Health and Care Bill

Debate between Baroness Finlay of Llandaff and Baroness Walmsley

Lords Hansard _ Part 1 & Report stage
Wednesday 16th March 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I was glad to have been able to put my name to Amendment 166 about PERT. In this Bill, the Government have introduced a milestone in changing the care of people who are facing serious illness at the end of life.

The reality, as we have already heard, is that the majority of patients with pancreatic cancer are diagnosed late, because it comes in the head of the pancreas. The pancreas has two parts—the head and the tail. But, because it can grow without causing much pain in the initial stages, it often goes undetected until it is fairly advanced. That means the outlook is poor. The other thing it does, as it grows, is block off the flow of enzymes into the gut. Without replacement, these patients get a malabsorption syndrome; they can get terrible diarrhoea and muscle wasting, because they are not absorbing the nutrients they need.

This amendment is very important. It could quite easily build on the network that will now be in place to commission specialist palliative care services. The move the Government have made has been welcomed across palliative care in this country and is being seen as a way to dramatically change the care of patients. With data information flows now integrated and networked across the NHS, we will be able to get accurate data on how many patients with pancreatic cancer are getting replacement therapy when they need it. Some people do not need it; some need it later on. This is part of building on the important foundation the Government have laid. It was that which persuaded me to put my name to Amendment 166.

Another point I would like to make is about improving things for the lowest quartile of the population. Incidence of pancreatic cancer is highest in the most deprived areas and it is higher in women than in men. Part of levelling up, to help people to live well for as long as they can, is making sure they get the enzyme replacement they need.

[Baroness Walmsley (LD)]

My Lords, I have in my hands the latest cancer waiting time figures. It is very unfortunate that, despite the hard work of NHS staff, every single metric was worse in January than in December. It therefore seems a great pity that not all patients who have a diagnosis of this dreadful disease of pancreatic cancer can get this medicine, which can improve and even extend their lives.

I well remember a senior, well-loved and well-respected Member of the Labour Benches who died of this dreadful disease. We lost him far too early, because this disease takes people very quickly. Anything at all the Minister can say to encourage us that this effective and approved medicine can be made fully available to everybody who needs it—depending on the conditions, as outlined by the noble Baroness, Lady Finlay—would be helpful.

Health and Care Bill

Debate between Baroness Finlay of Llandaff and Baroness Walmsley

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I support these amendments and all that has been said already.

I will put a slight tone of reality on the size of the mountain which has to be climbed to get to the point we want to reach. I do not know how many people last night watched the Channel 4 documentary, “Emergency”, about four trauma centres. It is well worth watching if noble Lords want to see what the NHS is like now under pressure. I happen to know that, on one day last week in one of those major trauma centres, there were seven mental health acute patients in the emergency department but only one mental health nurse was present for all of them. One-to-one care should have been provided. There was nowhere for these patients to go; a further 20 acute patients also needed admission and there were no beds available in the hospital.

This illustrates that the intention behind all this is excellent and laudable—we are finally getting there. However, we have not got to the end of the road; we are just at the beginning. I hope that no one in the public, or in the service, has unrealistic expectations, because it will take a lot of work on everyone’s part to reach the goals we want to reach.

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for listening very carefully to what noble Lords from across the House have been saying about the need to recognise the parity of esteem between physical and mental health, and for giving us some reassurance that the funding for mental health will increase in the future. A lot of mental distress has been caused by the fact that many patients suffering from mental ill health have not been able to reach the threshold for access to services. The reason for that has been a shortage of resources and a properly trained workforce which can deliver the therapies required. At the end of the debate, I hope that the Minister will be able to assure us that those resources will be made available.

My noble friend commented that she hoped that the new standards would not have the unintended consequences of transferring delays from the initial diagnosis to further down the treatment pathway. That is a very important consideration. We will talk about the importance of increasing the NHS workforce later in our debates. However, will the Minister consider how focusing increased resources on early intervention and prevention will save both money in the end and a lot of distress, as dealing with it early will save patients having to go into more intensive therapies further down the track? It is very important that any increased resources—or, at least, much of them—are focused on early intervention and prevention. I hope the Minister can reassure us of this.

