Health and Care Bill

Baroness Cumberlege Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

Moved by

[Baroness Cumberlege]

At end insert “, and do propose Amendment 29B in lieu—

29B: Clause 35, page 42, leave out lines 14 to 19 and insert—
The Secretary of State must, at least once every three years, lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of the health, social care and public health services in England.
(2) This report must include—
(a) an independent assessment of health and social care workforce numbers, current at the time of publication, and the projected workforce supply for the following five, ten and 15 years, and
(b) an independent assessment of future health and social care workforce numbers based on the projected health and care needs of the population for the following five, ten and 15 years, taking account of the Office for Budget Responsibility long-term fiscal projections.
(3) NHS England and Health Education England must assist in the preparation of a report under this section.
(4) The organisations listed in subsection (3) must consult health and care employers, providers, trade unions, Royal Colleges, universities and any other persons deemed necessary for the preparation of this report, taking full account of workforce intelligence, evidence and plans provided by local organisations and partners of integrated care boards.””

[Baroness Cumberlege (Con)]

My Lords, I thank my noble friend for that wide-ranging introduction on workforce. There are a lot of issues that we will want to consider later, but at the moment we have before us the issue of what the Commons have done. They have returned our amendment back to the Lords, and it is now for us to consider whether we wish to pursue it.

I want to go back to the situation on Report in this House, and the amendment to Clause 35 of the Bill on the subject of workforce planning. That was passed by your Lordships with an overwhelming majority in this House. I thank noble Lords who gave their support and welcomed that we wanted to return this issue to the Commons on that occasion. I want to stress strongly that it was supported not only in this place but by over 100 different organisations throughout the country—charities, patient groups, think tanks, royal colleges, professional bodies and organisations representing NHS management and those working in the service. They are extremely worried about our workforce numbers and the future. What is going to happen to our services if we do not have enough people in the workforce? We need a proper plan. We need to know how we are going to take this forward.

We had hoped that the Government would listen to the strength of the arguments put last time and the strength of feeling, not to mention that in the Commons. We also hoped that the Government would agree that workforce planning is the greatest problem facing the NHS and social care and that we are in crisis. We have to handle this problem. We hoped there would be agreement that we need better planning, because we know that, without improved planning, we will not be able to tackle the growing backlog in procedures and appointments, with people waiting to be treated by the service. Even this morning, on the “Today” programme, one of our charities—Macmillan Cancer Support—came forward to speak about cancer services and to strongly say, “Please will you sort this problem because it needs sorting?”

Regrettably, despite the extraordinary consensus in favour of the amendment, it was, as noble Lords know, rejected in the other place. The case for improvements to workforce planning has been made by me and many others many times during the passage of this Bill. The current NHS waiting list stands at 6.1 million, and it is rising. More people are joining the waiting list every day—more than those who are being treated. This is not a new problem; according to the King’s Fund, it has been like this since 2016. Of course, we have had to deal with the pandemic, which has made matters a great deal worse.

I thank my noble friend the Minister very sincerely for the time he and the Bill team have spent with me trying to sort this problem out. But today, and often in previous debates, we are told that there are record numbers of staff in the health service. The fact remains that this does not seem to be enough—but of course we do not really know. We can experience it but we have not got the figures. We do not know whether we have the right people in the right place at the right time. We do not know if we have a plan for retention of the wonderful staff already working within the NHS and social care. As the backlog figures suggest, we are not meeting, and we will not meet, the public’s expectations when they turn to the NHS for care and support.

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Given all this, I humbly ask my noble friend Lady Cumberlege to consider not moving her Motion and ask that the House accepts the Motions in my name.

[Baroness Cumberlege (Con)]

My Lords, I thank my noble friend Lord Kamall for that masterful summing up. It has been such a wide-ranging debate, so full of interest, and I thank all those who have supported the amendment, which is rather narrow compared to the enormous expanse of interest that we have had—and it has not only been about the UK. People have gone abroad and talked about China and all the things that are happening over there.

I particularly thank the noble Baroness, Lady Brinton, who has been such a stalwart friend of mine and a great supporter of workforce planning. The noble Lord, Lord Stevens, has, of course, had more experience of this than most of us, running the great NHS England and NHS Improvement. I very much want to thank the noble Baroness, Lady Harding, who has been a really strong supporter. I remember that in an earlier debate she said that no great organisation would run without knowing their workforce. Here we are with the NHS, this tremendous organisation that we have in this country, and we really do not know where it is going or how many staff are employed. We must look forward to see how it is going. As the noble Baroness, Lady Harding, said, it is a wicked problem that we have to solve.

I thank the noble Lord, Lord Blencathra, so much. The noble Lord said that he supported this amendment, and then we had this very interesting segue to China and other countries, about the way in which certain products are sourced from around the world and how we have to be very careful that they are not subject to slavery. Certainly, that was true of the remarks of the noble Lords, Lord Hunt, Lord Alton and Lord Rooker, and I thank them all very much for that very interesting part of the debate.

I also thank the noble Baroness, Lady Finlay, who really works in the NHS. She knows what it is like, and she can understand what it is like not to have enough staff to do what you want to do, and her figures were so worrying and interesting. She described it as a dereliction of our duty if we do not grab this issue and come to some resolution on it.

I thank the noble Baroness, Lady Tyler, so much, too, for her support, as well as the noble Baronesses, Lady Watkins of Tavistock, Lady Bennett of Manor Castle and Lady Walmsley, who again has always supported the workforce plan. Finally, I thank the noble Baroness, Lady Merron, very much for what she was saying, and for the support that she has given us. We have to face this challenge and come to some resolution.

I say to my noble friend Lord Kamall that I really am very grateful for the work that he has tried to do on this, and the meetings that I have had with him and the Bill team. He has explained the other issues that he and the Bill team want to explore. However, rhetoric is very compelling. We have the most wonderful wordsmiths in the Department of Health, and in the Civil Service generally. They can win our hearts with the words that they use—the rhetoric—but that is not good enough. We want the numbers; we want to know exactly where people are working, what their skills are and what the future is, to take this forward.

