow me.” We went in his car for five miles outside the hospital to the health authority. We then went into a lift, down into the basement and through lots of corridors, and finally came to a door at the end of the corridor. The door was opened and in a dimly lit room was a middle-aged woman, surrounded by piles of paper. I said, “Who’s this?” I was told, “This is Gladys. Gladys is responsible for quality.” It was seen as someone else’s job.

That is why I have cringed a little when the Minister has said, in previous debates and Answers on health inequalities, that the Office for Health Improvement and Disparities is being established. That is well and good, but that office is not responsible for reducing health inequalities; everyone in the healthcare system and its partners must work together to reduce health inequalities. That is why it is really important that this is explicit. It is not just about health issues; it is about people’s income, work, environment, green space and transport. It should be explicit in the Bill as part of the triple aims—which will become four aims—and become part of monitoring. This issue must become central because something that I have learned about the health service is that unless the centre asks for it, and asks for it to be monitored, it just does not get done because it is not seen as important. That is why monitoring this at both local and national level will hold people to account so it does not become Gladys’s responsibility.

The Bill gives us a once-in-a-lifetime opportunity not just to put health inequalities centrally in the Bill but to make them explicit in the way that the NHS and its partners work. With a little extra legal push to the mill, so to speak, as well as the monitoring, the data and holding people to account, I believe that we can finally start to deal with these issues in a systematic way that shows improvement and will allow the NHS and its partners to know where to push a bit harder to get this done. That is why I support the amendments.

[Baroness Finlay of Llandaff (CB)]

My Lords, this debate has shown clearly that attacking health inequalities must go beyond the bounds of the NHS as the impact of external factors is massive. I remind the Government that in 2015 poor housing alone was estimated to cost over £10 billion. That was in part because of the poor housing but it was compounded by inactivity and, as a result, obesity.

We should look at the antecedents of complex problems. Marie Curie’s report Dying in the Cold revealed failures in healthcare, bereavement and grief and the challenges of providing care for those with complex needs. Learning difficulties and autism, for which we often do not know the underlying causes, are disproportionately prevalent among people who are socially excluded and at high risk of homelessness, yet for them managing homelessness alone is particularly difficult because of their overall vulnerability. It has been estimated that autism alone has a twelvefold prevalence in those who are homeless compared to the general population.

The antecedents of many of the problems go back to childhood. They carry a life sentence of their trauma, which feeds into worsening health inequalities, aggravating factors such as alcohol and drugs consumption and other behaviours. Unless we strengthen the wording in the Bill to monitor and do something about the data that comes forward, the proposal of my noble friend Lord Kakkar—it is essential that we address this as a core problem to be tackled—will not be realised. I hope that when the Minister replies he will provide some assurance that the Government will consider strengthening the wording in the Bill in the light of this debate.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, I wonder if I might be allowed to speak at this point for the simple reason that I am shortly due to take over from the noble Baroness, Lady Fookes, in the Chair and if I do not contribute now, I will not be able to at all. I have no special expertise to bring to the scrutiny of the Bill, therefore this is the first time I have spoken on it and it may be the last. I want to speak in support of the contribution of my noble friend Lord Howarth of Newport, right at the beginning of what has been a very long and extremely interesting debate but which, until recently, when my noble friend Lady Pitkeathley mentioned it, did not refer back to the points he raised.

In making my brief remarks, I draw attention to my own interests, which are mostly to do with the arts. I am thinking about what my noble friend Lord Howarth said about the arts sector and what it can contribute. I ask the Minister, when he comes to reply, if he would look to one side of his department—particularly towards the Department for Education and to the Department for Digital, Culture, Media and Sport—for further evidence, in addition to the very strong evidence my noble friend Lord Howarth put forward, of the impact of engagement with the arts, particularly on people suffering from often multiple disadvantages.

It is very clear that the data emerging in relation to education points to a strong impact on the health, particularly the mental health and well-being, of young people in education settings when they are able to engage creatively with the arts and arts practitioners. It would be very easy, in thinking about the huge diversity of issues that have been raised here which bear on health inequality, to see engagement with the arts as a “nice to have” extra—something that, if we get everything else right, we can perhaps add in. But it is more important than that, as the evidence is now strongly beginning to show. I therefore ask the Minister not to forget what my noble friend Lord Howarth said at the beginning of the debate in his reply, and to consider very seriously how health inequalities can be properly and creatively addressed by further engagement with the arts sector.

I will say one last thing, which perhaps seems not quite at the heart of it, but it is important. My noble friend Lord Howarth, in giving his examples, spoke about arts organisations, many of which are trying to contribute to this area. To be able to do that, they need people with skills who can deliver the work. Nearly all the people who can deliver the work and have those skills are freelancers. As we all know, they have suffered hugely in the last two years as a result of the crisis that we have all been through. Freelance workers in all sectors, but particularly the cultural sector, have had a very bad time and quite a lot of them have left. I add that as an additional thing to remember when we look at the expectations we can reasonably—and should—have of the arts sector. It needs to be able to properly support the people it has to engage to deliver the work that it can do.

