Elective Care Recovery

Baroness Barker Excerpts

Monday 7th February 2022 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for not speculating. All I can say about the elective recovery plan is that there have been active discussions between my department and the Treasury, and we expect to publish it very soon. On waiting lists, we are looking at how we can best target the backlog. We know that about 75% of patients do not require surgical treatment but require diagnostics. About 80% of patients requiring surgical treatment can be treated without an overnight stay in hospital. Around 20% of patients are waiting for either ophthalmology or orthopaedic services. We are quite clear about what the issue is, and we hope to publish the elective recovery plan very soon.

[Baroness Barker (LD)]

My Lords, the Government have set out in some detail the scale of the waiting list for elective surgery in secondary care, but are absolutely silent on the backlog in primary care. Is that because there is no plan to deal with the backlog in primary care, which has an inevitable knock-on effect on hospital care?

[Lord Kamall (Con)]

We are looking at elective recovery all the way through; some of that will be in secondary care but, clearly, some of that will be in primary care. One of the issues that we want to be sure of is that we have more and more diagnoses, which is why we have rolled out many community diagnostic centres. We are looking to tackle the complete backlog, which is why we have committed an additional £2 billion this year and £8 billion over the next three years and why we will publish the elective recovery plan very soon.

Personal Protective Equipment: Accounting

Baroness Barker Excerpts

Wednesday 2nd February 2022 Lords Chamber

[Lord Kamall (Con)]

The noble Baroness raises a very important point about storage costs, and we are looking at how we can reduce them. We have managed to reduce weekly storage costs at the moment, but one of the things we are looking at is how we can pass on, donate or sell some of the equipment that is in storage. We have certain standards, other countries have other standards, and we are making sure that we are selling stuff that meets WHO standards.

[Baroness Barker (LD)]

My Lords, in December 2021, Edward Argar reported that the Government were paying £4.5 million a week for storage costs for PPE. Are those storage costs for stuff which is now unusable?

[Lord Kamall (Con)]

As I said earlier, a very small percentage was unusable, but we are looking at some of the things that are supposedly past their use-by and sell-by dates—rather similar to food; people know about the debate around food wastage. We have put out a tender for scientists to look at the equipment to see whether its life can be extended or it can be used in a useful way.

Health and Care Bill

Baroness Barker Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I very much support the noble Baroness, Lady Greengross, in her amendments. We should be clear that continuing health needs are ignored by assessors because of the issue of who will pay. I have experienced this twice with neighbours and friends. It was clear to me that both patients had complex needs, mentioned by the noble Baroness, Lady Finlay, and had undeniable continuing care needs, so I was puzzled as to why the families were working out how to fund places for their relatives. They had never been told of the possibility of continuing NHS funding. I suggested that they quote the legislation back to the assessors and of course when they did so they found that funding would be provided—and some years later it is still being provided. Without this chance encounter with me, and asking the right questions, those families would have been denied the funding that is their right.

[Baroness Barker (LD)]

My Lords, as ever, it is a great pleasure to row in behind my former boss at Age Concern—the inspirational leader of Age Concern for so many years—to return to an issue that Age Concern and its successor body Age UK have for decades raised with successive Governments during successive NHS reorganisations.

It is important, at the outset of this debate, that we understand the true importance of NHS continuing care. On one level, an individual level, it is about enabling people who have long-term conditions to live dignified lives in the community. At a strategic level, in terms of healthcare planning, it is about keeping people out of acute hospitals, which is the most expensive form of care.

The reason why it is right, again, that we seek to put these amendments on to the face of the Bill is that, at an organisational level within the NHS, there has never been a full accountability path for NHS continuing care. That means that, when it comes to individual decision-making on the part of members of staff in relation to individual patients, the decisions fall down. We have not just wide variation between different organisations but wide variation between particular practitioners, who sometimes resort to using non-standard checklists to make decisions, with inconsistent decision-making.

As a result of that, it is hardly surprising, but a real condemnation of a long-term failure of the NHS, that there is a need for an organisation such as Beacon to exist. It is a social enterprise set up by the main charities that gives information to older people and their carers. It should not have to exist. The fact that it does, and that it is a profitable social enterprise business, is testimony to the extent to which older people and their relatives are being badly let down on this.

