Thursday 20th January 2022

(4 months ago)

Lords Chamber
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Committee (4th Day)
12:27
Relevant documents: 15th and 16th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee
Clause 16: Commissioning hospital and other health services
Amendment 50
Moved by
50: Clause 16, page 14, line 4, at end insert—
“(j) fracture liaison services to identify people at increased risk of fragility fractures and prevent future fractures.”Member’s explanatory statement
This amendment ensures equity of access to Fracture Liaison Services for people with osteoporosis.
Lord Black of Brentwood Portrait Lord Black of Brentwood (Con)
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My Lords, Amendment 50 is supported by the noble Lords, Lord Hunt of Kings Heath and Lord Rennard, and the noble Baroness, Lady Masham, underlining the cross-party interest in and support for this vital issue. I am grateful to them. I note my interest as co-chairman of the APPG on Osteoporosis and Bone Health. I also support Amendment 101B in this group, on mental health, and much look forward to the debate on the other amendments.

Amendment 50 is, at heart, about equality of access to services for people with osteoporosis. If accepted, it would end the current appalling postcode lottery which means that so many people are suffering unnecessarily from the pain and distress of avoidable broken bones. It will do this by making the provision of fracture liaison services—FLS—one of the core services that an integrated care board must consider for the people for whom it has responsibility, alongside dental and ophthalmic services and others.

12:30
I will give noble Lords a little background. We are fortunate to live in a country where each generation has lived longer than the last, but that brings with it many issues about how people can achieve a good quality of life in their later years. One of the biggest issues is broken bones. The uneven patchwork of fracture liaison services across England and Wales means that every year around 90,000 people with a new fracture who should have treatment are not being treated with the bone strengthening medication they need, so problems which need not become acute are routinely left to escalate, with numerous missed opportunities for prevention.
The lack of equitable access to fracture prevention services has led to entrenched health inequalities. People who live just the wrong side of a catchment line are being left to suffer life-changing spinal and hip fractures that with modest investment and better planning could have been avoided. These people are falling through the cracks in the system every day, and they are at the heart of the amendment.
Some 3.5 million people in the UK have osteoporosis and a fracture is, sadly, often the first sign of their condition. If the fracture is picked up and the underlying osteoporosis treated, further fractures can be prevented. Fracture prevention is therefore clearly beneficial to the patient, but also cost effective to the NHS. Fragility fractures caused by osteoporosis currently cost the NHS a staggering £4.5 billion each year, yet for every £1 spent on FLS the taxpayer can expect £3.28 back. Currently, however, access to an FLS to identify people at increased risk of fragility fractures and prevent future fractures is a postcode lottery in England and Wales. People will often have several fractures and no treatment before underlying osteoporosis is identified. There can be no excuse for that.
Secondary prevention is a well-established concept in clinical practice and should be at the heart of the work of the integrated care boards. After a heart attack, for instance, emergency treatment can be life-saving but it is the package of rehabilitation and treatment that supports a full recovery and reduces the chances of a further heart attack. Similarly, orthopaedic treatment to fix the fracture is essential for the 1,300 people who break a bone every day in the UK.
For people with underlying osteoporosis, a seamless package of identification, assessment and treatment is critical to support a full recovery and reduce the chance of further fractures. Without this, their risk of fracture remains high. This is exactly what a fracture liaison service is designed to provide and why this amendment is so important. An FLS identifies and treats people aged 50 or over who have had a fragility fracture, to reduce their risk of further fractures. The FLS model is an evidence-based, cost-effective, preventive intervention that can help to improve the health of the population and reduce health and care service demand.
The APPG on Osteoporosis and Bone Health launched an inquiry into FLS provision in March 2021 to understand the scale of the problem, the factors behind it, and what is required to ensure that everyone who breaks a bone due to osteoporosis receives the best care. The inquiry learned how in England only 51% of NHS trusts provide a fracture liaison service, while both Scotland and Northern Ireland provide 100% coverage. The inquiry’s report made a number of recommendations for government and policymakers on how to drive up both quality and access to FLS, the key one being a government commitment to ensure that all patients have equitable access to a quality-assured FLS, thereby delivering on the mantra that the first fracture should be the last fracture. Amendment 50 would achieve that aspiration.
The impact of osteoporosis on individuals can be devastating. Fragility fractures can lead to the loss of independence, mobility and the capacity to carry out everyday tasks. The Royal Osteoporosis Society conducted a survey last year of over 3,000 people living with the condition. Three in five respondents said that their osteoporosis affected them physically; 55% had suffered height loss or change in body shape; 22% had digestive difficulties; 19% experienced breathlessness; and 10% experienced incontinence. Many people expressed anger, frustration, resentment and sadness about the activities that they could no longer do. Fragility fractures can cause pain, both acute at the time of fracture and in the longer term. The survey found that more than one in four people experienced long-term pain; of these, one in three said that their pain was either severe or unbearable.
A fragility fracture is a red flag that predicts further fractures. This is particularly the case with vertebral fractures, which are powerful predictors of future vertebral, hip and other fractures. Without identification and treatment, a person with a vertebral fracture is nearly three times more likely to have a hip fracture, and five times more likely to have another vertebral fracture.
Hip fractures are the costliest fractures to treat. The average length of stay in hospital is 20 days. Hip fractures account for about £2 billion of the £4.5 billion cost of fragility fractures per annum to the NHS. When we consider that 50% of people with a hip fracture have broken a bone in the past, it is clear that investment in secondary fracture prevention makes both clinical and financial sense. I also point out that, tragically, around one in four of those who fracture their hip will die within a year of doing so.
The current variation in services and outcomes for those with osteoporosis is sobering but the amendment underlines how straightforward the process of change can be. There is no need for any discovery phase for new solutions: the British-born fracture liaison service model has been shown the world over to be a game-changer for dramatically reducing the risk of further fractures. But a repeated theme has been the doggedness among a few individuals it takes to get an FLS set up. This is where the leadership role of government—I say to my noble friend—can transform the picture through clear strategic direction. This amendment would drive 100% population coverage of FLS, ending the postcode lottery. This is what this Bill should be all about.
If we get this right, we can disrupt the pathway from first fracture through to devastating hip fracture, preserving people’s independence and making Britain a safer place in which to grow old. I hope that this amendment will find support on all sides of the Committee and, indeed, from the Government. I beg to move.
Earl of Kinnoull Portrait The Principal Deputy Chairman of Committees (The Earl of Kinnoull) (CB)
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My Lords, the noble Baroness, Lady Masham of Ilton, is taking part remotely. I invite her to speak now.

Baroness Masham of Ilton Portrait Baroness Masham of Ilton (CB) [V]
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My Lords, I have put my name to Amendment 50 and will speak also to Amendment 57. I am a member of the All-Party Parliamentary Group on Osteoporosis and Bone Health. I thank the noble Lord, Lord Black of Brentwood, for leading on this cross-party amendment.

Osteoporosis is a condition which can cause much pain and debilitation to many people, mainly women. Prevention is important and this is a condition which needs treating by a fracture liaison service. This service should be available to and in easy reach of patients who can be frail and elderly and whose bones can be easily fractured.

I would like to bring to your Lordships’ attention the case of the local hospital which serves the north part of North Yorkshire, a very rural area: the Friarage Hospital, Northallerton, which, sadly, over the years has been downgraded. It used to have an excellent orthopaedic unit; the senior consultant was a brilliant surgeon who unfortunately had to go back to South Africa. He was the brightest and the best. The health service needs leaders, and both staff and patients need up-to-date equipment for satisfactory outcomes. Now there is a visiting consultant, who wanted a DEXA scanner to save his patients the long journey to James Cook University Hospital in Middlesbrough. Many of the patients are elderly and frail. Transport can be a problem. The consultant did not get his DEXA scanner, which diagnoses osteoporosis. I thank the Minister for looking into this case after I tabled a Parliamentary Question.

The problem is upgrading with new equipment. This generally goes to the large hospitals. Women’s orthopaedic wards always seem to have to fight for what they need. A good fracture liaison service, which patients can reach, helps prevention of ill health and without doubt has benefits for everyone, especially the frail and elderly. If they are to be treated in an accessible clinic, near their homes, it must have the correct equipment and well-trained staff. I think it was Winston Churchill who said, “Give them the tools and they will do the job.” The big need at the moment is finding and retaining trained, dedicated, enthusiastic staff. They are the National Health Service’s biggest asset; without them, the job will not be done.

Amendment 57, in the name of the noble Lord, Lord Farmer, follows on well from Amendment 50, and I would like to say a few words on that amendment. It requires that

“health services are available in a community setting where possible, in order to improve access.”

At the moment, weekends are becoming very difficult in rural areas, such as the one where I live. From Friday afternoon to Monday, there is no GP service. On a Sunday, a young woman I know went with an eye infection to the nearest A&E department only to be told that it was not an emergency and she should wait and go to her GP. She did so and was given some eye drops, which were not the answer. When the eye infection worsened, she rang 111. They sent an email to the GP, as the infection had spread to both eyes. She was then sent to the eye clinic at the same hospital that had sent her away from A&E. She was off work for two weeks. Only if the correct treatments are available quickly can infections be treated and days off work saved.

The correct antibiotics for infections are so important to stop resistance to drugs. We also need a first-class pathology service, with test results coming back quickly. I do not think the public always realise what an important job these services do. I hope the failing health service in rural areas can be revived, where it is desirable to have a service in the community near where people live. We need the specialist health services as well—which may be miles away from rare diseases, serious accidents and illness. Wherever the best treatment is, the relief of being treated by experts who know what they are doing is unbeatable.

Will the Minister agree that there is a lot to do to get the health service back on the road post Covid-19? We all want to see it thrive. Thank you.

12:45
Lord Farmer Portrait Lord Farmer (Con)
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My Lords, my Amendment 57, which the noble Baroness, Lady Masham, has mentioned, is also supported by the noble Baroness, Lady Walmsley. I declare my interest as a director and controlling shareholder of the Family Hubs Network Ltd, which advocates for family hubs and advises local authorities on how to establish them. I am also a vice-president of the LGA.

In speaking to my Amendment 57, I would point out that in Chinese medicine you traditionally saw the doctor when in health. They were paid a retainer to keep you that way and, if you became sick, they would not be paid until health was regained. This speaks volumes about alternative health paradigms to our own. Even if we never go that far, the prevention of disease and the maintenance of health should be an overriding priority for the health service.

In placing the duty to prevent the development of poor physical and mental health directly under the duty to promote the NHS constitution, it is my intention to make it a similarly fundamental duty. Prevention is always better than cure. Yes, prevention is already mentioned in the Bill, for example in Clauses 5 and 16, and elsewhere in Clauses 20 and 59. However I do not consider that it is given sufficient weight, particularly given concerns shared with me by members of the Family Hubs Network.

Family Hubs Network members work with existing integrated care systems and note that the main issue faced by these ICSs is the management and throughput of the frail, elderly population to address bed-blocking and the onward delays to elective surgery. Hence they can lean towards an acute hospital reactive care model. Family Hubs Network members are already seeing the consequence of this with, for example, few if any ICS strategies focusing on population health through prevention and early help, especially for children and families.

Indeed, more and more ICSs are seeing community-based contracts swallowed up by the acute hospital conglomerates. They rarely, if ever, hold the necessary cultural understanding of community care, prevention and early help, and their interests do not lie in these. Children’s health services, which would ideally be delivered in the community, can be drawn into acute hospital structures which are more reactive than preventive in nature. Yet in some cases these very same services, such as continence, speech and language, allergies and others, are being delivered in community settings, close to families, through integrated family service hubs. Given that many of these health needs are also psychosocial and practical, accessing them from such settings enables families also to receive local authority-commissioned early help. This surely is integration in action.

My amendment also specifies that health services should be available in the community where possible, to improve access and help prevent conditions from worsening. A local-by-default approach would cut down the number of patients required to make prohibitively long journeys when a service could instead be delivered in a primary care or local authority setting. We need a reverse Beeching for healthcare, where we reopen community hospitals. Out-of-area specialist mental health hospitals, which remove people from the social networks which help them get better more quickly, were in the news again this week. Local units have closed and there is a lack of care in the community, even though this is a far less expensive option and the setting in which many prefer to be treated.

Returning to the issue of our ageing population, a reactive care model is completely unsustainable. Unless we focus on preventing big-ticket items such as diabetes, depression, anxiety and dementia—the list is endless—the cost of providing healthcare will keep going up year on year, by even more than it already does. A preventive paradigm would ensure greater ruthlessness about educating parents and healthcare workers about the psychotic effects of high-strength cannabis, for instance.

The eminent professor, Sir Robin Murray, recently said:

“I think we’re now 100 per cent sure that cannabis is one of the causes of a schizophrenia-like psychosis. If we could abolish the consumption of skunk we would have 30 per cent less patients”—


this was in south London—

“and we might make a better job of looking after the patients we have.”

In 2019, Murray’s research team reported in the Lancet Psychiatry their finding that south London had the highest incidence of psychosis in Europe and singled out cannabis as the largest contributing factor. He expressed concern that some liberal-minded parents would rather see their children smoking pot than drinking, without appreciating the potential associated dangers and the social and economic costs. These multiply with skunk, which is several times more potent than the drug they might have been used to in their day.

It is not just parents who need educating, including about higher-strength forms: experts say that cannabis addiction is treated by health professionals as a low-risk soft drug, yet, since 2005, there has been a 777% increase in the number of those aged 55 and over who need treatment for it. When cigarettes’ contribution to the development of lung cancer was firmly established, action to prevent smoking was taken despite it being fashionable and popular—more than 60% of adult males smoked; now that number is approaching 15%.

When there is incontrovertible evidence that something harms mental or physical health, a duty to prevent would mean that such damaging ignorance was no longer allowed to prevail. Ditto foot-dragging on access: mental health care in the community has been talked about since we began to close asylums in the early 1960s, yet it is still in the NHS long-term plan. I am keen to hear from my noble friend the Minister why prevention should not be given prominence as a duty in the Bill.

Baroness Hollins Portrait Baroness Hollins (CB)
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My Lords, it is a pleasure to follow the noble Lord, Lord Farmer. I really appreciate his remarks about Professor Murray’s work and his interpretation of it.

This is a Bill about integration, but how much integration will it actually achieve? We have spoken many times about wanting health and social care to work better together, but there is a difference between collaboration and integration. The former achieves two separate systems that, while better aligned in, for example, their information sharing, still operate without particular reference to the other. Those who use both systems continue to straddle a divide between the two and, too often, fall between those gaps.

Integration, on the other hand, speaks of synergy and of systems that enable one another and close the divide between the two, so that people can move between them without the terrifying leap of faith that currently exists. This is what will truly make a difference for those who use these services.

Unfortunately, the Bill in its current form will struggle to bring about this true integration. It requires the production of only a health outcomes framework, which will simply entrench the divide between health and social care, as both will continue to pull in different directions with different objectives, which are often conflicting.

Currently, health and social care sectors work towards two different sets of aims: social care is led by the well-being objectives of the Care Act 2014, whereas the NHS is led by various objectives set out in documents such as the NHS constitution, the NHS Oversight Framework and the NHS Long Term Plan.

An integrated service would mark a major shift in how the two systems view their role in supporting those who use their services. For example, it could see the NHS adopting an approach that was informed by ensuring the independence of its patients in a similar way to the principles that lead the provision of care and support. The greatest problems have been caused when health and social care start to gatekeep their domains: I have had to speak too often about the abhorrent placement of people with complex needs in in-patient units far from home, as a result of catastrophically poor alignment of health and social care support to meet their needs locally. I declare an interest as chair of the Department of Health and Social Care-appointed panel to oversee the discharge of people with learning disabilities and autistic people who are detained in long-term segregation.

I want to thank Mencap and Skills for Care for briefings on my amendments in this group. My Amendments 85 and 88 would place greater emphasis on the provision and quality of social care services and on the integration of health and social care services. I also declare an interest as president of the Royal College of Occupational Therapists. This is relevant because occupational therapy is a health profession that is equally at home in the NHS and in social care, and because occupational therapists have a role in tackling long-standing health inequalities through community rehabilitation and in prevention.

The history of health and care integration is littered with a natural reflex towards health and the pressing political priorities of the day. The ICB is primarily NHS focused and will hold responsibility for strategic planning and monitoring of services against the needs of an ICS population, but the answers cannot all come from health alone. We are in danger of missing an opportunity.

A duty to promote integration must include adequate provision for both health and care by taking a holistic approach. The outcomes from one will impact significantly on the other. Viewing the duty to promote integration through a health lens alone limits our understanding of what social care has to offer—think back to the debate on my noble friend Lord Mawson’s amendment on Tuesday. In some areas, integrated care system planning seems to focus mostly on integration within healthcare and not on integration between and across health-led provision and social care. At present, provider alliances are largely acute trust led.

Let us take discharge co-ordination as an example. It is currently suboptimal, with too few care co-ordinators, a lack of social care representation and feedback in assessment decisions, and a neglect of the resources and expertise of voluntary and independent providers.

The staffing context is complex. According to Skills for Care, there are 17,700 organisations providing or organising care, delivered through 39,000 establishments. Some 41% of those are residential, 59% are non- residential and 68% are CQC regulated. More than 6,000 organisations have fewer than four employees. That is a very broad church of employers. Not only does it make it much more difficult to communicate but social care lacks the infrastructure of the NHS to disseminate and co-ordinate.

My amendments propose strengthened provisions for ICBs to consider how integration benefits and can benefit from social care. My Amendment 89 would require ICBs to develop and publish a health and social care outcomes framework at least every two years to ensure that health and social care services are properly integrated.

ICSs present an opportunity to co-ordinate services, improve population health and plan on a system-wide basis to attract and retain staff with the right mix of skills. The ICS role should therefore ensure that the right staff skill mix is available to deliver this singular vision, a vision of person-centred and outcome-based care through multidisciplinary teams operating with and around each individual. Integrated care would mean that people would only have to tell their story once to receive high-quality, joined-up and seamless care. The approach each system takes to workforce planning will rightly vary to meet local needs and requirements, but that does not mean that their workforce plans cannot be measured against a joint outcomes framework. In collaboration with partners, Skills for Care has developed principles of workforce integration which address the above points.

The aim of this amendment is to ensure that health and social care do not pursue two different sets of objectives but work to a common aim to underpin transformation. I ask the Minister to reassure the Committee on these points. I believe these amendments will be helpful.

13:00
Baroness McIntosh of Pickering Portrait Baroness McIntosh of Pickering (Con)
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My Lords, I am delighted to follow the noble Baroness, who speaks with such knowledge and authority on these issues. I will speak to Amendment 110, but first I will make some comments on the amendments spoken to by the noble Baroness, Lady Masham, and my noble friend Lord Black.

The noble Baroness, Lady Masham, highlights the difficulties that those of us living in rural areas have. I regret to see the downgrading, in particular, of the Friarage Hospital in Northallerton, where my father, for one, was treated to great effect. I associate myself with the comments of the noble Baroness, Lady Masham. I know that the Minister is familiar with these arguments now, because he very kindly spent an hour with his team listening to me on these issues. Whereas before, national health policy used to recognise and measure rural health policy, particularly as regards rurality and sparsity of population, those markers have now gone.

The House will be familiar with my work with the Dispensing Doctors’ Association. I regret the fact that, whereas my father and my brother in their time would have been rewarded by the number of patients that they had on their list, and by the distance they had to travel from the surgery to visit patients in their own homes or when called out to an emergency, that has now gone. Much of the bread-and-butter income, as I understand it, for dispensing doctors and pharmacists in rural areas is made up from dispensing. So a separate argument to be had on another day is how, from the beginning of April, I understand, those reimbursements are going to come under the cosh. I will just leave that with my noble friend; I will ask for a separate meeting with him on that. I pay tribute to the work that dispensing doctors do in rural areas under these pressures and I am delighted to be working with them in this regard.

My noble friend Lord Black spoke eloquently on osteopenia. There is a cohort of people—mainly women—who, like myself, are diagnosed with osteopenia. I had not been in the House very long when, having broken one bone six months previously, I broke another. I was sent to the fall clinic where, unsurprisingly, we were mostly women being tested to see how likely we were to have a fall and break a bone. When my noble friend said that many women could die within a year of breaking a hip, I recalled that I was told that I had an 11% chance of breaking a hip. The good news, I suppose, is that I have an 89% chance of not breaking a hip, and that is something I cling on to.

I was put on a course—as I am sure others have been as well—of very strong vitamin D tablets. Since I completed that course, I have had no further treatment, but also no recommendations as to how to prevent the condition—in my case, and I am sure in the cases of other women—deteriorating into osteoporosis. I will just leave the Minister with the thought that, given the seriousness of the condition, those who are on the cusp of descending into osteoporosis itself should perhaps be given greater guidance.

Amendment 110 is intended as a probing amendment, and I am delighted to see that the noble Baroness, Lady Bennett of Manor Castle, has lent her support to it. I am very grateful to her for that. We had many debates on domestic abuse in the context of that Bill, now an Act, but domestic abuse remains a scourge in our society. While it is recognised as a crime, it is most often manifested initially in a GP’s surgery, not at a police station. In the context of the noble Baroness, Lady Hollins, describing the Bill as essentially an integration exercise, I believe it is important to see and recognise a victim of domestic abuse in a safe place or a safe haven—in a setting with trusted professionals, such as a GP’s surgery.

I am sure that the Minister will share my concern that there is currently no training for GPs or other health professionals enabling them, or expecting them to be able, to spot or treat an individual suffering from mental or physical abuse or to instruct them on how to engage with the police. Does he share my concern that that is indeed the case? I understand from Anne Marie Morris, my honourable friend in the other place who moved this amendment at that time, that Devon is the only health system to have a dedicated individual on the CCG board and a health and care strategy for victims of abuse. That strategy has improved health and care outcomes through training and other interventions. Surely, this should be rolled out nationally for other local health services to benefit from.

While it is welcome that the Government have agreed to take this issue into account—and I understand that the amendment was agreed in the Commons—I urge the Minister and the department to go further. ICBs should be mandated to have a strategy to deal with domestic abuse. I am sure that the Minister would agree that, if it is not mandated, it probably simply will not be done. Additionally, the role of the domestic abuse and sexual violence lead on the ICB is essential to spearhead the work in this area and to provide essential expertise. As there is only such a lead at the moment in Devon—who does fantastic work which can be seen first hand, and has been seen to help a number of related pilots roll out in that area—I would like to see this work rolled out throughout the country.

Amendment 110 therefore sets out a duty to prepare a strategy to support victims of domestic abuse using the services set out in that amendment. It asks for various consultations to take place not only with the local authority for the area within the integrated care board but with the domestic abuse local partnership board and other persons whom the integrated care board considers appropriate. I humbly submit that this is a gap in the Bill at the moment that Amendment 110 would fill.

Baroness Barker Portrait Baroness Barker (LD)
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My Lords, I will speak to my Amendment 297J in this group, but I will preface my remarks by returning to the purpose of this Bill. The stated purpose of this Bill is to promote integration of health and care services in order to reduce health inequalities and to promote better outcomes. I have chosen, in this amendment, to speak on the issue of HIV and AIDS services. I have spoken in previous debates about access to sexual and reproductive health services such as contraception and abortion. They are two services which we would do well to look at in considerable detail, because they are services addressing issues that cannot alone be solved by the National Health Service. They are services which will only be solved by not only integration but collaboration between health and social care. Having, like many Members of this House, discussed these issues for many, many years, I come back to the point made by the noble Baroness, Lady Thornton, the other day, that we are trying to seek integration and collaboration between two fundamentally different services. One is organised as a national and essentially top-down system, and the other is organised on a local and democratically accountable basis, with a completely different ethos.

At this point it is worth us taking advantage of the presence of the noble Lord, Lord Stevens of Birmingham, and noting what he said the other day about the National Health Service. He said—and I paraphrase—that one of the best ways to ensure that the National Health Service does what we expect it to do is to ensure that it has resources, and he is absolutely right. Would that people took the same attitude to social care—but they do not, and in the matters of both sexual health services and HIV services, we see in graphic and demonstrable terms the failure to do just that.

Turning to HIV services, it is important to note that although, overall, we have a very good story to tell on HIV in this country, and a reasonably good story to tell in the last few years as we are on a path towards the complete ending of transmission by 2030, we do have some problems. Last year, the number of people living with HIV in the UK rose to 106,000. In 2020, the number of people being tested at clinics decreased by 30%, and more so in black and minority communities, where late diagnosis, with all its complications, remains stubbornly high. However, there was a very great increase in online testing. HIV is an area in which there have been and will be, over the next few years, huge technological changes in diagnosis and treatment, which the NHS and social care should be up to speed with if we are to get to the stated aim of ending transmission by 2030—which we can do. The problem is that, at the moment, we have an increase in the rate of late HIV diagnosis—it was up to 42% in 2019—and we know the concomitant costs that that presents for the health service.

Anyone who has spoken to anybody involved in HIV services, be it in social care, local authorities or the NHS, will have heard exactly the same story since 2012. Just look at commissioning. HIV testing in sexual health clinics and community settings is commissioned by local authorities; HIV testing in GP settings, where it is clinically indicated, is commissioned by NHS England; HIV testing in GP settings as a public health intervention is commissioned by local authorities; HIV testing in secondary care, where it is clinically indicated, is commissioned by CCGs; HIV testing in secondary care as a public health intervention is commissioned by local authorities—keep with me, my Lords. Home testing, which is increasingly popular, is commissioned by local authorities and by Public Health England, for some periods, at some times in the year. Is it any wonder that it is a mess? We are not taking advantage of any of this and we are letting people down. The fragmentation in this area—even for people who have HIV, who are some of the savviest patients the NHS comes across and who are up to speed, sometimes in advance of their clinicians—is really difficult and does not make sense on any level; it does not make sense on a public health level or an individual level. I do not need to go into great detail, as noble Lords can work out for themselves all the consequences of that.

It is quite interesting to talk about one piece of work that the All-Party Parliamentary Group on HIV/Aids did. We did some in-depth research in south-east London, where there are some of the most advanced integrated care services for HIV. Even there, where there is very high prevalence and they know, largely, what they are dealing with and the populations where this is the biggest problem, they struggled to make sense of this fragmented commissioning picture.

I am not asking that all this funding be put into the NHS—most definitely not, because we all know that once money goes into the NHS, it never comes out again. I think there is a case to be made for increasing budgets, not least the budgets of local authorities, which have been slashed, in order for them to carry on doing what is important, which is getting to people long before they are anywhere near being any kind of medical priority.

What I am asking for in this amendment is a formal duty to collaborate. I have no doubt that the Minister will say that that is not necessary, but we cannot carry on as at present: we are badly wasting resources when we should not be. We have enough knowledge in this Committee of the levers that make decision-makers and commissioners change what they are doing, not least when they understand that there are new and more efficient ways to meet the needs of the population. I propose this amendment with no great sense of hope, but, if he does not accept it, I hope the noble Lord will at least understand that we cannot continue with this inefficient way of dealing with known issues. We must stop failing people when we could be sorting out the issues.