13:45

[Lord Mawson (CB)]

My Lords, I did not want to speak in this part of the discussion but I will make a few comments. I absolutely support what the noble Baroness, Lady McIntosh, and the noble Lord, Lord Howarth, have been saying.

When I first arrived in Bromley-by-Bow 37 years ago this year, I found on my doorstep the largest artistic community outside New York and none of the systems had even noticed or understood its significance. Over the last 37 years, we have been exploring the whole arts and health agenda and the massive impact it can have on local people’s lives.

When we began to put the Olympic project together —as I said on Tuesday, I was involved in it from day one for 19 years—we took that really seriously and engaged with that large artistic and creative community in health, jobs and skills, education et cetera. That £1.2 billion development going on at the moment in the middle of the Olympic park, bringing together University College London, the London College of Fashion, Sadler’s Wells, the V&A, the BBC orchestra and others, is all about this innovation agenda. It is moving it to scale. If this is to happen, we need the systems of the state and the public sector to learn from this entrepreneurial behaviour, which is happening on the ground, in real places and now to scale, and to understand the detail of what it means for the macro systems of the NHS.

I will say more about place later today, but I thank the noble Baroness for making those points, and the noble Lord, Lord Howarth, because this is fundamental. It relates to the fundamental question: what is a human being? A human being is fundamentally a creative being. Health and creativity and, I suggest, entrepreneurship and doing things, are fundamentally connected.

[Lord Bethell (Con)]

My Lords, I came face to face with the nation’s health inequalities every morning in the departmental Covid response group, the COBRA meetings and the COBRA gold, when we went through the hospitalisation details and ICU data and heard stories from the front line of how people who had comorbidities particularly associated with obesity were filling up our hospitals as the virus spread through the country in wave after wave. That health inequality hit this country hard in very real terms. It cost a lot of lives, caused a lot of misery and cost our health system an enormous amount of money. It cost this country and its economy a huge amount of money and it is time that we came to terms with that challenge and solved the problem.

As a number of noble Lords have pointed out, the NHS must step up to its responsibilities in this area. There are complex reasons for these inequalities; some are environmental, some are behavioural and some are to do with access. But the NHS and whole healthcare system must realise that it needs to be involved in all aspects of those, and prioritise and be funded accordingly. The Bill already does an enormous amount to change the healthcare system’s priorities. Putting population at the heart of the ICSs is one really good example of that.

To anticipate some of his remarks, I know that the Minister will point to the Office for Health Improvement and Disparities. As the noble Lord pointed out, however, it has a tiny budget and cannot take responsibility for the nation’s health. Our councils are stony broke, as I found in my experience of dealing with them over the last two years. There is no one else to do this; this is not someone else’s problem. This is to do with the British healthcare system, and it needs to stand up to that responsibility. Zero progress has been made in the round over the last few years and we have gone backwards in the last two years in a big way. We need to make this a massive priority.

This is a fantastic Bill; I am really supportive of it. It came from the healthcare system originally. In this one area, however, there is a graphic lacuna that needs to be addressed. The noble Lord, Lord Kakkar, put it so well in his inimitable way. The prioritisation of inequality must be put in the Bill and it needs to be heard throughout the healthcare system that this is the new, central priority that needs to be added to everyone’s job description.

If, for some reason, we do not do that there will be huge consequences. The healthcare system is unsustainable in its current form. We cannot continue to have a large part of the population carrying grievous comorbidities or disease and afflictions which are undiagnosed or not properly mended turning up in our hospitals at a very late stage and costing a fortune to mend. These health inequalities, whether they relate to disease, injury or behavioural issues such as obesity, are costing us a fortune. Only by putting tackling inequality on the face of the Bill can we really give it the priority it deserves.

I also say to the Minister that there is a sense of political jeopardy about this as well. We went into the last election committed to levelling up on health. We have gone backwards in the last two years through no fault of the Government, but if the Government do not step up to their responsibilities in this area, and if the NHS and the healthcare system do not change their priorities, the voters will judge us extremely harshly. For that reason, I urge the Minister to listen to this debate and look very carefully at ways of amending the Bill.

[Baroness Neuberger (CB)]

My Lords, I want to pay tribute, as other noble Lords have, to the noble Baroness, Lady Thornton, for her very thoughtful introduction. It is remarkable and absolutely wonderful to see consensus breaking out across the Committee. I will speak specifically to Amendments 152, 156 and 157 in the name of the noble Lord, Lord Young of Cookham, whose words on the need to make this really serious by stating it on the face of the Bill I echo.