I thank my noble friend, whose patience is amazing and inexhaustible. We have been round this issue so often, but I am afraid that I was not convinced by what I heard today. I am not convinced by strategies or reports, unless they really have the figures, and I have no confidence that the reports that he mentioned, and the strategy, will have that. So with great regret, I would like to test the opinion of the House.

Health and Care Bill

Baroness Cumberlege Excerpts

Lords Hansard - Part 1 & Report stage
Monday 7th March 2022 Lords Chamber

The GMC has suggested that such a register is best held at local level, but clinicians move around. Some do extra contracted sessions in other units, while GPs are self-employed. There could also be a consortium of people working in private practice. One way to hold a register that could be checked up on regularly would be if it was held by the General Medical Council. In an ideal world, it should of course be multiprofessional, but we have to start somewhere, and it would seem sensible to start with the medical register, as almost all the people to whom a patient is referred are doctors on that register—although people may sometimes have been referred directly to specialist nurses, such as wound-care nurses and so on. Holding it centrally would ensure the register is accurate and accessible; it would be kept up to date through appraisal and therefore enforceable. It could eventually become multiprofessional in scope. I hope the Government will take this concept forward.

[Baroness Cumberlege (Con)]

My Lords, I thank the noble Baronesses, Lady Brinton and Lady Finlay, for supporting Amendment 184ZA, which I have tabled. I think the noble Baroness, Lady Neuberger, is going to speak—yes, she is—and I look forward to that. I very much hope that other noble Lords will want to support this amendment, too. They would be in very good company with the royal colleges and the remarkable past editor of the British Medical Journal, Professor Fiona Godlee, who has done a lot on this subject. We have also had contact with a host of doctors and some very rewarding conversations with them. Many feel it would actually be to their benefit to make this all transparent and accessible to the public.

I pay tribute to Simon Whale and Professor Sir Cyril Chantler, who have done sterling work on this amendment. I know that Sir Cyril is known to many in this House because he has so many qualities: of leadership, clinical management and research, and in lots of other fields. This is my one opportunity to pay tribute to him through the Bill.

I also thank my noble friend the Minister and his officials. They have given their precious time, working very hard with me and my colleagues throughout the Bill’s passage. I mention particularly the government amendments concerning the declaration of industry payments to doctors and others that my noble friend introduced in Committee, and which I thoroughly welcomed.

Turning to the amendment before us, I am delighted to say that together we have fashioned a form of words which reaches, I hope, common ground. Together with my team, we have constantly amended many amendments in discussing with officials what they thought was particularly important and what we thought was important. I think we have reached a happy place. My noble friend the Minister and his officials deserve praise and thanks for their tireless efforts and, unreservedly, I give those to them now.

In Committee, we debated an amendment on establishing a register of doctors’ interests. My noble friend made the point that this information should be collected locally by those who employ doctors, rather than nationally by the GMC. I understand what the noble Baroness, Lady Finlay, said about it making sense to have the GMC involved, but in the end we agreed that this information should be collected locally. The problem is that these declarations are often out of date or incomplete, and in some cases the information is not collected at all, so it is very difficult for patients and the public to find out where that information is—and now they will have to go to the employer of the doctor. Sometimes it is hard for them even to find out if it exists, so I understand the logic that has just been proposed by the noble Baroness, Lady Finlay, that the GMC should be the body that collects this information. However, we have had very strong pushback on this. So, in the end, we have agreed with my noble friend that this information should be collected locally and made available to patients and the public.

Amendment 184ZBB simply puts into law what should be happening already. It would require any organisation that employs, contracts with or commissions a medical practitioner to provide medical services, or provides practice rights—we put that in because we wanted to cover the private sector as well—to obtain from that doctor a declaration of his or her financial and nonpecuniary interests. This, as I have said, can be done locally and it will be done through the annual appraisal that trusts have to carry out with employees. I think the missing piece in this puzzle is the doctors’ regulator. This amendment requires the GMC to take reasonable steps to assure itself that doctors are providing this information locally: that is very important. Following discussions with the Minister’s officials, the amendment now also requires the CQC to assure itself that employers are collecting the information and publishing it. We think this is sensible and I am pleased that we are all agreed.

I hope this puts all of us—my noble friend, the GMC and those of us who have tabled this amendment and support it—on the same page. However, I would be very concerned if none of this was laid down in legislation. These requirements and responsibilities are clearly spelled out in law at present, and we see from the research that this leads to very patchy compliance. This is not acceptable to any of us. So, finally, this amendment is simple and clear and is aligned with the position of the Government and the GMC. It requires employers and doctors merely to do what they should already be doing, but are not in all cases. It places a light but important duty on the GMC and the CQC to assure themselves that doctors and employers are indeed doing what they should. This is in the interests of doctors. Indeed, Professor Carl Heneghan, in oral evidence to our review First Do No Harm, stated:

“I think it’s important that if I’m treating you, you know who’s paying me.”


We owe it to patients and the wider public to improve transparency and to ensure that nothing undermines trust in our medical professionals. I hope my noble friend the Minister will agree that this amendment does achieve this in a way that he can support and that it fulfils all our aims.

[Baroness Neuberger (CB)]

My Lords, I support the noble Baroness, Lady Cumberlege, in what she has just said, as well as my noble friend Lady Finlay and the noble Baroness, Lady Brinton. I pay tribute to the noble Baroness, Lady Cumberlege, for the extraordinary work she did on First Do No Harm, which led—gradually—to this amendment. I too pay tribute to Cyril Chantler, who I first knew when serving on the General Medical Council with him. I declare an interest as chair of University College London Hospitals NHS Foundation Trust and of Whittington Health NHS Trust. I am, as I just said, a former member of the General Medical Council, and I am somewhat surprised, I must say, that it has said yet again, including this afternoon by email, that it does not really support this.