13:15
Lord Layard Portrait Lord Layard (Lab)
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My Lords, Amendment 101B, in my name and those of the noble Baroness, Lady Watkins, and the noble Lord, Lord Alderdice, is a fundamental amendment to remedy the shocking imbalance between the provision of mental and physical healthcare. As was said in the debate last week, people with mental disorders who receive treatment are a minority—35% of children and 40% of adults—while for people with physical illnesses, the vast majority get treated. This is not parity of esteem; in fact, I think it is one of the greatest cases of discrimination in our public life. There is only one way to remedy it, which is that the funding of mental healthcare has to rise faster than the funding of physical healthcare. In other words, the fraction of NHS funding devoted to mental healthcare has to rise—it is a matter of simple logic. This is such a fundamental point of principle that it should be put into law.

The increase does not of course have to go on for ever, but only until the inequality has been eliminated and mental health is treated like physical health. In the words of the amendment, the rise should continue until

“people coming forward with mental health problems are as likely to be offered treatment as people with physical health problems”,

and, of course, to receive it within a period of time appropriate to their problem. Only then will we have achieved parity of esteem.

The amendment is a statement of principle. As we know, there are always problems of definition and interpretation with statements of principle, but such statements are common in our statute law. This is a sector, in financial terms, as big as the police service, and it is right that there should be legal principles governing it. If we want to secure justice for the sector, it needs a statement of principle. This is a stronger statement than any of those discussed last week, but if this is what we believe, it is what we should say.

The main argument for the amendment, as I have said, is one based on simple equity, but there is also a strong economic argument. Mental illness is mainly a disease of working age, while physical illness is mainly a disease of retirement. Half of all working-age disability and absenteeism is due to mental illness, so when we successfully treat mental illness, the savings to the economy and to the Exchequer are massive, especially when compared with the economic savings from the majority of physical healthcare. These economic savings were a key argument that led to the establishment of IAPT, Improving Access to Psychological Therapies, from 2008 onwards, and they have been verified in what has happened since in that service.

There is also another very important source of savings: savings to NHS physical healthcare. Psychological therapy has been shown to reduce the cost of physical healthcare for people with comorbid physical conditions. This can be seen in a major nationwide controlled trial done recently, which provided IAPT treatments to people with long-term physical conditions such as diabetes, CVD and COPD. This trial found that, within a year, the savings on physical healthcare covered the total cost of the psychological therapy—so the mental health service is saving money for the physical healthcare service. As a result, this approach is now being rolled out nationally.

So mental health is a classic case of spend to save, and extra spending is desperately needed. Some of it would fill the massive gaps in existing services, including for severe mental illness, and some of it would provide services to key groups of people who are barely helped at present, many of whom were referred to earlier in this debate.

First come the tragic children who fall below the CAMHS threshold, who are sometimes assessed and sent back home as not sick enough, but who desperately need help. For these young people, the Government are developing mental health support teams in schools, but the rollout is incredibly slow and the services also need to include a much higher level of expertise.

Then there are millions of people whose lives are wrecked by addiction to drugs, alcohol and gambling and who need psychological therapy. There are the victims and perpetrators of domestic violence, who have already been mentioned, and other forms of violence. So many of our social problems have a strong mental health component. There are good, evidence-based psychological treatments which NICE recommends for these problems, but they are not provided. They should be provided. Extra spending on mental health could massively improve our society.

There is one further point in the amendment. If we spend the money, we need to know what it is achieving. In IAPT we know the progress of 100% of those treated, but in most parts of adult and child mental health services we currently have very little quantitative data on what is being achieved. That has to change, so universal routine outcome measurement should be a reasonable quid pro quo for extra funding, but the extra funding is crucial. It is not enough to talk about parity of esteem. We must have a clear statement of how to recognise it and the funding principles to achieve it.

Baroness Watkins of Tavistock Portrait Baroness Watkins of Tavistock (CB)
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My Lords, I rise to speak to this group of amendments with an emphasis on Amendment 101B, in the name of the noble Lord, Lord Layard, whom it is a pleasure to follow.

Last night, I went to the ballet and saw “Raymonda”, which has been placed in the context of the Crimea. It reminded me that Florence Nightingale took a hammer to a store-cupboard to get food and blankets for some of her patients because nobody knew what was inside it. She went on to be a leader in sound data for health- care, recognising that without data we could not plan for the future. This amendment emphasises measuring the outcomes of mental health nursing and other mental health interventions in order to ensure that we learn from practice and develop best practice cost-effectively. That is why I have put my name to Amendment 101B.

We need to look at similar patterns for care to those for physical illness. For example, the onset of paranoia and delusions which threaten the safety of an individual or those close to them could perhaps be equated with a suspected cancer where you wait for two weeks for an initial diagnosis. How many people are sectioned under the Mental Health Act for assessment because they have not managed to get an out-patient appointment for assessment earlier? I believe that is an example of discrimination against people with severe mental health problems. If we could get parity of access for assessment, it would be an extremely good beginning. I recognise that there are other physical and mental health problems that are less urgent, but I use that as a comparison.

Yesterday at a meeting concerning mental health reform after the pandemic, the Minister for Care and Mental Health Gillian Keegan and the chief executive of Mind were panellists. At that meeting, it was noted that investment in NHS mental health services currently increases year on year, largely due, I think, to action under the leadership of the noble Lord, Lord Stevens of Birmingham. It was £11 billion in 2015-16 and is £14.3 billion today and it will continue to increase, including an additional £2.3 billion by 2023-24. It was said yesterday that the Government will ensure ICBs will increase spending on mental health in their area in line with growth in their overall funding allocations to meet the mental health investment standard. To address backlogs, the Government have published their mental health recovery action plan backed by an additional £5 million to ensure that the right support is in place. This illustrates that the Government are committed to the improvement of mental health services. The amendment would place a duty to monitor this investment and evaluate its effectiveness. I hope that the Minister feels able to support the principle behind the amendment and will meet those of us interested in this area to try to find a summary solution to the issues we are raising on parity not only for mental health care but for the care sector that has been outlined so comprehensively by my noble friend Lady Hollins.

All the points that were made by the noble Lord, Lord Black of Brentwood, concerning osteoporosis could be made for drug-induced psychosis, schizophrenia and other severe mental illness problems. I hope that this Committee will be able to influence an amendment to the Bill that will ensure that the monitoring outlined in the amendment introduced by the noble Lord, Lord Layard, will be taken forward.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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My Lords, I have added my name to Amendment 50 tabled by the noble Lord, Lord Black, but I want to say how much I agree with Amendment 297J, tabled by the noble Baroness, Lady Barker, about the mess we have between local government and the NHS on sexual health services in general and the HIV services that she mentioned.

My view is that local government has a choice. It either accepts that it is part of a national service here and agrees to earmark funding allocations, or the service will have to go back to the NHS. The current situation is not working. Some local authorities are having to take on the responsibilities of others because some local authorities are not spending sufficiently. There is a movement of people, largely into the big cities, and it is an unfair system. We have to do something about it.

I also support the noble Baroness, Lady McIntosh, in her Amendment 110. Anyone listening to the debates during the recent passage of the domestic abuse legislation would have noted that one of the big challenges is the lack of integration among local agencies. I am afraid the NHS is a part of that and the noble Baroness’s amendment would give a very clear indication to the NHS that we expect more of it.

I have no doubt that, in winding, the Minister will say that Amendment 50 is not necessary because there is already a general duty on the NHS to provide fracture liaison services and the department is doing all it can to encourage the NHS to implement them. However, the dilemma for us is that the positive outcomes from those services have been known about for many years, yet progress in moving to the standard adoption of them through the country is very slow indeed.

As far back as 2010, the Royal College of Physicians produced an audit of the quality of clinical care of patients who had fallen, had a fracture and had been seen in a hospital emergency department. It reckoned then that only 32% of patients with a non-hip fracture received an adequate fracture risk assessment. Just 28% were established on anti-osteoporosis medication within 12 weeks. As a result, the Department of Health incentivised primary care services to initiate these treatments for relevant patients, but, by the end of the first year of that scheme, fewer than one in five patients were receiving the treatments.

13:30
Moving forward to 2018, the Royal College of Physicians came back to the issue. It found that there had been some improvements, but there was still very marked variability in access and quality of care provided by those services. So, less than a quarter of fracture liaison services were able to assess over 95% of patients within 90 days, and 28% of fracture liaison services saw less than half of patients in the recommended time- frame. Only 41% of patients who were prescribed anti- osteoporosis medication were monitored in the 12 to 16 weeks post fracture. My question to the Minister is this: after years of reports showing the effectiveness of these services in terms of outcomes, during which time Ministers have said this is something they agree with, and when it is clearly cost-effective for the health service to invest in these services, why has so little progress been made?
If we could forecast the next NHS restructuring Bill in a year of two, do we think much will have changed? I am afraid that it will not have, and this is why legislating is about the only way we can go forward, and why I support the noble Lord, Lord Black.
Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (CB)
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My Lords, this has been a really interesting debate and it made me think of Aneurin Bevan’s original vision, which incorporated the concept of dealing with the problem and then secondary prevention in rehabilitation and concepts of convalescence. After this debate, I am tempted to go back and read again In Place of Fear, because it is a very short book but it is worth reading.

There seems to be a theme coming through here really strongly. If we do not integrate these services and pull them together, we will never get not only the primary prevention but the secondary prevention which, as the noble Lord, Lord Black, highlighted, is so important. You do not just fix the problem; you prevent the next set of problems coming along.

I was slightly alarmed to note that in 2018 alone, there were over 6,000 deaths attributed to falls. A lot of those were on stairs. They were just simple trips on steps, yet they resulted in deaths. It took me back to when I worked at the Westminster Hospital, which, of course, is no longer across the road. Somebody tripped on the steps of the Tate and subsequently died from a head injury after hitting the concrete. One sees that at stations and so on, too, and we now see it with these scooters, where people scoot into trees and lampposts.

Anyway, to return to the subject of the amendments, the reason for my Amendment 100 is precisely to promote that rehabilitation and remind everybody that rehabilitation is not just a medical and nursing issue. It involves many different professionals, and volunteers quite often, at different levels. A rehabilitation plan at the ICS level could provide the co-ordination required, across different settings and services, to properly support early discharge from hospital, provide access to multidisciplinary teams and incorporate the psychological support that is needed. At the moment, things are organised in condition-specific medical silos, and we have already heard about the fragmentation of provision.

We need to respond more effectively to the needs of people with long-term conditions. When we come to measure outcomes, it is much easier to immediately measure the outcomes of an intervention. The outcomes from long-term secondary prevention are much more difficult to measure and quantify, particularly in a population that has multiple pathologies. So there has been poor data collection in part because it has been very difficult.

A simple example is that NICE guidelines suggested that over 1 million people with COPD every year should be referred for pulmonary rehabilitation, but only 15% are referred. We need to understand why. These are people who are breathless. They are getting chest infections and becoming oxygen dependent—so the consumption of NHS resources goes up. After a stroke, people have very marked rehabilitation needs in many different areas. That may be physiotherapy, occupational therapy, speech and language therapy and so on, going much more widely.

We also have a problem with our housing, because many people are not in accommodation that is suitable for them to go to when they are discharged from hospital. It has been estimated that there are 10,000 people in hospital at the moment who do not have a suitable home to go back to—hence the problem of where they go after hospital. So it is not only about providing a social care workforce to go in. We have already debated last week the problem of housing.

I do want to speak specifically to Amendment 51A in my name and the name of the noble Baroness, Lady Jolly. That is about having responsibility for every person present in an area. If we take the south-west, which is dependent on tourism, it goes from relatively low populations to absolutely bursting at the seams with holidaymakers. We have all seen it. These areas have an additional problem: when people are on holiday, their guard is down, they are less vigilant about what they do and they are less risk averse. Going back to falls, they are much more likely to have a fall or an accident. People fall off cliffs, fall down surfaces and so on. All of a sudden, in the tourist season, these people are at higher risk of something going wrong. They often go away and forget to take their medication, or they take something that interferes with it and end up with different side-effects and so on. They put a huge pressure on the emergency services in the area, so I am quite concerned at the way the funding might flow, in the way this Bill is written. We could inadvertently find that some areas are incredibly pushed at certain times of the year because of the way the population moves. I hope that will be taken into consideration.

Baroness Whitaker Portrait Baroness Whitaker (Lab)
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My Lords, following the impressive, high-calibre tour d’horizon from the noble Baroness, Lady Finlay of Llandaff, I rise to support the importance of proper and full rehabilitation as in Amendment 100, again supported by the Royal College of Speech and Language Therapists. Perhaps I should have declared, at my last intervention in Committee, that I speak as a vice chair of the All-Party Parliamentary Group on Speech and Language Difficulties—I apologise.

Very briefly, an annual plan, as in Amendment 100, would ensure that rehabilitation is explicitly integrated. Rehabilitation spans many disciplines, as the noble Baroness, Lady Finlay, said. It is what enables those who have degenerative diseases, strokes, cancer, autism and learning difficulties, to name only a few, to communicate—how essential is that for even minimal well-being?—as well as helping people to, for instance, swallow without choking and stay alive. As ever, it is the vulnerable who suffer when these structural underpinnings to ensure joined-up, consistent care are not there. I hope the Government will adopt these amendments.

Baroness Harding of Winscombe Portrait Baroness Harding of Winscombe (Con)
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My Lords, first, I apologise for arriving a little late for this debate. I hope that your Lordships will allow me to add my voice of support to this group of amendments.

We all come to this Bill with the same intentions and belief that collaboration and integration are the future for a health and care system. This group of amendments tackles the uncomfortable reality that, despite everyone’s best intentions—both in our NHS and in local government social care and even in the private sector—to collaborate and deliver integrated care, we are not doing that. A number of these amendments practically point at ways in which we can move from the rhetoric to practical change.

I particularly support Amendment 101B, in the name of the noble Lord, Lord Layard. As a great economist, he is pointing us in the direction of an economic structure and nudge that will force us on to a path to do what we have all talked about for a long time, which is to create parity of esteem between mental and physical health. We debated the importance of mental health in great detail last week, so I do not wish to repeat that, but I want to add my voice to that of the noble Lord in supporting his amendment because it is very practical.

By creating a ratchet that gets us on to a path whereby inch by inch—week by week, month by month and year by year—we start to close the gap between physical and mental health provision, we would start practically on the path that we want to go on without creating a funding hole. This would allow the NHS and our overall health and care system to go step by step at an achievable pace, while recognising that we come out of the Covid pandemic with such enormous physical health waiting lists that achieving parity of esteem will be even harder than it was two years ago, so it is even more important that we force a mechanism in. The second element of this amendment would also force outcome measurement.

This is a very smart and simple amendment. I know that my noble friend the Minister cares deeply about this agenda, as does the Secretary of State, and I urge them to adopt it.

Lord Rennard Portrait Lord Rennard (LD)
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My Lords, I draw the Committee’s attention to my registered interests in healthcare equipment. I have added my name to Amendment 50, moved by the noble Lord, Lord Black of Brentwood. The noble Lord, Lord Hunt of Kings Heath, demonstrated clearly, as have others, that it simply cannot be said that the amendment is unnecessary.

The recent report on fracture liaison services from the APPG on Osteoporosis and Bone Health makes important reading. It shows clearly that the health and independence of tens of thousands of older people who suffer from osteoporosis are threatened by great inconsistencies in accessing vital services and treatment. Far too many people are suffering multiple fractures before their condition is properly diagnosed. Much unnecessary pain is caused and more permanent disability results from failures to diagnose osteoporosis in thousands of cases. Those failures add significantly to the future costs of the NHS and care system than would have been the case with early diagnosis.

The Committee has already heard from the noble Lord, Lord Black, of the significant cost savings to the NHS where a fracture liaison service is in place. The Royal Osteoporosis Society estimates that extending fracture liaison service provision to cover the whole population would require a modest initial investment of about £27 million in England and £2 million in Wales. There should be much more long-term cost-benefit analysis of provision such as this, and it would more than justify those sums of expenditure.

There are many examples in preventive healthcare where focused interventions dramatically improve outcomes for patients and cut long-term costs. We need to raise awareness of conditions such as osteoporosis, provide more education and training for healthcare providers about diagnosing it and increase support for people who suffer from it. Osteoporosis is a long-term condition. It is more prevalent than many people realise and we should all recognise that a spinal or hip fracture is equivalent to a heart attack or stroke in terms of its clinical implications. Fractures are often preventable through use of pharmacological treatments supported by lifestyle modifications, which include appropriate exercise and smoking cessation as well as nutritional supplements such as calcium and vitamin D.

There needs to be much greater public awareness of how to maintain or improve bone health, particularly for the most at-risk populations. The introduction of integrated care boards will provide an opportunity to better co-ordinate and integrate fracture prevention and osteoporosis care. It is currently too dispersed across different parts of the system, as so often our short debate on this group of amendments has shown is the case. For fracture liaison services we need universal access. We need a clear mandate from government that the new boards have a specific responsibility to provide fracture liaison services for the whole population.

13:45
Baroness Pitkeathley Portrait Baroness Pitkeathley (Lab)
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My Lords, it is clear from the number of noble Lords wishing to speak in this debate that this group of amendments is extremely important. I want to speak particularly in favour of the amendments from the noble Baroness, Lady Hollins, about integration, which she put before us so eloquently.

In the 40-odd years that I have been working on these issues, I have never heard anyone say anything other than that collaboration would be a lot better than the current situation and that collaboration between health and social care is absolutely vital. Everyone always says that, and in recent years we even have had the hope that, when the Department of Health changed its name to the Department of Health and Social Care, we would begin to see more movements towards integration. Sadly, little progress has been made.

If one asks any patient about integration between health and social care, they think that it already exists. Most patients have absolutely no idea about different jurisdictions, how one sorts out a medical bath from a social bath or how different pots of funding ensure different points of view. That is, of course, until the patients start to find their way around the system in the way in which the noble Baroness, Lady Barker, brought so amusingly to mind. The lack of incentives to integration in the Bill are disappointing. I have not seen anything in it that will stop 15-minute visits by overworked and underpaid care staff or any ideas about integrating services and having much better integrated budgets—still less about data sharing. Those are all the things that we need if we are truly going to move to proper integration.

As the noble Baroness, Lady Barker, reminded us, at a time when waiting lists for the NHS are growing longer by the minute, should it not be a priority to ensure that no one stays in hospital longer than they have to by having discharge procedures that provide a seamless transition and making sure that the all-too-frequent readmission because of inadequate co-operation between the NHS and local authorities does not happen? We hear that care jobs are unfulfilled and that requests for care are turned down because of staff shortages. Local authorities struggle to recruit enough workers to meet increasing demands. No wonder that that is the case when one can earn more by filling shelves at Sainsbury’s.

A truly integrated service would mean that, the minute that someone is admitted to hospital, plans should be being made between health services, social care and the often-ignored but often significant voluntary services about what is going to happen on discharge. Sadly, the usual pattern is for a conflict to emerge, usually on a Friday afternoon, between a hospital ward desperate to empty beds and social care services inadequately prepared or even informed. What happens? The person goes home, the care services are not adequate and so the person is readmitted to hospital. I know someone in my local area in Herefordshire, an elderly lady who has been admitted 14 separate times since last July, and still care services to keep her adequately at home are not provided.

The Bill is a failed opportunity because we are seeing social care once again as the poor relation, the tail-end Charlie, that is considered after everything else is settled. Social care could be at the heart of a levelling-up agenda if we had a vision for its workforce and the impact that it has on the health of a community in the broadest sense. Care providers could be encouraged to diversify their businesses to reach out creatively into the community by providing tax incentives, for example, or reductions on business rates. If we want a high-skill, high-wage economy, what better place to start than social care, with its huge workforce badly paid but certainly not unskilled? Those skills could be developed by providing training, and retention could be dealt with by better career progression and recognition of qualifications. It is sad that we are not looking at practical ways in which to develop that integration in the Bill.

Fixing social care requires two things: money and better integration. We will come on to money later in the Bill. For the moment, I hope that the Government will give proper recognition of and acceptance to the amendment on integration in the name of the noble Baroness, Lady Hollins.

Lord Warner Portrait Lord Warner (CB)
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My Lords, I will speak briefly in support of the amendments in the name of the noble Baroness, Lady Hollins. I had intended to put my name to them; I apologise to the noble Baroness for being so slow off the mark. I also strongly support the amendment in the name of the noble Lord, Lord Layard.

Both these amendments, in their different ways, go some way to righting what I consider to be two big wrongs inflicted on local government in the past, where responsibilities have been transferred to it but have not had their funding sustained into the future. The first was the closure of long-stay hospitals in the 1980s and 1990s. When I was a director of social services, I was the NHS’s favourite person when building provision and making available services for people coming out of long-stay hospitals. After a few years, I and my many colleagues became forgotten men and women because the money that was transferred was never maintained in real terms over a couple of decades.

Fast-forward to the 1990s and the setting up, with much enthusiasm, of the Roy Griffiths community care changes. These enabled the Government to get off the hook of an expanding social security budget. It was another repeat performance: the money was not maintained in real terms in the longer term. What we saw in both cases was local government having to pick up the tab without support from the Government—successive Governments, that is; I am not making a party-political point—to ensure that those services could be maintained for the people who became the responsibility of local government.

The amendments in the name of the noble Baroness, Lady Hollins, remind people that there is an obligation to make sure that both health and social care produce good outcomes for the people who are now primarily the responsibility of local government, which, as the noble Baroness, Lady Pitkeathley, gently reminded us, has been underfunded over a long time in terms of maintaining these services. The amendment in the name of the noble Lord, Lord Layard, is another righting of a wrong and we should all get behind it.

Lord Scriven Portrait Lord Scriven (LD)
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My Lords, I support Amendments 85 and 88 in the name of the noble Baroness, Lady Hollins.

We must be clear. The previous two speeches highlighted the elephant in the room: you cannot have integration on a sustainable basis unless you reform health and social care together. We have to be honest with ourselves that this Bill is predominantly about the reform of healthcare.

That was highlighted eloquently in the speech by the noble Lord, Lord Hunt, in response to my noble friend Lady Barker, about who should commission sexual health services. These have been lobbed to the side of the commissioning silo but it should be about how to break down this silo so that we have joint and sustainable commissioning around outcomes, rather than around which silo or which part of the health and social care framework should deal with it. It is the elephant in the room, but we are where we are so we must make this Bill better knowing that that is the real issue.

This is about three little words: social care services. It is clear to those who understand health and social care that the Bill has been written predominantly through the lens of healthcare. I do not blame anybody for that but clearly this is a healthcare commissioning reform Bill, with a little tinkering with the structure, and does not deal predominantly with those people who do not understand social care—unless they are asking for an NHS long-term care package, when the argument tends to be about not the care provided but the funding, including who is going to fund what part. That is when it affects people’s outcomes. Those three little words are really important, which is why the noble Baroness’s amendments are important. If they were accepted, the Bill would actually say that social care service and health outcomes are jointly important.

It is important that this is about integration. The noble Baronesses, Lady Pitkeathley and Lady Hollins, said that there is a significant difference between collaboration and integration. You can have two people collaborate but, if their silos send them in different directions, the outcomes will not be joint. The real issue is how we bring about integration. It will not solve all the problems but it will help to bring about the first stage of integration if you have a joint framework on outcomes for which both healthcare and social care are held accountable. That is why Amendment 88 is so important.

The Bill’s intention goes in the right direction but the three amendments in the name of the noble Baroness, Lady Hollins, will significantly help in that journey. They will not solve the problems fully but they are an important way to say to people who work in health and social care that they will be held responsible for the outcomes of individuals, whether their needs come under healthcare or social care. That is why I support these amendments.

Baroness Tyler of Enfield Portrait Baroness Tyler of Enfield (LD)
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My Lords, I support Amendment 101B in the name of the noble Lord, Lord Layard. Before I speak to it, I want to say how much I agree with the sentiment expressed by noble Lords on all Benches that true integration will be achieved only if the Bill is as much about social care as it is about health. It is such a fundamental point that I wanted to underline it.

I see Amendment 101B as an important continuation of our deliberations last week on parity of esteem because “parity of esteem” are simply meaningless words unless they are reflected in the provision of funding. First, like the noble Baroness, Lady Watkins, I acknowledge the welcome fact that NHS England has met its commitment to ensure that the increase in local funding for mental health is at least in line with the overall increase in the money available to CCGs through the mental health investment standard. It is also welcome that, from 2019-20 onwards, as part of the NHS long-term plan, that standard also includes a further commitment that local funding for mental health will grow by an additional percentage increment to reflect the additional mental health funding being made available to CCGs. I recognise all of that.

But—and it is a big but—the investment standard relates only to CCGs, and that total spending had already declined in 2019-20 compared with 2018-19 as a percentage of total NHSE revenue spend. Also, given the urgent need for healthcare, which, as other noble Lords have said, has been much exacerbated by the pandemic, this amendment would help strengthen the consideration of mental health services when large amounts of money are announced for Covid recovery—this is welcome—but it all falls outside the remit of the mental health investment standard.

We need to know how much of the money is currently going to preventive and community services—prevention is the overarching theme of this group of amendments—as opposed to acute services. We also need to know whether the spending increases we are seeing are simply because crisis services are so in demand; indeed, they are overwhelmed in some cases. We know from a recent survey by the Royal College of Psychiatrists that two-fifths of patients awaiting mental health treatment contact emergency or crisis services, with one in nine ending up in A&E. That is not a sustainable position.

14:00
As I think we all know, the burden of mental illness in the UK far outstrips NHS spend. In our debate last week, I quoted from the King’s Fund. I highlighted the fact that mental ill-health makes up around 23% of the burden of ill health in the UK but receives roughly only 11% of the spend. With that burden outstripping demand, we also know that referrals have been at a peak during the pandemic. Indeed, modelling from the Centre for Mental Health estimates that 10 million people—a very large number—will need either new or additional mental health care as a result of Covid-19.
I am also very concerned about the very great regional variation we see at the moment. I will not quote all the figures, although I have them, but there is huge variation in access to CAMHS services depending on which part of the country you live in. That is also the case for access to IAPT services, which the noble Lord, Lord Layard, talked about, and other mental health services.
Given the chronic underfunding of mental health and the frankly egregiously low historical baseline, there is still far to go for mental health to reach parity with physical health services. The foundations provided by the £500 million Covid-19 recovery funding need to be built on in the coming years to ensure that the long-term planned trajectory is restored, the demand arising from the pandemic can begin to be addressed, the Mental Health Act reforms, which we have not heard very much about recently, are successfully implemented, and the waiting time targets arising from the clinical review of standards can be introduced effectively.
Baroness Bennett of Manor Castle Portrait Baroness Bennett of Manor Castle (GP)
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My Lords, this has been an extremely rich and informative debate on a diverse set of amendments. My contribution will be fairly brief, but I want first to reflect on the comments of the noble Lord, Lord Scriven, about the elephant in the room. He reflected on many other contributions about the lack of real integration of health and social care in the Bill, and the way the Bill is essentially written for health. I do not disagree with that identification of that elephant, but a second giant creature in the room is being ignored—let us call it a mammoth—which is the lack of adequate funding and numbers of people for health and social care. That means that those silos are seeking to defend their funding and resources, and reserve it for what they see as their core functions. They therefore find it very difficult to reach out and stretch into new areas even where that would have huge net positive impact overall.

To reflect on a couple of other things, I heartily endorse the call from the noble Lord, Lord Farmer, for a reverse Beeching for the NHS with the reopening of community hospitals. I am not sure whether he coined that phrase; I might borrow it, if he does not mind.