Health and Care Bill

Debate between Baroness Finlay of Llandaff and Baroness Walmsley

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, this group of amendments is concerned with rehabilitation services. Very briefly, because the hour is very late, I will set out why it matters so much.

People in hospital, as the Minister said previously, lose muscle mass at an alarming rate when they are confined to bed. They risk thrombosis, lose their ability to balance, their confidence and their social contacts, and can become lonelier, isolated from friends and family, and depressed as they see themselves able to do less and less. They then become terrified of going home and often feel quite dumped when they get home because there is a sudden cliff edge from being supported in an environment to feeling like there is no one there. That same cliff edge also happens for patients when they leave intensive care units and go from the very intensive care down to a general ward—so we have huge steps in our system at the moment.

Assessment in hospital, as has often happened, does not often make any sense, because people know their own home. So assessing whether someone can make a cup of tea in a hospital kitchen may bear no relationship at all to their own kettle, their own kitchen, the floor, where they keep things, and so on. They need to be in their own home to be assessed. In their own home, there are often trip hazards, if they are not detected, and if people are not supported to navigate around their own home and furniture, they will have a fall and end up back in hospital very quickly. They need seven-day support at home, because they need to have people whom they can contact.

The problem is that, at the moment, recovery and maintenance of personal independence, although central to the Government’s long-term ambition for social care services, just do not seem to be integrated. In the document, People at the Heart of Care, there is a reference on 68 occasions to the importance of the role of adult care services in maintaining independence for people at home in the community, but there is no mention of local authority rehabilitation services at all.

Rehabilitation services in the community are not subject to regular monitoring and inspection. There are no consequences for poor or absent provision beyond individual complaints, which is why this amendment proposes that they should be brought into the purview of the Care Quality Commission. In the other place, the Minister Edward Argar stated his belief that services were already covered by the existing legislation. But that is not the everyday experience in operation. For example, if we look at vision rehabilitation services, in an audit undertaken by the RNIB, half of the lead counsellors for rehabilitation had no idea that vision rehabilitation was in their remit.

I shall move on rapidly to Amendment 241, because these amendments are all linked. I should have said at the outset that these have been proposed and supported also by the Chartered Society of Physiotherapy, of which I am president. In this amendment, in large part, professions involved in local authority rehabilitation are regulated bodies with recognition in health, such as OTs, physios and speech and language therapists. But there are other people in local authorities involved in providing rehabilitation who are currently completely unregulated and unregistered, so the Rehabilitation Workers Professional Network is currently seeking registration with the Professional Standards Authority in order to take this group of staff on to a list of statutorily regulated social care staff.

Amendment 306, also in this group, would bring local authority reablement and rehabilitation activities, defined by care and support statutory guidance as tertiary prevention, into regulation and enable the Secretary of State to require information on how the service is operated. Anecdotally, there is wide, unwarranted variation in both the quality and breadth of service offered across England. There is no centralised reporting of performance. Bringing these services explicitly into regulation would enable NICE to develop guidelines and quality statements that could be used to inform the quality of provision of services, which, as I have already said, could then be properly inspected. We might then get nearer to having a level playing field.

I also have my name to the amendment of the noble Baroness, Lady Greengross, which is about hospital accommodation, and I will speak to it briefly. At the moment, we have a severe shortage of beds. We know that patients come out of ICU to general wards, and there are patients who cannot then be discharged to home. Often, they are in that twilight where they are really not well enough to go home. They need more rehabilitation, they need more support, but the hospital is deeming them fit to discharge because of the incoming pressure on their beds.

If we had some more step-down beds, we could provide care in much more imaginative ways, such as happens in some parts of Europe, where, for example, family members are expected to come in and help with some of the basic care—feeding, personal hygiene and so on—of their own relative, as they all get used to rehabilitating together, so that that person can go home with that family member understanding how to care for them and what to do, and therefore being able to support them better in the community and pick up early warning signs.