Health and Care Bill

Baroness Cumberlege Excerpts

Lords Hansard - Part 2 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Lord Kamall (Con)]

I thank noble Lords for those interventions. If they will allow me, I will come to answer them in my remarks.

We understand the concerns about how these powers will be used. It is in the interests of nobody, least of all the Secretary of State, to be making every decision in the system, and stakeholders will be encouraged to continue to resolve matters locally where possible. Duties for those responsible for reconfigurations to involve patients and consult the local authority will continue. Nevertheless, the Secretary of State is ultimately accountable for all changes to the health service. Therefore, it is entirely consistent with democratic principles that he or she should have the ability to intervene where it is deemed to be in the interests of the public.

We recognise that, in exercising these powers in this clause and schedule, it will be vital that the Secretary of State receives expert and clinical advice. That is why the Independent Reconfiguration Panel will continue to provide independent advice to the Secretary of State, allowing them to benefit from its many years of experience. This will mean that the Secretary of State will have independent advice that will include the views of both overview and scrutiny committees and patients, and the clinical case for change—

[Baroness Cumberlege (Con)]

I thank my noble friend. On this clinical advice, he is aware of the enormous changes that were made to stroke services in London. In the reconfiguration that took place, many lives were saved. But when it came to east Kent, the reconfiguration request, which was to do with stroke services, sat on the Secretary of State’s desk for two years. I just wonder how many people died for that delay.

When I put forward an amendment in Committee, I said that a decision must be made within three months by the Secretary of State if it is before his view, on his desk. Delay costs lives. It is absolutely critical that decisions are made fast in these reconfigurations, because we will lose lives.

[Lord Kamall (Con)]

Indeed, sometimes it is absolutely critical that decisions are made quickly. Where there are concerns about the speed of those decisions, the Secretary of State may ultimately decide to intervene, subject to advice from the Independent Reconfiguration Panel, overview and scrutiny committees, and patients, and based on the clinical case, should he or she decide to exercise powers under this clause.

I understand the concerns raised in this House and have heard the arguments presented today and in Committee. However, I think it would help if I reminded noble Lords that the Secretary of State’s powers included in the Bill are to ensure accountability. The public rightly want to hold the Government to account for the health service, and these powers allow that to happen effectively. The other place acknowledged that approach and supported it—

Health and Care Bill

Baroness Cumberlege Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

Moved by

[Baroness Cumberlege]

80: Clause 35, page 42, leave out lines 14 to 19 and insert—
“(1) The Secretary of State must, at least once every two years, lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of the health, social care and public health services in England.(2) This report must include—(a) an independently verified assessment of health, social care and public health workforce numbers, current at the time of publication, and the projected workforce supply for the following five, ten and 20 years; and(b) an independently verified assessment of future health, social care and public health workforce numbers based on the projected health and care needs of the population for the following five, ten and 20 years, taking account of the Office for Budget Responsibility long-term fiscal projections.(3) NHS England and Health Education England must assist in the preparation of a report under this section.(4) The organisations listed in subsection (3) must consult health and care employers, providers, trade unions, Royal Colleges, universities and any other persons deemed necessary for the preparation of this report, taking full account of workforce intelligence, evidence and plans provided by local organisations and partners of integrated care boards.”Member’s explanatory statement
This amendment would require the Government to publish independently verified assessments every two years of current and future workforce numbers required to deliver care to the population in England, taking account of the economic projections made by the Office for Budget Responsibility, projected demographic changes, the prevalence of different health conditions and the likely impact of technology.

[Baroness Cumberlege (Con)]

My Lords, as this is Report, I declare my interests, which are that I am employed by NHS England to implement my report on maternity, Better Births.

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I am grateful to everyone who contributed to the debate. I hope I have given some reassurance. I hope noble Lords will recognise that I have engaged with them on a number of different issues in an attempt to close the gaps. I am afraid that, on this issue, I am unable to go much further at this stage. On that basis, I hope—perhaps in vain—that my noble friend will feel able not to press her amendment.

[Baroness Cumberlege (Con)]

My Lords, thank my noble friend very much. He has certainly gone as far as he can today; I am afraid it is not far enough. We have had informal conversations on this and I think it is no surprise to either of us that I was hoping for a great deal more. We have heard 17 speakers and the debate has taken around an hour and a quarter. It has been such an interesting debate—I always learn more in this Chamber, and I learned so much more today.

I want to thank the 17 speakers who have supported my amendment. As far as I can see, not a single one had any reservations about Amendment 80, because it is so simple. It is not groundbreaking; it simply wants a plan that people can recognise, and one that will fill the gaps in the workforce requirements according to demography and the needs of our population. The amendment is simple and clear, and it will make such a difference, not only to those working in the NHS but to the public, whom we are here to serve.

I thank all those who have taken part, particularly from my own Benches, and all the other noble Lords. I have to say, with some regret, that I have not heard anything that counters the arguments put forward. I was hoping that after Committee we might have found some common ground, but I sense that we have not. I am disappointed by that, so I seek to test the opinion of the House.

Health and Care Bill

Baroness Cumberlege Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

Moved by

[Baroness Cumberlege]

284: After Clause 148, insert the following new Clause—
“Industry reporting
Companies involved in the production, buying or selling of pharmaceutical products or medical devices must publish any payments made to—(a) teaching hospitals,(b) research institutions, or(c) individual clinicians.”Member’s explanatory statement
This amendment requires companies involved in the production, buying or selling of pharmaceutical products or medical devices to publish any payments made to teaching hospitals, research institutions, or individual clinicians.

[Baroness Cumberlege (Con)]

My Lords, Amendment 284 would implement one of the major recommendations of the Independent Medicines and Medical Devices Safety Review. I will say from the start that I so welcome the government amendments. I thank the Minister and the civil servants for crafting them in such a thorough way.

There is one glitch, however, about which I have given the Minister forewarning. All the government amendments say that the Secretary of State “may”—and of course that is a very sneaky word. What we want to see is a more robust word: the Secretary of State “shall.”