I hope that in raising this yet again we have shone a light on a part of the NHS system that goes to the heart of what this Bill is supposed to be about. If we do not make this an express responsibility of the NHS in the Bill, yet again it is just not going to happen.

[Baroness Walmsley (LD)]

My Lords, I, too, support the noble Baronesses, Lady Greengross and Lady Finlay. It is right that people should have the cost-effective continuing care to which they have a right. I have my name on the amendment tabled by the noble Lord, Lord Sharkey, and I intend to make some very brief comments about that, although I make the point that the need for us to be brief is the Government’s own fault, because they have not given us enough days in Committee—fewer in fact that in another place.

On the amendment, we refer to the 15th report of the Delegated Powers and Regulatory Reform Committee. I have rarely read such a hard-hitting report by this highly respected committee. One of the worst of the Henry VIII measures that it mentions is allowing zero scrutiny on allowing NHS England, merely by the publication of a document, to impose a financial liability on an ICB. It specifies the circumstances in which an ICB is legally liable to make payments to a provider under arrangements commissioned by another ICB. The Government claim that this is an operational matter. However, if you believe that an ICB should be in total control of deciding how its funds are spent in its area in order to fulfil its duties, you might think that this is an important thing—a legal liability to pay for something that another organisation has decided to commission is quite a serious matter. The DPRRC thinks so and so does the Constitution Committee.

In their response to the DPRRC, as quoted in Appendix 1 of the committee’s 16th report, the Government said that they

“recognise that the Bill contains a significant number of guidance making powers, powers to publish documents and powers of direction.”

They suggest that

“these are appropriate because they reflect the often complex operational details, which are better illustrated by examples and guidance rather than legislation.”

The Government go on to say that there is currently a precedent in the powers of the clinical commissioning groups.

Health and Care Bill

Baroness Barker Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[Baroness Barker (LD)]

Following on from that, one point that we should take into account is the extent to which the private sector and the NHS rely on the same workforce. That is particularly the case in relation to consultants and less so for nurses.

While we can argue about the location, price or quality, perhaps, of treatment and aftercare, the key issue is diagnostics, which is a huge issue at the moment in the NHS. I have a slightly different take on that. For all of my life, my mum was deaf, and I have to say that the quality of NHS hearing aids was about 10 years behind the private sector’s—but people trusted them; they trusted the quality of the diagnostics and the advice that they were given. We have moved a long way in terms of diagnostics for eyecare and hearing aids, but it does not matter where that happens; what the general public want to do is to be able to trust the quality and independence of the diagnostics that they get. If we can do that, I rather suspect that the general public, in the wake of the pandemic, when they see the NHS struggling in all sorts of ways to make up for two years in which their staff have been pulled around, sometimes away from their specialties, would be quite forgiving—as long as there are some very basic agreements about how it will work and the integrity of the work and systems.

[Baroness Finlay of Llandaff (CB)]

I am most grateful to the noble Baroness, Lady Barker, for adding some clarification to the point that I was trying to make. I am not for or against any system; all I am saying is that the arrangements have to be in place so that nobody is jeopardised—and indeed, in the event of a patient being transferred from a private facility back into the NHS, that part of the NHS is appropriately recompensed, particularly if the patient comes from a long way away.

Health and Care Bill

Baroness Barker Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

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 (LD)]

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.

--- Later in debate ---

[Baroness Hollins (CB)]

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 (LD)]

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.

--- Later in debate ---

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 (LD)]

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 (CB)]

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.

--- Later in debate ---

[Baroness Chisholm of Owlpen (Con)]

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.

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

The noble Lord, Lord Howarth of Newport, is taking part remotely. I invite him to speak.

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

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.

Health and Care Bill

Baroness Barker Excerpts

Lords Hansard - Part 1 & Committee stage
Tuesday 18th January 2022 Lords Chamber

Moved by

[Baroness Barker]

20A: After Clause 12, insert the following new Clause—
“Appointment of a National Clinical Director for Women’s Reproductive Health
NHS England must appoint a National Clinical Director for Women’s Reproductive Health.”Member’s explanatory statement
This amendment would require NHS England to appoint a clinician to provide national clinical leadership, advice, input and support on issues relating to reproductive healthcare.