We need to learn from the military rehabilitation units and the new NHS national rehabilitation centre that is being built near Loughborough, because there is evidence that if you can move people through the system more appropriately and get them back home, they recover better and quicker and do not risk that deterioration I referred to at the beginning. A community rehabilitation plan would improve co-ordination, integration of rehabilitation units and community rehabilitation. I beg to move.

[Baroness Walmsley (LD)]

My Lords, numerous reports from Select Committees of your Lordships’ House have recommended that the NHS and care system do things differently in order to use resources efficiently while providing better care and independence for patients. It is well known that most of us cost the NHS more as we get older, particularly if we have multiple morbidities. This is why the Government launched the Ageing Society Grand Challenge—to achieve five additional years of healthy life by 2035. So your Lordships’ Science and Technology Committee looked into this and published a report on 15 January last year. Sadly, we had to conclude that the Government are not on track to achieve this.

Health and Care Bill

Debate between Baroness Finlay of Llandaff and Baroness Walmsley

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

[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.

[Baroness Walmsley (LD)]

My Lords, the problem to which the noble Lord, Lord Warner, is suggesting a possible solution is the result of long-term underplanning and underfunding of staffing in the NHS, and underfunding also of the capital budgets of hospitals, which sometimes have to choose between mending the roof and buying a piece of equipment that would get patients through the system more effectively and efficiently.

On the comments from my noble friend Lord Rennard on self-management, it is of course not just better care that that produces—it is also very cost effective. I draw noble Lords’ attention to page 3 of the Bill, line 13, where one of the three things to which NHS England has to pay regard about the wider effects of its decisions is

“efficiency and sustainability in relation to the use of resources”.

The resources are much better and more efficiently used if the patient has a decent choice of the equipment and treatment that is most effective for them, and it is often a great deal cheaper.

I also agree with the noble Lord, Lord Lansley, that we need the guidance. We need to see it before Report, and I hope that the Minister will be able to provide that.

Health and Care Bill

Debate between Baroness Finlay of Llandaff and Baroness Walmsley

Lords Hansard - Part 2 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I must declare that I am an elected member of the BMA ethics committee and a past president. The BMA has been particularly concerned about ICB membership. I know we have already debated this, so I expect this group to be quite quick—I am sure the Committee would also hope that.

The Bill sets out a core minimum membership of integrated care boards, but this does not go far enough. We have just discussed not being prescriptive, but there are dangers in that. There is no guarantee of clinical leadership on the board and there is a real danger of undercutting truly representative clinical leadership by failing to retain some of the positive elements of clinical commissioning groups. Clinicians are already demoralised and a failure to give space to their voice and enthusiasm will only worsen this.

ICBs should have clinical representation from primary care and this amendment suggests that there should be two people for this, given the wide area that the boards cover and the very different types of practice within each area. Boards also need a secondary care clinician who is in a front-line, not a management, role and a public health representative. As we have already discussed, without public health representation on the board, there is a real danger that the evidence of health gain and the potential to reduce inequality will not be adequately voiced. The board needs public health input to be able to act as a population health organisation.

Some boards have acknowledged the shortcomings and allocated additional positions for general practice, secondary care and public health within their draft constitutions, but others have not. They appear to be ignoring the voice of the very people who work in front-line healthcare. Unless these voices are heard, along with the voice of public health, there is a real danger that the boards’ decisions will be distant from the reality and that they will become bad decision-makers themselves by losing clinical trust and confidence. I hope that the Government will rethink and ensure that the boards are able to have members who can provide a solely professional view of the whole population for whom the board has responsibility. I know we have already debated much of this, but I want the Government to think again, given the dangers of a further demoralisation in both primary and secondary care. I beg to move.

[Baroness Walmsley (LD)]

My Lords, it is essential that the board have available to it the skill set that you find in people at the clinical front line. I was interested to see that, putting the amendments from the noble Baroness, Lady Finlay, together, we have three people who are not representing one of the big acute hospitals, and one who is. Given the danger referred to by a number of noble Lords that the big acute hospitals will continue to have more influence in an integrated system than perhaps they should, that is a good element of putting the two amendments together.