I am a former chief executive of the King’s Fund and am currently chair of University College London Hospitals and Whittington Health. These issues are very dear to my heart and the hearts of those institutions. I also want to say thank you to Crisis for its briefing and add to the words of the noble Lord, Lord Young of Cookham, in praise of Pathway, which has done the most extraordinary work in this area over very many years.

I want to talk particularly about the NHS-funded Find & Treat service, which was set up 13 years ago and is run by UCLH, which I chair. This service was set up in response to a TB outbreak in London and aimed to provide care for people experiencing homelessness and people facing other forms of social exclusion. The service did exactly what it says on the tin: it went out and found people—and still does—who were at risk of contracting TB, wherever they were sleeping, and offered them diagnosis and treatment. Back in 2011, a study concluded that this service had been not only effective in helping to treat people with TB who were experiencing homelessness but cost effective in doing so, both in terms of costs saved to the health service and improved quality and length of life for the people receiving care. Fast-forward a decade and the evolution of this service meant it could be similarly mobilised at the beginning of the Covid pandemic. It provided urgent and necessary care to people who continue to experience the poorest health outcomes.

The King’s Fund published a report in 2020 on delivering health and care for people sleeping rough. It supported the need for inclusion health services to be provided much more broadly than at present. Importantly, it also concluded that local leadership is absolutely vital in crafting that approach and said that local leaders should model effective partnership working across a range of different organisations.

Embedding inclusion health—I cannot say I really like the term, but everybody knows what it means—at the level of integrated care partnerships will help ensure that our healthcare system can no longer ignore, forget or overlook people who are all too often considered “hard to treat”, despite proven interventions showing the opposite. It will ensure that integrated care partnerships and systems take that vital first step towards closing the gap of the most significant health inequalities in our society by having to recognise and consider people facing extreme social exclusion and poor health outcomes in their local areas.

We all know that there will be considerable discussion during the course of this Bill on the need not to be overly prescriptive and burdensome to ICSs and ICPs by way of legal duties. But ICSs and ICPs know all too well the realities of failing to support people with complex and overlapping needs. I know that the chair of my own North Central London ICS, Mike Cooke, is sympathetic to the spirit of these amendments and believes it is important that extra steps are taken to meet the health needs of the most excluded, such as street homeless people. The chief executive of UCLH, David Probert, and the chief executive of Whittington Health, Siobhan Harrington, concur in thinking that if we extend the aspiration to reach out to excluded groups to something that all ICSs, ICPs and systems must focus on, it would be hugely beneficial for planning and joining up systems to avoid inappropriate or unnecessary admissions and poor care planning. Plenty of people want to do this within our health system.

I support Amendments 152, 156 and 157 and look forward to working with the Government and colleagues across the House and within the NHS to ensure their success in achieving a critical and long-needed systemic change to our health and care system. Addressing the needs of the most excluded has to be on the face of the Bill.

[Lord Crisp (CB)]

My Lords, I will make three very practical points about the impact of some of these amendments. First, on tobacco, we have heard from at least two noble Lords that half the difference in life expectancy between the rich and the poor in society is due to tobacco. It seems a no-brainer that work on this has to be continued. I also make the point that it took something like 50 years after the evidence was first available for the control of tobacco to be put into legislation, despite the efforts of the noble Lord, Lord Young of Cookham. It is not a quick win; we need to persevere, keep the pressure on and keep this very firmly in NHS plans at all levels.

Secondly, I want to pick up on the vital point that housing needs to be much more integrated with health and care. Let me take us back in history to 1919 and the first Ministry of Health, which had responsibilities covering health, housing and planning for many years, understanding the very important links there. Covid has shown that a house and home is an absolute foundation for health and well-being in all kinds of ways. I will not labour that point at this stage in proceedings, but will pick up another that has not come up, which is how important housing is to the provision of NHS services.

Seven years ago, the Royal College of Psychiatrists asked me to look at the reasons for the pressure on admissions to mental health acute wards. I did so; I think it expected me to say that those wards needed more beds, but I came out saying that we needed more housing. I found that something like one-third of the patients in mental health acute wards in adult hospitals either had been admitted because there was nowhere else for them to go or were staying there because there was nowhere for them to live to be discharged to. Housing was the biggest issue. Of the 25 NHS trusts around the country, only about three had specific, strong links with their local housing associations. There is a really big pressure for integration there.

Thirdly and finally, I come to Amendments 152 and 157 about the so-called inclusion health services. I agree with my noble friend on the nomenclature and that the naming is rather awkward, but these are extraordinary vital. We have heard examples of services that work; the issue here is how we can make sure that those services are spread and used elsewhere. I remind the House that, when we talk about inequalities, we all, including me, talk in fairly general terms. If you have a quantum of money and invest it in the health of the well-educated middle classes, you will get a small gain. If you invested that same quantum of money in the needs of this group, you would have a massive gain. That should inspire us to keep the pressure on the Government to make sure that we put tackling inequalities absolutely at the heart of the Bill.