I will also comment on Amendment 51A in the names of the noble Baronesses, Lady Finlay and Lady Jolly, about emergency services going to everyone in the area. I see that the noble Lord, Lord Davies of Brixton, is in his place. This very much ties in with an amendment that he spoke to on Tuesday. He told a tale, which I will not repeat, about a case in which someone was denied a treatment in a neighbouring area that they desperately needed because of arguments about which area they were in. This is potentially a huge problem with the structure we are creating that has to be taken on board. Amendment 51A deals with the responsibility, but of course there also have to be funds to go with that responsibility.

It has not got a lot of attention, but I also commend Amendment 100 in the name of the noble Baroness, Lady Finlay, on the duty to promote rehabilitation. When we talk about dramatic medical interventions—the high-profile stuff—it is generally acknowledged, but always as an afterthought, that the person who has had that big dramatic intervention will not suddenly be cured tomorrow, in most cases. There is a long process of recovery. Indeed, I have put on my reading list Recovery: The Lost Art of Convalescence by Dr Gavin Francis, which has been glowingly reviewed in many places. That is something we all should be thinking about a lot more.

Finally, I come to Amendment 110, in the name of the noble Baroness, Lady McIntosh of Pickering, to which I attached my name because, as the noble Baroness said in her introduction, this is something that we have addressed again and again in the police Bill and the Domestic Abuse Act, but it is very acutely an NHS problem. I draw on an article from the Nursing Times on 24 December. It is an account of a nurse, who was called Claire in the article. When she was going through a checklist with a patient that had been provided by a charity—this was something extra added in from the outside, not core NHS—she realised that she herself was a victim of domestic abuse. She had said yes to more of the questions than the patient had. That is a demonstration of what the noble Baroness, Lady McIntosh, said: training is not given to medical professionals to see what is happening to themselves and to their patients. Maybe it is added in because a charity has managed to get something into the system, but it will certainly not be across the system.

We hope we are doing this Bill for the long term—although perhaps we are not so certain, as the noble Lord, Lord Hunt, said—but we have to note that this is happening in the context of the Covid-19 pandemic. I note that the NHS sexual assault referral figures for the first half of 2020 dropped significantly. That also picks up a great deal of domestic abuse, yet online searches for domestic abuse were up by 350% in the same period. We have an NHS that has been forced to focus on the Covid-19 pandemic, often drawing away resources that might have started to deal with domestic abuse anyway. We have a huge rise in the problem. Considering the moment we are at now, it is crucial that domestic abuse is in the Bill.

Baroness Walmsley Portrait Baroness Walmsley (LD)
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My Lords, this is an enormously important debate because it deals with my favourite word in health and care: prevention. Prevention is so important because it is cost effective. Although successive Governments give more and more to health services, no Government will ever be able to give enough to the NHS, because we have an ageing population and innovative medical interventions are getting more and more expensive, unless we do things differently and more cost effectively.

The noble Lord, Lord Black of Brentwood, outlined one very good, cost-effective intervention. It is an excellent example of something that has absolutely powerful evidence of its cost effectiveness but which is not being undertaken everywhere. I would like to know what evidence those areas that are not using fracture liaison services have that their way of doing it is better and more cost effective. I do not think they have that evidence. It is an example of where if you do not mandate it they will not all do it, and then they will not be spending their money effectively. I support the noble Lord’s amendment.

It is also very important that we prevent not just the second fall but the first, because, as the noble Baroness, Lady Finlay, said in her very important intervention, including what she said about tourist areas, which is very significant, people do die from falls. I had a very old friend who recently did. It was the first fall. I am afraid that person died because he had internal bleeding that nobody spotted. It is really important.

My noble friend Lord Rennard mentioned something really important that is pre-primary intervention: health education. If you know that you are likely to have good, strong, healthy bones from weight-bearing exercise and a diet that has enough calcium and vitamin D, you are much less likely to have the first fall. Fortunately for the Minister, that is beyond his remit. I am sure he is pleased about that, because he has quite enough to do. The Department for Education should listen to that.

My noble friends on these Benches have highlighted some other areas where effective prevention services are not being done properly. I think we were all struck by the chaotic situation that my noble friend Lady Barker highlighted; something really has to be done about that. A lot of good has been done but a lot more could be done, and, again, it would be cost-effective.

The noble Lord, Lord Layard, has suggested a very cost-effective intervention. If we diagnose and intervene on mental health issues early then we can prevent all kinds of more severe mental and physical health problems. I support the ratchet method that the noble Baroness, Lady Harding, referred to of increasing the amount of funding that goes there. Although the noble Baroness, Lady Watkins, rightly listed the number of times that the Government have put more money into mental health services, the question is: have they kept up with the demand and the backlog? I do not think they have.

We have an opportunity in the Bill to improve our measures to prevent ill health, as well as treat it, which is of course more cost-effective, especially when services are delivered by small social enterprises working at community level. I have added my name to the amendment from the noble Lord, Lord Farmer, because I believe these prevention services should be available as close as possible to those who need them most. If that does not happen then the people who need them will not access them, and health inequality will continue.

That is particularly important for those communities where health inequality is at its worst and where preventable diseases are most prevalent. For example, the services might include healthy weight management services, therapies to address less severe mental health conditions, and alcohol and drug addiction services, in addition to the usual GP services. The population groups are not just those in poverty but marginalised groups such as homeless people, those in temporary accommodation, refugees, Gypsy and Traveller communities, and others who may not be plugged into regular services, and that includes those in rural areas.

Many of these services are delivered very effectively by social enterprises or charities, where any surpluses are ploughed straight back into more services. Many of them also provide weekend services, which were mentioned as lacking by the noble Baroness, Lady Masham. Boards that do not ensure the survival of such services are really missing a trick that would help them to deliver their duty to level up health inequalities, because these organisations are usually very close to their communities and know exactly what is needed and where. They are not constrained by the regulations or the culture of large organisations, and are therefore more flexible and fleet of foot, and therefore very cost-effective.

On rural areas, I shall give your Lordships a brief example from my noble friend Lady Jolly, who lives in a very remote part of Cornwall. She says:

“We have a satellite surgery in our local village, it is in the ground floor of an old cottage. The pharmacist visits once a week, and a practice nurse visits once a week. When she is seeing a patient they have to switch the radio on so that no one can hear the conversation”—


because of patient confidentiality. In that village you have to drive 20 miles to reach a GP. That is the sort of place where we really need community access to health services of all kinds. It would be nice to think that the ICB would be aware of that and act accordingly, and it might perhaps be worth putting a duty in the Bill.

Baroness Thornton Portrait Baroness Thornton (Lab)
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My Lords, this is an assortment of amendments that are all linked to the core of the Bill, which is about integration. The issues, as ever, are about whether it is appropriate to place such a detailed level of specification in the Bill, and where.

Amendment 50 seeks equity of access for fracture liaison services. In many ways the amendment by the noble Lord, Lord Black, supported by my noble friend Lord Hunt and others, is about the balance between a national mandate and local delivery in order to ensure that there is equity of access—in this case, for fracture liaison services. I would be interested to learn how the Minister believes such a thing could be implemented and assured, and in how we can best express that in the Bill.

14:15
Amendment 51A briefly touches on the well-trodden ground of the 2012 Act and the differences in the famous Sections 1 and 3 of the National Health Service Act 2006, which varied the wording around the duties of the Secretary of State. Some saw that as a device to try to exclude patients or treatment as a cost-cutting measure; others saw it as simply tidying up the wording to meet reality. In fact, experience since 2012 indicates that fears were indeed overstated at that time. However, as the noble Baroness, Lady McIntosh of Pickering, said:
“Surely, this should be rolled out nationally”,
and that is the aspect that we are discussing here.
The amendment seeks to ensure that emergency care cannot be refused when it is needed just because a patient is not resident in the ICB area. We touched on that last week—or perhaps it was earlier this week; I cannot remember—but, frankly, if you break your leg in Blackpool but live in Bolton, the ambulance will still come for you. As far as I know, there is no mechanism for checking where you live or even whether you are ordinarily resident in an area in the case of non-emergency hospital in-patients. We all know that infectious diseases and emergency care can and should be properly protected.
Amendment 57 from the noble Lord, Lord Farmer, is very much in line with Labour’s policy of promoting care close to home, with a focus on prevention, but achieving that probably goes beyond what the Bill says it will do. It will take a change of attitude and culture throughout government. For example, in Wales, the focus on well-being and adequate funding getting to the right places in the NHS and beyond is about tackling the determinants of poor health. That policy was put in place at least five years ago and is now beginning to have effects, so this is a long-term change of culture and attitude.
Amendment 100 in the name of the noble Baroness, Lady Finlay, is about rehabilitation and patient support. I fully support the aim that this serves and how it highlights, as have other amendments, the fragmentation of sources of support.
Amendment 110 would require ICBs to publish a strategy on support for victims of domestic abuse. Again, I agree with that, but we have to work out how best to deal with it, because such a strategy would require agreement across a much wider range of stakeholders, which is exactly as it should be.
Amendment 101B, in the name of my noble friend Lord Layard, addresses parity of esteem, an issue that many noble Lords have addressed. We know that two things appear to work in the NHS, and the Minister, as a distinguished economist, knows this: money and targets. So we hope that the amendment in the name of the noble Lord, Lord Stevens, and that of my noble friend Lord Layard, could, as it were, work together across the House to produce an amendment that addressed those issues: the targets, progress and resourcing to deliver parity of esteem. We on these Benches are certainly very keen to see that happen and to be part of the process that will take us there.
Through the important discussion that we have had today, perhaps we can see that something needs to be done and will, I hope, work towards those things. I was struck by the remarks of the noble Baroness, Lady Barker, about HIV, which highlighted three matters: inequalities, innovation and fragmentation. It is unacceptable that we are having to look at an area where there is great innovation and scope for great improvement but where there are huge inequalities and huge fragmentation. That underlines the issue of the lack of integration and the case for public health to be at the core of prevention and integration. I look forward to the Minister’s response to this debate, because I hope we are on the cusp of making some improvements to the Bill that will actually take us forward.
Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
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My Lords, this has been a fascinating debate, covering issues around prevention, as the noble Baroness, Lady Walmsley, said, and talking about what we mean by integration and how we make sure that it is more than just a word. I remind noble Lords that we have a forthcoming paper on integration as part of the overall package of the Bill, and a social care paper as well.

The noble Baroness, Lady Thornton, mentioned culture and attitude. I think it is very important to recognise that you can change structures and have legislation but you have to make sure that the culture and attitude are right across the system. I say to noble Lords that we fully sympathise with the intentions and I hope I can offer some reassurance.

In my departmental job as Minister for Technology, Innovation and Life Sciences, I feel very strongly that one way to drive integration is through better use of data across the system. Even before we look at integrating with social care, the NHS as it is at the moment is not sharing data well across the system. There are still a number of inefficiencies. I really believe in the digital transformation agenda and will give a quick example of that.

Just before Christmas, at a time when the NHS was under extreme pressure, I had my annual check-up in two parts. One part was an ECG at a local community centre; the second was supposed to be a telephone conversation with a consultant a week later. When the phone call came from the consultant, he started talking and I had to stop him. I said, “Have you seen my ECG results?” and he said, “No. What ECG? When was that?” I said, “This is all part of the same appointment. Can I now give you the date and time when I had it so you can look at the results?” “Don’t worry about that,” he said, “we’ll just have to make a new appointment”.

This was at a time when the NHS was under extreme pressure, as it is every winter. That shows the challenge. Even though we have been talking about the integration of health services since 1948, we still have these problems. That is why I believe so strongly in the digitisation and data-sharing challenge. It is not just because I am a geek and love technology; it really can make a difference, save money and lives and mean a more effective service all around.

I start by addressing Amendment 50 on fracture liaison services. Fracture liaison services and fragility fracture prevention are recognised by NHS England as critical to both healthy ageing and elective recovery. Within its high-impact restoration strategy, NHS England recommends that all systems optimise the secondary prevention of fragility fractures. NHS England is working closely with stakeholders to support the implementation of secondary fracture prevention services where they do not exist already and to support sustainability and quality improvement where services exist. Once again, this will rely on good data being shared across the system.

There are already duties in the Bill to require ICBs to commission such services. As fracture liaison services aim to identify people at risk and therefore prevent future fractures, their provision would already be covered in Clause 16 under new Section 3(1)(h), which places a duty on ICBs to commission such services or facilities for prevention, care and aftercare as the ICB considers appropriate. As I hope noble Lords will agree, it would be inappropriate to be overly specific in setting out the services to be commissioned as part of the new Section 3 that would be inserted by Clause 16, given the wide range of services the NHS needs to commission. However, I hope I can give assurances to noble Lords that NHS England will continue to monitor this and ensure that ICBs are commissioning effective fracture services. I hope we continue to drive this data being shared appropriately.

I turn to Amendment 51A. It makes sense that people should be able to receive emergency treatment wherever they are, as the noble Baroness, Lady Thornton, alluded to. We believe that is already the case. Once again, data would make a huge difference. If I am in Newcastle and fall off my bike and am taken to hospital, and if I have an existing condition, would it not be great if the clinicians when they triage me could know about it? I have asked my local GP practice to share my data on the app and it still has not done it. The mechanisms are there but the culture and attitudes are a huge challenge for whichever Government are in power.

The Bill confers a power on NHS England to publish rules that determine the people for whom each ICB is responsible. Those rules must make sure that everyone registered in the area, or everyone who may have need of services, is looked after. The Secretary of State may make regulations expanding that responsibility or creating exceptions where necessary. This was the case with existing CCGs and will continue under the ICBs. I hope I can reassure your Lordships that these regulations will be replaced to ensure continuity in this between CCGs and ICBs,

I now turn to the noble Lord, Lord Farmer, and his amendment. I also thank him for sharing his wisdom and his experience of family hubs. It is incredibly important. We agree with the spirit behind Amendment 57. We fully agree that, generally speaking, as the noble Baroness, Lady Walmsley, said, prevention is better than cure. One of the things that I have been reassured by in my early conversations in my role as a Minister for Health is the number of people in meetings who have said that they want to move towards a focus on prevention. That is not avoiding cure. We have to tackle cure, of course, but we can avoid a lot of that and save resources and time and promote better health and healthy living if we focus on prevention.

There are also duties in relation to the improvement of services for the prevention of illnesses as well as a duty to obtain appropriate advice, which expressly includes a requirement to seek advice from people with expertise in the prevention of illness. The NHS is already working hard to prevent ill health but, once again, we have to make sure that, in this prevention, people are all talking to each other, we are learning from best practice, and ICBs and trusts are learning from each other. As a number of noble Lords have made clear in their contributions in Committee, the issue is wider and social prescribing, for example, and other issues are really important.

Commissioners have also developed good practice, including funding alcohol care teams and tobacco treatment teams in hospitals, and expanding the diabetes prevention programme. This was re-emphasised in the NHS Long Term Plan, which contained commitments for the NHS to focus on major causes of ill health such as smoking, poor diet, high blood pressure, obesity and alcohol and drug use.

I remind noble Lords that prevention is not simply also a matter for ICBs. It involves local authorities and sometimes law enforcement authorities. It is a multiagency approach, led by local authorities but with ICBs, the NHS and other agencies playing their role.

I acknowledge the point that my noble friend made about cannabis and young people and I will write in more detail about that rather than take up time now. But we also have to look at such issues in the round. For example, in the United States Michael Cannon of the Cato Institute wrote that a lot of drug enforcement or anti-drug policy disproportionately affects young black men who then get thrown into the criminal justice system. How do we tackle that? One of the interesting conversations I have had with the noble Lord, Lord Paddick, was about his experience as borough commander in south London, an area that my noble friend mentioned. He gave the example that young black men in possession of drugs were far more likely to be picked up than a white middle-class male or female.

We have to make sure that we look at this as a whole. When we look at the tackling inequalities strand that we all feel so strongly about, we have to make sure we get the right balance. It is, of course, very difficult on a case-by-case basis but we have to be aware of unintended consequences.

On the integration duty, we are sympathetic to the intent behind the amendment from the noble Baroness, Lady Hollins, and support greater integration between health and social care. We hope that we can make sure that stakeholders work together and that, with all the papers, we are able to push through this integration.

Baroness Thornton Portrait Baroness Thornton (Lab)
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I hesitate to take the words of the noble Baroness, Lady Hollins, away from her, but she is talking about putting a duty for this integration in the Bill. That is the way forward. Assurance is not the point here. I think we have gone past the point of needing assurance. We have been assured about this for years. This is about the duty.

Lord Kamall Portrait Lord Kamall (Con)
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I was just about to come to duty, so I thank the noble Baroness for hurrying me along.

14:30
The duty to promote quality social care services rests with local authorities. The Care Act 2014 already requires local authorities to integrate services where they consider that this will improve the quality of care or support in the local authority area, including the outcomes that are achieved for local people. However, I sense the strength of feeling on the duty from the Committee and given some of the conversations—
Lord Scriven Portrait Lord Scriven (LD)
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I do not think that the Minister really understands. Yes, there may be a duty on local authorities. The amendment tabled by the noble Baroness is basically a duty to promote integration. At the moment, the Bill says that:

“Each integrated care board must exercise its functions with a view to securing that”


health services are provided in an integrated way. The amendment says “and social care”. It then justifies at what point that integration must be done. Why does the Minister feel that not putting this in the Bill somehow strengthens the main aim of the Bill, which is to look at the integration of health and social care for individuals who are going through a health and social care episode?

Lord Kamall Portrait Lord Kamall (Con)
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The Bill complements these existing duties by placing an equivalent duty on ICBs to integrate the provision of health services with the provision of health-related services and social care services, where this will lead to improvements in quality or reductions in inequalities. Taken together with the wider introduction of integrated care boards and integrated care partnerships, this gives the NHS and local authorities the best platform on which to build new ways of working. New provisions in the Bill will also complement and reinvigorate existing place-based structures for integration between the NHS and social care, such as health and well-being boards, the better care fund and pooled budget arrangements. We will, of course, be listening throughout the passage of this Bill to other ways in which we can facilitate the NHS, local authorities and others to work together to deliver integrated care for patients and the public.

Lord Scriven Portrait Lord Scriven (LD)
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I am sorry and will not delay the House much longer, but this is a really important point: the heart of the Bill.

As the Bill is written at the moment, the only integration that the integrated care board is responsible for is to ensure that health services are integrated. That means integrating primary, mental health and acute. It does not say that it is for the integration of social care. That is exactly what the noble Baroness is trying to achieve. As this is written, is it not the case that the duty in the Bill is for the ICB to secure that only health services are integrated?

Lord Kamall Portrait Lord Kamall (Con)
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One of the reasons for the introduction of integrated care boards and integrated care partnerships is to give local systems, both NHS and local authorities, a platform on which to build new ways of working. That includes social care. If the noble Lord feels that this duty is not explicit enough or that we should bring it out, we should have further conversations.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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The architecture is very curious regarding why we must have an integrated care board and integrated care partnerships. It has never been clear to me why the Government have not attempted to set up a health and care board to bring those services together. We know that the funding systems will be different and that there is a clear difference between free at the point of use and means-tested social care, but surely that is what an integrated board, jointly owned by the NHS and local government, with councillors at the table not officers, is trying to sort out. Why have we ended up with this nonsense of a structure? We are carrying on with health and well-being boards as well. That is the great puzzle here.

If the Government are not willing to move on that, we must come back to the point made by the noble Lord, Lord Scriven. By splitting it, you then must say to the integrated care board, “Ah, but in your duties, you must ensure that you integrate with social care as well.” It really is a mess. The Minister said earlier that this is what the NHS wanted. Yes, this is an NHS Bill designed by NHS managers with a focus on the NHS. I do not know why it is called a care Bill, because it has nothing to do with care.

Lord Warner Portrait Lord Warner (CB)
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Before the Minister responds to that, can I amplify what is being refused here by the Government? As I understand it, he is trying to rely on the Care Act to get local government to co-operate and integrate care with the great elephant, the NHS. This is asking a minor player to take on a major player with far more resources. Amendment 89, tabled by the noble Baroness, Lady Hollins, makes the NHS come back every two years about the outcomes. That is a fairly modest challenge to the NHS and I fail to understand why the Government cannot simply accept that in principle and then negotiate the drafting.

Baroness Walmsley Portrait Baroness Walmsley (LD)
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I am so sorry to delay the Minister again, but briefly. After we have pushed this Bill through Parliament, we will have an integration Bill and a White Paper and legislation on social care. When we have had this, those and those, can we come back to this?

Lord Kamall Portrait Lord Kamall (Con)
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These are all building blocks. I thought that might get a laugh.

In response to the noble Lord, Lord Hunt, ICPs were the idea of the Local Government Association, and we want to ensure that they work with the ICBs. Also, we must recognise that local authorities are accountable to their local electorates and fund many of the services for which they are responsible from local taxation. While we encourage local authorities and the NHS to work together as much as possible and pool their budgets where it is beneficial for local people, we are not mandating this, as this would probably require significant shift in how local authorities are held accountable for managing their money. One of the reasons why we have this strange ICB-ICP partnership is to ensure that it is at the right level and, beneath that, to have the health and well-being boards at place level. I sense the strength of feeling in the Committee, and I see the noble Baroness, Lady Hollins, giving a wry smile.

Baroness Hollins Portrait Baroness Hollins (CB)
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I love this debate—it is brilliant—but it makes the point that this is an ideal opportunity to pre-empt a later Bill and get on with the job now where it belongs. Given the strength of feeling in the Committee, if we cannot reach a solution to this, I will bring it back on Report.

Baroness Barker Portrait Baroness Barker (LD)
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My Lords, I feel for the Minister in his position. He is right: people observing our proceedings will see us laughing, but in practice this is really serious. I talk to colleagues in local government who receive endless requests from the NHS to turn up to meetings and they do not go, and why? It is not because they do not think that it is important, but because local government has been hollowed out over the last 10 years to the point where it has very senior management and front-line staff, and does not have large numbers of people in the middle doing middle-management planning jobs that exist in the NHS. That was the reality before Covid and is the reality now. Each of those building blocks that the Minister is putting in may be some great stepping-stone to a nirvana for the NHS, but they are just another obstacle for local government. It is so important that we in this House are not tied to constituencies or particular areas of importance. Speak truth to power—to the Government. We are building something unsustainable that will not work.

Lord Kamall Portrait Lord Kamall (Con)
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I thank the noble Baroness for her sympathy for my role. Debates like this are important. They give the Government a measure of the strength of feeling on particular issues. It would be blind for me not to acknowledge the strength of feeling and the support for the noble Baroness, Lady Hollins. As I have done with some of the other issues discussed in this debate, I will take this back to the department and call a meeting of those who are interested, as we did for mental health, and hopefully we can have a discussion to find a way forward. I thank noble Lords for expressing the strength of their feeling. It is very helpful to know where we can focus time and resources as we try to get this Bill through and ensure that it is workable and leads to the integration that we all want to see.

I will also add that NHS England intends to assess ICBs, as I does CCGs. This may not be reassuring, given some of the strength of feeling about NHS England’s drive behind the Bill. The CQC will also make assessments of ICSs and systems, and part of that will be to consider how health and social care are working together.

I will now talk about rehabilitation—not of my career but of health. Our intention with this legislation is to establish overarching principles and requirements, while allowing ICBs space and discretion. This means avoiding being prescriptive, wherever possible. I am sure that noble Lords acknowledge that. Looking at the duties on ICBs that are relevant here, the first—in Clause 16—requires an ICB to arrange for the provision of the listed services it considers necessary to meet the needs of those for whom it is responsible. This includes aftercare which, in turn, includes rehabilitation. The ICB is also required to develop a joint forward plan, setting out how it will meet the health needs of its population—which should consider rehabilitation. ICBs are also under a duty to seek continuous improvement in the quality of care. That of course has to include rehabilitation. We hope that, without legislating for the production of a separate annual plan, ICBs will be required to provide, and improve provision of, community rehabilitation services.

I turn to Amendment 101B. I can assure noble Lords that the Government fully support the increased focus on mental health spending. I thank noble Lords who met with me earlier this week to discuss some of the issues around mental health and how we make sure that it gets the profile it deserves. We are trying to move towards parity between mental and physical health, and indeed all other types of health service. If I may, I will leave that there for now. If we have to continue the conversations about mental health, those who were not invited to this week’s meeting might like to drop me an email to let me know if they are interested in joining the meetings, and I will make sure that the Bill team invites them.

I am trying to get through this as quickly as possible. Turning to Amendment 110, I thank my noble friend Lady McIntosh of Pickering for the conversations we have had on inequalities, particularly in rural areas. A number of noble Lords alluded to this. I should also like to record my thanks to noble Lords in the Committee and in the other place who have campaigned so strongly on this issue. We have listened. The amendments already accepted in Clause 20 have directly addressed the need to consider victims of abuse, including victims of domestic and sexual abuse.

Clause 20 ensures that integrated care boards and their partner NHS trusts and foundation trusts set out a joint forward plan for any steps that the ICB proposes to take forward. As the noble Baroness, Lady Barker, said, we also have to make sure that this is not seen as just an NHS issue. We want to make sure that we work more widely with all agencies in the area to tackle these issues. For these reasons, we do not feel that a separate strategy is necessary in the Bill. Also, the accepted amendment is more comprehensive. It covers all forms of abuse. There are also duties on CCGs to consider the needs of victims of violence, including a joint strategic needs assessment. CCGs must respond to these, and this will be transferred to the ICBs.

Under the Government’s new Domestic Abuse Act, local healthcare systems will be required to contribute to domestic abuse local partnership boards. It is also worth noting that the Government are undertaking wider work to protect and support victims of domestic violence. Clearly, further action is needed beyond the NHS. In particular, the Police, Crime, Sentencing and Courts Bill will require action from across government, and we will ensure that this work is aligned as much as possible.

The proposed amendment would place a requirement on ICBs to have a domestic abuse and sexual violence lead. We agree with the principle, but we think we can do this effectively through existing legislation and guidance, as set out in the Government’s recent violence against women and girls strategy. My department will engage with ICBs and partnerships to make sure that we have appropriate guidance.

Beyond ICBs, there is a huge opportunity for ICPs to support improved services for victims of domestic abuse, sexual violence and other forms of harm through better partnerships. I hope that I have given noble Lords some assurance about this.

14:45
Once again, I am grateful to the noble Baroness, Lady Barker, for tabling Amendment 297J. Good sexual and reproductive health and healthy relationships make a significant contribution to our health and well-being. We believe that access to appropriate and high-quality interventions is much needed. As the noble Baroness once again said, this is not just for the NHS. We are currently developing a new sexual and reproductive health strategy, which will be published this year. In the HIV action plan, published last year, we set out our plans to end new HIV transmissions in England by 2030. This amendment would require us to report to Parliament within six months of the passage of the Bill—also subject to the findings of the report.
We accept that there are concerns about fragmentation in commissioning and delivery of SRH services across England, which were so eloquently laid out in the contribution from the noble Baroness. In her words, we cannot continue in this inefficient way. The Government are determined to address this, given the shared agenda on sexual and reproductive health between local government and the NHS, as well as having stronger commissioning and leadership responsibilities. We want to see stronger collaboration and co-operation right across government to ensure more efficient and effective services.
Subject to the successful passage of this Bill, we will update the existing duty on ICBs and local authorities to co-operate with each other. Clause 66 will give us the power to issue statutory guidance on the duty of local government and the NHS to co-operate. We will consider using this power in relation to sexual and reproductive health services to support the implementation of our new strategy and our ambitions for both our sexual and reproductive health and HIV programmes.
I regret that the Government cannot accept these amendments. I hope I have given noble Lords some assurance on the issues where I have sensed the strength of the House’s feeling. I hope we can continue these conversations. In that spirit, I hope that noble Lords will not press their amendments.
Lord Black of Brentwood Portrait Lord Black of Brentwood (Con)
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My Lords, even by the standards of your Lordships’ House, this has been an exceptional debate. The noble Baroness, Lady Pitkeathley, said that this is a really important set of amendments which go right to the heart of the Bill. They cover a remarkable range of issues. I, for one, am profoundly grateful to all the speakers who have taken part.