However, I do not want to detract in any way from the burden of my amendment, which is that relationships between the pharmaceutical and the medical device industries on the one hand, and the hospitals, medical research institutes and individual clinicians on the other, can be a huge force for good. Industry collaborating with doctors, researchers and scientists working in the NHS, academia or elsewhere has led to great breakthroughs and great treatments that we have been able to introduce. No one should want to stop that happening—but we do have a right to see where the money goes. Despite all the undoubted good that collaboration between industry and the rest of healthcare brings, we know that there are long-standing concerns about undue influence.

We need transparency so that trust can be rebuilt where it has been undermined in the past. Voluntary arrangements are all well and good, but they have a drawback: they are voluntary; they are not a requirement; they carry no teeth. So I am encouraged to see that the ABPI, which represents many pharmaceutical companies in the UK, agrees. It is supportive of moving to mandatory disclosure.

Amendment 284 would make it a requirement for payment by the industry to teaching hospitals, research bodies and individual clinicians to be published by the companies themselves. Such legislation exists and works very effectively in the United States. It is called the Physician Payments Sunshine Act, and it has been in existence since 2010. All the information is held on a public website. Americans can see at a glance which pharmaceutical or device companies have made payments to physicians or others: when, why and how much. It is not just the US which benefits from this level of transparency; various European countries have similar legislation in place, and we should not be the poorer cousin.

I of course welcome the Government’s own amendments that are grouped with mine and very much look forward to what the Minister has to say about them. I hope we can all agree that transparency, trust and good, safe care go hand in hand. That is why the amendments are so important.

[The Deputy Chairman of Committees (Lord Brougham and Vaux) (Con)]

My Lords, I invite the noble Baroness, Lady Brinton, to speak remotely now.

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[Lord Kamall (Con)]

I have two points to make to the noble Lord. First, I have been advised that this is standard wording. Secondly, I have made the assurance at the Dispatch Box. It is here; it is on public record that the Government intend to bring forward regulations. On the timeframe, I will either write to noble Lords or arrange a follow-up meeting. I will make sure that there is some communication to bridge that gap.

[Baroness Cumberlege (Con)]

My Lords, I thank everybody who has taken part in this debate, particularly my noble friend the Minister for the work he and his officials have done to bring this into the Government’s remit. That is so important, because I learned through the passage of the Medicines and Medical Devices Act that we could incorporate the patient safety commissioner and some of the other things we wanted to achieve only through government amendments. My heart leaped when I saw these amendments and I thank the Minister.

I still think these amendments could be improved and it is important that we get the word “shall” in, or “might” or whatever others have said, rather than “may”. I was looking at the Oxford English Dictionary. My father-in-law was the publisher to the Oxford University Press, so the dictionary is very close to my heart. The dictionary says that the verb “shall” relates to the right or sensible thing to do, whereas the verb “may” is defined as a possibility.

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[Lord Hunt of Kings Heath (Lab)]

My Lords, in speaking to my Amendment 297D, I thank the noble Baronesses, Lady Masham and Lady Brinton, for their support. However, I also express my general support to the noble Baroness, Lady Greengross, the noble Lord, Lord Howarth, and the noble Baroness, Lady Hodgson, for their amendments. The common theme of this collection of amendments is the question of how we support vulnerable people.

My amendment is about the experience of many of us who have seen the harm caused to our loved ones in care homes during Covid when visits were not allowed for so long. Even now, it can be difficult to visit in some homes because of the Covid restrictions that continue or where a member of staff or visitor has Covid and then 14-day long impositions are imposed. It is a bit rich when one hears in the media that all restrictions are being lifted, because for many of us, in practice those restrictions have not been lifted at all.

The Joint Committee on Human Rights in its report on care home blanket bans and other excessive restrictions recommended that regulations for care and treatment should include a requirement to ensure face-to-face contact wherever possible between residents and the people most significant to them. I do not underestimate the difficulties faced by care homes in the past two years. They have faced huge challenges. My personal experience is that many of them have risen to the challenge and provide high-quality care. But even before the pandemic, serious concerns were growing about the use of care home visitor bans to punish relatives for complaining about standards of care. Indeed, as far back as 2016, the “Victoria Derbyshire” programme reported that hundreds of care homes were guilty of this method of what it described as institutional abuse. In 2019, the Relatives & Residents Association was coming across at least one case per week and warned the problem was increasing.

One woman found her mother dressed in other people’s clothes, left in her own urine and with her hair unwashed for weeks. The Local Government and Social Care Ombudsman upheld the daughter’s complaint, reporting that after raising her concerns with the care home, she and a doctor were prevented from seeing her mother when they tried to visit. The care home later told the ombudsman the ban was because of a previous incident reported to the police of the daughter and her partner’s behaviour, but could not provide any evidence that an incident had occurred or was reported to the police.

As visiting restrictions are, hopefully, going to be relaxed in the weeks ahead, I am afraid we have the prospect of seeing more residents’ families being victimised in this way. Helen Wildbore, director of the Relatives & Residents Association, has found from its helpline calls that relatives and friends play a vital role in spotting potential human rights violations, particularly around abuse and neglect. When they are locked out by bans, people in care lose crucial support: their advocate and confidante—they might be the only person they tell about their concerns. Sometimes residents are even threatened with eviction or actually evicted in reprisal for complaints about their care. The Joint Committee on Human Rights was told about a family whose mother was threatened with eviction after they merely asked to discuss concerns with the head office of a care home.

These are the kinds of abuses my amendment seeks to tackle and get over the problem that regulations are not sufficient. These regulations may specify the standards of care against which care providers are regulated by the CQC through its inspection process, but the CQC is not going to pick up individual complaints, so there is a gap. There is a strong case for a statutory duty of care sitting alongside CQC regulations to require care providers to facilitate such contact with families as is reasonably practical and to prohibit evictions where non-vexatious and non-repetitive complaints are in progress. In my amendment, I am not proposing that. All I am asking for is a review; an independent review charged with examining these options. I hope that the Government will agree that there needs to be some reflection on what has happened and how we can prevent this kind of abuse in the future.