14:00

[Baroness Walmsley (LD)]

My Lords, I shall speak more briefly than I had intended, because this has been a very long debate, absolutely full of expertise, about a suite of amendments all of which have considerable merit. I know that both Ministers on the Front Bench have been listening very carefully and have noted the consensus across the Committee that this Bill will not succeed unless it addresses very clearly the disgraceful health inequalities in this country at the moment.

Health inequality affects quality of life, life expectancy and, in particular, healthy life expectancy, which has now stalled across certain demographic groups. As we have heard, it has been analysed brilliantly by Professor Sir Michael Marmot. It affects the well-being of the patient and their family. The really sad thing is that much of it is preventable. These things are particularly rife in the poorer parts of the country, because that is where the social determinants of health such as housing, referred to by my noble friend Lord Shipley and others, have most effect. We have heard a number of statistics about health inequalities, but I shall give your Lordships just one. People living in the most deprived areas of the UK spend almost a third of their lives in poor health, compared to only about a sixth of those living in the least deprived areas. That says it all.

Unfortunately, inequalities were not at the forefront of the Government’s response to the pandemic. They suspended equality impact assessments for legislation, resisted publication of evidence of the impact of the virus on BAME individuals—as pointed out to them eloquently by the noble Baroness, Lady Lawrence—and failed to provide adequate isolation support for those on low incomes, forcing them to go to work. The Covid pandemic has therefore seen the biggest shift in life expectancy in the UK since World War 2: a fall of 1.2 years in males and 0.9 years in females. It is therefore essential to heed Sir Michael Marmot’s words and “build back fairer” and not just “better”.

The noble Baroness, Lady Greengross, kindly mentioned the report of the Science and Technology Committee on healthy ageing. I was a member of that committee under the capable chairmanship of the noble Lord, Lord Patel. It became very clear from our witnesses that unhealthy ageing happens years before the person is old and depends enormously on their demographic and their lifestyle. For their sake and for the sake of the future of the NHS, for which no Government will ever be able to provide enough funding unless something is done on prevention, we must do something to level up the health outcomes of the nation. This Bill is a very good place to start all over again on that agenda.

I have added my name to Amendment 11, so ably introduced by the noble Baroness, Lady Thornton, whom I must congratulate on the way she analysed these issues at the beginning of this debate. I thank her for that. Also crucial is Amendment 14, so ably promoted by the noble Lord, Lord Patel, and my noble friend Lady Tyler. Amendment 11 is an attempt to ensure that NHS England produces guidance about the collection, analysis, reporting and publication of the data which makes transparent the performance of various NHS bodies on health inequalities. Without collecting that, we cannot judge the performance of those organisations. If it is not done consistently, we cannot assess an organisation’s performance in comparison to other similar bodies. That is why such guidance must come from the top. I know that the Government want each ICS to do its own thing in a way which it considers most appropriate for its area. However, for the important objective of levelling up health outcomes across the population, judgment of performance can be made only if the data is comparable between one ICS and another or one trust and another, so we cannot leave it to them to collect the data in any way they like.

Of course, there are big issues about the resources available for the collection and analysis of data, but such information is essential if improvements are to be made. Therefore, a duty to “have regard” to guidance published by NHSE would put pressure on the organisations to so arrange their finances as to ensure adequate resources for this, and, of course, it would be cost-effective.

I also have Amendments 61 and 63 in this group. They would insert “assess and” into new Section 14Z35 inserted by Clause 20, which covers the duty of an integrated care board to reduce inequalities in access to health services across its population and in the health outcomes achieved. Although it is well known that, in general, the lower the demographic the greater the health inequalities, this is by no means uniform, even across a single local authority, let alone across a large ICS area. Indeed, even within a single local government ward, which may be fairly affluent in general, there are often pockets of deprivation. Every local councillor knows where they are. In order to devise policies and deploy services geographically in a way that improves access and outcomes for those deprived communities, the ICS needs to drill down and do the detailed work to identify where they are and what factors are damaging health. It may be poor or overcrowded housing. It may be lack of access to shops selling healthy food. It may be lack of access to leisure and sports facilities in which to take exercise. It may be poorly performing schools or overstretched primary care services. It may simply be poverty, preventing people heating their homes adequately or buying nutritious food. In rural areas, it may be lack of access to pretty well everything, as the right reverend Prelate reminded us. Whatever it is, you cannot fix it until you know what and where it is.

That is one of the reasons why we reject the new power of the Secretary of State to meddle in the reconfiguration of health services locally, but that is a debate for another time. In cases such as this, an overview will not do, and local knowledge is key. That is why we believe it is essential to mandate an ICB to do the detailed research on which to base its commissioning decisions, so that it can fulfil the duty to reduce health inequality put on it by this Bill—once it has been amended by a lot of these amendments.