I think we all have some sympathy for my noble friend the Minister. He will have heard a number of messages loud and clear. I would like to mention the powerful contribution from the noble Baroness, Lady Masham, with her very important personal insights on the issue of fractures and the problems in rural communities. The noble Baroness, Lady Hollins, gave us a comprehensive view of the integration of services. It certainly struck a chord with me, as I am currently grappling with the problems faced by an elderly friend who is seriously ill and for whom these issues are very real and distressing. My noble friend Lady McIntosh told her own story of osteopenia, which underlined how vital early diagnosis and treatment are.

I thank the Minister for his comprehensive response. I think we all welcome his comments on data and digitisation. These are obviously good, but it is not just about data or monitoring, nor about building blocks, however important they are. It is about structures and obligations, and about effective integration being written into the Bill.

I am afraid that the elephant in the room, identified by the noble Lord, Lord Scriven, is still sitting out there. The Minister will have seen the strength of feeling of the House. As he said, there should be further conversations, which I think everybody would welcome. Otherwise, these issues will come back on Report.

It is essential that we tackle the issue of bone health and, as the noble Lord, Lord Rennard, said, this Bill is the right place to do it. The noble Lord, Lord Hunt of Kings Heath, summed it up superbly. We have known the benefits of proper prevention for a very long time, but progress has been at a snail’s pace. There was no answer to that point. In purely economic terms, as well as for the care of individuals, this is—in the vernacular—a no-brainer. If we do not make progress, we are letting down patients, taxpayers and the NHS.

I hope we can make further progress on all the points that have been raised by noble Lords in this extraordinary debate. In the meantime, I beg leave to withdraw my amendment.

Amendment 50 withdrawn.
Amendments 51 to 53 not moved.
Amendment 54
Moved by
54: Clause 16, page 14, line 47, at end insert—
“3AA Duty of integrated care boards to commission approved treatments(1) This section applies where—(a) a treatment has been approved by the National Institute for Health and Care Excellence,(b) an integrated care board has not arranged for the provision of that treatment under section 3 or 3A, and(c) a clinician has recommended that treatment for a person for whom that integrated care board has responsibility.(2) The integrated care board must arrange for the provision of that treatment to the person for whom it has responsibility.(3) In subsection (1) “clinician” means a medical professional employed by or acting on behalf of an NHS Trust, NHS Foundation Trust or primary care service from whom the integrated care board has arranged for the provision of services.”Member’s explanatory statement
This amendment would require an integrated care board to arrange for the provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area.
Baroness McIntosh of Pickering Portrait Baroness McIntosh of Pickering (Con)
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My Lords, I will speak particularly to Amendments 54, 74 and 97 in this group. I warmly thank the noble Lords, Lord Patel and Lord Hunt, for lending their support to all three amendments, and the noble Lord, Lord Warner, for supporting Amendment 74. I pay particular tribute to the noble Lord, Lord Patel, and his historic work prior to the setting up of NICE; it was a great contribution that deserves to be recognised.

We are all aware of the procedure that, when a medicine is approved, it goes through two processes. First, it goes to the Medicines and Healthcare products Regulatory Agency, known as the MHRA, a body which checks whether a drug is safe and effectively does what it says on the tin. It then goes through a separate process run by the National Institute for Health and Care Excellence, known as NICE, which looks at cost-effectiveness and value for money. After those two hurdles have been passed, the medicines should, theoretically, be accessible to anyone. That is very clear in the NHS constitution, which explains that there is a legal right for people to have access to NHS NICE-approved drugs if it is right in their particular circumstances that they should. Indeed, the NICE guidelines say very clearly that there should be automatic adoption within 90 days of approval, if clinically appropriate and relevant.

For a drug then to be prescribed, it must not only have been approved by NICE but go on to the approved list of drugs in the local health authorities, called a formulary. The problem is that somebody must put the drug on the formulary and, currently, while in theory there is a system under the NHS NICE guidelines, this does not actually happen. Sadly, this results in a postcode lottery where some areas have the product on their formulary and others do not. Sometimes this is a process failure, but sometimes it is to avoid budget overspends. Therefore, I would say that it is at the patient’s expense that they are deprived of the drug.

To give an example of the problem, there is currently a drug for multiple sclerosis that patients are still waiting after 150 days to see go on to the formularies in around 25% of the local health systems across the country. There is a state-of-the-art flash monitor for type 1 diabetes, but the uptake across the country varies between 16% and 65%. What is most worrying is that those parts of the country with the greatest levels of deprivation have the lowest level of uptake.

I make a plea to the Minister: in my view, ICBs should be required to ensure that all NICE-approved medicines and devices are available and promoted to their population, because the cost of these drugs is covered by the VPAS reimbursement scheme agreed between the NHS and the pharmaceutical industry. If a treatment is unavailable in one ICB footprint, they should be required to commission the required treatment from another ICB. The Government should also promote uptake through the ICBs of NICE-approved medicines and report uptake of new medicines annually.

Amendment 54 would require an ICB to arrange for provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area. Amendment 74 would require ICBs to ensure that all NICE approvals are available and promoted to their population via a publicly accessible format, normally online, and to report on their uptake annually. Amendment 97 would mandate integrated care boards and healthcare providers, notably hospital trusts, to update their formularies to include all NICE-approved medicines or devices within 28 days of market authorisation, to ensure they are available for healthcare practitioners, through either their physician, for example, or prescribing pharmacist, to make available for suitable patients.

I thank those who submitted briefings to me while I was preparing for today, notably JDRF, which makes a number of recommendations on this issue, particularly in regard to type 1 diabetes. These aim to reduce inequalities, remove the postcode lotteries to which I referred and make sure that treatments, such as those for type 1 diabetes, are uniformly available across the piece. I also thank EMIG, a pharmaceutical trade association for small and medium-sized companies, for its briefing. It says that the uptake of NICE-approved medicines is critical for NHS patients to benefit from the latest and most promising innovations. Finally, I am grateful to Vertex Pharmaceuticals, which submitted a briefing that again supports the conclusions reached. Among the proposals it highlights is the introduction of a modifier to take account of the severity of a disease and efforts to more fairly consider uncertainty in the evidence for highly innovative and complex treatments for rare and severe diseases, including through greater use of real-world evidence.

On this small group of amendments, I look forward to hearing what the noble Baroness, Lady Finlay, has to say in connection with her neat, simple amendment, which would strengthen what we are proposing to do here. I urge the Minister and the department to address these postcode lotteries and make sure that NICE does not just make the guidelines but ensures that treatments reach the formularies and ultimately the patient in question. I beg to move.

Lord Russell of Liverpool Portrait The Deputy Chairman of Committees (Lord Russell of Liverpool) (CB)
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My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite her to speak now.

Baroness Brinton Portrait Baroness Brinton (LD) [V]
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My Lords, I wish to speak in support of Amendments 54, 74 and 97, tabled by the noble Baroness, Lady McIntosh, and Amendment 163, tabled by the noble Baroness, Lady Finlay. I too pay tribute to the historic work of the noble Lord, Lord Patel, prior to the setting up of NICE.

While it is not an interest in the formal sense, I declare that I have autoimmune disease and have experience of being on the NICE rheumatoid arthritis care and treatment pathway for 19 years, which has been regularly updated by NICE over that time. Where it has been applied in full and from diagnosis, patients have found it very beneficial and, with new and more effective drugs being approved every few years, many are now in remission. I pay tribute to the consultants trying to do their best for their patients and the National Rheumatoid Arthritis Society and Versus Arthritis helplines which support RA patients in navigating their way through access to their NICE treatments when these have been blocked.

I thank the noble Baroness, Lady McIntosh, for her introduction to this group and for explaining the problem with the formulary list. She is right that this should be addressed formally. However, I want to focus on some of the commissioning practices on NICE-recommended treatments, including those on the formulary, in the current CCGs, because I believe these explain the need for the amendments in this group.

In May 2014, the High Court ruled that Thanet CCG could not disagree with NICE guidance merely because it disagreed with it, even when there is no statutory duty to provide that treatment. This specific case was about access to fertility treatments for a woman who was about to undergo bone marrow transplantation to put her severe form of Crohn’s disease into remission. NICE’s 2013 clinical guidance recommended that

“oocyte or embryo cryopreservation as appropriate”

should be offered

“to women of reproductive age … who are preparing for medical treatment for cancer that is likely to make them infertile”.

This was not cancer, and the CCG’s own policy was to not grant funding unless there were exceptional circumstances.

15:00
One might think that, after the High Court ruling, CCGs would follow the High Court judgment, but many have found ways to delay the implementation of NICE treatment pathways recommended by consultants for their patients. A particularly unhelpful practice is that many CCGs have developed a committee for considering the initially more expensive NICE pathways. A nasty delaying tactic employed by some sub-committees, reported to me by consultants, is to meet only a limited number of times a year, meaning that there is an automatic minimum delay of some months before any request for a biologic drug can be approved for autoimmune disease. Worse still, one consultant told me that, when budgets are tight, some CCGs use bureaucracy to wait until the committee is due to meet, and at that point write back to the consultant to say that their proposal does not exactly meet the NICE pathway as they understand it and, like a game of snakes and ladders, the consultant must apply all over again. I am sure that this is because of budgetary means, but it makes a mockery of the principles behind the NICE pathway.
Some CCGs are interested only in the medication side—the noble Baroness, Lady McIntosh, talked principally about medication—and ignore the other elements of a NICE treatment pathway. In the RA pathway one key recommendation is that all newly diagnosed patients have access to specialist physiotherapy and occupational therapy, hand exercises, podiatry and psychological interventions, among others. Far too many patients are not offered any of these. The importance of this at diagnosis is that it helps to reduce symptoms, reduce bone damage and reduce future costs to the NHS.
My local CCG, among others, used to have specialist provision, but it now refers new patients to cheaper, non-specialist physios and occupational therapists, wasting valuable time to prevent damage to patients’ joints. I am horrified when talking to recently diagnosed patients to discover they have not been referred to any of the wider multidisciplinary teams, despite the clarity of the NICE guidelines.
NICE uses experts to develop the most effective and cost-effective treatment pathways. In the case of RA, this includes a ladder of medications that consultants and patients progress up, ensuring value for money as well as value for treatment. Providing a consultant uses the NICE guidelines and pathways, it should not be within the gift of any commissioning body to change or delay that.
These amendments place in the Bill the duty of ICBs to approve and deliver treatments as set out by NICE in full. We delude ourselves if we think that ICBs will not try to behave in a similar way to CCGs, not least because many of the staff who deal with the commissioning will have been TUPE-ed straight across from CCGs.
Amendment 54 tackles the problem of the patient in the High Court case I referred to, by proposing that if a clinician recommends a NICE-approved treatment, even if the treatment is not available to other patients in their area, the patient should receive that treatment. I agree.
Amendment 74 deals with the problems of poor practice in some of the CCGs, which I have outlined, and ensures that if NICE has an approved treatment pathway, ICBs should not be able to refuse it. The reporting mechanisms in Amendment 97 would hold ICBs to account publicly. I like the way that Amendment 163 links all this back to the NHS mandate, because of course the NHS is going to be providing the funding for CCGs.
To do anything less than accept these amendments is to demean the work and statutory role of NICE and its experts, to frustrate consultants trying to do their best under those guidelines for their patients, and to deny patients their fundamental right to access to treatment as approved by NICE. I look forward to hearing the Minister’s response and hope that it will be helpful.
Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (CB)
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My noble friend Lord Patel has had to leave because of pre-booked travel, but he has given me the honour—and it is an honour—of having his brief speaking notes, from which I would like to start, and then move on.

Before I get on to that, I think it is important for us to remember that NICE was set up to establish the evidence base behind what we do. Before NICE was established—and I have worked with Deirdre Hine, who was very involved in setting it up when she was Chief Medical Officer for Wales—people were doing things because they had always done them and because they liked doing them that way, with no evidence base, and often they were doing things that made situations worse, not better.

As Lord Patel wanted to stress, clinicians have a strong belief now in evidence-based healthcare, and guidelines are critical to ensure high and consistent levels of evidence-based clinical practice across the NHS. The guidelines developed by NICE can be adapted to the local situation, and they are also under review. I should declare that I have served for three years as vice-chair of the group looking at ME/CFS guidelines, and it was very instructive to see the depth to which everything was explored and the rigour of the processes; to the point that, when we were asked to review again some papers, we went back to the beginning and reviewed them all over again. Interestingly, in doing that, we slightly downgraded their scoring, rather than upgrading it, which is what had been expected. I was really impressed at the rigour of the process, including the health economics impact.

That experience has been behind the push to make sure that there is compliance. My proposed amendment would be a way of assessing compliance with the guidelines as predetermined and set out in the NHS mandate. The mandate could select a few that would act as proxy markers across the piece and include a date line, so that their implementation across the country could be benchmarked. It would not increase the workload, because it could draw on existing sources of data in the NHS. As the Minister has said, data is our key to understanding and unlocking things.

The noble Baroness, Lady McIntosh, in her comprehensive introduction to this group of amendments, spoke about type 1 diabetes and highlighted that, in some areas, the adoption of continuous glucose monitoring is as low as 0%, whereas in other areas it is up to 20%. There are a couple of other emerging areas; one is in atrial fibrillation, where direct oral anticoagulants have made warfarin a drug of the past. Yet the variation between clinical commissioning groups’ adoption of the guidance is quite horrifying. There is a threefold variation in prescribing, so there are areas of the country where a lot of patients are being denied an intervention that has been shown to be beneficial compared to what was done before.

We have already alluded to another emerging area: the new biologics. On the face of it, they are very expensive, but they are often remarkably effective—they can revolutionise the management of some diseases. We have a budgetary problem here, because the NHS budgets are year-on-year, and the face-value cost of the new biologics is very high; but if you look at the whole lifetime cost of healthcare interventions then they come out much lower. Take the example alluded to, of Crohn’s disease, and consider the cost of someone having their bowel removed, who might then end up on total parenteral nutrition; it is not only the cost of that nutrition but the costs in all other domains in their life, and the lives of their family. In comparison, the new biologics can rapidly get this disease’s process under control and revolutionise things.

The proposal is to give the CQC the powers routinely to address the adherence to guidelines—that would be specified by the NHS mandate, so a national standard could be set—and introduce a reporting metric using current data sources as a starting point to establish a benchmark. I want to stress, as I know does my noble friend Lord Patel, that we are not advocating for guidelines to be mandatory—that would not be right, because each patient is different and individual—but we are asking for a system to be introduced that gives powers so that there can be scrutiny of whether the guidelines are being adopted, because their adoption would narrow the gap in inequalities. We both feel that we need to commit to address this in this important legislation, because it is a way of achieving tangible action to ensure equity in access to quality in healthcare.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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My Lords, I have added my name to the three amendments that the noble Baroness, Lady McIntosh of Pickering, has referred to. I was the first Minister for NICE, going back to 1999. At that time, we were confronted with a paradox which continues to this day, which is that, although the NHS is full of innovation and we have an incredibly strong life sciences sector and industry, the NHS is also very slow to adopt those innovations. NICE was developed to speed up the introduction of effective new medicines and devices. Right from the start, we had a problem with the NHS being reluctant to implement its recommendations and, within a few months of it starting, a regulation had to be put through which required it to implement them within 90 days. That has been slightly modified since, but none the less, it is still in being. The NHS has become very adept at finding ways to get round this through the various blocks that have been put in at CCG level—the noble Baroness, Lady Brinton, explained clearly the kind of blocks, devices and bureaucratic machinations that are put into place.

The result is that we continue to be very slow to introduce proven new technologies and medicines. NHS patients are very disadvantaged compared to patients in most countries. It then impacts on pharma and the devices industry—I think that pharma is more reluctant now to introduce medicines and develop R&D in this country as a result.

The Minister knows that there is an agreement—it is called VPAS at the moment—whereby NHS expenditure on drugs is capped and industry pays rebates if the cost goes over that cap. Given what I have always thought to be an imaginative agreement and given that industry is essentially underwriting some of those additional costs, surely there must be a better way to approach this which would allow the NHS to implement NICE recommendations enthusiastically, rather than essentially putting into place blocks.

I doubt that we are going to spend two and a half hours on this group of amendments, but these are just as important as the last group, because they go to the heart of whether NHS patients get access to the drugs, devices and technologies that they should. At the moment, they do not. I hope that the Minister might be prepared to take the amendment away. Legislation is the only way that we can see of leveraging the kind of change we need.

Baroness Fraser of Craigmaddie Portrait Baroness Fraser of Craigmaddie (Con)
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My Lords, I support Amendment 163 in the name of the noble Baroness, Lady Finlay, to which I was delighted to add my name.

Perhaps I may remind the Minister of his very first session at the Dispatch Box. He confirmed to your Lordships that the Government had full confidence in the processes at NICE. In a follow-up letter to me he wrote:

“The National Institute for Health and Care Excellence (NICE) is the independent body that develops authoritative, evidence-based guidance for the health and care system to drive best practice. NICE is one of the few organisations with a remit spanning the NHS, public health and social care, meaning it is well placed to provide a system-wide perspective and support Government priorities for the health and care system.”

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As noble Lords have outlined, and the Government have acknowledged, the process for publishing guidelines is authoritative, evidence-based and drives best practice. Why then would the Government not want to include a review of compliance with NICE guidelines to be stipulated in the mandate, which is all that Amendment 163 seeks?
I declare my interest as chief executive of Cerebral Palsy Scotland. I want to highlight the challenges faced by people with long-term conditions, particularly adults with cerebral palsy, who struggle to find co-ordinated, specialist services. The guidelines for adults with CP were published in January 2019. I can confirm that the process was indeed thorough and collaborative; Cerebral Palsy Scotland contributed as a registered stakeholder, even though NICE does not necessarily apply in Scotland. The process had wide cross-sector and specialty support. However, the guidelines are yet to be implemented.
In addition to the guideline, a year later, in January 2020, NICE published a quality standard on care and support for adults with cerebral palsy. This included a recommendation that adults with cerebral palsy be referred to a specialist multidisciplinary team. Adults with CP feel that they are second-class citizens. Their daily experience is of struggle to access any specialist services, in contrast to other lifelong conditions. For some reason, health services for people with CP are concentrated in paediatric services, and despite the fact that having CP does not in itself give you a reduced life expectancy, the NHS seems to believe that once you reach the magical age of 18, your cerebral palsy suddenly is not a problem any more.
The NICE guideline and quality standard both recognise the challenges that adults with CP face and that some people require access to specialist multidisciplinary teams, experienced in the management of neurological impairments, who can work to identify their needs, understand how they may change over time and refer on to specialist and local services as appropriate. Unfortunately, not enough of these services exist. The policy framework might be there, but we are doing absolutely nothing to ensure that it is implemented. People with cerebral palsy are asking, “What is the point of NICE?”
Since the Government clearly value the work of NICE, I urge the Minister to take the opportunity of these amendments to ensure that NICE guidelines are put into practice. Therefore, I look forward to the Government’s support for the amendments.
Lord Warner Portrait Lord Warner (CB)
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My Lords, I support all the amendments in this group, particularly Amendment 74, to which I have added my name. I was one of the successors to the noble Lord, Lord Hunt, as a Health Minister responsible for NICE. I pay tribute to his sterling work in establishing it. However, I encountered the same difficulties as he encountered with the NHS speedily taking up NICE recommendations and had to wrestle with this same problem.

I had a long and slightly exhausting chat with the chief executive and the chairman of NICE about what they could do to help the NHS implement their recommendations. We arrived at a concordat, and the NICE people went away and developed a rather helpful system for enabling the NHS to prepare for a NICE recommendation and to implement it. As far as I am aware, looking at the NICE website, it still has that system in place, so it is not as though NICE is simply putting its recommendations in the public arena and leaving the NHS to get on with it; it has done its level best to produce a way of helping the NHS to prepare to implement those recommendations.

What I do not understand is why we have not moved faster over time to recognise that more action needs to be taken with the laggards within the NHS to make this happen. I think that one method is captured in the amendment from the noble Baroness, Lady Finlay.

If NICE is so important and it is so important that the NHS implements its recommendations, that ought to figure in the regulator’s assessment of the performance of those NHS bodies. I can see no reason it should not, and I wonder whether the Minister could tell us a little more than I know—and more, I suspect, than the Committee knows—about the current position on the failures of NHS bodies to pursue NICE recommendations. Do the Government accept that the regulator of these bodies should take account of their ability and willingness to implement NICE recommendations? Perhaps the Minister could clarify some of those issues. If he cannot clarify them today, perhaps he could write to us.

Lord Stevens of Birmingham Portrait Lord Stevens of Birmingham (CB)
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My Lords, I had not intended to speak but, animated by the contributions of colleagues who, like me, were there at the conception of NICE, I thought I would offer a couple of contextual remarks to this group of amendments, supporting their underlying motivation, which is to ensure the spread of best practice as fast as possible across the National Health Service.

I was also motivated by the noble Baroness, Lady Watkins, who spoke earlier about the Crimean War, to recall that this is not a new problem. The world’s first controlled clinical trial took place in 1754 on board HMS “Salisbury”, when the Royal Navy was trying out the use of citric fruit—in lemons and limes—to combat scurvy. That experiment showed that scurvy could be tackled with lime juice, and it took the Navy 41 years to mandate its introduction more widely—fortunately, just in time for the Napoleonic Wars, which is why some argue that, contrary to Winston Churchill’s dictum that it was “rum, sodomy and the lash” that contributed to the Navy’s success, it was in fact lemon and lime juice.

The point is that this is not a new problem. We have been grappling with this but, despite that, we have seen the remarkably quick adoption of new clinical practices over the last two years during Covid, as new randomised control trials, following in the wake of the 1754 example, have shown the benefits of treatments such as dexamethasone. My point of context is that we need to be clear, if this group of amendments is to advance, about the terminology incorporated in the amendments. These will inevitably be, if they find their way into the Act, litigated against in the High Court and Court of Appeal.

In the drafting, there is reference to the marketing authorisations given by NICE, although I think it is the MHRA that provides marketing authorisations. There is a clear distinction to be made between the technology appraisals NICE undertakes and the development of guidelines. Although a number of noble Lords have referenced the importance of the guidelines, it is worth saying that a quick look at the NICE website reveals there are 1,591 guidelines, pieces of advice, quality standards and all the rest of it—most of which have not been subject to the full cost-effectiveness and affordability assessments that the gold standard technology appraisal performs. Before there could be a legal mandate for those guidelines, there would be some very significant methodological considerations for NICE. Without those, the risk is that mandating those guidelines would take resources away from other parts of needed care, such as mental health and community nursing—Cinderella services that have not been subject to those same processes.

We should also recognise that, vital though NICE is, the bigger contribution to the diffusion of best practice will probably be made in other ways. Certainly, reporting could help. Although one amendment makes the perfectly reasonable proposition of an annual report from integrated care boards on their adoption and uptake, that still feels a slightly 20th-century solution. If you go to Oxford University’s superb www.openprescribing.net, you can see your own GP practice and your own CCG’s prescribing patterns against the national norm, including, as the noble Baroness, Lady Finlay, said, for the DOACs, the anticoagulating medicines. Those technologies are already available, and the role that clinical pharmacists are now playing, including the thousands of new clinical pharmacists hired to work alongside GPs to improve their prescribing habits, is also likely to have an important influence.

Finally, there is this question of whether, just occasionally, conflicts of interest might arise on the part of prescribers or clinicians over the medicines or devices being used. The noble Baroness, Lady Cumberlege, has drawn attention to this in her important work, and that is perhaps something the House might return to at a later date.

Lord Lansley Portrait Lord Lansley (Con)
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My Lords, I want to intervene at not too much length. I welcome these amendments and am grateful to my noble friend Lady McIntosh of Pickering for bringing hers forward. It enables us to touch on a subject which those of us involved in the Medicines and Medical Devices Act will recognise. This is a short version of the debates we had then, but it gives us an opportunity to update a little on those and me an opportunity to ask my noble friend on the Front Bench a few questions arising from that. We are all grateful to the noble Lord, Lord Stevens of Birmingham, who clarified some of the terminology, which saves us going wrong. But I want to do a bit of clarification about some of the amendments as well.

The timing of this is terrific. We are discussing this today and NICE published the outcome of its methods review yesterday, so we can respond immediately. My starting point is to applaud NICE for having taken up and accepted the proposition that there should be a modifier in relation to its appraisals and assessments on severe diseases. We can argue about the precise detail, but it has taken that up.

Secondly, randomised control trials are terribly important but they are not the whole story. NICE has rightly accepted it should look at more real-world evidence and that, too, we can welcome, but it leads me directly to a question. Part of that real-world evidence, and one of the reasons it is not going directly to NICE, though NICE can use it, is the innovative medicines fund. NHS England published its proposal for the innovative medicines fund in July and said that it would consult on it, but it has not done so yet. My first question to my noble friend is therefore: when will NICE and NHS England consult on the innovative medicines fund?

The third point on NICE’s methods review is that it will take account of the wider impacts of the treatments it appraises. That is terribly important, especially given the present opportunities for personalised medicines and gene-based treatments, when one looks at how these can impact substantially on people’s lives from a relatively early stage and the contributions they can make to society and the economy. That is all good news.

The press release from NICE, however, did not draw specific attention to where it had proceeded in a way that its stakeholders did not support. It has maintained a reference-case discount rate of 3.5%, although NICE itself admitted that there was evidence that a lower discount rate would give significant benefits. It said that there would be wider implications for policy and fiscal complexities and interdependencies if it were to do this, which I think means “The Treasury said no”. We need to think very hard about whether a discount rate as high as 3.5% is appropriate for NICE’s application of its appraisals. I ask my noble friend, though he will not be able to give me the answer to this: who is telling NICE that it cannot adopt what it regards as the evidence-based discount rate for the appraisals it undertakes?

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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My Lords, on that basis, I have seen it said elsewhere that NICE has referred to its “national stakeholders.” I can only assume that they are Her Majesty’s Government.

15:30
Lord Lansley Portrait Lord Lansley (Con)
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Given NICE’s remit, it might be the Welsh Government as well, but the noble Lord may well be correct. We are all surmising, but I think we are probably not too far off the mark. It gave us an opportunity to respond to that.

So far as the amendments are concerned, the proposition that approved treatments should be adopted by the NHS is a proper one. What, of course, has not been brought into the debate is that the world has moved on, even in recent years. NHS England has taken what I think is an appropriately substantial interest in the approval of treatments, the uptake of treatments and their adoption by the NHS. When it started out, people said, “Oh dear, NICE is going to approve a treatment and then NHS England is going to tell people not to use it because it is going to cost them a lot of money.” In fact, we all agreed in the debates on the Medicines and Medical Devices Bill that there was everything to be said for NHS England, NICE and the pharmaceutical industry working together early, proactively, for the planned introduction of new medicines, including taking account of their cost. That is an NHS England role, not a NICE role. NICE does gold standard appraisals, but it does not take responsibility for the fiscal consequences of those appraisals, so all these things need to be put together. The pricing decision should not be something that comes out at the end.

