Health and Care Bill

Debate between Baroness Barker and Baroness Walmsley

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

[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

Debate between Baroness Barker and Baroness Walmsley

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

[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.