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

My Lords—

[Noble Lords]

Hear, hear.

[Lord Kamall (Con)]

You have not heard what I am going to say yet.

I thank all noble Lords who have taken part in this debate; it has been fascinating. It has touched on a number of things that I feel strongly about personally. Before we go further, and given my background and that of my right honourable friend the Secretary of State, I want to assure noble Lords that we both feel very strongly about inequalities. I say that as someone who grew up in a working-class immigrant community. I was born at Whittington Hospital; I also accessed North Middlesex hospital and Chase Farm Hospital, with which I know the noble Baroness, Lady Tyler, is associated, though I am not sure I will get any more points for that, to be honest.

One thing I feel strongly about, and saw in many areas when I was an MEP for London, is where the state has failed, whichever Government was in power. I have worked with non-state, local community, bottom-up projects which understood the issues in their communities far better than any national or local politician—there was sometimes even a distance between them and their local ward councillor, as the noble Lord, Lord Mawson, and I were discussing the other day.

I thank the noble Baroness, Lady Thornton, not only for the thoughtful way in which she opened the debate and introduced the amendments but for pointing out some of the people who are often forgotten; for example, the homeless. I have worked with a number of local community homeless projects, such as the Hope Foundation in Acton and Vision Care for Homeless People. Perhaps I may also do a quick advert for the Take One, Leave One project, which is based outside Vauxhall station on Fridays, between 12 pm and 3 pm —people can leave excess clothes and homeless people can pick them up. I urge any noble Lords passing through Vauxhall station on a Friday to support this.

Sex workers, the Traveller community and drug users have been mentioned. Sometimes we think that these issues are remote from us and will not affect us—but everyone is only one of two steps away from homelessness. A broken family, mental health issues, your friends saying, after a while, “Actually, you can’t stay on my sofa any more”—where do you go? When I have met homeless people, they have quite often come from a very different place, not the stereotype that we often hear. They have come from quite a stable family, a good relationship, a good job: but two or three things have gone wrong in their life and suddenly they are homeless. It happens to many people who resort to such desperate measures.

Another thing I am slightly concerned about, if I am honest, is that when I was a young child growing up in immigrant communities, there was a distrust of authority. We see the difficulty, for example with the vaccine schemes, in trying to reach some of those communities. It was not only authority that we were quite suspicious of and concerned about but—I hope noble Lords will forgive me for using this phrase—white, middle-class do-gooders who thought they knew best what was best for us as working-class immigrant people and could tell us what was best for us, rather than listening to us and our real concerns. Quite often we felt that they had captured the agenda, and that was why the money and resources which were supposed to be helping us did not reach the people who needed help: it got captured by the white, middle-class do-gooders.

I pay tribute to the noble Lord, Lord Howarth, and the noble Baronesses, Lady Greengross and Lady McIntosh of Hudnall, for the emphasis on the arts and creative industries. Sometimes, music and the arts are a way of overcoming this distrust, learning about the culture of those communities and also aligning the culture and the issues with some of the very real problems and tensions we face. The noble Lord, Lord Desai, talked about prevention being better than cure. It is an issue we talk about constantly in the department, and the NHS also talks about it. The noble Lord, Lord Desai, as an economist, will acknowledge that economics is often simply about the allocation of scarce resources and finding the most efficient way of achieving that.

My late father once told me, “Never forget where you came from and what you were”, and this is one of the reasons I feel very strongly, as do many noble Lords across the Committee, about the issue of inequalities. How do we tackle this, what is the best way to do it? Will putting it in the Bill solve all the problems? Actually, it will not, but we can discuss how we can make it more effective, and not just feel, “Great, we’ve got it in the Bill, job done”. It has to be more than that. As the noble Lord, Lord Scriven, said, it cannot just be an institutionalised Gladys; it has to be more than that. So, I am deeply grateful that we gave this issue the time it deserves. It is really important for me personally. We want to tackle health inequalities and ensure that everyone has the same opportunity to enjoy a long and healthy life, whoever they are, wherever they live and whatever their background or social circumstances.

I hope I can assure the noble Baroness, Lady Greengross, with whom I have had a number of conversations about music and dementia. I have volunteered, perhaps rather rashly, to organise a fundraiser with my band and other bands for that. I hope that does not give me an excuse to lay the YouTube link to my band in the Library: I shall try to avoid that temptation.

However, to deliver on the commitment on 1 October, we launched the Office of Health Improvement and Disparities within the Department of Health and Social Care—the noble Lord, Lord Scriven, anticipated that I would say this—and we also set up a cross-government ministerial group to identify and tackle the wider determinants of poor health and health disparities. It is important that this cannot be top-down; we have to go to some of the social enterprises and local communities, but also we must not prejudge, prevent or duplicate the work of the integrated care systems in this. NHS England is already tackling health disparities through the NHS long-term plan. That sets out a clear intention to set measurable goals and to make differential allocations targeted at reducing health inequalities and disparities. This has resulted in funding increases to some of the most deprived parts of the country.