One of the things I have been going on about for a decade or more—actually, 15 years—is that we should not end up in a position where there is an effective medicine that is properly approved by the MHRA and authorised for use; clinicians can use it and they know it is the right thing for their patient; but, because of the absence of an appropriate pricing decision, the answer to the patient is “no”. We should not arrive at that position. With NHS England and NICE working together with the pharmaceutical industry, we stand a better chance of the answer not being “no” in those circumstances as long as the resources are, indeed, available.

I do not think, on the face of it, that we should be legislating to change the medicines mandate from where it is now. My noble friend Lady McIntosh, in introducing her Amendment 54, referred to devices. The amendment does not refer to devices, but it should refer to devices. My further question to my noble friend the Minister is: when are we going to get a proper funding mandate on devices, which I think I was promised during our deliberations on the Medicines and Medical Devices Bill but we have not yet formally had it? Some good work has been done on some devices each year, but I am hoping that we will get a proper funding mandate on devices.

On formularies, my noble friend did not actually refer to the British National Formulary. Of course, NICE has had responsibility for the BNF for about seven or eight years, and even if it is not a legislative method, there is everything to be said for the NHS and clinicians looking to the BNF and NICE’s role in the BNF.

My noble friend and the noble Baroness, Lady Finlay of Llandaff, were quite right about the adoption of NICE guidance and standards on the use of them in clinical circumstances. However, via the regulator—the CQC—we already have a process by which the CQC looks at quality standards produced by NICE and incorporates what NICE itself isolates as the essential aspects of the standards that, in order to provide safe and effective care, must be reflected in the practice of a health provider.

My question to the noble Baroness, Lady Finlay of Llandaff, is: if she thinks that is not sufficient, how much further should the CQC actually go in adopting quality standards? At the moment, it has compromised and said, “We will take the essential steps, because those are a few, generally about five, specific things that we can look at to see whether they are being done, in which case, okay; or are they not being done, in which case it clearly needs improvement, or may not be meeting the standard.”

Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (CB)
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The noble Lord asked me a question to which I feel obliged to try to respond, but I really want to answer the question with a question: does the CQC have enough powers to benchmark as it would want to do, and to publish those benchmarks? I hear the concerns of my noble friend Lord Stevens in relation to fear of litigation and how that is an objection to the amendments, but I am also quite worried that that is potentially a way of avoiding adopting the guidelines themselves, thereby inhibiting a change in practice and a move to best practice.

While there are sources of information that those who are very health-literate, IT-literate, and so on, can access to establish their own benchmarks about what is happening, many people, particularly those in the most deprived areas of the UK, do not have any knowledge of even where to begin looking for these things. That was the motivation behind the amendment: to try to make sure that in the poorest and most deprived areas, people would still be able to access this. That would drive up standards gently but would not create a mandated requirement that a NICE guideline is adopted, for the reasons I outlined previously.

Lord Lansley Portrait Lord Lansley (Con)
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I can see that my noble friend is eager to come in but I will conclude by answering the noble Baroness. I am not an expert, but I think the CQC has the powers—since it presently does it—to take account of the NICE quality standards and to incorporate specific indicators from those quality standards as part of its regulatory review. If the CQC was to attempt to introduce large-scale application of the guidance as a question in a regulatory review, I do not think the issue would be whether it had the power to do it, but whether it would make the headline conclusions it reaches in relation to healthcare providers increasingly difficult to interpret. At the moment, they are relatively straightforward to interpret. There is a small number of specific indicators in relation to services provided and they are either doing them or they are not. With guidance, it becomes much more complicated and many more value judgments have to be applied about the circumstances in which they are or are not complying. So, there is a real difficulty in going far beyond where we are now.

I will listen with great care when my noble friend the Minister responds to the questions I have asked.

Lord Mackay of Clashfern Portrait Lord Mackay of Clashfern (Con)
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My Lords, I support these amendments, subject to the economic difficulties. As I listened to the local Baroness, Lady Brinton, I wondered whether the amendments might be strengthened by some reference to the timescale in which they must be implemented. That might have some beneficial effect for many people who are waiting.

Baroness Merron Portrait Baroness Merron (Lab)
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My Lords, I welcome these amendments, which relate to the National Institute for Clinical Excellence—NICE. I thank all noble Lords for tabling these amendments and for their contributions today, which certainly expanded my knowledge of the subject, as I am sure they did across the Committee. The debate has shown that there is a need for change, as I am sure the Minister has heard, to better equip the National Health Service to provide the patient what they need when they need it.

The noble Baroness, Lady McIntosh, spoke clearly about hurdles that must be overcome, whether they are bureaucratic, process, budgetary or administrative. All these hurdles get in the way of the end result: meeting the needs of patients. That, I believe, is what this debate is focused on.

NICE is well recognised as a partner to our NHS. Its objective approach and evidence-based analysis rightly gain respect. However, as my noble friend Lord Hunt said—he can now be called the first Minister for NICE—although the National Health Service is full of innovation, it is also slow to pick up on it; that point was emphasised by the noble Lord, Lord Warner. That begs the question: what kind of partner should NICE be to the NHS? Is it going to be an enabling partner, or will it frustrate at times? Of course, we all want to see NICE in that fully enabling capacity.

However, beyond what NICE approves in terms of treatments, pathways or otherwise, there must be procedures for it to implement and connect effectively to patients’ needs. We know that no system or set of procedures will ever be perfect; we have heard that today. Understandably, therefore, as the Minister has heard, pressure and a will for change—in a positive sense—is contained in these amendments. The noble Baroness, Lady Finlay, spoke about how important it is to have evidence-based healthcare and to have known guidelines and see them complied with, as is right and proper.

There are cautionary considerations to note in this debate; we have heard some of them. One is whether it is wise to put what in some cases appear to be operational requirements in the Bill. I am sure the Minister will address this. The new world is certainly paying a lot of attention to flexibilities. We want to make sure that anything contained in the Bill does not inadvertently work in another direction.

My understanding is that NICE guidance is mandated, in effect, with the guidelines somewhat less so. Amendment 54 contains a proposal to reinforce the intention that, once a treatment has been properly assessed and recommended, all patients should be able to gain the benefit. We know, and we have heard in this debate, that this does not always happen, and that clinical commissioning groups follow different policies. However, in considering the amendment at face value, it is important that we consider what impact this latitude might have. I am sure we are all keen not to accidentally invoke some kind of fallout, such as taking away all leeway from commissioners. At present, they can depart if they can set out an objective case for doing so; for example, with requests for certain drugs and therapies through individual funding requests.

Similarly, it would be unfair if a patient could cross an integrated care board border and receive a treatment that was not available in another ICB area. That would seem inadvertently to achieve what we do not want to achieve: the worst of a postcode lottery. Equally, if we have locally based approaches, the reality is that some localities will differ in their priorities and services. I know that we will return to this topic many times in our consideration of the Bill because the care that patients receive should certainly be equitable and fair and not based on where they live.

15:45
At this point I refer to the contribution of the noble Lord, Lord Stevens, who reminded your Lordships’ Committee that what we are dealing with is not a new problem but was considered over the matter of lime juice many years ago. It is right that the noble Lord, Lord Stevens, raised questions about the terminology in the amendments. If they are to advance, I am sure that your Lordships’ House would want to look at how the terminology is set out and what the wider impact of the amendments would be.
On Amendment 74, the intention for information to be promoted is sensible, as is a process to report on usage of online information sources. Again, I expect—I hope—that the Minister will at least find favour with this amendment, but he may question whether it is straying outside the legislative territory. That is a matter we should also consider about Amendment 97.
Amendment 97 is about a timeline for the updating of the systems of integrated care boards and healthcare providers to make NICE-approved medicines or devices available. I certainly support the intention here. However, if this is a direction to take, we need an examination as to whether a deadline of 28 days would actually provide for the intention of this amendment, and whether this is something of concern for primary legislation.
I had assumed when looking at Amendment 163 that the inspections referred to were by the Care Quality Commission. I am grateful to the noble Baroness, Lady Finlay, for confirming that. It makes sense for the CQC to look at many aspects of compliance and the amendment would ensure that focus is directed at ensuring equitable access to technologies and treatment.
In closing, I hope that the Minister will have felt the mood of this debate, which is supportive of NICE in all its excellence but also in a wish to see perhaps a nimbler and more responsive partner to the NHS so that we can see benefits for patients on a fair and equitable basis.
Lord Kamall Portrait Lord Kamall (Con)
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I thank all noble Lords who have spoken in this debate, both to the amendments and in making wider points about NICE. I take this opportunity to pay tribute to Gillian Leng, who recently stepped down as chief executive of NICE after a number of years.

I turn to Amendment 54. I am sure noble Lords will appreciate that we all want NHS patients to benefit from proven and cost-effective treatment; no one would want otherwise. That is why we see NICE as playing a vital role in supporting patient access to new treatments. I have heard the criticisms from previous Health Ministers, who were responsible for NICE. I sometimes feel in debates such as this, when I am with former Health Ministers, that it is like a special edition of “Doctor Who”, with previous regenerations. I hope we do not create a fracture in the space-time continuum. NICE recommends the vast majority of new medicines for use by the NHS. In fact, in 2020-21 100% of new medicines were recommended by NICE and many thousands of NHS patients have benefited from access to some of the most cost-effective treatments as the result of its work.

Another interesting thing is that when a decision is made and it is difficult to access medicines, patients will get frustrated—rightly so, given that they know it is available or maybe has been recommended. At the same time, on the global stage NICE has a well-earned reputation. It is one of my three priorities; I have mentioned technology, the second is life sciences and the third is international health diplomacy—how we use our position on health as part of UK soft power. One of the institutions people across the world look to and want to learn from is NICE. NICE is looking to be at the centre of a number of global networks on the issues where it has a reputation.

NHS England and clinical commissioning groups are already under a statutory obligation, under Regulations 7 and 8 of the snappily titled National Institute for Health and Care Excellence (Constitution and Functions) and the Health and Social Care Information Centre (Functions) Regulations 2013, to fund any treatment recommended by NICE through its technology appraisal or highly specialised technologies programmes, usually within three months of guidance being issued. As the noble Lord, Lord Stevens, mentioned, NICE also operates a separate medical technologies programme, which supports faster and more consistent adoption of medical devices, diagnostics and digital products.

I assure noble Lords that these funding requirements will apply to the ICBs once established. Therefore, we do not see the amendment as necessary at this stage for clinicians to prescribe NICE-recommended treatments for their patients. I also thank the noble Baroness, Lady Merron, for pointing out some of the unintended consequences and scope of such amendments. I remind your Lordships that, since April 2021, NHS England’s medtech funding mandate has supported faster access to some of these innovative technologies recommended by NICE.

I know that I am going to try to reassure noble Lords on a number of things but, on Amendment 74, I hope they note that the funding requirement on ICBs for NICE-recommended treatments goes even further than the requirement to promote what the noble Lords propose in the first part of the amendment. This will ensure that clinicians will continue to be able to prescribe NICE-recommended treatments for their patients.

The second part of the amendment would replicate existing arrangements that are in place to measure uptake and use of NICE-recommended medicines. Since 2013, NHS Digital has published an innovation scorecard that reports uptake of medicines that NICE has recommended in the last five years at a national and local level. Data on the uptake of NICE-recommended medical devices is not currently reported in the innovation scorecard as it has been more complicated to collect. However, I assure noble Lords that work is under way, by both NHS Digital and the Accelerated Access Collaborative, to address this gap. The Government consider that it is more appropriate and proportionate that this information is collected and published by a single national body using an agreed methodology, not by multiple organisations that will each have different ways of measuring and presenting the data.

On Amendment 97, I can tell noble Lords that NICE works closely with the MHRA—I thank the noble Lord, Lord Stevens, for pointing out the distinction —which issues marketing authorisations to ensure that licensing and appraisal timescales are aligned wherever possible. The NHS in England usually funds any treatment recommended through NICE’s programmes within three months of positive final guidance. We believe that three months is a realistic framework for providers to prepare for and introduce a new technology, and I hope I can assure the Committee that NICE and NHS England already work closely to facilitate the adoption of recommended technologies as quickly as possible.

As the noble Lord, Lord Stevens, again alluded to, there is a high level of transparency in the operation of local formularies. Formularies have their own public websites, which list the selected medicines and associated guidance, and area prescribing committees publish the minutes of meetings, which identify the medicines added or removed from formularies. We believe that there is therefore no need to publish an annual list.

Although healthcare providers are encouraged to use local formularies when prescribing, they are not restricted to them. The decision as to what to prescribe lies with the prescriber, who will act in the best interests of the patient. Indeed, some of the correspondence I get as a Minister for Health often refers to when people cannot get access to a medicine that is not recommended, but the clinician has the authority to suggest that that medicine can be available to the local area.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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I am sure the Minister is right about how this system is meant to work, but there are far too many examples of clinicians seeking to prescribe medicines that have gone through the technology appraisal and then finding that CCGs have set up the various devices that the noble Baroness, Lady Brinton, mentioned to delay or stop it. Does he recognise that CCGs are engaged in a process of seeking to delay implementation for as long as possible? Will this be accepted under ICBs or will it be tackled?

Lord Kamall Portrait Lord Kamall (Con)
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I thank the noble Lord, Lord Hunt, and the noble Baroness, Lady Brinton, for raising this issue. I should be honest; I was not aware of the suggestion that CCGs often delay and whether that situation will be transferred to ICBs. I ask noble Lords whether I can look into that situation further to understand it more. I simply say that I was not under that impression.

Lord Warner Portrait Lord Warner (CB)
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When the Minister is looking into that, will he also look at the issue of the usual suspects? The problem that the noble Lord, Lord Hunt, probably encountered—I certainly encountered it—was that many of these areas that are slow to implement NICE recommendations are the same areas where overall performance is pretty poor. There is an issue here about whether we can clearly identify the laggards and take action with them, rather than have a generalised look at the performance of particular areas.

Lord Kamall Portrait Lord Kamall (Con)
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Perhaps I may suggest, following the interventions of both noble Lords and their experience of being Health Ministers and of NICE, arranging a follow-up meeting with them to discuss this matter in more detail so that I can understand the situation more. As I am sure noble Lords will appreciate, I have been in this job for only four months and am still learning an awful lot. In fact, I am learning far more in this Committee than I have in my first four months. That shows that sometimes there is no substitute for learning on the job.

NICE has a suite of more than 300 guidelines and, as the noble Lord, Lord Stevens, said, more than about 1,900 medicines, spanning the whole of health and social care. It makes dozens of recommendations that can be complicated. We do not think it proportionate or feasible to require compliance with NICE guidelines but, given what I have just mentioned, I should like to consult previous Health Ministers with experience in this area and perhaps have further discussions to see what is relevant in the future.

I shall end with the CQC reviews of ICSs. We will look more broadly at the entire system of how the ICS areas are performing. A requirement for the CQC to specifically consider compliance with NICE guidelines as part of these reviews risks adding a considerable burden to this process. I can, however, assure the Committee that the Government expect the healthcare system to take NICE’s recommendations fully into account, subject to what noble Lords have told me about the performance of some CCGs. I am also aware that NICE works closely with system partners to support implementation where possible. It is probably best henceforth for me to have those conversations with the two noble Lords and any others with experience of this matter. There are more than two former Health Ministers in this House and we should have those conversations.

Let me see if I can answer some of the specific questions. As regards VPS—how do I put this in the most diplomatic way?—I have been asked to look at that issue. The industry has complained, for example, because we also have therapeutic tendering at the same time as expecting this. I am grateful to my right honourable friend the Secretary of State for asking me to look into this issue in further detail. I have asked what would happen, for example, when some of the life sciences companies ask whether it makes the UK less attractive in some ways. I am assured that it does not but I am looking into this issue as part of the life sciences aspect of my portfolio.

I think that I have covered all the questions but all that I ask at the moment is to let me have further conversations. That is probably best. In that spirit, I ask noble Lords to consider withdrawing or not moving their amendments.

Baroness McIntosh of Pickering Portrait Baroness McIntosh of Pickering (Con)
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My Lords, I am grateful to all who have contributed to this debate and for the number of issues that have been raised.

At the outset, the noble Baroness, Lady Brinton, highlighted and a number of us focused on the hurdles—as the noble Baroness, Lady Merron, described them—to be overcome. However, there has been a lot of focus on the problems of the budgetary challenge. It would be incumbent on my noble friend the Minister to meet not just with the two noble Lords he highlighted but the drafters of the amendments: myself, the noble Baroness, Lady Finlay, the noble Lords, Lord Hunt and Lord Warner, and the noble Lord, Lord Patel, who sat so patiently through the whole of today’s proceedings and had to leave before this discussion was reached. As he had such success in the mental health meeting, I hope that we replicate that and take up a number of the issues raised here.

16:00
I was very taken by what the noble and learned Lord, Lord Mackay, mentioned about strengthening the amendments by reference to timescales. I think that is very important indeed.
I am disappointed that my noble friend was not aware of, and has not fully answered the questions on, budgetary challenges, how to get on to and off the famous formularies and the process to be completed at that stage. Rather than pursue this now—I do not think we can take it any further at this stage—I hope my noble friend will use his good offices, so we can meet around the table on Zoom and take this further before Report. With those few remarks, I beg leave to withdraw the amendment at this stage.
Amendment 54 withdrawn.
Clause 16 agreed.
Clause 17 agreed.
Schedule 3: Conferral of primary care functions on integrated care boards etc
Amendments 55 and 56 not moved.
Baroness Garden of Frognal Portrait The Deputy Chairman of Committees (Baroness Garden of Frognal) (LD)
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I call the noble Lord, Lord Low of Dalston, to move Amendment 56A—or the noble Baroness, Lady Hollins. Is the noble Baroness, Lady Finlay, moving Amendment 56A?

Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (CB)
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My Lords, perhaps I might put in a slight plea to the Committee on behalf of the noble Lord, Lord Low. He has sat patiently through this debate for a long time. He was expecting that the other amendment would be moved and, on realising that it was not, has made every attempt to return to his place as fast as possible.

Amendment 56A

Moved by
56A: Schedule 3, page 151, line 16, at end insert—
“116C Primary ophthalmic services for people with learning disabilitiesNHS England must make arrangements for the assessment of the need for primary ophthalmic services by people with learning disabilities, including access to sight tests, and ensure primary ophthalmic services are commissioned to meet those needs.”Member’s explanatory statement
Under Schedule 3 of the Bill, NHS England retains its powers to make arrangements for the provision of primary ophthalmic services itself or direct Integrated Care Boards for such provision. This seeks to improve eye care for people with learning disabilities.
Lord Low of Dalston Portrait Lord Low of Dalston (CB)
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Right on cue, my Lords, I am rising to move Amendment 56A, which seeks to improve eye care for people with learning difficulties, as they are much more likely to have a sight problem but much less likely to access primary ophthalmic services, including access to NHS sight tests. The Bill offers an opportunity to seek improvements to an often-overlooked area of primary care: namely, primary eye care or ophthalmic care. Schedule 3 to the Bill contains amendments to the National Health Service Act 2006, regarding primary ophthalmic services: that is to say, commissioning of NHS sight tests and more.

Primary eye care is vital for the health of the nation. We know that half of sight loss could be prevented but is not because people do not go for sight tests as frequently and regularly as they need to. Many people are living with sights problems that could be picked up and treated quickly if people were going for regular sight tests. We also know that our hospital eye clinics are overwhelmed and are one of the busiest outpatient specialities. There were delays to treatment prior to the pandemic, but now these have been greatly exacerbated as a result of the pandemic. Work is under way to look at how primary eye care can add capacity to the system through an NHS England eye care transformation programme. Just like their colleagues in general practice, dentistry and pharmacy, there are optometrists and dispensing opticians working in primary care who have the clinical training to provide early and ongoing support to patients but do not have the chance.

Supporting primary eyecare makes sense in very many ways. However, we know that, as with other areas of healthcare, there are inequalities in primary eyecare. Some parts of the population are not accessing regular sight tests, even if they might be eligible to have them free under the NHS. In 2018, the All Party Parliamentary Group on Eye Health and Visual Impairment explored this issue, particularly for people with learning disabilities and people who are homeless. This work was supported by the APPG on learning disabilities. I know that the noble Baroness, Lady Hollins, supports this amendment, but she has not been able to stay to join in the debate.

The APPGs on eye health and visual impairment and on learning disabilities took evidence from the charity SeeAbility. People with learning disabilities are much more likely to have a sight problem but much less likely to access NHS sight tests. Vision problems in people with severe learning disabilities are so high that researchers have said that this population should be considered visually impaired unless proven otherwise. SeeAbility’s work in special schools found that more than four in 10 children had never had a sight test. In other studies, it was found that half of adults with learning disabilities had not had a sight test in all the recommended period. SeeAbility found that many children were attending hospital eye clinics for routine eye tests.

A recommendation that the APPGs made in 2018 that there should be a sight-testing and glasses-dispensing service in all special schools is now being taken forward by NHS England, which is excellent news. It will reach around 130,000 children and help address and prevent avoidable sight loss, as well as reducing the need to use hospital eye clinics. Once the proof of concept phase is completed in 2023, it is understood that a new special schools scheme will need to be legislated for to provide for an additional service to be added to the National Health Service ophthalmic services contract through an amendment to regulations. It is hoped that at the appropriate time the Secretary of State for Health and Social Care will ensure that the special schools eyecare service has the legislative authority that it needs. The commitment by NHS England to this service is commendable, and it must continue with that commitment as these children deserve an equal right to sight. This is something we will all want to follow closely.

However, the APPGs went further in 2018 and also recommended that there is a continuing need to improve eyecare outside special schools for people with learning disabilities. There are an estimated 1 million people with learning disabilities in England. The APPGs noted that the tariff for primary eyecare acts as a disincentive to carry out sight tests within optical practices when seeing adults or children with more severe or profound learning disabilities, despite this group being at most risk of having a sight problem. This compares poorly with other areas of primary care, such as the GP annual health check for people with learning disabilities, or special needs dentistry. The local optical committee support unit’s learning disability eyecare pathway, which is endorsed by SeeAbility and Mencap, can be commissioned by clinical commissioning groups to provide more targeted, longer and adjusted optical appointments for people with moderate to severe learning disabilities. However, it has been commissioned in only a few areas in England and it really needs to be countrywide.

Eligibility for NHS sight tests under secondary legislation has also missed out people with learning disabilities from the exclusive list of eligible groups—that is, children, older adults, people in receipt of certain means-tested benefits and high-risk groups such as those with a family history of glaucoma or diabetes. This places the burden on the person with a learning disability to work out whether they are eligible in other ways. For that reason, no data is collected on how many people with learning disabilities access NHS sight tests in the community. For the purposes of this debate, this is a straightforward amendment that bolsters NHS England’s existing commitment to the special school eye care service across England’s special schools. It reminds us that all people with learning disabilities are in need of particular attention when it comes to eye care.

Schedule 3 to the Bill amends the section on primary ophthalmic services in the National Health Service Act 2006 by introducing general powers to make arrangements, in Section 116A, and to publish general information, in Section 116B. The amendment would supplement that with a new Section 116C, which would simply oblige NHS England to make an assessment of the needs of those with learning disabilities for primary ophthalmic services, including access to NHS sight tests, and ensure that services were commissioned to meet those needs.

The amendment’s national focus is needed because the local discretionary approach to introducing the aforementioned LOCSU learning disability eye care pathway by clinical commissioning groups has not worked. It exists in only six areas of the country when it really needs to be available across the country as a whole. The amendment would allow for the possibility of extending eligibility for NHS sight tests to all people with learning disabilities once the evidence was reviewed.

The Bill clearly envisages that the Secretary of State and NHS England can work together and both can exercise powers to improve primary ophthalmic services, with NHS England having a clear national oversight role. The amendment is supported by three existing NHS England objectives into the bargain: first, the programme of work to address the health inequalities of people with learning disabilities; secondly, the programme of work to improve community eye care and reduce the unnecessary use of hospital eye clinics; and, thirdly, the commendable work in primary optometry of the special school eye care service.

There may be those who would say that no population needs to be explicitly prescribed for in primary legislation and that matters can be left to the discretion of secondary legislation and directives. However, the health inequalities experienced by people with learning disabilities justify putting them in the Bill. People are dying of avoidable health issues at least two decades before their peers. We cannot have a situation where people are living without good sight and even going avoidably blind because NHS services overlook their needs. I beg to move.

16:15
Lord Crisp Portrait Lord Crisp (CB)
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My Lords, I shall speak to Amendment 112 and 17 others that are in my name. I am very grateful to the three noble Lords who have added their names to these amendments. These are terribly straightforward; it is the same point in a number of different contexts. As we put it in the explanatory statement, the amendments

“would require Integrated Care Boards to work with the four primary care services … when preparing and revising their five year plans, in the same way they are required to work with NHS trusts and NHS foundation trusts.”

It is a very simple, straightforward point and a matter of proportion. It is appropriate to give a similar level of influence and respect to primary care as we give to acute services.

I will mention that there are some practical difficulties —obviously, there are many more primary care services than NHS trusts—and come back to that at the end. If it is not obvious enough that we should do this, I want to pull out three points about why this is so important; I expect that others will mention other points. I am talking here about GP surgeries, as opposed to the other three services, although I totally endorse everything that my noble friend Lord Low just said about ophthalmology services.

First, if it is true, as Members across this Committee have argued for however many sessions it has been, that a large part of the future is community-based, then alongside public-health figures and their clinical work, it is primary care—nurses and others, not just doctors—who will be the essential guides and specialists to help all those place-based, arts, non-clinical and inequalities-busting activities that we have talked about for a considerable part of this debate. They have that key role.

Secondly, I was dismayed by the way the Government criticised GPs recently. Primary care is under enormous pressure and I do not understand why the Government chose to do that. A large part of the problem is that there are simply not enough primary care specialists of all kinds, including GPs, and I do not think any progress has been made towards the promised 5,000 extra GPs. Primary care is under enormous pressure throughout the country and, while I greatly welcome the focus in the Bill and in government policy on waiting lists, I believe that it will be here in primary care that we will see the real battle for the future of the NHS. It is really important that we give those who are doing so much in our services the respect, influence and prominence that they deserve.

My third and perhaps, in some ways, biggest point is that primary care is changing very fast in all kinds of ways; it is an area where there is enormous innovation. As the Royal College of GPs itself says about the role of the GP, there is a place for one-off consultations—a place for the GP on the railway station, or wherever, where you can have a very quick consultation—but there is an even bigger place for the sort of continuing role based on the relationships between a GP and their patient that we are familiar with traditionally and which I thought the noble Baroness, Lady Cumberlege, described so well in describing her father as knowing his patients “inside and out”. That relationship, however, is not just with individual patients; it is a relationship with the community. Many GPs have taken that role, but more are taking on the role of a relationship with their community.

Some GPs are rewriting this role so that it is more of a public health role in some ways. There is Sir Sam Everington at Bromley by Bow, whom the noble Lord, Lord Mawson, mentioned in his great, eloquent speech on our last occasion in Committee, and others such as Dr Gillian Orrow, who is bringing together groups in the community and leading Growing Health Together in Horley. Others are taking on wider roles, such as Dr Laura Marshall-Andrews in Brighton. People are thinking about their role in a very different and important way and I apologise for giving three southern examples—they happen to be ones I know very well, but I know that this sort of innovation is going on around the country. More generally, of course, we can think about social prescribing and the way that that is changing primary care.