[Baroness Barker (LD)]

My Lords, I declare an interest as the co-chair of the All-Party Parliamentary Group on Sexual and Reproductive Health. At Second Reading, I said that it was not at all clear exactly what contribution the Bill would make to the strategic aims that all parties have to turn the NHS into a body that is preventive, forward-looking health promotion service, which concentrated far less on the acute sector and looks at population health much more strategically while making greater use of technology and, in doing so, seeks to reduce health inequalities. On day 3 of the detailed examination of the Bill in Committee, I am still no clearer about that.

In every set of amendments that noble Lords have put forward, they have tried to ascertain from the Government exactly how the Bill will achieve that aim—and, as yet, the answer is unclear. But if the Bill is about anything, it is about enabling those within the NHS, as well as patients and interest groups that work with them, to take what we have as a National Health Service at the moment and introduce into it new and innovative ways of looking at conditions, to build different pathways and processes of treatment in order to bring about the much-improved health outcomes that we believe are possible from the NHS.

In this amendment, I am very much influenced by the 2009 report from the Royal College of Obstetricians and Gynaecologists, Better for Women, which did exactly that: it took a longitudinal life-course investigation of women’s health needs. The report decided that the way health services have traditionally been provided is lacking, because it is by and large built on some fairly old established ways of thinking from a provider’s perspective rather than from the perspective of women and their partners. In terms of reproductive health, the RCOG report showed, with a number of different stakeholders, the many different ways in which we could look at women’s health and achieve far better outcomes.

The RCOG report started by looking at the data on reproductive health. Bear in mind that reproductive health is unique. It is perhaps the one area of medicine in which the people engaging with health professionals are, for the most part, not ill. They are in need of medical intervention and occasionally surgical intervention, but by and large they are not ill. They are going through a process that is natural but needs the informed intervention of health professionals. It is very different from other areas of acute medicine.

We have a national health service and all the years of experience behind that, yet we currently have very poor outcomes for women. Almost half of British women experience very poor reproductive and sexual healthcare. It is estimated that about 45% of pregnancies in the UK are either unplanned or there is ambivalence, and that is after decades of different Governments making concerted efforts to deal with unwanted pregnancies. The abortion rate is probably the highest it has been since records began and, crucially, access to contraception, and to particular forms of contraception, including long-acting reversible contraception, is now in significant decline. Also crucially, cervical screening for eligible women is at 70%, significantly below the national target of 80%.

This is largely due to one simple fact: we have completely fractured service provision. We know that reproductive health services were traditionally part of primary care; indeed, access to information about reproductive health services was part of the education service. We know that an element of women’s reproductive health will always have to sit in the acute sector, yet in all these years we have failed to build a coherent system that works with the three different elements—primary care, acute care and the education system—and in which women can access what, by and large, they know they need.

For some sections of our community, the outcomes are even worse. We know that the figures are much worse for women from black and minority ethnic communities. Eight per cent of abortions occur in women who report as being black, but that is in 3% of the general population. We also know that black, Asian and minority ethnic women also have much worse outcomes in maternity services. Only of late has that begun to be looked at and systematically analysed by one or two very good, interested professionals in maternity units.

The amendment, which calls for a national director, was tabled to highlight the case for having somebody in the leadership of the NHS who can look at the whole question of information for women, access to services and the different outcome statistics for different methods of arranging reproductive health services. We have different arrangements in the four nations of the United Kingdom because this is a devolved matter, so we can have comparative statistics to see which approaches work better.

If we follow the lead set out in the RCOG report, we can have an inclusive approach to women in all their diversity, and inevitably we will look at systems that are beneficial to men. Clearly reproductive health has a particular impact on the lives of women, but men are included too.

It seems to me that, if this Bill and the flexibilities in it are a route to better outcomes, this is perhaps one way in which we could try to have innovation at the centre. It impacts in different ways throughout the system, which hopefully will be integrated between local government, primary care and tertiary care. It is in that spirit that I beg to move the amendment.