[Baroness Cumberlege (Con)]

My Lords, I should like to speak to the amendment proposed by my noble friend Lady Hodgson.

From the age of five, I was a child of general practice; it was my world. I accompanied my father on home visits, patients came to our house and the telephone rang constantly—my mother was the secretary and took all calls. My father loved his patients and they loved him. He knew them inside and out, and their families as well. He attended road traffic accidents, of which I have to say there were plenty, and he delivered babies at home—he never lost one. I remember him telling me one day when he came back from a birth that it had been a very difficult birth, but the mother praised my father for having helped her to produce a very healthy little boy. “Doctor”, she said, “we will call the baby after you. What is your name?” My father replied, “Lambert”. “Right”, said the father, “we will call our son Tom.” I mention this only because maternity has been the love of my life, and in this area relationships are critical to a safe and good experience. In my youth, maternity was part of general practice.

After being appointed much more recently to chair the maternity review for England by Simon Stevens—as he was then; now, of course. the noble Lord, Lord Stevens of Birmingham—I was determined to introduce relationship care, sometimes called “continuity of carer”, where the final “R” stands for relationship. We have much respected and credible research from the Cochrane Collaboration in Oxford which shows that women who receive relationship care are less likely to have a preterm birth, less likely to lose their baby before 24 weeks and less likely to lose their baby overall.

We now have in the NHS 371 relationship teams with 2,355 midwives in place where the midwife provides all three elements of midwifery care: prenatal, birth and postnatal care, which is sometimes called follow-up care. In the James Paget Hospital, 90% of maternity care is provided through continuity and it has a waiting list for midwives to join the hospital. Through this initiative, we are transforming maternity care. The women and their families value hugely the relationship with their known midwife, and the midwives who are providing this care absolutely know that what they are doing is the right way to work. They would leave their hospital and go to one that provided such care if their hospital gave it up.

Listening to my noble friend Lady Hodgson, is not this what she seeks for general medical practice? Her amendment is well drafted and reflects an interesting report produced by the Royal College of General Practitioners, entitled The Power of Relationships: What is Relationship-based Care and Why is it Important? and published in June last year. In his foreword, Professor Martin Marshall, chair of the college, writes:

“COVID-19 has radically changed the face of general practice. We have moved from a predominantly face-to-face service to one in which most consultations are delivered remotely, either by telephone or video call … Remote consultations are certainly here to stay. For many patients, they enable quicker and more convenient access to a GP appointment, which of course is hugely important.”


But then he asks the following questions:

“But should speed and ease of access be our primary measures of effectiveness? They are certainly easier to quantify. But what about the quality of care? What about the relationship between doctor and patients which, to me, is the essence of general practice?”


He goes on to say that

“The evidence for the benefits of a trusting relationship is compelling—better patient experience; better adherence to medical advice, fewer prescriptions, better health outcomes, better job satisfaction for doctors and even fewer deaths.”


Indeed, he says that the relationship between the patient and their GP is as important as the scalpel is to a surgeon:

“If relationships were a drug, NICE would mandate their use.”

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[Baroness Cumberlege (Con)]

I understand that I have overrun so I will say to my noble friends on the Front Bench that we should value general practice. We should build with the best. We should learn from the best. I know that there are hundreds of general practices; it is up to us to applaud them and cherish them and ensure that we see another era of general practice which is different but which values patients and relationship care.

[Baroness Smith of Newnham (LD)]

My Lords, I support Amendment 297A in the name of the noble Baroness, Lady Hodgson, to which I have added my name. I shall speak briefly, given that that I am only an irregular participant on this Bill. This amendment is particularly important. I come to an understanding of general practice from a very different perspective from the noble Baroness, Lady Cumberlege, as somebody who has only either received the care of a doctor or seen my parents receive or not receive that care.

When I was a young baby, I was extremely ill. I realise in these days where people talk about conspiracy theories about vaccines that this might be something that should not go into Hansard, but I had a reaction to the smallpox vaccine and my mother went to the public telephone box and called the doctor. The family doctor who came was equally concerned and brought a consultant from the local children’s hospital to our home to see me. That would be the sort of gold standard that we could only dream of now. However, it is the sort of care that we need to be looking to in terms of having a family doctor or a doctor in the community who actually knows individuals. As the noble Baroness, Lady Hodgson, said, this is particularly so for the over-65s, when a range of issues might be beginning to affect them.

The situation today is so very different. The Minister in answer to an Oral Question a few weeks ago repeatedly said that everyone has the right to see a doctor in person and the doctor must give a clinical reason for refusing to have an in-person consultation. I assure him that this very rarely happens, because ordinary patients cannot simply ring up and speak to the doctor and say, “I need to see you”. They will get to a receptionist who will triage them and decide whether they feel that it is appropriate for this person to see the doctor, or to have a telephone conversation or maybe some other virtual consultation.

There is a real need, particularly for older people, to have the opportunity to know that there is a doctor who understands their medical situation and can join up the dots. Somebody who seems now to have low blood pressure might have that because of the previous set of medication that another doctor has prescribed for them. If somebody rings up and gets a telephone consultation or is sent a prescription without proper assessment, the danger is that the whole picture is lost and individuals’ lives can be blighted because they are not getting the medical care they need.

This is not the fault of any individual practice or of any individual general practitioner. However, we have ended up with a system where that traditional idea of a family doctor who knows their patients has disappeared, and somehow we need to get an element of that back. The other three amendments in this group in many ways fit as part of a suite because, if your GP knows that maybe you have early onset dementia or another sort of dementia and you need different types of therapies, they will know what to recommend.

Furthermore, if your GP knows that you have gone into a care home, visits you and thinks, “That person has lost a stone and a half in weight in the last six weeks”, a GP who knows the individual will be able to respond. Somebody who randomly sees a patient will not. I strongly support the amendment in the name of the noble Baroness, Lady Hodgson, and the other amendments in this group.