Here is the really big point: these doctors, nurses and others in primary care are acting as clinicians, of course, but they are also agents of change. They are the animateurs, the facilitators enabling local health-creating activity. For that reason, we need to have people like them fully engaged in the planning and all the mechanisms of the new NHS structures so that they can have the influence needed for the future.

I come back to the practical note I made at the beginning. Of course it will be difficult to engage primary care appropriately in every way and there might not be the same structure and arrangements in every part of the country, but it is really important that we get these primary care inputs into the five-year plans, their monitoring, planning and discussion so that they can really influence what will happen in the future. I understand that the Royal College of GPs is in discussion with the Department of Health. I urge the Minister to encourage his officials to find a way to make this obvious thing, which needs doing, work. It is vital that we do not disfranchise a key and currently quite largely demoralised sector or, as importantly, lose their valuable contribution.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
- Hansard - - - Excerpts

My Lords, I have Amendments 117 and 218 in this group. I have also put my name to the series of amendments put forward by the noble Lord, Lord Crisp, but I start by endorsing what the noble Lord, Lord Low, had to say. I hope the Government will come back sympathetically in relation to that.

My Amendment 117 would ensure that primary care professions would have mandated roles within integrated care partnerships, with members appointed by each of the four practitioner committees: the local medical, dental, pharmaceutical and optical committees. Secondly —and this is very consistent with the amendments from the noble Lord, Lord Crisp—this would ensure that, in preparing their annual strategic forward plan, the integrated care board and its partner trusts and NHS foundation trusts would need to consult the relevant primary care local representative committees and publish an explanation of how they took account of those views when publishing their plan.

I have the same arguments as the noble Lord, Lord Crisp, and I will not repeat them because he put them so well. History has shown that, even when clinical commissioning groups were nominally under the control of GPs, they often found it very difficult to get the rest of the system to listen to their issues and concerns. I agree with the noble Lord that there is now so much pressure on primary care that there is a great risk that they will be ignored in the work of the ICBs in particular. That would be a great pity. It is not just GPs, but the other parts of the primary care world. The noble Lord, Lord Low, already referred to ophthalmologists and opticians, but there is also this conundrum about the ability of pharmacists to take some of the load off the system but there is also often the inability of the local NHS to talk to them and embrace them sufficiently.

I hope the Minister will be sympathetic. If he says that he is not willing to tell ICBs that they must embrace representatives of the local committees then there is now a clear conflict. He is saying that it is up to the local ICBs to decide, but it has become abundantly clear that NHS England is giving out very heavy-handed guidance about who should be on ICBs. I would make this point to him: you cannot have it both ways. Either you leave it up to ICBs and withdraw this guidance, or Parliament has a role and a right to determine the governance arrangements. The action of NHS England in being so heavy-handed, such as saying that local councillors cannot serve on ICBs, means that the argument he put forward really does not stand up any more.

I move to my Amendment 218. On this one I must remind the House of my membership of the board of the GMC. The noble Lord, Lord Crisp, talked about the crisis in workforce issues generally, which I am not sure we are going to get on to today now. In relation to GPs, it is very apparent that not only do we have a chronic shortage but there is a grossly inadequate distribution of GPs throughout the country. Recent data, published by NHS England in November, shows that the primary care network covering an area in Gloucestershire described as 4PCC and comprising Cadbury Heath, Close Farm, Hanham and Kingswood had an average list of 1,138 patients per full-time equivalent GP. There are some others with similar figures. At the other end of the scale, Shore Medical primary care network in Dorset had an average list of 7,317 patients per full-time equivalent GP. York Priory Medical Group PCN had an average list of 7,154 patients per full-time GP and the Marsh Group PCN in Kent had an average list of 7,040 per full-time equivalent GP. These are huge disparities and there are many other areas that have average lists of under 1,600 and plenty with averages of more than 6,000.

The situation is really reminiscent of the situation before the start of the NHS. That is why in 1948 the Medical Practice Committee for England and Wales started work. It was charged with ensuring equitable distribution and, to a large extent, I believe it achieved its objectives. It was abolished in 2001 and I had better confess to the House that, I am afraid, I took through the legislation abolishing it. However, we were at the start of a massive expansion in the workforce at that time and felt that at that point the kind of bureaucratic way in which the MPC worked probably was no long fit for purpose.

We have a real problem here and confirmation of the dire situation was provided recently in research by the University of Cambridge’s department of primary care. A team including Dr Rebecca Fisher found that the significant GP workforce inequalities I have talked about are increasing and that workforce shortages disproportionately affect deprived areas. If you look at the situation in deprived areas, practices often have lower CQC scores, lower quality and outcome framework performances and lower patient satisfaction scores. Patients in those areas often have shorter GP consultations despite the fact that they have more complex health needs.

General practice is paid according to how many patients they have, with an adjustment made for the workload associated with those patients. Since 2004, the global sum allocation formula, known as the Carr-Hill formula, has been used to make that adjustment. However, Fisher argues that the consultation length is a flawed proxy for need and that the formula has long been widely acknowledged to be incapable of accurately weighing needs associated with socioeconomic deprivation. In 2020, after accounting for need, practices serving deprived areas received about 7% less funding per patient than those in non-deprived areas.

There is also the targeted enhanced recruitment scheme. This offers trainee GPs a one-off payment of £20,000 when joining a practice in an area that had long-standing difficulty in getting more doctors. However, this has not made a significant difference and clearly is not the answer to this enormous problem.

In the amendment—and I am very glad to have the support of the noble Lord, Lord Warner, and the noble Baroness—I have proposed the creation of

“the General Medical Practitioners Equitable Distribution Board”

as a first step. I envisage the board being invested with discretionary powers of negative direction, as was the MPC. It would consider applications from primary care networks, and they would be expected only from adequately doctored, or more than adequately doctored, PCNs. It would be a way of intervening in the market and making it more difficult to appoint GPs in those areas that are already very well supplied with doctors.

I accept that this is not the only approach, but it is an approach that has worked in the past. Frankly, I do not think that we can carry on without some major intervention to try to spread the load, because it is clear that all the odds are stacked against you if you are in an area of high deprivation where there are many more patients per GP. You get burnout among the professions and things become very difficult indeed. It looks as though financial incentives are not the answer. Clearly, we need to get more GPs into those areas to lessen the load, and then improve the quality and outcomes. I hope the Minister will be prepared to take this back and give it some consideration.

16:30
Baroness Uddin Portrait Baroness Uddin (Non-Afl)
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My Lords, I hesitate to rise. I had not originally intended to participate in this debate, but I feel obliged to speak and make some general points in support of the noble Lord, Lord Low, and his powerful and compelling arguments for his amendments. I declare an interest: the House will be well aware that my son, who is 43 years old, has a learning disability and is autistic, so I have some experience of the arguments spoken about by the noble Lord. I have also been a member of the All-Party Parliamentary Group for Disability for more than a decade, and I know of the fantastic work that SeeAbility has undertaken for its membership for many years.

I want to say something, because this group of adults has suffered dreadfully over the past two years, particularly during lockdown. They do not have the privilege of being at school or in early college education and being looked after by the system. I hope the Minister and the whole NHS system will agree with the suggestions made by the noble Lord, Lord Low, including the suggestion that these services should be available. I assume that making ophthalmic services available in schools and colleges is one of the easiest things to achieve. However, it is not so for adults with a learning disability and autism who have just left school and are at that age when nobody cares about them anymore. That is where the problem occurs.

I had enormous difficulties. I do not want to speak about myself in any way, because I am more than able to argue my case, find out where services are by ringing people and looking at services on the internet, and challenge when I face difficulty. I challenge more now than I was when my son was younger. I am also well attuned. I speak regularly with organisations on the ground that work with the parents and carers of people with learning disabilities and autism, so I know fully how much they struggle to ascertain and obtain information about ophthalmic care.

I want quickly to share the experience I had with my adult son. All his appointments were cancelled for nearly a year. I could see that his eyesight really suffered. He was not able to co-ordinate his way even around his own home where he is very comfortable. I had to push them hard. It was suggested that I should speak to the nearest ophthalmologist and look for these services. I admire all these services, which are trying hard to work with the NHS in the absence of patients being able to go to hospital for ordinary services, but they are not equipped or trained. They do not have the necessary equipment to produce the best results or give effective services to the people who need them. As the noble Lord, Lord Low, said, it is grossly unfair when there is sight and all someone’s eyes need are a little attention to make a fundamental difference and enrich their life. It is really important that the Government take the noble Lord’s amendments on board with the same passion that he argued with. I hope they also understand the passion of the millions of parents, carers and service users who stand behind him.

I thank noble Lords from all sides of the House for their leniency over this interruption.

Lord Scriven Portrait Lord Scriven (LD)
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My Lords, I have attached my name to a whole raft of amendments in the name of the noble Lords, Lord Crisp and Lord Hunt. I am pleased to follow the noble Baroness, Lady Uddin, who has explained powerfully and passionately why primary care in one area is so important to the health and well-being of people. I also thank the noble Lord, Lord Low, for introducing this suite of amendments with such a graphic and powerful explanation of why primary care, particularly for people with learning disabilities, is also important in relation to ophthalmology.

I wanted to put my name to these amendments, because they go right to heart of the purpose of the Bill. Let us be clear about the purpose of the Bill. Its purpose is to integrate healthcare to improve health outcomes and to reduce health inequality. You cannot do that if your focus is purely on the acute sector. The acute sector is the repair system. It is not the part of the system that can really deal with the prevention and innovation that keeps people out of hospital. I am sure that was never the intention of the drafters of the Bill, and I am sure that it is not the Government’s intention. However, the way the Bill is written, the power emphasis is with the acute sector in monitoring, reviewing and strategic plans.

I am sure the Minister will say that that is not the case, but the way the Bill is written it is the acute sector that will have the power over who sits in the ICB and whose plans they are. So I say to the Minister in a very friendly way that the noble Lords, Lord Crisp and Lord Hunt, and I have been involved in the management and leadership of health in different parts of the system. I was involved in acute and primary care myself. When I came into the health service, the noble Lord, Lord Crisp, was so powerful and mighty that he was the chief executive of NHS England. It was the same with the noble Lord, Lord Hunt. I feel in very esteemed and very grand company.

However, the point we are trying to make is that the real way in which healthcare works and how it is developed is that the acute sector is very powerful, even at place. If you do not give a voice and power to primary care, you will not have the innovation and the change that you require. These amendments are a way of trying to make sure that the purpose of the Bill at least moves faster and is eased by having that primary care voice right at the heart of the ICB, and, being statutorily in the Bill and having been there right at the beginning in the planning, monitoring and evaluating, being able to determine what is happening. That is what these amendments are about, nothing more. They are not amendments that should be deemed difficult or trying to slow things down. They are genuinely helpful amendments.

I say very gently but powerfully to the Minister that he really needs to incorporate these amendments. If he cannot incorporate and accept them now, the Government need to come back with a set of amendments that really crystalise the role of some great primary care people, whether they are in GP surgeries, ophthalmology, pharmacy or dental, who can actually help with the purpose of this Bill, which is to improve health outcomes, integrate healthcare and reduce inequalities. It is vital.

Lord Warner Portrait Lord Warner (CB)
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My Lords, I will speak in support of Amendment 218, in the name of the noble Lord, Lord Hunt, to which I have added my name. Before I get down to that, perhaps I could make a few remarks about the amendments from the noble Lord, Lord Crisp, and the other remarks that have been made.

When I was sitting in Richmond House as a Minister, we had a description for the chief executives of the acute trusts. They were called “the barons”. When the House of Lords Select Committee, chaired by the noble Lord, Lord Patel, took evidence on the long-term sustainability of the NHS and adult social care, three or four of them—I cannot remember exactly how many—came in to give evidence. Their opening salvo was, “We need 4% a year real-terms increase every year, stretching into the future”. I suspect that culture has not changed that much since I was around in Richmond House, and it has to be changed—forcibly if necessary—if we are actually to deliver the sustainability of the NHS.

Since 1948, the acute hospitals have been magnificent in laying down the law about how much money they need. Even when money was short, they were pretty good at it. My personal experience as a Minister was that, if I wanted the go-to people on change, I would go to the GPs. They were much more flexible and willing to have a go at doing things differently. We need to bear some of that in mind.

About 90% of people’s encounters with the NHS are with primary care, not with acute hospitals. People’s vision of the NHS is those encounters. I just want to mention an encounter my wife and I had over vaccinations which illustrates some of this. Our very efficient, local general practice was fast out of the starting blocks and we had two jabs very quickly. Some months later, we were both individually approached by two NHS acute trusts, which shall remain nameless. They asked us when we were going to get round to having our vaccinations. There was absolutely no contact between these two parts of the NHS. One part had no idea that another had dealt with the patients perfectly satisfactorily. This is what we are up against. The least we can do is accept the amendments suggested by the noble Lord, Lord Crisp.

I turn to Amendment 218. I will not repeat the arguments set out by the noble Lord, Lord Hunt. The numbers speak for themselves. In any service that claims to be national, it cannot be right to have such a wide range in the per capita workloads of GPs. After all, these doctors are the gatekeepers of patient access to specialist diagnosis and treatment. They should not be required to handle case loads that vary from around 1,000 to more than 6,000 patients. Such variations are likely to create significant variations in patient treatment outcomes.

I will make two further brief points in support of the amendment in the name of the noble Lord, Lord Hunt. First, there have been many worthy amendments tabled about the long-standing, serious problem of health inequalities. Many places with the most serious health inequalities are places where the patient load of GPs is very high. So the patients with the most need of clinical attention and help have the doctors with the least time for individual attention. I have to say, that is a brilliant piece of public policy that we have managed to develop.

My second point relates to the Government’s worthy aspiration to level up the quality of life in many neglected areas of this country. We now have a Secretary of State for Levelling Up, and no doubt we eagerly await the game plan he has for living up to his title. A fairer share of the national supply of GPs would be a tangible piece of levelling up in many of those deprived areas. Can the Minister say whether the Government have considered a move in the direction of the amendment tabled by the noble Lord, Lord Hunt, as a useful part of their levelling-up strategy? I hope the Government will give that consideration on those grounds alone.

16:45
Baroness Hollins Portrait Baroness Hollins (CB)
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My Lords, I have some brief points to add in support of my noble friend Lord Low’s Amendment 56A, which the noble Lord set out so clearly, and also in support of the amendments tabled by the noble Lord, Lord Crisp. It is very clear to me that primary eyecare has lagged well behind other areas of primary care in terms of any commissioned schemes for children and young people who are not in special schools and for adults with learning disabilities.

My experience with my son sound very similar to those described so well by the noble Baroness, Lady Uddin. The similarities are quite extraordinary, and my heart goes out to her. This week my son went to see the optician. He is visually impaired; he has a learning disability and autism. Fortunately for him, the optician responded well to the request for some reasonable adjustments to be made—which are required by law, but perhaps not well understood in local high street opticians.

Some years ago I did some research with SeeAbility, and together we created a visual, word-free resource. I declare an interest here, because this was with the charity I founded and chair: Books Beyond Words. We created a story called Looking After My Eyes and I read this with my son before he went to his optician’s appointment yesterday. It helped him and it helped the optician. But we need targeted improvements in optical care for everybody with a learning disability across the country. For this reason, I thoroughly support my noble friend’s amendment.

Baroness Bennett of Manor Castle Portrait Baroness Bennett of Manor Castle (GP)
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My Lords, in the wake of such a hugely powerful group of contributions, mine is very much a supporting role and I will be brief. I can only endorse the contributions to the amendment put by the noble Lord, Lord Low, and what we have heard about why it is so urgent. I will speak to Amendments 112 and 218, to which I have attached my name.

I attached my name to Amendment 112 because, as I was looking through the amendments, it struck me as such a crucial one. It was one that, even at this stage, it was really important to have four signatures on to show broad cross-party support. I am afraid I did not go for Amendment 113 and the rest of the list as well, on the grounds that I thought my name was there enough already, but I think the rest are—if not technically, certainly practically—consequential on Amendment 112.

After I had done that, I received a briefing from the Royal College of General Practitioners, writing also on behalf of the Royal Pharmaceutical Society and the Association of Optometrists. I will quote one sentence. The college says:

“We think this is a classic example of where secondary care is at the centre of decision-making, while GPs and primary care are ‘consulted’.”


I think that reflects what the noble Lord, who has a great deal of expertise, said, and this is one amendment that is a total no-brainer.

Moving to Amendment 218, the noble Lord, Lord Hunt of Kings Heath, outlined the technical background to this and the statistics. The only thing I will add is that many think tanks, including the Health Foundation, the King’s Fund and the Nuffield Trust have produced information about how extreme the variation in availability of GP services is and how much effect that has on inequality. As the noble Lord, Lord Warner, said, if the Government have a levelling-up agenda, this also is surely essential.

The reason I was personally attracted to this amendment is that in my days as Green Party leader I travelled around the country a lot and quite often ended up meeting GPs, very often talking about public health issues. I encountered so many desperately hard-working, utterly committed people who were exhausted and felt that they could not retire or cut back their hours. They were wearing themselves to the bone because no one was coming to replace them. I felt that I needed to stand up and speak for those people.

Sometimes people think of this as something that affects rural or remote areas. However, the Norfolk Park health centre in Sheffield nearly closed last year because, after extraordinary efforts, it had been unable to find an extra partner to come in. As the noble Lord, Lord Scriven, knows, this surgery is a fairly modest bus ride from the centre of a major city. It is a purpose-built health centre and only eight years old, but it could not find a GP partner to come in. Eventually, after a great deal of public campaigning, the surgery remained open. That is a demonstration of just how broad this problem is, yet, as the noble Lord, Lord Hunt, said, there are parts of the country—broadly the wealthier parts—that have expansive GP coverage.

Something has to be done, but, like the noble Lord, Lord Hunt, I am not sure that the proposal here is exactly the right way forward. We often say that something needs to be done, but we really need to see something done here. As with so many of the amendments that we discussed this morning, the Bill we have before us is the chance to sort out an urgent problem that must be sorted out.

Baroness Cumberlege Portrait Baroness Cumberlege (Con)
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I would like to say a few words and will start by complimenting the noble Lord, Lord Crisp, on all his amendments. I agree with the noble Lord, Lord Scriven, that these are not contentious. In fact, I do not think it would harm the Government at all to include these amendments in the Bill. They are trying to reinstate the primacy of primary care.

We all know that the glamour is not in primary care but hospitals—you have only to see where politicians like to be photographed; when they produce newsletters, they are always pictured in a hospital with a very sophisticated piece of new machinery that that hospital has bought. It is understandable, because that is so easy to recognise. With a photograph of a GP in a consulting room, you do not know quite where this is, who it is, or what he is doing. One can understand why the media goes for the picture of the hospital, because that is what people recognise.

In this debate and these amendments, we know that the absolute foundation of the NHS is primary care. It is so important and we have to build its primacy. I am a child of primary care; I grew up in it. My father joined the NHS in 1948. He welcomed it and thought it was a marvellous innovation. I had a very happy childhood as Dr Camm’s daughter; I had status in the community. Then I segued into being Mrs Cumberlege and my status plummeted—because I had married a farmer. We celebrated our wedding 61 years ago last week, so have had a diamond wedding. My husband said to me, “Julia, what do you want?”, and I said, “Well, it is a diamond wedding”. He delivered, and I was just delighted.

I will not extol the virtues of my father’s practice, but want to think of the role of the GP in the future and how it has already changed. In our practice, all the GPs are now part-time. They are men and women, and they have other lives to lead. None of them is a full-time GP, and that makes continuity of care quite difficult, because you are never quite sure whether they will be there or not. If you want an urgent appointment, of course you can get one, but it will probably not be with your GP. So that has changed.

There has been another change. My father built a health centre. In fact, it was the county council that built it, but he put all the pressure on to build it, and it was called the “health centre”. Today, it is not called that; it is called the “medical centre”. That is because the doctors are transactional. They just do what is in front of them. Health is not part of their remit, and it is our community that provides the health. It is the church which has the social work and provides a huge amount of the social services for our community. So things really have changed.

A very good paper was produced by the Royal College of General Practitioners, in June of last year, The Power of Relationships: What Is Relationship-based Care and Why Is It Important? It is such a good paper, and I recommend that noble Lords look at it before we have the debate led by noble friend Lady Hodgson on relation- ship care and what it means. The statistics show that people live longer with relationship care. They are happier. We have some really good evidence, but I shall talk about that when we come to that amendment.

I have been working with Sir Cyril Chantler, whom many people in this House will know. We have been talking about community hubs. We think they are a very good way of moving forward and getting together not only doctors but social care, voluntary organisations and all the community facilities to ensure that they are in a hub. We know that, with integrated services and boards and the work that is going on in integrated care, the populations are enormous. We have to break it down a bit to make it more accessible to people. The next time we have a chance to debate this matter, which will be in the context of relationship care, I shall talk about community hubs with populations of about half a million. We are already establishing maternity hubs. I have said to them, “No, not maternity hubs—you’ve got to make them community hubs; you’ve got to bring in all the other resources that are in the community, because they’ve all got something to offer, and we would all benefit.”

I hope that my noble friend the Minister will think seriously and work with his colleagues to try to ensure that these amendments, or very similar ones, are introduced into the Bill, because we need to ensure the primacy of primary care. I am afraid that it is not there now; it is all about hospitals.

Baroness Walmsley Portrait Baroness Walmsley (LD)
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My Lords, it is a great pleasure to follow the noble Baroness, Lady Cumberlege, and I am delighted that her status has now gone up again because of her ennoblement and all the excellent work that she has done. We really benefit from her knowledge and wisdom in your Lordships’ House.

I support the noble Lords, Lord Low and Lord Crisp, and want to make just one point. Correct me if I am wrong or if I am out of date—I am sure that some noble Lord will if I am—but I think it is the situation that if an acute hospital overspends, the NHS bails it out, whereas social care and primary care cannot overspend because nobody will bail them out. I think that says it all.

Baroness Thornton Portrait Baroness Thornton (Lab)
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My Lords, in many ways we are drifting back to 1946, when the NHS started on three legs: hospitals, services such as health visitors and ambulances provided by local authorities, and services that were contracted out, such as GPs, dentistry, ophthalmology, pharmacy and so.

17:00
This debate, of course, has been about integration again. The noble Lords, Lord Low and Lord Crisp, my noble friend Lord Hunt—to whose Amendment 117 I added my name—all talked about primary health care in its different forms. Before I talk about primary health care—and I am sorry if I am repeating myself—there is a point I made, I think when the noble Baroness, Lady Hollins, was speaking earlier: we know that when an area gets services for those with learning disabilities right, everybody benefits in that area, not just those with learning disabilities. That is because it changes the mindset and priorities of the way that healthcare is delivered in that area. It is absolutely the right thing to do. The truth is that primary care services—I should retrospectively declare an interest as a member of a CCG for three years—deal with the vast majority of patient interactions. They are often underplayed; they are not in the big expensive buildings with the massive machinery.
Although the 2012 Act went some way to restoring the balance, by putting primary health care professions in the driving seat for commissioning with our clinical commissioning groups, in fact the big hospital trusts continued to dominate. Primary care, along with mental health and other community-based services, continued be underresourced and underplanned. Again, this Bill offers an opportunity to turn that around and look for proper integration with primary and community healthcare. They need a boost if we are to deal with health inequalities.
So we see merit in the amendments in this group. The only thing the groups lacks, as far as I can see, is anything that bigs up the poor state of dentistry—but I hope we will return to that matter in due course. As my noble friend Lord Hunt said, the distribution of GPs is another issue that needs to be highlighted and to which attention must be drawn. We talk about how to represent the voice of primary care in planning by the ICB. Having a local representation committee could do that—they have a long history and they could be given a place in the system’s planning, so I think they are deserving of consideration.
Lord Kamall Portrait Lord Kamall (Con)
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I thank all noble Lords who spoke in this debate for once again increasing my understanding of some of the challenges within the system, in addition to briefings I have had thus far. I thank the noble Lord, Lord Low, for his patience and his just-in-time mode of operation and, more than that, for his contribution to the debate today. We appreciate that people with learning disabilities experience a higher prevalence of visual impairment than the general population, and that this prevalence increases with the severity of the learning disability. Children with learning disabilities are, for example, 28 times more likely to have a serious sight problem, and over 40% require glasses.

NHS England continues to responsible for the contracting of the NHS sight testing service. This will eventually be transferred to ICBs. Sight tests are widely available across the country through our very dedicated primary ophthalmic services workforce. Those eligible for a free NHS sight test include children, those on income-related benefits and those at particular risk of eye disease. We expect that those with severe learning disabilities should meet the eligibility criteria in other ways, and for these reasons we do not believe that, at this moment, extending eligibility further is necessary. Where those with learning difficulties are unable to access NHS sight tests on the high street, hospital eye departments also provide routine eyecare services and ongoing care. Children are usually referred on to hospital eye services via visual assessments delivered by specialists in special schools. Others are referred by GPs, school nurses or high street practices. We have also seen the development of special pathways in some parts of the country that cater specifically for adults with learning disabilities and we want to make sure that, via the NHS England central team, we share best practice on a national level, so that all regional teams and all ICBs can benefit from learning from the local initiatives and pilots.

NHS England also tells me that it recognises that more needs to be done to ensure equality of access. That is why the NHS long-term plan committed to ensuring that children and young people with learning disabilities, autism or both in special residential schools have access to eyesight, hearing and dental checks. In order to fulfil this commitment, there is a proof of concept programme building on the work by SeeAbility in London, which was launched in 2021, to provide sight tests and dispense glasses on school premises. My honourable friend the Minister for Care is due to make a visit to one of the schemes.

I now turn to the amendments on primary care providers. I understand noble Lords’ interest and that it has been widely acknowledged that CCGs, for example, are dominated by trusts, particularly for acute care. I take the gentle encouragement of the noble Lord, Lord Scriven, to understand that more, and particularly to make sure that the voice of primary care providers is heard. That is also the Government’s ambition. We support the idea that primary care should be integral to ICB planning, which is why at the moment at least one member of the ICB will be nominated by primary care providers in the area.

We all know that primary care service providers are predominantly independent entities that hold contracts with the NHS, unlike NHS trusts and foundation trusts, which are largely statutory entities. If all types of primary care service providers were named in the Bill, it would mean that every provider in the area of the ICB would have a duty to contribute to the development of the joint forward plan. We do not believe it would be a feasible option for all primary care providers to contribute to the plans, but I acknowledge the points made by noble Lords about how we can raise the profile and contribution of primary care providers.

I turn briefly to Amendment 117. We agree that it is important to consult the relevant primary care local representative committees, which is why we already have a provision under new Section 14Z52 to introduce a duty to consult anyone the ICB and its partner trusts consider appropriate when preparing the plan. There should also be a summary of the views expressed by anyone consulted and an explanation of how those views were taken into account. We expect members of the primary care sector to be consulted and their views summarised in this way. We understand that NHS guidance will provide for that.

We also want to allow ICBs to focus on arranging safe, high-quality care, and making an additional, explicit requirement in the Bill does not align with our desire to reduce the bureaucratic burden on ICBs. I understand that this is all part of the general debate about whether, if we accepted every amendment about who should be on the ICB, it would be more inflexible and unwieldy. These are conversations we should have in the round about the priorities for ICBs, what should be mandated, what should be in guidance and what the ICB’s duties are expected to be. I hope that we will have those conversations in the round so that we can come to some sort of consensus across the Committee.