[Baroness Walmsley (LD)]

My Lords, I support my noble friend’s proposal for this simple reason: it would enable focus on the very particular needs of women’s reproductive health. As we heard earlier in our debate, children have specific needs. Well, so do women, particularly with reference to their reproductive cycle.

I am particularly keen on the element of prevention of ill health. Many services for women focus on it. Obviously, we all have cause to be grateful for the breast and cervical screening services that are available; I was professionally involved with them many years ago. It is also, however, cause for concern that the number of women taking advantage of those important preventive services has been falling. A national lead would have the expertise, responsibility and ability to focus on areas where women need to be encouraged to take advantage of the services that are available to them.

There must be concern about the quality of maternity and perinatal services, given some of the dreadful cases that we have heard about and the poor quality that has been rife in a few centres in the country in the past. I hope that things are being put in place to improve that, but there is an element of prevention here too. Good-quality maternity services prevent women and their babies having a bad experience at the beginning of their life together. It is so important for the ongoing mental and physical health of the child that women can bond with their children and babies can bond with their mothers. That bonding starts at the very beginning, but it is less likely to happen with poor-quality maternity services, which of course cost the health services and the country later on.

These services are vital for preventing further problems not just for the mother but for the children. It is the sort of thing that a highly qualified and knowledgeable national lead can focus and advise on in trying to ensure that access to good-quality services is available to all communities in the country. My noble friend Lady Barker highlighted the difficulties that some communities face in getting those good services. I hope that the Minister will consider this amendment in a positive light.

--- Later in debate ---

[Earl Howe (Con)]

My Lords, I am most grateful to the noble Baroness, Lady Barker, for bringing Amendment 20A before the Committee today, and to the noble Baronesses, Lady Walmsley and Lady Thornton, for their very wise insights. I do not think there can be anyone in Committee who does not agree that delivering high-quality reproductive healthcare is critical for the health service.

This is definitely a priority area in the Government’s work on the women’s health strategy for England. Proof of that, I hope, is that on 23 December 2021 we published Our Vision for the Women’s Health Strategy for England. The vision is informed by analysis of the call for evidence, which ran for 14 weeks from March to June 2021.

On reproductive health specifically, the vision sets out our ambition that

“women can access services that meet their reproductive health needs … and women’s experiences of services and reproductive health outcomes are improved”.

As a bit of further background, we were clear that the strategy should be evidence-based, so the vision is in fact underpinned by the analysis of what we heard through the nearly 100,000 responses to the call for evidence. We owe it to women and girls across England to get it right, and when we publish our full strategy later this year we will set out our ambitions in more detail and will follow that up with full delivery plans where appropriate.

Joined-up national policy and clinical leadership are essential to the delivery of women’s reproductive health services. I can assure the Committee that this is also recognised as a priority by NHS England and NHS Improvement. We continue to work closely with NHS England and NHS Improvement on the development of the women’s health strategy for England. We will also be working closely with NHS England and NHS Improvement on the Government’s forthcoming sexual and reproductive health strategy to ensure that, together, the women’s health and sexual and reproductive health strategies take a holistic and comprehensive approach to improving women’s reproductive health. The sexual and reproductive health strategy will consider how we can strengthen leadership and accountability in relation to reproductive health, as well as how we improve access to contraception.

Self-evidently, NHS England regards these as major areas of work. We do not, however, think it appropriate in the Bill to require NHS England to appoint an additional national clinical director specifically for reproductive health. The first reason is because, within the current NHS England and NHS Improvement, the role of national clinical director for maternity and women’s health already exists. This position is responsible for clinical advice and leadership on obstetrics and gynaecology matters, which are of course important areas of women’s reproductive health. The post is currently held by Dr Matthew Jolly. The national clinical director works alongside the national speciality advisers for gynaecology and four other national speciality advisers, covering broader aspects of obstetrics and public health. Creating an additional post of national clinical director for reproductive health is likely to be counterproductive, in that it may lead to duplication or less clarity over responsibilities and clinical leadership.

Secondly, as a point of principle, we should try to resist the urge to specify the clinical directors that NHS England should appoint. If we make a habit of doing that, it strips it of its operational autonomy. It is better to allow it to determine the directors it needs, based on the challenges it faces.