Finally, I note that the amendment in the name of the noble Baroness, Lady Hodgson, comes immediately after the amendment in the name of the noble Lord, Lord Forsyth of Drumlean. If anyone were minded to support assisted dying, they should certainly support the following Amendment 297A, because how on earth could any doctor reasonably say that we can sign somebody off when they have no idea who that individual is?

Health and Care Bill

Baroness Cumberlege Excerpts

Lords Hansard - Part 3 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I would much prefer that the noble Baroness, Lady Cumberlege, should open on this group. I will speak to the question of whether Clause 40 should stand part when that has happened.

[Baroness Cumberlege (Con)]

My Lords, I will speak to Amendment 179 and the other amendments in my name. I thank the noble Lords who put their names to these amendments: the noble Lords, Lord Shipley, Lord Hunt of Kings Heath and Lord Patel. We are told that the driving force of the Bill is to ensure that health and care services are delivered at place; and to empower local leaders—leaders who know what their local communities’ needs are and who will make decisions about how care is delivered. I am sure that is music to the ears of my noble friend Lord Mawson.

We are told that the integrated care systems—the ICSs—will be given the flexibility to plan, to commission and to provide services according to the specific needs of their population. This principle is undermined by the unchecked power that the Bill gives the Secretary of State over local configuration of services. I am pleased to tell your Lordships—particularly my noble friend Lord Howe, who is on the Front Bench for this item—that Amendments 179 to 183 have the support of a number of influential voices. These are voices from the health and local government sectors, the NHS Confederation, the King’s Fund, NHS Providers, the LGA, the BMA, National Voices and the Centre for Governance and Scrutiny. These organisations cover NHS leaders, local authorities, clinicians and patients. It is significant that they are united in their deep concern about the powers that the Secretary of State would have over local reconfigurations as the Bill currently stands.

Of course, there is an existing system for local reconfiguration and it works very well. It is overseen by the Independent—that word is very important—Reconfiguration Panel, the IRP. This has helped take politics out of the difficult decisions surrounding services. Crucially, the current process for service reconfiguration starts with local consultation and consideration of clinical advice. These elements are fundamental, and they must be maintained in a future process. In short, the Secretary of State should be able to intervene in a decision about local services only once local people have had their say on the proposed changes, and once clinical advice has been considered. It will be to the detriment of patient safety if it has not. Under the existing arrangements, when the process takes too long, it has often not been about the IRP but about the Secretary of State’s failure to reach a decision, yet the Government state that the new powers are needed to speed up the process.

--- Later in debate ---

[Baroness Cumberlege (Con)]

My Lords, before the Minister goes on—just so I do not lose the thread here— could he tell us why the Independent Reconfiguration Panel has to go? What are the problems with it? Why do we have to move it off in order to bring in a politicised system with the Secretary of State making the decisions?

[Lord Kamall (Con)]

I must clarify here. I have said that we expect the Independent Reconfiguration Panel to continue to consider views. We are not getting rid of it.

[Baroness Cumberlege (Con)]

So that presents a problem. What does the Secretary of State do, and what does the independent panel do? Is it a question of the scale of the change that is being proposed? Where are the boundaries?

[Lord Kamall (Con)]

The Secretary of State will be advised by the Independent Reconfiguration Panel, especially where there is a difficult decision that takes time, just as in the case of the Medway.

On Amendment 182, the Secretary of State’s decision-making process must already take into account the public law decision-making principles, all relevant information and his legal duties, including the public sector equality duty. The Secretary of State is also under several duties in the National Health Service Act 2006, including to promote a comprehensive health service and to support continuous improvement in services.

Health and Care Bill

Baroness Cumberlege Excerpts

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

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

My Lords, I support the spirit of these amendments. The noble Lord, Lord Mawson, in his working life at Bromley-by-Bow and more recently in north-west Surrey, and in his very full speech, has demonstrated the significance to healthcare of the principle of subsidiarity, the freedom to innovate and the mobilisation of community resources. If ICSs are to mobilise the full power of place this must indeed be a governing principle.

Although there might be definitional issues to clarify, I particularly applaud the ambition expressed in Amendment 159A that resources should be used at local discretion to promote collaboration by local groups, and that the procurement processes should take account of the benefits of stable partnerships. How could anyone dissent from that? Yet, the experience of so many non-clinical and VCSE organisations is of chronic financial instability and of promising work being aborted because of policy discontinuity.

I will give one instance of damaging discontinuity of funding. The Alchemy Project used dance as a form of early intervention in psychosis. The project was developed jointly by Dance United, South London and Maudsley, and King’s College London. Two cohorts of participants were drawn from young people in south London boroughs where the rate of psychosis is very high. With no previous experience of dance, after four weeks they performed a specially commissioned piece at the Shaw Theatre and Sadler’s Wells. Academic evaluation demonstrated clinically significant improvements in well-being, communication, concentration and focus, trust in others and team working. The project helped participants to develop relationships with their peers and restore relationships with their families. The Alchemy Project had to be abandoned, however, when a fragile consortium of funders did not renew its funding. ICBs and ICPs will need to be less fickle and less prodigal, bolder in supporting innovation, and more consistent and farsighted in their relationships with their providers and communities.

[Baroness Cumberlege (Con)]

My Lords, I also support these amendments. Earlier in Committee, I described the noble Lord, Lord Mawson, as

“a man of infinite resource and sagacity, an entrepreneur and … a great achiever”.—[Official Report, 18/1/22; col. 1575.]

I am sure that, if noble Lords are not convinced, these amendments will further endorse my description.

I now add that the noble Lord is a very determined reformer. He has told us how the present systems serving the public are not fit for purpose. The Government are trying through this Bill to remedy that through greater integration and other measures. It was Edmund Burke who said that, if you want to preserve something important, you need to be prepared to reform it. Our systems are important and need reforming.