Lord Crisp Portrait Lord Crisp (CB)
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The amendment in my name specifically requires ICBs

“to work with the four primary care services … when preparing and revising their five year plans”.

It does not specifically ask for a seat on the ICB. That is a different request. I hope the Minister understand that and will respond to it.

Lord Kamall Portrait Lord Kamall (Con)
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I thank the noble Lord for that clarification and also for the advice he has given me in my first few months in this job. I do appreciate his experience. I will take the noble Lord’s point back and make sure it is clearly understood by the department when we consider how we respond to it. We believe in working with appointed ICBs, but we expect primary care to be consulted.

NHS England has also stressed the importance of ensuring that there are robust place-based structures in place. We hope that the ICB will exercise functions through place-based committees, where a wider group of members can take decisions, and we expect that primary care, including individuals from medical, dental, pharmaceutical and optical committees, will be particularly involved at the place-based level under the principle of subsidiarity. We will have some influence on the drafting of the forward plan of the ICB. Additionally, guidance that NHS England publishes for ICBs will include the commissioning of primary care at the place-based level.

Lord Warner Portrait Lord Warner (CB)
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I have listened very carefully to what the Minister is saying in response to these amendments but, at the risk of being a historian again, is he aware that influence on key decision-making in the NHS is diminishing for primary care in general and GPs in particular? If we go back to 1990 and the GP fundholding changes to the NHS made by the noble and learned Lord, Lord Clarke of Nottingham, if we move through the Blair years of practice-based commissioning and go to the changes by the noble Lord, Lord Lansley, with clinical commissioning groups, these are three examples where GP influence on decision-making—strategic, local and tactical—is very considerable.

As far as I can see, that has been diminished in this Bill and they have been put back in their box without a lot of influence on key decision-making. They are poked down at the local place level. That is not right. What the Committee is saying needs to happen in the NHS. The Minister must go back to his department and talk through what is happening here, because it is diminishing the role of the GP in particular.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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My Lords, the noble Lord has said that the Bill came because this is what the NHS wanted. But we must be clear who in the NHS wanted it, and it is obvious that it was the senior chief executives at the local level and NHS England. No wonder primary care has been completely squeezed out of it. Listening to this debate, it seems to me that the proposals from NHS England never had any scrutiny. Ministers just accepted this and, because NHS England does not engage externally, there has not been the testing that you would normally get, and we are having to do it now. Frankly, the wheels are falling off. It is tempting to invite the noble Lord, Lord Lansley, to come in, because clearly CCGs were all about putting primary care in the driving seat. This seems to be removing them altogether and it is worrying.

Lord Lansley Portrait Lord Lansley (Con)
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My Lords, in response to that, may I say that when I was shadow Secretary of State for several years, GPs consistently told me that if only they were given the responsibility, they could do it so much better than primary care trusts? So we gave them the responsibility in ways that were very like the locality commissioning that was the endpoint of the GP fundholding of the noble and learned Lord, Lord Clarke of Nottingham. To be fair to them, there was less money, but no sooner did they take this responsibility than NHS England said, “Hang on a minute, you’re not doing what we’ve told you to do.” It took about 18 months, perhaps slightly less, before NHS England effectively said, “You have no further autonomy. You’re going to be in the sustainability and transformation plans,” which are the forerunners of ICS. I do not think that the clinical commissioning groups ever got the chance to do what they were asked to.

We have now reached the point where, as the noble Lord, Lord Warner, rightly says, they are being written out of the script, but they are not complaining, which is very interesting. They are not complaining because they do not want to be responsible for the budgets; they want to be responsible for the patients. They always said that they wanted to decide how locality commissioning should be done and the good ones have put tremendous things in place in terms of population health management, patient pathways and commissioning linked to those patient pathways. That is why, if we can do something with this Bill, it is to retain all that locality commissioning with GP input. But be prepared for the ICS, the big battalions, to go away and fight with the barons in the big hospitals.

Baroness Thornton Portrait Baroness Thornton (Lab)
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I wish you good luck.

17:15
Lord Kamall Portrait Lord Kamall (Con)
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Anyone else want to come in? Look, I thank all noble Lords for their contributions and friendly advice, however put. Actually, I appreciate their passive-aggressive demeanour, in that way. I know it is all well-intentioned and that noble Lords speak from experience of previously tried schemes. The main point here is how we make sure that primary care is better represented and not dominated by acute trusts. I do not think I am going to have the answers to convince noble Lords completely or even partly tonight. Therefore, this clearly needs more discussion and for me to go back to my department, but also, once again, us to have another discussion on these issues between now and Report.

Baroness Cumberlege Portrait Baroness Cumberlege (Con)
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My Lords, can I quickly intervene? Of course, it is absolutely right that one should learn from history. But looking to the future, I just wonder whether the Minister has heard about the movement there is by some foundation trusts to try to take over primary care. I just wonder what the implications of that would be for primary care, whether he and his officials have heard of that and whether they would like to discover what that would do to patient care.

Lord Kamall Portrait Lord Kamall (Con)
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I thank my noble friend; I was not aware of that. But at the end of the day, the result has to be the care that the patient receives. There will always be debates on how you can configure who should be involved at what level, but at the end of the day, it has to be the quality of the care the patient receives. To a wider point, we must also focus on prevention. We are seeing a lot of innovation in the primary sector; we are seeing GP services sometimes merge into primary care centres, taking on medical procedures that were previously considered the domain of hospitals. We have seen more blurring of the lines, and patients welcome that innovation in many cases.

What matters at the end of the day is the experience of the patient and making sure they have a decent service all the way through their life. It is one of the reasons we are talking about integration. In this country, care is literally from the cradle all the way to the grave, as we integrate social care more. That is why some of these discussions we have been having on social care and palliative care have been important. We are aware of that.

There are a couple more points I would like to make before I allow people to get in before the 5.30 pm deadline for getting a teacake. We support the idea that all areas should have an adequate number of GPs. That is why we launched the targeted enhanced recruitment scheme to attract doctors to train in locations that either have a history of under-recruitment or are currently finding it difficult recruiting. The scheme reflects the fact that trainees who are attracted to these areas usually stay on after training. Hundreds of doctors have trained in hard-to-recruit places since the scheme’s introduction, with 500 places available in 2021 and, we hope, 800 in 2022.

We also recognise that each community has different health needs, which emphasises the point noble Lords have made—that it is so important to hear the voice of primary care more loudly. We are taking steps to diversify the general practice workforce, such as by recruiting 26,000 more primary care staff. Making sure we have the correct mix of skills available in general practice is critical to delivering appropriate patient care across England.

One of the issues that we have to appreciate, though, is that as most GP practices are private partnerships and GPs are free to choose where they practise, a general medical practitioners equitable distribution board would have limited influence over the distribution of GPs across England, which is why we have to look at other ways to target those areas that are underserved. That is why it remains critical to continue encouraging trainees to train in hard-to-recruit areas and diversify the primary care workforce to support general practice in meeting the needs of its local community across England.

I have heard, once again, the mood of the Committee. That has become a familiar theme. I hope noble Lords will accept that I am open to further conversations in this area, particularly on how we hear the voices of all those in primary care, not just those of GPs but all of them, including those in ophthalmology, dental care and others. I hope that, in that spirit, noble Lords will feel it appropriate to withdraw or not move their amendments at this stage.

Lord Low of Dalston Portrait Lord Low of Dalston (CB)
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My Lords, I thank the Minister very much for his response and all other noble Lords who have participated in the debate. I moved a rather modest little amendment but I am encouraged that it has stimulated such a rich discussion with so many knowledgeable contributions. If nothing else, my amendment has stimulated a discussion that has emphasised the importance of primary care. If we can take that message away, we will not have been wasting our time. I shall leave it there. I thank everyone for their contributions and the Minister for his response. I am sure he will have been enriched by the way the discussion has focused on the importance of primary care. It has been beneficial all round. I beg leave to withdraw the amendment.

Amendment 56A withdrawn.
Schedule 3 agreed.
Clauses 18 and 19 agreed.
Clause 20: General functions
Amendments 57 and 58 not moved.
Baroness Pitkeathley Portrait The Deputy Chairman of Committees (Baroness Pitkeathley) (Lab)
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Before I call the next amendment, I remind your Lordships that the noble Lord, Lord Howarth of Newport, is taking part remotely.

Amendment 59

Moved by
59: Clause 20, page 16, line 20, at end insert—
“(1A) To this end, an integrated care board must engage providers of non-clinical services, including creative and nature-based services and other services in the voluntary, community and social enterprise sector, ensuring that it has effective channels for dialogue with these sectors.”
Lord Howarth of Newport Portrait Lord Howarth of Newport (Lab) [V]
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My Lords, in this suite of amendments to Clause 20, which lays down duties on integrated care boards, I am proposing that we should articulate a duty for ICBs to embrace non-clinical practice in their whole way of working. By non-clinical practice, I am referring to a range of services and interventions that promote human flourishing, such as: engagement with the arts and culture to stimulate the creative imagination; a healthy discovery of meaning, self and personal agency; engagement with nature to provide a sense of wholeness, wonder and well-being; physical exercise and sport to energise the body and mind; engagement in voluntary work to lift people from self-absorption and melancholy, and to enable them so they are useful and valued members of society; and meditation to impart calm and perspective. All this is ancient wisdom that is being rediscovered by more and more people. This rediscovery is, indeed, innovative and the Bill requires ICBs to promote innovation.

In no sense am I suggesting that such practices should substitute for modern medicine where diagnosis and good sense indicate that modern medicine is needed. Modern medicine achieves extraordinary things, but too often we resort to it without first considering non-clinical approaches. As a society, we are over- medicating; witness the almost exponential growth in the prescribing of antidepressants. Our national passion for the NHS should not be an addiction. The NHS needs, gently but firmly, to steer us into asking less of it and taking more responsibility for maintaining our own health. That should be a new norm built into the legislative framework for the NHS that the Bill provides. Unless that happens, the system will collapse under the burden of the demands and expectations that it has created.

Unless the Government systemically address the social determinants of health, we shall not have a healthy society. The Bill, harking back to the time of Aneurin Bevan, who as Minister for Health was also Minister for Housing, rightly describes the provision of housing as a health-related service. Amendment 90 goes further, to insist on well-designed housing and urban and green environments. Research evidence shows that living in greener urban areas is associated with lower probabilities of cardiovascular disease, obesity, diabetes, asthma and mental distress among adults, and obesity, poor cognitive development and myopia in children. In every place that ICBs serve, they should be promoting debate about what good urban design should mean and how it should be achieved. Encouragingly, in the new Ebbsfleet Garden City planners are co-locating cultural facilities alongside a health and well-being hub.

There is a substantial and growing body of high-quality research and evaluation demonstrating that creative health and other non-clinical approaches, as the All-Party Parliamentary Group on Arts, Health and Wellbeing said in its report, Creative Health,

“can help keep us well, aid our recovery from illness and support longer lives better lived … the arts can help meet major challenges facing health and social care: ageing, longterm conditions, loneliness and mental health”,

and

“the arts can save money in the health service and social care”.

Since the publication of that report in 2017, there has been increased recognition of this among health policymakers and in the clinical establishment. Research has been commissioned. The NHS long-term plan, with its new emphasis on prevention, acknowledged the benefits of social prescribing. The National Academy for Social Prescribing was set up. Link workers, linking GPs with community providers, are being funded, though not the community providers themselves. NASP has allocated £1.8 million to its thriving communities fund to increase the scale of social prescribing activities, and the Government have a £5.8 million cross-departmental project aimed at preventing and tackling mental health through green social prescribing.

However, this activity is still marginal and its funding almost indiscernible in the NHS budget. Amendments 104 and 105 make clear that an ICB has the power to fund non-clinical providers and that there must be financial equity between clinical and non-clinical providers. If the NHS will struggle to provide enough initially, the wider levelling-up strategy should enable that funding.

Non-clinical health providers cost a fraction of conventional medicine and represent remarkable value for money. The Evaluation Report of the Social Prescribing Demonstrator Site in Shropshire showed significant improvements in health factors such as weight, physical activity, smoking and blood pressure, and a reduction of up to 40% in GP appointments. Dance is inexpensive to lay on. As the Dancing in Time project in Leeds showed, by improving gait, flexibility and strength, it reduces falls among the elderly, who are expensive to repair.

To fail to invest on a reasonable scale in creative health and other non-clinical services is to look a gift horse in the mouth. This is recognised in some ICSs, with which the National Centre for Creative Health, a charity which I chair, is working on pilot schemes. In the Shropshire, Telford and Wrekin ICS, the personalised care team is using creative health and co-production methods with children and young people suffering from asthma. In the Suffolk and North East Essex ICS, clinicians looking for ways to support patients with long Covid have introduced singing for breathing, which is beneficial for lungs and loneliness. Creative Minds in the South West Yorkshire trust has developed creative activities that now benefit the physical and psychological well-being of 6,500 people a year. One user of the Creative Minds “Art for Well-being” programme, Debs Teale, a trustee of the NCCH, said:

“I am eternally grateful to … Creative Minds for giving me the wonderful opportunity to discover a mind released from the fog of depression. I have been five and a half years medication-free”.

17:30
The Lived Experience Network, or LENs, brings together people with lived experience of ill health who provide powerful personal testimonies of the benefits of creativity and the arts to their own health and well-being. As the Bill recognises in the requirement for ICBs to promote the involvement of each patient, the voices of people with lived experience should always be heeded as we shape the health service and consider the prescriptions and treatments that are appropriate.
The culture of the NHS is predominantly science-based, technical and bureaucratic. Doctors and nurses of course seek to imbue their practice with empathy. Some of the wise among them recognise, in the words of Dr Elaine Yeo, in a recent letter to the Guardian, that
“general practice is an art—the art being when to use the science.”
It is time the science knew when to use the art.
Medical education and training, which the Bill states it is the duty of ICBs to promote, must be the fountainhead of culture change in the NHS. The education of clinicians, public health specialists and other health and care professionals should follow the example of pioneering medical schools, such as the University of Exeter Medical School, which has a compulsory study unit enabling students to work with creative practitioners. A new master’s in creative health at UCL has a strong practice-based component, delivered in partnership with community organisations. In York, Dr Nicola Gill delivers a CPD course for GPs on the power of the arts and the value of community-based resources for self-care and care of patients.
Noble Lords will have understood the purport of the amendments in this group and it would be excessively laborious for me to explain each one. I invite the Committee to look at them as a whole and to consider whether ICBs should be under a legislative duty to work in full partnership with non-clinical providers to gain the benefits they can offer for the health and well-being of individuals and communities.
As the noble Lord, Lord Mawson, reminded us in an earlier debate:
“A human being is fundamentally a creative being.”—[Official Report, 13/1/22; col. 1237.]
I know that the Minister, the noble Lord, Lord Kamall, will need no persuasion of the salutogenic virtues of the arts. He is himself a musician—a bass guitarist, indeed. I do not know whether his band is still called Exiled in Brussels; I hope he has not renamed it Exiled in Whitehall, because, like all of us, he needs to think positive, not least in accepting these amendments. I beg to move.
Baroness Barker Portrait Baroness Barker (LD)
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My Lords, it is a pleasure to speak in support of the noble Lord, Lord Howarth. When I read these amendments I was immediately taken back about 20 years, to the offices of a charity that noble Lords might remember called the British Trust for Conservation Volunteers. It had a very worthy reputation. I think most people who knew vaguely of its work but did not know it in any great detail regarded it as middle-class do-gooders in bobble hats who went out and cleaned up local rivers and things that nobody else much bothered about. But 20 years ago, it began to do some of earliest work that charities did in drilling down into not only what they did but the impact of what they did. When the trust did that, it discovered two things. First, it discovered that the volunteers were much more diverse than one would have thought—there were all sorts of people from all sorts of different backgrounds, many of them in urban settings. Secondly, it found that the biggest impact it had was on the mental health of the people who volunteered. As an organisation, it tracked that as best it could in its non-clinical fashion.

I bring my observation up to date, to about three years ago, just before lockdown, when I had the great good fortune to be invited to the offices of Google one night. I remember it was a winter’s night with absolutely filthy weather, and 250 young people—or youngish people—turned up to talk about mental health and tech. The big question was around what we can do, given who we are, who we work for and the data that we are amassing now, about not just what people are doing but what they intend to do and the profiles we are beginning to build up about people’s behaviour.

It is to those two memories that I attach these amendments, because I think the noble Lord, Lord Howarth, is right. Everybody knows the value of this—we all know it as individuals. Who did not go nuts during lockdown and head out to the nearest bit of green space to cheer themselves up? We all know it, but how do we prove it to those in the NHS who, rightly or wrongly, hold fast to scientific data and evidence?

My point is simply that we should be trying to get this on to the agenda of the acute services, rather than primary care, and that we need to do so in a way that is collaborative. I think we should be challenging the acute services to tell us how they would evaluate this—what evidence would convince them? It might be the sorts of biometric evidence that people who are involved in mindfulness are beginning to generate; the fact that we can actually see differences in people’s brain patterns if, over a sustained period of time, they are engaged in things such as mindfulness.

I sincerely hope that we do not pat these amendments on the head and send them on their usual way into the background and to the byways of primary care. I hope that, although the amendments may not make it into the Bill, noble Lords might well challenge the department, NHS England and the acute sector to see this as a far more important part of prevention, particularly in mental health but also in a number of physical conditions, than they might otherwise have done.

Baroness Greengross Portrait Baroness Greengross (CB)
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My Lords, I am in favour of the amendments in this group in the name of the noble Lord, Lord Howarth, specifically Amendments 59, 67, 71, 77, 80 and 82. My own Amendment 290 will be debated in group 41 and specifically addresses the importance of social prescribing for people with a dementia diagnosis and how this can form part of a wider care plan.

Social prescribing plays a very important role, not just for people with diagnosed conditions but generally, as part of wider brain health. Research by Arts 4 Dementia found that music-making provides a tool for a total brain workout and improves plasticity in the cortex, which enhances the ageing brain’s cognitive abilities, perception, motor function and working memory. It also improves cardiovascular strength while reducing stress. The Coda Music Trust provides a range of musical social ensembles and bands, as well as courses and classes for learning and well-being. In other studies, drama and poetry have been found to improve concentration and cause new neurons to develop and adapt.

Social prescribing has been recognised as playing an important role. It is part of the NHS long-term plan, and the Department of Health and Social Care has allocated funding to establish a national academy for social prescribing. This growing recognition of the role that social prescribing, specifically of music and art, can play in overall health is a welcome development because many of the programmes that exist at present rely on the voluntary sector.

During the pandemic, these programmes, like most of the voluntary sector, have struggled with funding and with being able to continue their work under Covid-19 restrictions. We also know that many arts venues have struggled through this time and many theatres and music venues now face an uncertain future. This sector therefore needs much more support right now if it is to continue its work. It is crucial that integrated care boards are empowered to promote social prescribing and can work with organisations that provide these services.

Although the evidence for the benefits of social prescribing is growing, more work is needed to research what types of social prescribing are successful for specific conditions, a point that I will elaborate on when we debate my Amendment 290, which addresses social prescribing and dementia. To help promote social prescribing, we need more training for GPs and other health professionals on how and when to prescribe these services. We also need to include arts awareness for mild cognitive impairment in the medical and social care educational curriculum.

There also needs to be greater availability of these services, with links to every GP. The current NICE guidelines for dementia recommend referring patients for these services only post diagnosis when, in fact, to promote overall well-being and brain health, we should encourage them much earlier from the onset of symptoms. For this, we need training, and integrated health boards must prioritise the availability of these services.

I thank the noble Lord, Lord Howarth, for these amendments and fully support their inclusion in the Bill. I look forward to the Minister’s response. I also want to take this opportunity to thank the noble Lord, Lord Kamall, whom I have often heard recently. He confirmed that his blues band, Exiled in Brussels, will play at an event supporting Music for Dementia later this year.

Lord Best Portrait Lord Best (CB)
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My Lords, I thank the noble Lord, Lord Howarth of Newport, for his inspiring speech. I declare an interest as a vice-president of the Local Government Association. I also chair the University of Oxford’s Commission on Creating Healthy Cities, which brings together academics, policymakers and practitioners. We hope to support city leaders and their citizens by shedding light on the policy interventions that are most likely to be effective in enhancing the health of their cities.

The Oxford commission is not due to report until later this year, but it is already clear that the two core issues raised by the noble Lord, Lord Howarth, in this group are likely to be central to our conclusions. The first relates to the wider determinants of health creation that take us beyond the integration of health and social care services towards recognising the relationship of public and personal health to other non-clinical services, including those affecting the built environment. The second issue relates to the value of engaging local and community organisations in a variety of ways in achieving health outcomes.

17:45
Our Oxford commission is learning about the underlying causes of health inequalities, looking at interventions that address healthy lifestyles, such as: combatting poor diet and obesity; the value of social prescribing, which is getting a good airing tonight and will get even more as the Bill progresses; healthy transport, such as encouraging walking and cycling, with linked impacts on air quality; and healthy homes in healthy environments.
It is the last issue, housing and place, that I want to address in the context of, in particular, Amendment 90 in the name of the noble Lord, Lord Howarth of Newport. I hardly need to emphasise the significance of housing as a health issue. Obviously, homelessness causes every manner of physical and mental health problems, and your Lordships’ debate on Tuesday drew attention to the exclusion of homeless people from the healthcare system.
However, housing conditions impact on a vastly larger number of citizens. Overcrowding clearly has serious health impacts, as revealed in the Covid statistics, for example. Cold and damp conditions lead directly to hospital admissions and excess winter deaths. In his analysis of health inequalities, I note that Sir Michael Marmot has given housing a very high priority. For later living, homes that are in bad condition and/or have unmanageable steps and stairs mean not only hospital admissions for older people but serious delays in hospital discharges and swift readmissions. Incapacitating housing drives older people into costly and unpopular residential care. Better housing is key to the health and well-being of our ageing population.
As the All-Party Parliamentary Group for Housing and Care for Older People—and I declare my interest as its co-chair—has long maintained, health, care and housing represent three legs of the same stool. All three components need to be integrated through the new ICBs in a way that health and well-being boards have not be obliged to achieve. Such a duty for ICBs has special resonance in relation to older people for whom getting the right housing is fundamental to health, whether by right-sizing to accessible, manageable, companionable, new accommodation that can also end years of loneliness or by retrofitting unsatisfactory, unhealthy, existing homes.
The health and social care White Paper demonstrated dawning recognition of this housing dimension with a planned boost to grants for home adaptations. Now the Bill before us takes a step in the same direction. The clause to which Amendment 90 draws our attention states that:
“Each integrated care board must exercise its functions with a view to securing that the provision of health services is integrated with the provision of health-related services,”
wherever this would improve the quality or outcomes or reduce health inequalities. It adds that
“the provision of housing accommodation is a health-related service.”
This duty in the promotion of integration seems to me to represent a very welcome breakthrough in the recognition of the health impacts that housing can achieve and demands, at last, the greater integration of health and care and housing which a number of us have sought for so long.
Amendment 90 seeks to extend the inclusion of housing in the duty on ICBs to promote integration to embrace the wider environment. Health is certainly enhanced by access to nature, parks, green spaces and a quality urban environment, as the noble Lord, Lord Howarth, noted so, without wanting in any way to diminish the reference already in the Bill to housing, I certainly support the addition of reference to the wider environment.
The other aspect of the amendments tabled by the noble Lord, Lord Howarth, in this group calls for recognition of the role of
“the voluntary, community and social enterprise sector and creative and cultural bodies.”
These various organisations—perhaps exemplified by the enterprises established by the noble Lord, Lord Mawson, to whom fully justified tributes have been paid this week—can make a fundamental difference not only to the way local needs are recognised and services are provided but to the buy-in, the acceptability, of actions within local communities that are necessary but seldom universally popular.
In keeping with my housing theme, I wish to highlight the voluntary and community bodies that comprise the non-profit social housing sector which, while being regulated but independent of the state, contributes immeasurably to the nation’s health. Today, social housing providers are almost universally present throughout country, working in partnership with local authorities. Many are themselves community-led enterprises doing brilliant work which is improving health and well-being.
Although we need the scale of provision achieved by today’s major housing associations, which have developed over the last 50 years from tiny origins to massive social businesses, some of the most innovative and entrepreneurial social housing bodies are those that remain embedded in their local communities, such as the housing charity Giroscope in Hull, which provides housing, employment and training by renovating derelict and empty properties. It helps ex-offenders, the long-term unemployed, those with mental health problems and those recovering from alcohol and drug misuse. The Leathermarket community-led housing organisation works in partnership with Southwark Council to develop truly affordable homes designed by and for the local community, as witnessed on a recent visit from your Lordships’ Built Environment Select Committee. These community-based housing enterprises are among hundreds of varied initiatives up and down the country that deserve the recognition proposed by these amendments.
In conclusion, I welcome the inclusion of housing in the Bill, as part of the integration of services to achieve health and well-being objectives. I support the amendments in the name of the noble Lord, Lord Howarth of Newport, in extending this to embrace the wider urban and green environment that impacts health and well-being. I also commend the noble Lord’s amendments that would give prominence in the Bill to the voluntary and community bodies of which, I maintain, those with housing objectives now represent an important part of the country’s social fabric. I support the amendments.
Baroness Morris of Yardley Portrait Baroness Morris of Yardley (Lab)
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My Lords, I also wish to support the amendments that have been moved by the noble Lord, Lord Howarth, and supported by other speakers. I do not want to make a long speech, but I want to add weight to the argument by standing up and offering support. I will not repeat his arguments, but I want to pay tribute to the work that the noble Lord, Lord Howarth, has done in this regard. He chairs the All-Party Parliamentary Group which produced a report that was pivotal in taking this debate forward. The work that he has done with the National Centre for Creative Health has given us an army of evidence on its importance.

The amendments seem to fall into two groups. There are those around social prescribing for people with dementia as the noble Baroness, Lady Greengross, said, and the notion of health promotion by creating a better environment in which we live and preventing illness. That collection of amendments is an idea whose time has come. There is an amendment for later consideration to which I have added my name, for which the same arguments are being made for sport and recreation. I think of this as the whole area of health promotion, which is looking at non-clinical providers of healthcare. I think these amendments follow on very well from the last group of amendments that was debated.

The noble Lord, Lord Scriven, talked about the aims of this legislation as being about promoting well-being, and the noble Baroness, Lady Cumberlege, gave a very good example of how a community centre that had doctors in it has become a medical centre, and the message that they gave. Every single one of us here could make the arguments that we have heard so far, either from our own example—from our own health and well-being—or from something we have seen.

I wanted to mention two things. First, I declare an interest: I am director of the Royal Liverpool Philharmonic Orchestra, and the work that it does with Mersey Care NHS Foundation is magical. It sometimes goes unnoticed outside the region, but people with quite serious mental health needs are finding their well-being is promoted. They are enjoying themselves and feel more part of the community.

My second example is some work I did in Derbyshire with a charity of which I was patron, First Taste. The artwork it did in a care home meant that the prescription of drugs for sleeping and other things was reduced. All those arguments can be well made but my problem is this: I would have put money on no one standing up and arguing against these amendments. If you could stop 50 people out there and find three who will argue against these amendments, I would say “Well done”.