The noble Baroness, Lady Barker, rightly pointed out the disparities that exist between different groups of women in this country. I can only express my agreement with the points that she made on that subject. It is essential that we recognise that women are not a homogenous group. The different characteristics that make up each woman’s identity can lead to multiple, sometimes overlapping barriers to accessing healthcare and can contribute to disparities in health outcomes.

When we launched the call for evidence that I mentioned, we said that we wanted to better understand where there are disparities between men and women and between different groups of women. As set out in the vision, a key priority running through this work is to ensure that all women have equitable access to and experience of services and that disparities in outcomes are reduced.

In addition, NHS England and NHS Improvement regularly review their clinical leadership, including national clinical director and national specialty advisor roles, to ensure alignment with strategic priorities for the NHS and patients, as set out through the NHS Long Term Plan, and to support areas in which NHS England and NHS Improvement are taking forward major programmes of work or areas identified as priorities for improvement. In other words, this is not a static landscape. I hope that the noble Baroness will be reassured by this and so will be able to withdraw her amendment.

[Baroness Barker (LD)]

My Lords, I thank noble Lords who have contributed to this debate. I realise that time is at a premium, but it was useful to air these issues. I thank the Minister for his full response, although it was not entirely unexpected.

I do not doubt that NHS England has a number of clinical directors, but the stats speak for themselves: 45% of pregnancies are either unplanned or ambivalent and abortion rates are at their highest level. Whatever we have at the moment is not working. The call for this director came from the Faculty of Sexual and Reproductive Healthcare and RCOG; they are people who know this subject in great detail.

I know that across the NHS there are different initiatives trying to bring a greater understanding of gender in medicine. For example, for NHS England I know that the Government are working with the Royal College of Physicians to try to bring about a greater understanding of gender in medicine in the form of training for medical students. But this area of medicine is one in which information, and particularly digital transformation, is already having a significant impact and could have an even greater impact on outcomes. That in itself is a challenge to practitioners, and NHS practitioners are not always the best at dealing with that sort of challenge to their existing practice. Therefore, there is perhaps a case for refreshing the clinical leadership of NHS England in this respect.

If the stats do not improve, we will definitely have to look at this before too long. I listened to what the Minister said about the two strategies that are coming out and I will look at them with a keen eye. In the meantime, I beg leave to withdraw this amendment.

Amendment 20A withdrawn.

Health and Care Bill

Baroness Barker Excerpts

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Health and Care Bill

Baroness Barker Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Barker (LD)]

My Lords, “It’s a Sin”: I invite noble Lords to think back to 40 years ago, when a deadly virus came out of nowhere. The NHS had just gone through the most radical change in years; it had developed a purchaser/provider split. We should now go back and look at everything that followed from that. I congratulate the noble Lord, Lord Stevens, on his remarks, in which he talked about this legislation being “evolutionary”. We have a question to ask of this Bill: to what extent do its proposals bring about change?

Looking back over those 40 years, the big changes happened when there were panics and big challenges to providers to stop them doing things that they had always done in the way that they had done them, and, crucially, when people in communities—sometimes geographical, but sometimes communities of interest—went and found the scientists and the medics and worked together with enlightened providers to bring about change. Given where we are, and given the experience of the last year, to what extent does this Bill do that?

It is a rather curious Bill; its arrival in this place was very strange. We have had very odd White Papers and a funding settlement on something that was supposed to be quite strategic, but we have not yet had the integration papers. So on the one hand the legislation is attempting to be very big and strategic, but, on the other, it seems to be all rushed and muddled. As far as I can see, it does not, for example, fully take into account some very big changes in demography.

We know that, at the moment, that we have 1 million people aged over 60 who do not have any children, and that their number will double by 2030, yet we have a health and care system that is presaged on the fact that a person will have children to oversee and manage their care. That is not in the Bill at all. It also does not take into account the enormous development and change in therapeutics and diagnostics that we are on the edge of. I want to talk very briefly about HIV. As of last week, with the major breakthrough in injectable medicine, we know that we are on the cusp of some very big changes, yet this is not reflected in the structures of the Bill.