As we know, making sure that these deprived areas get the most funding does not mean it will trickle down to those who really need it; it could well be captured by some of the do-gooders I mentioned earlier. The noble Lord, Lord Howarth, talked about those targeted interventions. NHS England and NHS Improvement is also taking forward the Core20PLUS5 initiative as an approach to addressing health inequalities. This will focus on improving outcomes in the poorest 20% of the population, along with inclusion health groups and five priority clinical focus areas.

14:15

I shall now turn, if noble Lords will allow me, to Amendments 14, 94, 186 and 195. I am grateful to the noble Baronesses, Lady Thornton and Lady Tyler, and the noble Lord, Lord Patel. I hope I can reassure them that much of what they ask for is in the Bill. First, NHS England and integrated care boards have a duty with respect to health inequalities. The duty requires them to have regard to health inequalities in both access and outcomes for patients in the provision of health services. NHS England and the ICBs will have regard to this duty alongside the triple aim and, in NHS England’s case, when it produces guidance on the triple aim. NHS trusts and foundation trusts will, along with the ICBs with which they partner, have to prepare a joint forward plan each year, which will include plans for discharging the ICBs’ health inequalities duty.

The noble Lords, Lord Kakkar and Lord Shipley, and the noble Baroness, Lady Harding, talked about the triple aim. This triple aim is directly conducive to addressing health inequalities. Having organisations consider the wider effect of their decisions will encourage more collaboration and engagement with communities on how best to meet their needs. For example, the aim of

“considering the health and well-being of the people of England”

means we have to look at those populations with the greatest levels of need, including those not currently accessing services. Indeed, when you ask how an ICB is reaching this aim, the obvious question is, “What about inequalities? Are you just reaching part of the population or the whole population?” So, I assure noble Lords that it really is implicit.

Similarly, it is a key aspect of improving the quality of services to consider those areas within the ICB or the ICS area where they need improvement. You cannot just say “Everything’s great in the richer areas and we’ve considered the wider population”. We mean the wider population, all the population, wherever they come from, whatever their background and whatever their wealth level. To support this, we expect guidance from NHS England to make it clear how bodies can discharge the triple aim duty in such a way as to address inequalities.

I now turn to Amendment 11, in the names of the noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley. This places a statutory duty on NHS England to publish guidance about the collection, analysis, reporting and publication of performance factors by relevant NHS bodies with respect to inequalities. We agree that collection of accurate and timely data is an essential part of the department’s commitment to tackle health disparities in terms of planning, goal setting and the use of evidence-based interventions. As my noble friend Lord Bethell said, seeing that data made real to him and others the fact that there were these disparities, and it is important that we continue collecting it. However, we feel that collection of data on disparities and protected characteristics can be best achieved through operational guidance. We want to offer flexibility for the system to adapt the focus and methods of that data collection and analysis, and the power to do that is in the Bill.

We will continue to work with counterparts in the NHS and other system partners to make sure that this data is adequately identified, reported and assessed, and which further amendments, if any, will be required for the ongoing work. High-quality data is fundamental to our approach to reducing the stark disparities in health that exist in the country. If any policy changes are identified which require legislation, we do not rule out bringing them forward.

I turn now to Amendments 61 and 63, for which I thank the noble Baroness, Lady Walmsley. These amendments would add to the duties currently in the Bill on ICBs with regards to health inequalities. I hope I can reassure the Committee that we feel that this is already done. As members of local health and well-being boards—place-based, not just at the ICS level but at the place, as the noble Lord, Lord Mawson, talked about so eloquently—ICBs will be closely involved in the development of local joint strategic needs assessments, which are the means by which local leaders work together to assess and understand the needs of local people. We are concerned that it might duplicate this effort if an entirely separate assessment were to be made of one aspect of local needs. Perhaps we could look at ways to draw out this particular aspect so there is no duplication. Furthermore, it is our view that ICBs could not effectively discharge their duties in respect of inequalities if they did not identify the inequalities they are seeking to address, making use of the most up to date evidence and data available and learning from each other what data is collected. Is the data collected in a local ICS really giving a better picture as compared with elsewhere?

To help the process, NHS England has published a range of tools and resources to help NHS organisations to take effective action on inequalities, and continues to develop a health inequalities improvement dashboard, making sure that we learn from that data so that we monitor, measure and inform actionable insight to make improvements to narrow those health inequalities. It covers the five priority areas for narrowing health inequalities in the 2021-22 planning guidance, as well as the Core20PLUS5 programme.