The danger for this area of policy is that no one is against it, but not enough is being done to get it to the top of the agenda. Sometimes, when no one is against it, you do not have the argument that promotes it up the national agenda. Everyone says “Great”, “We agree”, “It will be a great thing” and nothing happens. The stage of this area of policy is that everybody is doing a little bit. It is in the long-term plan. There are examples of good practice. We have the evidence that it works and the Government are investing some money, but it is never going to be an entitlement or a policy that has been enacted nationally unless something else happens.

In all public sector policies—it is the same in education—the biggest challenge is scaling up good practice. We now have lots of examples of good practice. What we need, and what is behind this amendment, is to scale it up so that it is not just a case of happening to live near an organisation or where somebody is making this happen. The amendments that we have, which are to the general duties of the integrated care boards, will be a step forward in trying to make this a national part of our well-being service. You are entitled to it; it is there and offered to you, no matter where you live.

That is the big task now. It is not making the case for social prescribing or non-clinical providers having a role to play in health promotion, but how we scale it up so that it goes higher up the agenda of people who are developing policy and deciding how resources should be spent in an area. Years ago, this would have been seen as a fringe interest and people might have thought the noble Lord, Lord Howarth, was eccentric in promoting such amendments. It is evidence-based now. It is what people know works and I think it is what people want. We just have to find a way of getting it up the agenda and making it happen. These amendments will go towards that end.

Baroness Tyler of Enfield Portrait Baroness Tyler of Enfield (LD)
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My Lords, I rise briefly to support this suite of amendments put forward by the noble Lord, Lord Howarth. I know how passionate he feels about this issue and how much work he has done in this area over many years. The noble Baroness, Lady Morris, has just taken the words right out of my mouth; I was going to start by saying that social prescribing is a phenomenon whose time has come. I think that is right. People understand that the approach of social prescribing is really opening up opportunities for people to improve health and well-being through non-clinical avenues. That is what this set of amendments is all about.

This is particularly relevant for people with long-term conditions and complex needs, particularly those with mental health conditions, suffering from dementia or experiencing loneliness. The one point I want to make, which I do not think has been talked about yet, goes right back to our opening debate today about how the ambitions of this Bill will be achieved only if there is true integration across health and social care. My big plea is: please do not forget social care when we are looking at this issue. When I say social care, I am thinking both about people who have domiciliary care in their own homes and people in care settings.

18:00
I will briefly use a quick example. My mother has been in a residential care home for a number of years with a range of complex issues and conditions. I have seen first-hand the difference that it makes when there are activities. Sometimes there are arts activities, sometimes it is music or a musical quiz. The difference to my mother’s well-being and sense of mental health is enormous—as, indeed, is her sense of agency and empowerment, because she used to be an artist. Once that was understood, it was even possible to organise an event where she was sharing her knowledge and her expertise with other residents. I know that did a massive amount to boost her self-esteem. Very sadly, however, during the pandemic and lockdown, there were so many times when residents were confined to their rooms and unable to go into communal areas, or when the person who normally delivered these activities was not available, so these events did not happen. It was only a matter of weeks before I saw my mother’s well-being really go down very dramatically indeed. I am therefore massively in favour of this group of amendments, designed to support vulnerable people who are lonely, isolated or experiencing poor mental health, or have learning disabilities.
I will finish on a point that we talked about earlier today, the problems of funding social care. The funding cuts that local authorities have received over the past 10 years are such that it can be really difficult for them to find the money for this sort of activity in social care. I really hope that the powers that these amendments envisage ICBs having would go across the whole range of health and social care and will not just be limited to people in healthcare settings.
Lord Crisp Portrait Lord Crisp (CB)
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My Lords, I congratulate the noble Lord, Lord Howarth, on introducing this very important group of amendments and other noble Lords who have made some very interesting points, such that made by the noble Baroness, Lady Morris of Yardley: this is becoming received wisdom, whereas it might have been regarded as eccentric even five or 10 years ago.

I have three points to make. First, this is a Bill about integration and partnership. It would be good to have a clear message that non-clinical groups such as the ones we are talking about are part of that, in whatever is the appropriate way—a duty or obligation or something of that sort on in the Bill—without being too specific about the detail.

Secondly, the noble Lord, Lord Howarth, made the point that this is the rediscovery of ancient wisdom, not least, as the noble Baroness, Lady Barker, pointed out, through Covid. I am talking about human flourishing going back to Aristotle and many others in the past: the merging of that ancient wisdom with very modern evidence—more evidence all the time about things such as relationships, as well as the arts and everything else that has an impact on our health.

My third point is about impact. I co-chair the All-Party Parliamentary Group for Prescribed Drug Dependence. Last year, 17% of the adult population were prescribed antidepressants. That is a huge amount: when I see such a figure, I always have to remind myself that that means that 83% of us were not. However, 17% is a huge number, and the sort of things that we are talking about can reduce that number to the benefit of the people who would otherwise be prescribed antidepressants, making enormous economic savings, time savings and so on.

Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (CB)
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My Lords, I strongly support this group of amendments. I would like to make sure that we realise that the medical humanities as a discipline have now been introduced in many medical schools. In my own, I was rather glad that AJ Cronin’s book The Citadel was introduced in general practice, particularly because, of course, he invented Dr Finlay, but there we are.

Quite seriously, we must not forget that loneliness kills. Loneliness is a true killer; it shortens lives. If people are not moving around well, they fall more and consume healthcare resources. Therefore, having green spaces and things such as sports for health, and so on is important. There is now also a body of evidence that the new intensive care units have used in the way that they are constructed, so that there is a view of outside spaces for those patients, rather than the total sensory deprivation that occurs to them in the very noisy and difficult environment of intensive care. Of course, music is used therapeutically during procedures and so on.

In the hospice world, lots of activities obviously go on in the day centres. As my noble friend Lady Greengross said, there is now good evidence for proper physiological mechanisms that explain why contact with these different disciplines—which were considered to be outside medicine—have a beneficial effect on healing, coping with pain and distress, resolving issues, reframing what is happening to you and so on.

I would like us not to forget that loneliness kills. Importantly, so many patients have said that they have a sense of personal worth when they are still able—however ill they are—to contribute to those around them and to a sense of community. These amendments go to the very heart of being human—that is, the inherent creativity within people that has been forgotten for decades in the provision of health and social care.

I can see that there are difficulties in bringing this into the Bill, but we should commend the noble Lord, Lord Howarth, for the sophisticated way in which he has worded some of these amendments. I hope that they can be built on as we go forward. This could save a huge amount of money for the NHS in the longer term. A huge number of side-effects of drugs could be avoided. People could be fitter. There would be fewer forms. There is a great amount of optimism behind these amendments.

Baroness Pitkeathley Portrait Baroness Pitkeathley (Lab)
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My Lords, what I want to say follows on very well from what the noble Baroness, Lady Finlay, said. I want to quote Sir Michael Marmot. He said:

“We need to adopt a health and social care system which prioritises not just the treatment of illness but how it can be prevented in the first place. The pandemic has made it crystal clear … why public health and … social determinants of health are so important. The health and social care agenda must be rebalanced towards prevention.”


This is essentially what the noble Lord, Lord Howarth, is saying. It is not just about the treatment of illness but about preventing it happening in the first place.

I commend my own general practice in north London. In despair at the quantity of antidepressants being prescribed with very little result, it took to organising community groups to do cooking, set up friendship groups and put people in contact with each other. It puts on bring and buy sales—all with people who, perhaps, in the past, might just have been prescribed antidepressants.

I want to say a word about the charitable aspect—the voluntary sector—to which the noble Lord, Lord Howarth, referred. Charities cannot operate unless their core costs are met. My own GP practice which did this wonderful work had to go to the local authority and to the lottery to seek some funding. We have to remember that, if we want voluntary organisations to participate in these wonderful preventive services, we need to ensure that they are properly funded.

Baroness Bennett of Manor Castle Portrait Baroness Bennett of Manor Castle (GP)
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My Lords, I join pretty much everyone else in commending the noble Lord, Lord Howarth, for tabling these amendments. I have attached my name to Amendment 67, although it could have been to any of them.

It is worth making two broad points. In her wonderful contribution on the last group, the noble Baroness, Lady Cumberlege, used the really key phrase,

“the community provided the health”.

That is what this group of amendments is talking about.

A couple of groups back, the noble Baroness, Lady Thornton, talked about how, if the health system is working for people with learning disabilities, it is working for everybody. If we bring in the kind of institutions, frameworks and supports that we are talking about here—if we think about stopping people getting ill and caring for ill people—we will make our communities vastly better for everybody. This is an important point to make.

Like most noble Lords, I could come up with a list as long as your arm of wonderful places I have visited. I will not, but I will mention one, which brings together three elements of this: creativity, nature and culture. The Green Backyard in Peterborough is the most wonderful space. I defy anyone to walk into it and not smile. It has amazing, colourful, moving sculptures powered by water, with food growing—amazing salads filled with flowers. When I visited, I spoke to the carer of another visitor. This visitor had very profound disabilities—she was blind and non-verbal—but her carer said, “I’ve never seen anything like it. After the first time we came to visit, the next Monday, which she knew was the day we visited, she was all packed up, dressed and ready to go out.” This was obviously catering to someone’s needs absolutely brilliantly, but it nearly got bulldozed and turned into a block of flats a few years ago. Luckily, it was saved, but that is the situation we so often find ourselves in.

I also want to mention Amendment 90, in the name of the noble Lord, Lord Howarth. The noble Lord, Lord Best, has already said a great deal on this, so I will seek to add just a couple of small points—well, one small point and one quite big one. There is something called the lifetime homes standard, which I learned about when I visited Derwenthorpe in York with the Joseph Rowntree Foundation. The thing I remember about it, because it was so simple and obvious, was that the two-storey houses there had all been built with a space between the joists so that, if you needed to put a lift in up to the first floor, where the bedrooms were, it was a really simple and low-cost thing to do. It was a very simple piece of design. This will not be covered in the Health and Care Bill, but this relates to so many aspects of our society. You could say that housing is a health issue. In the first group this morning, we talked about social care and how many people cannot leave hospital and go home because their accommodation is unsuitable. We need to think all the way along the line across our society to make sure that does not happen.

Finally, I want to pick out one or two words in this amendment, which talks about housing and urban environments. I thought here of the New Ground co-housing development in north London, which is for women aged over 50. One aspect of it is looking at how people can support each other, be good neighbours and form a community that can provide support. This morning, I attended a King’s Fund briefing talking about social care and there was a great deal of talk about the need for digital innovation and technology. I tweeted, “What about social innovation?” We have to think about how we organise our societies and urban environments so that people can form those kinds of communities. If you visit any area of new housing being built around the country, there is typically precious little in it to encourage that kind of community development. The housing point is obvious, as is the environment point, but let us not lose the community and urban structure points from that amendment either.

Baroness Walmsley Portrait Baroness Walmsley (LD)
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My Lords, it has been an excellent debate. We have heard about all the various kinds of arts and the effect of housing. We heard from the noble Baroness, Lady Morris, about sport and leisure. We heard about the importance of green spaces in helping us with our physical and mental health. The noble Baroness, Lady Finlay, rightly mentioned that loneliness kills. If one can address that, it affects not just one’s sense of worth and well-being, as has been said, but one’s sense of community.

Parliament is a community. It sometimes does not feel like it, because we have various groups, political parties, Members, staff and so on, but we also have a lot of all-party groups and this is significant. We have sports, arts and heritage, drama and music groups. I have been a member of the Parliament choir for 22 years and have found great solace in it—I really missed it during the pandemic.

18:15
My noble friend Lady Tyler said that we must not forget about social care. I was very interested to hear about her artist mother and how she had shared that within her social care setting. My mother was a singer, as am I. When she was in her 70s, we were rather amused because she would talk about going and “singing for the old people” in the local care home. She did that to great effect. She got a lot out of it and so did they. I say to the Minister that I have been known to sing with the jazz band of the noble Lord, Lord Colwyn, so if he is looking for a vocalist for his blues band, I might just audition.
If Parliament as a community can benefit from all these things, then every community can. It is absolutely right that the noble Lord, Lord Howarth, should raise these issues. I would be interested to hear how the Minister feels that this principle can be incorporated in the new world of integrated care services.
Baroness Thornton Portrait Baroness Thornton (Lab)
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My Lords, I am delighted that my noble friend Lord Howarth has brought this suite of amendments in front of the Committee and is bringing the wealth of his experience to our debates on the Bill. He is a great proponent of the role and value of the non-clinical services in healthcare and well-being, and quite rightly too. It would be great if, somehow or other, this could be recognised in whatever comes out of our considerations, though I challenge the Minister to tell us how we might do that.

We support the amendments in this group to establish a role for wider considerations beyond remedial, interventionist clinically-led care. Amendment 90 covers housing. The role of decent housing in good health and in tackling health inequalities cannot be overestimated. Amendment 103A would require IBCs to consult on youth health prevention and treatment through an advisory board consisting of young people. All these amendments have huge merit.

I know that we will have a wider discussion about the role of the voluntary sector and social enterprises in provision of healthcare in a later group. However, voluntary and community organisations and social enterprises have been central to the delivery of non-clinical services in healthcare and well-being, particularly during the pandemic.

Baroness Chisholm of Owlpen Portrait Baroness Chisholm of Owlpen (Con)
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My Lords, before I respond on this group, I want to apologise for the chaos that I caused at the beginning of this Bill today. I hope that noble Lords did not think I was being discourteous to the House. Luckily, next Wednesday, normal services will be resumed when my noble friend Lady Penn is in her seat.

I am grateful to the noble Lord, Lord Howarth, and other noble Lords for bringing this suite of amendments before the Committee. It was interesting that several noble Lords brought up my noble friend the Minister’s band, Exiled In Brussels, which I think he is now going to rename “Exiled From Brussels”. I can say that there is a YouTube clip of the band which my noble friend said he is willing to send out to everybody, so that is something to look forward to.

On Amendment 59, I recognise the noble Lord’s concern to ensure that the voluntary, community and social enterprise sectors are represented in the Bill. I understand the intention of his amendment. I certainly acknowledge the important work of these sectors and their contribution to our health system. I am sure that we all have examples of how these non-clinical services are of benefit to our health system.

However, our intention, quite rightly, is to use the Bill to set out a framework of duties for ICBs that ensures they fulfil their functions effectively while avoiding being overly prescriptive. The provision in question sets a clear requirement on ICBs to discharge their functions in a way that promotes continuous improvement in the quality of services, particularly in health outcomes.

The intention is to establish a culture of continuous improvement in everything the ICB does, but, importantly, leaving ICBs to decide how this will work for them. Setting specific parameters, as this amendment seeks to do, would in practice narrow the focus of how they may look to improve the quality of services. This may be to the detriment of taking a more holistic approach to how to improve the quality of services. That said, the current drafting of the provision would not prevent ICBs engaging providers of non-clinical services, including those mentioned in the amendment of the noble Lord, Lord Howarth of Newport. Indeed, we would expect that, where appropriate, ICBs would consult with relevant stakeholders, such as those from the voluntary sector, to ensure continuous improvement.

Turning to Amendment 69, co-production, where people, family members, carers, organisations and commissioners work together as equal partners to design and deliver services, is an important principle, and one that we would expect ICBs to champion. This is reflected clearly in NHS England’s draft implementation guidance on working with people and communities, which also sets out several practical steps ICBs should consider to appropriately promote and embody co-production. This includes visibly supporting and sponsoring co-production, and supporting the adoption of co-production approaches where appropriate. I feel it is important to point out that mandating co-production in all circumstances risks narrowing the duty and may lead to other valuable methods of involvement being marginalised. Therefore, while it will often be a desirable aim that we would expect ICBs to pursue, it may not be appropriate in every case, and we want to allow ICBs and patients discretion to determine what is best in their area.

I will address Amendments 71 and 77 together. I am grateful to the noble Lord, Lord Howarth, and the noble Baroness, Lady Greengross, and I appreciate the interest in including social prescribing in the Bill. On Amendment 77, I begin by assuring noble Lords that the Government are absolutely committed to the rollout of social prescribing in line with the NHS Long Term Plan commitment. The plan was to have 1,000 new link workers in place by 2020-21, a target which I am pleased to say has been exceeded, so that we now aim for at least 900,000 people to be able to be referred to social prescribing by 2023-24. As of September 2021, there were at least 1,582 social prescribing link workers in place. Furthermore, in relation to innovation, the Government have set up the National Academy for Social Prescribing, in line with our manifesto commitment, which has continued to support the expansion of social prescribing and promote innovation in health and well-being across all sectors.

The duty to patient choice should be considered by ICBs as part of the broader move towards more integrated, population health-management approaches. This requires embedding more personalised care models that enable patient choice and also consider non-clinical approaches, in line with the NHS Long Term Plan. This commitment is to make personalised care business as usual across the health and care system. Social prescribing and community-based support is already a core component of the NHS’s comprehensive model of personalised care. I hope I have reassured noble Lords of the progress being made and work being done on social prescribing and that they will feel able not to press these amendments.

I turn next to the amendments proposed by the noble Lord, Lord Howarth, and the noble Baroness, Lady Bennett of Manor Castle, which would insert a number of references to the voluntary community and social enterprise and creative and cultural sectors. This Government hugely value the contributions of the voluntary community and social enterprise sector, including creative and cultural entities, to the health and well-being of the nation, and recognise their important role in integrated care systems. However, we feel that the amendments are not necessary, as their intended effect is already possible through provisions within the Bill.

A key principle of the Bill is the legislative flexibility to empower local leaders to develop bespoke solutions to meet specific local needs. This principle is reflected in the current drafting of Clause 20. Several of these amendments would have the effect of being overly prescriptive in areas where we would already expect the VCSE sector to play a key role.

I assure noble Lords that many of these concerns will instead be addressed in guidance. NHS England and NHS Improvement have published guidance relevant to ICBs on partnerships with the voluntary community and social enterprise sector, outlining the importance of the VCSE sector as a key strategic partner in local health systems. It provides guidance on how VCSE partnerships should be embedded in how the ICBs operate. Furthermore, the guidance sets out that, soon after they are established, ICBs will be expected to develop a formal agreement for engaging and embedding the VCSE sector in system-level governance and decision-making arrangements.

I turn to related Amendment 80. I know that the noble Lord, Lord Howarth, has a special interest in this issue, and I listened with interest to his speech at Second Reading on the work of the National Centre for Creative Health, which he chairs. Research is very important, and I am pleased to say that the department funds research in this area through the National Institute for Health Research. The NIHR funds and supports a range of research conducted by multidisciplinary researchers from diverse fields, including social sciences, behavioural sciences and the humanities. For example, the MODEM project, jointly funded by the NIHR and UKRI, reviewed evidence on music therapy and identified that a structured programme of music therapy given by a trained therapist can reduce agitation among people with dementia—which I think the noble Baroness, Lady Tyler, mentioned in her speech.

We do not consider it appropriate or necessary to specify particular research areas in primary legislation. In addition, we expect that ICBs will already promote a range of research, including those on non-medical interventions, and the noble Lord already cited in his Second Reading speech where this has been done by existing integrated care systems.

On Amendment 82, the Government place the utmost value on supporting the health and well-being of NHS staff. We are taking a range of actions to ensure that this remains a priority across the health and care system, and we do not believe that a legislative duty is needed in this area. Over the past two years we have seen as never before the intense pressures on the workforce, and we recognised at an early stage the toll that this may place on the mental health and well-being of health and care staff, with a clear need to prioritise enhanced well-being and mental health support for all NHS and social care staff. We all know that the whole country owes these staff an immense debt of gratitude.

At a national, strategic level, the People Plan, published in July 2020, puts NHS staff health and well-being at its core and ensures that all NHS staff have access to a comprehensive psychological and emotional support package. This includes a dedicated support line that is available for staff 24/7, and free access to mental health and well-being apps. Alongside this, 40 dedicated mental health hubs have been established and are accepting referrals across the country to proactively identify at-risk people and groups and focus on staff with more complex needs, ensuring that they receive rapid access to evidence-based mental health services. To ensure that this offer continues to improve staff mental health throughout 2021-22, an additional £37 million has been invested in 2021-22, building on the £15 million in 2020-21. I hope that the noble Lord, Lord Howarth, will accept that this work is worth while and important and will continue without the need for legislative amendment.

18:30
On Amendment 90, we recognise, as we heard from the noble Lord, Lord Best, that good-quality housing is a vital component of a healthy life, and we support the ambition of closer collaboration between the health system and the planning system. However, housing is a local authority function, and we do not need to duplicate responsibilities by placing specific duties on ICBs. I hope I can give noble Lords comfort in that, in many places, integrated care partnerships are also intending to consider housing needs in their areas, alongside health, public health and social care needs, as part of the integrated care strategy. The ICP model is flexible enough to allow the right people to take part in the discussion.
I have spoken for rather a long time, but this is an important subject. I hope I have reassured noble Lords that it is very much part of health going forwards, but I regret that the Government cannot accept these amendments, and I ask noble Lords to withdraw or not move them.
Baroness Bennett of Manor Castle Portrait Baroness Bennett of Manor Castle (GP)
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Before the noble Baroness sits down, I would just like to go back to some of the earlier amendments and some of the words she used. She said this is included in the guidance on using social prescribing, and that it is expected that ICBs will work with local social enterprises, et cetera. I want to ask a question. If we were talking about NICE-recommended medical treatments or the best possible surgical procedures, would we be saying that it is expected that ICBs will do this as it is included in the guidance? This picks up on the point the noble Baroness, Lady Morris, was saying that this still seems to be somewhere in the second class, and it should be up there in the first class, treated in the same way as a medical treatment or a medical device.

Baroness Chisholm of Owlpen Portrait Baroness Chisholm of Owlpen (Con)
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Well, I think it is, actually. We all realise how important it is. Social prescribing is a key component of the NHS’s universal personalised care. It is a way for GPs or local agencies to refer people to a link worker. Link workers give people time to focus on what matters and take a holistic approach to people’s health and well-being. They connect people to community groups and statutory services for practical and emotional support.

For instance, a man had bad bronchitis and asthma and was continually going to the doctor and costing the NHS a great deal of money; and it was agreed that a humidifier would be prescribed to him for his house at £800, and that has been a huge success, with the result that he has not gone to the GP once for a whole year. I think social prescribing can work well for those who are socially isolated, whose well-being is impacted by non-medical issues and who routinely present to primary or secondary care as a result. We certainly are taking it seriously.

Baroness Barker Portrait The Deputy Chairman of Committees (Baroness Barker) (LD)
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The noble Lord, Lord Howarth of Newport, is taking part remotely. I invite him to speak.

Lord Howarth of Newport Portrait Lord Howarth of Newport (Lab) [V]
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My Lords, I am extremely grateful to the considerable number of noble Lords who have taken part in this reflective, interesting and important debate. I am most encouraged by the appreciation that has been expressed all around the House for the importance of the considerations that I have sought to advance in this suite of amendments.

I am particularly grateful to the noble Baroness, Lady Barker, for her opening speech, which very much set the tone of the subsequent debate, and for sharing with us her memories of Google on a winter’s night. She made a particularly important point about evidence that is developing to demonstrate, for example, that the practice of mindfulness has benign effects on brain development. That is profoundly important for health. This needs to be understood and taken seriously by those who fund research and those who are pioneering practice within the NHS.

The noble Lord, Lord Best, may remember, as I do fondly, that, many years ago—I mention this particularly to the noble Baroness, Lady Bennett of Manor Castle—he showed me the Lifetime Homes project that he led when he was in charge of the Joseph Rowntree Foundation in York. He has been an advocate of the importance of well-designed housing for a long time and is a voice that is hugely respected on this, as on so many other subjects, in your Lordships’ House.

My noble friend Lady Morris of Yardley raised the important point that yes, we have come a long way and these ideas are no longer seen as eccentric, but, at the same time, unless policy is much more clearly enunciated and embedded, little, if anything, will really change. That is a question that the Minister did not adequately address, but I shall come back to it in a moment.

I was also grateful for the support from the noble Baroness, Lady Tyler, and the emphasis that she rightly gave to the contribution that the arts, creativity and other non-clinical services can make to the well-being of people in social care. I should mention that the charity Live Music Now, founded many years ago by Lord Yehudi Menuhin, has been supporting young professional musicians to perform in social care settings for many decades. That is hugely appreciated and beneficial. If his efforts were supplemented by those of the mother of the noble Baroness, Lady Walmsley—indeed, by the noble Baroness herself—so much the better.

The noble Lord, Lord Crisp, has thought more deeply about these matters than almost anyone else I know. Along with other noble Lords, he is a valued participant in the work of the All-Party Group on Arts, Health and Wellbeing. I commend to noble Lords a recent and beautiful article written by him in Prospect magazine, entitled, “What Aristotle can teach us about building a better society”. In it he writes so wisely and so well about health and human flourishing. As he will be aware, I am indebted to him for some of the language I used in my opening speech.

My noble friend Lady Pitkeathley made a crucial point about how essential it is that funding is provided to cover the core costs of the voluntary and charitable organisations upon which we so largely depend for the delivery of non-clinical services.

The noble Baroness, Lady Finlay, gave us the stark warning: loneliness kills. I very much appreciate her deep understanding and acceptance of the propositions that I and others have been making around creative health, and the support that she gave us in the creative health project.

The noble Baroness, Lady Greengross, made a particularly important, specific and practical recommendation that people should be referred for music therapy or other kinds of creative health interventions at the onset of symptoms of dementia without having to wait for perhaps many months for a formal diagnosis.

I am sure that the noble Baroness, Lady Chisholm of Owlpen, who was, after all, a nurse, personally appreciates the significance and value of what we have been talking about, even if she was briefed to bat away these amendments. She sweetened the pill by promising us a viewing of the YouTube clip of the Minister’s band.

I understand why the noble Baroness contended that the Bill should not be overly prescriptive, but, if that is so, I wonder how she answers the crucial question posed by my noble friend Lady Morris of Yardley: if we do not embed these duties—I would contend they are legislative duties—and responsibilities in the formal arrangements of the system, how are we going to get the step change and scaling up? How are we going to get the decisive shift in the culture to make non-clinical approaches truly integral to the practice of health and social care?

I was surprised when the noble Baroness, Lady Chisholm, advised us that these amendments could have the perverse effect of militating against a holistic approach, but she gave encouragement in what she said about the VCSE sector, in the willingness of the National Institute for Health Research to provide funding and in the thoughtful, extended observation she made about staff needs and the importance of housing. She said that housing is a local authority responsibility. Yes, that is technically true, but that is exactly the problem we debated earlier this afternoon, on which my noble friend Lord Hunt of Kings Heath energetically put forward his thoughts, supported by many other noble Lords. If the Bill continues to demarcate the responsibilities of the NHS and local government in the way it so far does, it will fail to achieve integration in very important respects—and surely we do not want that sort of failure.

It is precisely because of the pressures of Covid and of the backlog, which will make huge demands on NHS resources, thinking and energy for a very long time to come, that it is all the more important that we should enact into law a duty on ICBs continually, from the moment of their formal inception and sustained through the years to come, to operate strategies for the prevention of ill health and the positive creation of a healthy society, working in a multitude of ways with the populations they serve. I beg leave to withdraw the amendment and give notice that I do not wish to move any of the other amendments in this group.

Amendment 59 withdrawn.
Amendments 60 to 71 not moved.
House resumed.
House adjourned at 6.45 pm.