As I said, it is important that clinical knowledge and experience be available to the board, but I would like to know that there is a balance and that this does not overwhelm other skill sets which all of us want to see represented; that became clear in the discussions we had last week about who should be on the board. With that caveat—the noble Baroness, Lady Finlay, might respond to that if she chooses to withdraw her amendment—I offer qualified support to what she is suggesting.

Environment Bill

Debate between Baroness Finlay of Llandaff and Baroness Walmsley

Committee stage
Monday 5th July 2021 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I have my name on several of these amendments—namely, Amendment 150A and Amendments 156A to 156M—and I support the others in this group.

Following the 1952 smogs, the Clean Air Act, as we have already heard, came in in 1956 and cut coal smoke from homes. In the 1970s, the output from power stations was high in sulphur dioxide, causing acid rain. Now, there is a lot of research to show that a major source of different particles is exhaust fumes from burning liquid fossil fuels. In 2018, the World Health Organization recognised the effects of these ultra-fine particulates, which are implicated in about 8.8 million excess deaths—around 13% of all deaths globally.

The report The Lifelong Impact of Air Pollution, from the Royal College of Physicians, has shown that it costs £20 billion in the UK alone, through 40,000 deaths per annum, ranging from heart disease, asthma, chronic obstructive pulmonary disease, lung cancer, diabetes and dementia—which are all linked to atmospheric pollution.

Our death rates from asthma are the worst in Europe. Three people die every day in the UK from asthma. It costs us £1 billion a year and there are more than 5.5 million people having treatment for asthma now. People with a genetic predisposition to asthma living by main roads have worse outcomes. It does seem there are some groups in the BAME community who have a particular genetic predisposition to a type of asthma that is particularly liable to lead to death. There have been 12,700 asthma deaths in England and Wales since 2010.

The role of atmospheric pollution was shown clearly and graphically by Professor Stephen Holgate to map against Ella Adoo-Kissi-Debrah’s very severe asthma attacks, including her final and fatal attack, with spikes of nitrous oxide and particulates corresponding clearly to her severe exacerbations. These particulates from fossil fuel exhausts also cross the placenta into the foetus, resulting in a higher incidence of asthma and impaired brain development.

This means it is essential that we tackle this on every front to come into line the WHO guidance as a minimum. We cannot tolerate continuing to allow particulate air pollution, and we must harness positive behaviour and change behaviours. The impact, in fewer heart attacks, strokes and deaths from asthma and lung cancer, would be phenomenal. That is why I added my name to Amendments 156A to 156M, because there is a need to give local authorities the power that they need to protect their own populations.

I will turn briefly to speed restrictions, so comprehensively introduced by the noble Baroness, Lady Sheehan. I endorse every point that she made. Let us not forget that 20 million children have their homes and schools in areas of high air pollution, particularly from traffic.

The report The State of the Evidence on 20mph Speed Limits, by Dr Adrian Davis from Bristol, provides a comprehensive review of the literature. Dropping the speed limit from 30 mph to 20 mph decreases particulates from petrol and particularly from diesel, as well as decreasing nitrous oxide and CO₂ emissions from diesel cars. Road traffic is responsible for 80% of particulate production, and diesel produces tenfold more particulates than petrol. When children are sitting in a car in a traffic jam, their exposure is even higher because cars draw in the surrounding air, which is laden with exhaust from other vehicles.

It has been estimated that a cut from 30 mph to 20 mph on urban roads would result in a drop of over 115 deaths from particulates alone, quite apart from the lower death rate in accidents. When traffic is less aggressive and moving more smoothly in urban areas, there is almost no significant delay in getting somewhere but the whole driving experience is calmer and safer. I should declare that I experience this, because I live in the Cardiff pilot area that has dropped from 30 mph to 20 mph and the benefit is tangible. I hope that the Government can support these amendments.

[Baroness Walmsley (LD) [V]]

My Lords, I declare an interest as one of the 5.5 million people with asthma. In winding up this debate on behalf of these Benches, I first thank the Minister for the fact sheet about the air pollution measures in the Bill. It certainly shows willing, but it also falls short of what we would wish to see and gives rise to a number of questions. In particular, why do the Government remain to be convinced and want a whole lot more consultation about the feasibility of the pollution reductions that we are seeking, despite confirmation from many experts that these things can be achieved and would be accepted by the public?