Amendment 159A is about the financial duties of the NHS in England and solidarity. In the previous debate, I mentioned Bromley by Bow, as the noble Lords, Lord Mawson and Lord Howarth, said. Bromley by Bow was the forerunner of other imaginative, ground-breaking and huge entrepreneurial schemes in the north of England, London and Surrey. The examples are breathtaking but they cost energy, hard work, original thinking and money. It is sad that these scarce resources are dissipated by the convoluted systems that we, the nation and the Government impose on burgeoning and, at the beginning, fragile schemes. However, Bromley by Bow is not one of these. It is well established but not secure due to having to navigate 41 different funding schemes, as the noble Lord, Lord Mawson, said. Huge effort and wasted time are spent trying to integrate these schemes for the use of a single neighbourhood centre.

I strongly support Amendment 210A. The noble Lord is right: he paints a compelling picture of the future, which will be realised only if our public health, prevention and provision of services collaborate in partnership with local organisations. They understand the history, dynamics and strengths that permeate their local place—their neighbourhood. The noble Lord is also right that, to thrive, ICSs will have to embrace the principle of solidarity, which is the essence of a successful project; that includes the financial duties of NHS England.

I have lived in my community from the age of five. In another debate, I said that my father, a GP, knew his patients inside and out. I, too, know my villagers inside and out in a different way. I treasure the relationships I have made with local organisations. We fight for every shop and organisation that is threatened. We welcome newcomers. We have produced a pocket list of 45 organisations with a mantra on the front saying, “Newick”—my village—“is here for you”. It goes on to say that there is so much going on in our village and there is something for everyone, whether you would like a new hobby, to make new friends or just give something back to the community. Get active, get involved and get happy.

I strongly support Amendment 210A, which urges local providers in particular to be prioritised. I certainly support that. This is not about get-rich-quick developers, who have no regard for the nature of the community in which they are going to build, building bricks and mortar. In our village, we fight for employment, which is absolutely critical in local communities. It reduces traffic problems and helps to mitigate global warming. Above all, it goes some way to generating happy communities. It generates the Government’s intention to make place an important component of a stable community. Surely that is what we all want.

[Baroness Thornton (Lab)]

My Lords, we on these Benches said everything we needed to say on this matter in support of the noble Lord, Lord Mawson, when we had the substantial debate. I do not know when it was—last week, I think. These two amendments flow from that. We probably could have taken them then, but I am sure that the Minister will have useful things to say.

Health and Care Bill

Baroness Cumberlege Excerpts

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

[Baroness Cumberlege (Con)]

My Lords, I shall speak to Amendment 170, in my name. I thank the noble Lord, Lord Stevens of Birmingham, who supported my amendment, the noble Lord, Lord Hunt of Kings Heath—I do not know whether he is coming back—and the noble Baroness, Lady Brinton, who has already spoken. I thank the noble Baroness for speaking to the amendments in her usual comprehensive and thorough way. It was interesting that she talked about Malawi and the Philippines, and the issue of local training, which is so important.

We have all applauded health and care workers, both on our own doorsteps and when we meet them, on or off their job. Omicron has put them under huge pressure yet again, but despite that—despite isolating or testing positive—we know that they will cope. The NHS will cope.

The NHS is a public service, which means the service works for the people. That is its sole purpose. To achieve that, normal service must resume as soon as possible. The public have been understanding: they understand that there is a crisis, and that normal service cannot be delivered right now. There can be no doubt that Covid and its variants are a crisis for health and care. But Covid is a crisis atop another crisis, a deeper malignancy, which constrains and threatens the NHS—and, of course, the care sector; we must think of the two together—with or without Covid. I speak of the workforce crisis, now considered by experts, and by people in the service and outside it, the single greatest problem that the service now faces.

Numbers can be used to make any argument stand up, even a spurious one. But in the case of our health and care workforce crisis, the numbers are real, stark and heading in the wrong direction. Two years ago, before the pandemic, the average number of vacancies in adult social care was 112,000; the average number of vacancies in the NHS was 101,000. It is no secret that Covid is making a very bad situation worse. Internal NHS figures showing total absences across acute, mental health and community trusts nationally hit almost 120,000 on Wednesday 5 January. NHS staff absence figures are published weekly over the winter. The reported figure for staff absences, published last Thursday, 13 January, show that a weekly average of almost 89,000 hospital staff in England were absent, with the highest one-day peak for this winter being over 94,000. This is piling pressure upon pressure.

That tells us that we have a serious problem here and now—and, as the noble Baronesses, Lady Masham and Lady Brinton, said, it takes a long time to train skilled health and care staff. We need to act now if we want to feel the benefit in future. According to the Royal College of Physicians, nearly 48%—nearly half—of advertised consultant posts went unfilled in 2020, mostly due, sadly, to a lack of any applicants. The noble Baroness, Lady Finlay, mentioned this in a previous debate.

There are nearly 40,000 full-time equivalent nurse vacancies in the NHS in England. That is a vacancy rate of more than 10%. The Royal College of Nursing expects 52,000 nurses to retire in the next few years. Nearly 7% of roles in adult social care were vacant in 2020-21. It is estimated that we are 50,000 doctors short, and in total the Health Foundation says we need 488,000 more healthcare staff in the next decade. I apologise for flinging so many figures at your Lordships, but they underline a simple yet serious problem—and if we do not have credible, reliable, up-to-date numbers, how can we plan?

The health and care sector urgently needs better workforce planning. We need to know how much slack is in the system, and how it can cope not only with the expected but with the unexpected. We know from the experience of the last two years that the unexpected can, and so often does, happen.

Behind all those numbers are real people—professionals working flat out every day and every night to keep the show on the road, to care for patients and to keep them safe. I think we all agree that they are doing a valiant job, trying to be professional and compassionate, often in desperately difficult circumstances. But there is only so much that people can do when their team is not at full strength.