One thing we have learned in the last year is that data and the communication of data are absolutely the driver of integration and change. I do not know whether any noble Lord has recently tried to follow a patient around a hospital—good luck with that. As for trying to follow a patient between hospital and social care—just no. What the NHS does really well is acute things in big hospitals, and it measures the outcomes. But what nobody does at all is get that same data for mental health, primary care and social care. Unless and until we begin to address the fundamental issue of information exchange, we are quite frankly rearranging some deckchairs, because we will never get it. Given the amount of effort and money that has gone into that over the last year because of the pandemic, we should be further along the way.

I want to very quickly highlight one area in which I will be assessing the Bill quite rigorously. Both providers of the service and women know that women’s access to reproductive health services and contraception has been utterly fragmented by the 2012 Act. It is now almost impossible for young women to get access to contraception in some parts of the country. We also know that, for every £1 invested in sexual and reproductive health, the NHS saves £49. Somewhere, in all our talk of place and of integration, we really have to get to grips with some of this basic information and put it into the hands of patients, who will challenge the providers to make the difference.

HIV and AIDS

Baroness Barker Excerpts

Wednesday 1st December 2021 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Lord for his question and pay tribute to his work during our many years together in the European Parliament, where he was probably one of the strongest champions for LGBTQ+ issues, and AIDS and HIV awareness. My only regret is that I was not able to champion as strongly as I wanted to on ethnic diversity and the lack of it in the EU. Of course, we remain committed to the Global Fund and to other partners, including UNAIDS and the global financing facility. It is important that we all work together on this issue, not only in our own countries but particularly in countries where the situation is difficult and people have challenging health systems, and in countries where, unfortunately, gay people or those suffering from HIV are discriminated against or even stigmatised. One of the things that we can be proud of in the UK is that we stand up for those people.

[Baroness Barker (LD)]

My Lords, over the past 40 years, this country has led the international efforts to overcome HIV and AIDS. We have done so by leveraging our contributions to international funds. Unfortunately, in 2021, those were significantly cut, jeopardising world-leading research at a point when we were very close to some game-changing treatments and diagnostics. Will the FCDO review look, as a matter of urgency, at restoring the funding for UNAIDS and Unitaid?

[Lord Kamall (Con)]

I am sure that noble Lords understand the reasons for some of those cuts in terms of the pandemic and needing to redirect resources, but we are committed to continuing with funding and working at an international level. In fact, this issue has come up at a number of G7 international health meetings attended by UK representatives. The UK is seen on the diplomatic circuit as one of the leaders standing up for the rights of both gay people and people with HIV/AIDS.

Gametes and Embryos: Storage Limit

Baroness Barker Excerpts

Tuesday 9th November 2021 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for that very kind offer, but we have already stated that it is the Government’s intention that no one misses out on the opportunity to extend the storage of their eggs, sperm or embryos. As she will be aware, in 2020 in light of the Covid pandemic, we took steps to extend the storage. We are currently considering options to make sure that no one misses out on the benefits of the new policy. Given the detailed consultation we have just been through, we hope to announce details in due course. Of course, if an amendment is laid to the forthcoming Health and Care Bill, we will consider it.

[Baroness Barker (LD)]

My Lords, the Minister will have seen in the press today the case of Megan and Whitney Bacon-Evans, a lesbian couple required to undergo 12 cycles of treatment before they can access NHS-funded fertility treatment. In effect, that makes it impossible for them to access safe, well-regulated healthcare in this country. That is contrary to the aims of the Act under which lesbians were enabled to access fertility treatment, so will the Government move to stop it?

[Lord Kamall (Con)]

The noble Baroness raises a very important point about same-sex couples’ access to insemination services. In England, details of the local fertility services are determined by the clinical commissioning groups, which take account of the NICE fertility guidelines. These were updated in 2013 to include provision for female same-sex couples who have demonstrated a clinical infertility. The criteria in the guidelines were developed as a way of achieving equivalence between opposite-sex and male or female same-sex couples. However, it is clear that the NICE guidelines are now outdated, and the department has therefore agreed with NICE to start a review of these fertility guidelines. We want the same thing as the noble Baroness: equality.