I hope that the noble Baroness, Lady Jones of Moulsecoomb, will forgive me for focusing on the amendments of my noble friends, but we also support her amendments, which very much overlap with ours. I support Amendment 150A, moved by my noble friend Lady Sheehan. If the Government were to support Amendment 150A, not only would our air be cleaner and healthier but injuries and lives would be saved because of the reduced speed.

As my noble friend said, electric cars reduce NO_x and CO₂ emissions, but they still produce NEE particulates from tyres and brakes. A default 20-mph limit would reduce these particulates as well as noise, and injuries and deaths through accidents. Children in particular would be protected from accidents and from organ damage caused by particulates. Will the Minister note what my noble friend said about how people in disadvantaged demographics are more likely to live in areas with high levels of PM2.5?

I accept that local authorities can already designate roads with a 20-mph limit, but my noble friend’s amendment would make it much easier for them, as 20 mph would become the norm in relevant streets. Local authorities are already strapped for cash and have been given additional responsibilities through this Bill, such as imposing civil sanctions where once there were criminal offences, liaising with air quality partners and other matters. However, it is important to consider how legislation could help them to carry out some of their many responsibilities.

There is already considerable support for this measure in Wales and Scotland. In May, as soon as we were allowed, my husband and I went to Scotland for a short break. We noticed how many villages now have 20-mph limits. The traffic moved smoothly, there were no jams and people moved around safely. It was a good example of what can be done and there are similar examples in Wales. If the Minister will not accept this amendment, how do the Government intend to encourage 20-mph zones?

In her Amendments 151A and 151B, my noble friend Lady Randerson wants local authorities to “raise their game”, to be more ambitious about monitoring air pollution and, critically, in publicising the levels specifically in sensitive areas to encourage a change in behaviour, and to be funded to do so. This is particularly important for the future health of our children as well as adults. I hope that the Minister looks at my noble friend’s proposals very seriously. I note the measures already taken, but the fact remains that awareness of pollution levels is low. There may be websites and air quality alert systems, there may be leaflets about smoke control areas and recycling household waste, but the most effective information is gathered and distributed locally, as the noble Lord, Lord Lucas, said.

I welcome initiatives such as the one in Liverpool funded by the air quality grant, which involves children in monitoring the area around their school. I am sure that they would be exerting pester-power and encouraging their parents to walk or cycle them to school, and certainly not to sit outside in their cars at the end of the school day with the engine running, as I have seen outside my local school. However, we need more. Can the Minister explain why we do not need my noble friend’s amendments?

I turn to Amendments 156A to 156M in the name of my noble friend Lord Tope. I welcome the Government’s acknowledgement of the risk to human health presented by poor air quality. That is a major step in the right direction. As we have heard, local authorities have a statutory duty to reduce emissions in their area, but even the Government have recognised that they do not have sufficient powers to take effective action to achieve such reductions, hence some of the government changes in this Bill. Public and government attention has focused mainly on the need to cut emissions from vehicles, but non-road pollution is a major problem, too often ignored, also emitting nitrogen oxide particulate matter that provides a major public health hazard, as we have heard from the noble Baroness, Lady Finlay. As we make improvements in reducing emissions from vehicles, we must shift our focus to these other sources of pollution too, which is what these amendments do.

We heard from my noble friend Lord Tope about the negligible impact on PM2.5 of the significant reduction in transport activity in London during the pandemic. This highlights the importance of reducing non-road emissions as well as speed, as emphasised by my noble friend Lady Sheehan. These amendments introduce a series of new clauses which would give local authorities additional discretionary powers. Through Amendment 156A, they would be able to designate an area as an air-quality improvement area. If the air quality in that area exceeded WHO air quality guidelines, the Secretary of State could set limits for emissions for a range of these pollutions and equipment. The amendments provide for offences for users and installers who break the regulations, and certain legitimate defences. There are also powers to time limit the use of certain plant which might have a legitimate use in case of a power cut, and to require users to provide relevant information.