I am the first to admit that my amendment will not solve the workforce crisis. It will, however, provide the NHS and the care sector with a regular accurate national picture of the numbers of staff needed now and in future to meet demand. It will be publicly available, so we will all be able to see what is needed. It will provide a strong and much-needed foundation on which to take decisions about funding, skill mix, regional shortfalls and shortages of specialists. It will be published every two years. I think published annual assessments are too frequent. Two years is a reasonable interval: say, twice in the average time between general elections—one to say the last Government got it all wrong, and one to put it all to rights.

We could, of course, carry on as we are, without the information, a proper strategy or the ability to plan for the future—travelling in hope rather than expectation. That is not working. We already know that; the dozens of outside organisations which support this amendment— from royal colleges and professional bodies to charities and think tanks—know that; and, most importantly, the public know that, because they can see the pressure that NHS and care sector staff are under. To carry on like this would be to condemn our care services to flying blind through a storm. This amendment gives us the ability to set and navigate a sustainable course. With the extraordinary consensus behind this amendment and the impressive cross-party support we have had throughout Westminster, one would hope that it will find favour in your Lordships’ House and with the Government.

I listened carefully to the debate on a similar amendment in another place. The main argument Ministers made then was that the planned update to Health Education England’s 15-year strategic framework for workforce planning, known as framework 15, would do the job instead. I beg to differ, as do the 88 organisations which support this amendment. Previous versions of framework 15 have not quantified the workforce numbers, and the Government have been unable to confirm that the revised framework will set out the required numbers of staff. Even if the updated framework 15 had included projections of future needs—it did not—it would only be a one-off, and there would be no requirement regularly to update these predictions.

Might there be a concern about the financial implications of enacting this amendment? Do some worry that it may herald an increase in health and care staffing costs? I hope not, because to reject this amendment on those grounds would be a false economy. The NHS alone spends vast sums on agency staff, one of the most expensive and least satisfactory ways to manage an endemic workforce problem. The latest number I could find was for 2019-20, when the NHS in England spent an eye-watering £6.2 billion on agency staff, which was an increase on the previous two years. This amendment paves the way for reducing those expensive sticking-plaster solutions in favour of something sustainable and more cost effective.

There are, of course, many hurdles to overcome if we are to improve workforce planning and capacity management. There are issues that far greater brains than mine need to think about—the rise of AI, for example. In my household, married as I am to a farmer, as Members will know, AI has quite a different meaning. I am not referring to artificial insemination, but rather to artificial intelligence. What impact will that have on workforce planning and staffing? What about the rising trend of part-time work, telehealth or changes to skill mix? Those are all good questions that these clever brains stand a far better chance of answering if they have alongside them the regular, credible, national picture that this amendment seeks to provide.

In my view, we owe it to the staff working in health and care, and to the public who rely on them, to do better, to plan better, to prepare for the future and to ensure that the NHS and the care sector are at full strength. This amendment points us in that direction, and I hope the noble Lords here to answer the debate today will work with their colleagues in government to see the value—the worth—of this very simple amendment.

Health and Care Bill

Baroness Cumberlege Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

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 (Con)]

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 (LD)]

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.

--- Later in debate ---

[Lord Kamall (Con)]

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 (Con)]

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 (Con)]

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.

Health and Care Bill

Baroness Cumberlege Excerpts

Committee stage & Lords Hansard - Part 1
Tuesday 11th January 2022 Lords Chamber

I hope that I have explained Amendment 4. It would enable this group not least to look at the mandate and, indeed, at Clause 4 in anticipation of the fact that we will not have a separate debate on it. I beg to move.

[Baroness Cumberlege (Con)]

My Lords, I will make a rather simple point. I listened very carefully to what the noble Lord, Lord Lansley, said, and a lot of it makes an awful lot of sense—of course it does. He is a very experienced politician and he led the NHS in an outstanding way. I have to say that some of us very much supported what was in the 2012 Act and we are finding it quite difficult now to try to discard that—although throughout the Bill points are made that bring it back in, which is to be welcomed.

Outcomes are extremely difficult. In the National Health Service, we have two sorts of outcomes: PROMs and PREMs. PROMs are patient-reported outcome measures, and we work hard to try to achieve that. At one time we used to take soundings from people on hospital wards on how they were getting on, and it did not quite work. Now we are trying to ensure that the patient-reported outcome measures are set out quite clearly, so that people can relate to them, and they have to be patient driven—it must be the patients who say what is important to them as outcomes. PREMs—patient-reported experience measures—are equally important, and are also extremely difficult to collect.

At the moment we are trying still to implement the report First Do No Harm; I chaired the group that led it. We spent two and a half years listening to patients—that is virtually all we did. Out of that report we have set up centres to address the issue of mesh that was inserted into women, which has proved very unsatisfactory, certainly in the majority of cases that we listened to. We have said what has to happen in these centres before they are fully functioning. We now have sites and staff and are going forward on them, but they will not be any use until we have these outcome measures. This is how we will have to judge things in the NHS in the future.

Of course we have clinicians who are extremely well trained and are very good and well-motivated people. But sometimes they can miss the obvious which is transparent to patients. They are the people we should listen to, because they are the people who receive the service and who, like all of us, pay for it. It is important that these outcome measures are taken much more seriously and that we put a lot more work into ensuring that they will work for patients and for clinicians. It is important that the staff in the NHS also understand that what they are doing is valued—or not. On the whole, of course it is valued, but on occasions it is not, as we heard in our report First Do No Harm. I just wanted to make that quite simple point.

[Lord Patel (CB)]

My Lords, my knee-jerk reaction was going to be, “I don’t agree with what Lord Lansley says”. However, I have put my knee hammer back in my pocket, because I do agree with him about the importance of using outcomes indicators as a measure of the performance of health in patients. In that respect the outcomes framework has always been a good development. Although Clause 4 focuses on cancer—and I hope we do not change that—it is an example of how it can be used for other conditions to improve healthcare.

The noble Lord has also identified one key omission in this Bill, which I hope we can find a way to fill: who will be responsible for making sure that there is continuous improvement and development in healthcare that measures the outcomes? That is not in the Bill. I hope we might find a way to do that, whether through the mandate or other ways. That is all I have to say.