I turn now to Amendment 65, in the names of the noble Lord, Lord Patel, and the noble Baroness, Lady Tyler, which would add a further explicit duty to implement systems to identify and monitor inequalities. It is the Government’s view that the ICBs could not effectively discharge the duties already contained in the Bill in respect of inequalities if they did not already do so; nor could they have any confidence that the actions they take are being effective if they do not monitor the outcomes achieved. You simply cannot do it if you are not monitoring. Furthermore, ICBs will have a duty to publish an annual joint forward plan setting out, among other things, how the ICB will discharge its duty in respect of reducing inequalities. Again, this could not be effectively done without having first identified those inequalities. Taken together, I hope the noble Lords might agree that this meets the intention of their amendment.

I turn to Amendment 66, in the name of the noble Lord, Lord Young, and spoken to so eloquently by the noble Lords, Lord Rennard, Lord Faulkner and Lord Crisp. This amendment would expand the duty on ICBs to have regard to the need to reduce inequalities to include modifiable risk factors such as smoking. We do not feel that this amendment is necessary, given the considerable work we are already doing in this area. We have reduced smoking rates in England over the years to a record low of 13.5% in quarter 1 of 2020, and we are aiming for England to be smoke-free by 2030. In a previous debate, in answer to a question about the plan asked by my noble friend Lord Young, we also identified those areas. Indeed, the noble Lord, Lord Rennard, referred to some of the statistics on the high levels of smoking still prevalent in some of our poorer communities. Our publication of a new tobacco control plan next year will include an even sharper focus on that issue.

We are also investing £27 million to establish specialist alcohol care teams in the 25% of hospitals with the highest rates of alcohol dependence-related admissions. We really have not, as a society, properly got to the stage where alcohol is seen as a social tool that loosens tongues and may make people relax, but the step from alcohol doing all those things to relax people to its abuse has a terrible impact on people’s lives. Moreover, it not only has direct health impacts but plays a role in murders, suicides, drownings and so on. We have to recognise what alcohol does as a drug and its terrible impact.

We also have an extensive strategy for tackling obesity, including some of the measures already debated on less healthy food and drink that are being introduced via the Bill. We are concerned that introducing an amendment as specific as this may not be the most effective way to prioritise actions to meet local population needs, a phrase so eloquently used by the noble Baroness, Lady Neuberger.

I turn next to Amendments 68 and 95, in the name of the right reverend Prelate the Bishop of St Albans. The Government are determined to address long-standing health disparities, including the geographic disparities experienced in rural and coastal communities. I pay tribute to my noble friend Lady McIntosh of Pickering and the noble Baroness, Lady Pitkeathley, who have constantly raised the issues of inequality of health outcomes in rural and coastal areas and how people there access services. For that purpose, the Bill already contains a requirement for the commissioning bodies to tackle these health inequalities, as well as a requirement to protect, promote and facilitate the rights of patients. This means allowing patients to choose to be treated outside their ICB area, particularly if that makes more sense, as alluded to by the right reverend Prelate. To support this, we expect ICBs to actively co-operate with each other for tackling these inequalities. We understand the duty to reduce inequalities to also encompass the need to reduce inequalities between patients with respect to geographical locations, such as rural or coastal areas. The proposed triple aim will also require ICBs to consider the quality of services that can be accessed both in communities but also geographically. I hope I have given the right reverend Prelate the Bishop of St Albans some reassurance on this.

Moving on, I turn to Amendments 152 and 157, in the names of my noble friend Lord Young and the noble Lord, Lord Shipley. These amendments would require the ICP to have regard to the needs of inclusion health populations. A number of noble Lords have spoken about the sort of clumsiness of that title of “inclusion health”. While we agree with the sentiment, I hope I can assure the noble Lords that these populations are already captured in the legislation. As noble Lords will be aware, the integrated care partnership will be tasked with developing a joint strategy to address the health, social care and public health needs of its system, based on the needs identified by the already-existing health and well-being boards, which are better placed to tackle these issues. The joint strategic needs assessments include the health needs of these populations, and those who need to be included more. The strategy prepared by the ICPs to address this will enable them to objectively identify what the inequalities are and target them. The ICP will be tasked with promoting the partnership arrangements. We hope that this will remove some of the traditional divisions between different healthcare services and between the NHS and local authority services.

I would like to touch on some of the work already ongoing in this area. For example, this year alone we delivered £52 million for substance misuse treatment services for people sleeping rough. This will fund evidence-based treatment. One of the criticisms of public health sometimes is that there is not enough evidence-based research, and it is essential that we have it. We will look at treatment and wraparound support for those with co-occurring mental health needs.

Let me turn, finally, to Amendment 156 in the names of my noble friend Lord Young and the noble Lord, Lord Shipley, and spoken to by the noble Baroness, Lady Watkins. It relates to the integrated care strategy, and how the ICP will be required to set out how the assessed needs in its area will be met. We recognise that health inequalities are driven by a range of complex factors. The noble Baronesses, Lady Watkins and Lady Finlay, and my noble friend Lord Bethell said this. These complex factors go way beyond people’s physical and mental health, and touch on some of the wider economic and societal issues, such as the one the noble Lords raise in this amendment. The Bill already ensures that services that have an effect on health, but are not health or social care services, are included in the clause that the noble Lords seek to amend. Even without this amendment, ICPs will be able to comment on whether housing services—which the noble Lord, Lord Crisp, raised—among other health-related services, will need to be better integrated with the provision of health and social care.

This has been an excellent and—I accept—long debate, as the noble Baroness, Lady Walmsley, said. It was probably one of the issues that I was most looking forward to learning and hearing more about. I was impressed by the level of commitment and the passion with which noble Lords spoke. I hope I have been able to give some measure of assurance that the Government take this issue extremely seriously. As I said at the beginning, both my right honourable friend, the Secretary of State and I, given our personal backgrounds, feel very strongly about this. We do not want it this to be captured once again, as it has been captured over many years, by the do-gooders.

I request that noble Lords do not press their amendments but, given the strength of the feeling that I have heard, it would be remiss of me not to offer further discussions with noble Lords so that we can close the gap in the understanding—as the noble Lord, Lord Kakkar, and my noble friend Lady Harding said—that it cannot be too NHS-centric. We have to work out how to address that gap. We think the Bill meets it; clearly, noble Lords across the Committee feel that it does not. Let us have further conversations. I hope noble Lords feel able, in that spirit, to withdraw or not move their amendments at this stage.

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for his very able response, but I have to say that I am very disappointed by it. He appears to be sticking to his brief and resisting all of our amendments. I suppose this is not surprising because his brief was written before this very powerful debate. Now that he has heard the debate, I hope he will go back to the department, discuss with his colleagues, and reflect on the need to put something in the Bill to ensure that the new world of integrated care systems really addresses health inequalities.

[Baroness Thornton (Lab)]

Hear, hear to that. As I stand in your Lordships’ House, I know that I am between noble Lords and their lunch, so I will do my best to be as quick as I can. I also feel that I need to declare an interest, as I am a non-executive director of the Whittington Trust, so my boss—the noble Baroness, Lady Neuberger—is in the corner over there.

14:30

I start by thanking the noble Lords, Lord Patel and Lord Kakkar, and the noble Baronesses, Lady Walmsley and Lady Tyler, for adding their names to and being part of this suite of amendments that I have been particularly concerned with. I am not quite sure which one of them said this—it was probably the noble Lord, Lord Kakkar—but Amendment 11 sets the national framework, and the following very short amendments which add inequalities into the Bill are about making sure that the local delivery actually happens.

I thank my noble friends Lord Howarth and Lady McIntosh for their remarks, which wonderfully illustrated how important it is to take—I hate this word—a holistic approach to health inequalities and well-being. I also congratulate and thank the noble Lords, Lord Young, Lord Rennard and Lord Crisp, and my noble friend Lord Faulkner, for again drawing the House’s attention to the importance and centrality of tobacco regulation to delivering health equalities. They were quite right about inclusion health services.

I also thank the right reverend Prelate the Bishop of Carlisle and the noble Baroness, Lady Walmsley, for speaking to the amendments about monitoring. Those of us who have been involved in dealing with equalities for the whole of our working lives know that if you do not monitor, assess and count, you will not know what effect you are having. Amendment 65 particularly recognises that, and that monitoring is vital to tackling inequalities. The noble Baroness, Lady Watkins, supported the need to address the needs of the most marginalised, and she was right that flexibility and the values of social enterprise are a part of tackling health inequalities at a local level. The right reverend Prelate the Bishop of St Albans and my noble friend Lady Pitkeathley were quite correct to draw rural areas and their needs to the attention of the House.

I think I need to thank the noble Baroness, Lady Harding, and the noble Lord, Lord Bethell, for their support for these amendments. I hope that they will bring their influence to bear on the Government to accept that there is a gap between the Bill as drafted and what the House wants to see in it.

I am not going to say very much more, but I was not convinced by the reasons for not accepting Amendment 11 and the other amendments in this group, and I think that other noble Lords will not be. I think the Minister can recognise when the House is determined to have on the face of a Bill something which addresses a wrong that they feel should be righted. We know—as I think the noble Lord, Lord Scriven, said—that words do not actually deliver the change, but words are the place where you have to start to deliver the change with inequalities. You have to see what is in the Bill and then move to implement that. There is a gap between us, but I hope—I am very encouraged by the noble Lord’s commitment to discussions—that we will be able to address it. I beg leave to withdraw my amendment.

Amendment 11 withdrawn.

Amendment 12 not moved.

Clause 3 agreed.

Clause 4 agreed.

Clause 5: NHS England: wider effect of decisions

Amendments 13 and 14 not moved.

14:34

House resumed. Committee to begin again at a convenient point after 3.34 pm.