Anaesthesia Associates and Physician Associates Order 2024

Baroness Harding of Winscombe Excerpts

Monday 26th February 2024 Lords Chamber

Finally, in the NHS we definitely need a shake-up. We know that we need new members of staff. I do not want to be somebody who says only the old roles count, but I came across something I refer the Minister to: the notion of medical assistants, put forward by Maureen Baker in July 2014 when she was chair of the Royal College of General Practitioners. Having visited the United States with Jeremy Hunt, she described this new group of people—medical assistants—which basically described what I think we need. I do not know why we cannot have them and why we have come up with this idea. I work with a lot of young people and there are plenty of bright young people desperate to enter medical school and become doctors and they are not able to. Why is that? That is the kind of situation that needs to be solved, rather than just making up PAs or getting into a row about the pros and cons of them.

[Baroness Harding of Winscombe (Con)]

My Lords, I support this Motion and, not for the first time in a debate on health, I find myself in almost complete agreement with the noble Lord, Lord Hunt, and the remarks he made earlier in an extremely powerful speech. We are exemplifying the right debate here, in that this is a subtle and important issue.

I do not wish to suggest that I challenge the esteemed clinicians from a number of the different clinical tribes who have spoken this evening. I speak as a non-expert, as a manager of people, and as a patient. Non-experts in healthcare would find it completely baffling that we have 3,000 people working day in, day out in clinical roles who are currently unregulated. It cannot be right, and I have not heard any argument this evening that suggests that anyone in the Chamber thinks it is right. I think we are all united in our agreement that these hard-working, brilliant people need proper professional statutory regulation.

I hope that, therefore, the order, as it stands, passes. But it is worth dwelling on why this has created so much controversy. Fundamentally, it is because change is hard—and people change is hard and scary. There is a real danger that we underestimate how important it is to look after the people who care for us, and that what we are really hearing from a number of the different clinical tribes is fear, frustration and hurt that they are not being looked after. The real tragedy is that, as the noble Lord, Lord Hunt, said, in the process we have made 3,000 more people feel hurt, unloved and uncared for in the awful debate out in the Twittersphere or X-sphere or whatever it is called.

I will not talk for very long. I just want to register that this has been far too long unfixed, that 20 years is too long for people to be practising without regulation, and that other countries around the world are far ahead of us on this. We should be discussing how we properly define the scope of practice and how we then extend that scope of practice, with the appropriate training for prescribing rights and the ability to order X-rays, just as happens in many other countries in the world. We are all in this Chamber rightly proud of the NHS, but we must not stick our heads in the sand and convince ourselves we are brilliant when others fixed this issue 20-plus years ago.

I finish by saying that regulation is clearly not enough. I completely agree with the noble Baroness, Lady Finlay: we have to recognise that our health and care workers feel unloved and uncared for. There are far too many stories of people unable to get a hot meal when they are working night shifts or having to cancel their own wedding because they are not rostered to be allowed to take the time off. None of that requires professional regulation; that requires professional management. We need both of those.

[Lord Bethell (Con)]

My Lords, I hope that my noble friend the Minister will not mind if I say that I am very grateful to the noble Baronesses, Lady Bennett, Lady Brinton and Lady Finlay, for the regret amendments and this debate today. Secondary legislation comes through the House and too often we overlook it. Every now and again we need to put a spotlight on some of the important measures that go through.

I regret two things. I deeply regret the way in which the professions of associate physician and associate anaesthetist have been denigrated in the press, in the lobbying material that has been sent around, and, frankly, in aspects of this debate. I agree with my noble friend Lady Harding and the noble Lord, Lord Hunt, that the feelings and sentiment of these hard-working contributors to our healthcare system have been overlooked. I was sent a very robust briefing by the BMA. I replied: “Is there nothing positive you can say about these hard-working healthcare professionals?” The reply came back—the noble Baroness, Lady Finlay, was copied in on it—that there was not: there was nothing positive it could say about them. I greatly regret that tone, and wish it had not happened.

I am not a clinician and I do not have anything to rival some of the comments made by the clinicians. However, I point out that our hard-working healthcare professionals are incredibly stretched. Take GPs, for instance: 350 million appointments were conducted in primary care last year, 160 million of which were by GPs themselves. That was 50 million more than in 2019, so 44 more appointments per practice. That trend is going up. Britain is getting less healthy, and there is a large amount of immigration. The number of full-time equivalent GPs—although the number of GPs has gone up, a lot of them are working fewer hours—has decreased from 28,000 in September 2015 to 27,000 in October 2023. The complexity of many people turning up to these appointments is very high.

We have to find people from somewhere to do some of these appointments, and there are going to be people who have a lot to contribute who do not necessarily go through the 10 years of qualification to become a GP. We should be embracing them. That is what is happening in every other professional walk of life—it is happening with the astronauts who fly to the moon, the people who fly our planes, and the lawyers who run our courts. The modernisation of workforces is happening everywhere; we should embrace that. My noble friend the Minister alluded to 12,000 AAs and PAs by 2036; that would be just 8% of the number of doctors. That is not a revolution or a threat that the doctors of Britain should be worried about.

If these regulations do not go through—the noble Baroness, Lady Bennett, has said that they will—then it would be difficult to enforce standards, there would be years of delay to regulate the professions, there would be a reduction in the number of healthcare professionals to support our healthcare system, and training programmes would be on hold. I support the passage of this legislation, so that we can modernise the workforce, increase primary care capacity, improve the lot of our hard-pressed GPs and make it easier for a wide range of talents to make a difference to the British healthcare system.

NHS Long-term Workforce Plan

Baroness Harding of Winscombe Excerpts

Tuesday 4th July 2023 Lords Chamber

[Lord Markham (Con)]

As I mentioned previously, the NHS plan is something that we or the NHS can publish, being the employer. With there being hundreds, if not thousands, of employers in social care, it is clearly a different situation. What we can do is make sure that we put the investment into the sector, so that there is pull through in the number of places. Over the next few years, we are looking at an increase of up to £7 billion, which is about 20%. We know that, of that £7 billion, around 65% to 70% flows through to staffing and wages. We are seeing a massive investment on our side, which we are looking to lots of employers to fulfil. By increasing the number of medically trained people, we will be increasing the supply base to fulfil that demand.

[Baroness Harding of Winscombe (Con)]

My Lords, I too thank and commend my noble friend the Minister, the Secretary of State and the leadership of the NHS for producing an extremely good plan. It is historic, not because it is the first time such a plan has been written but because it is the first time in 20 years such a plan has been published. The Minister has commented a couple of times that this is a living plan—one that will be updated at least every two years. Could he confirm that those updates will be published every two years, and that this House will be able to debate and discuss them?

[Lord Markham (Con)]

That is absolutely my understanding. For it to be a living document, people clearly need to have input and to be able to debate it in exactly the way we are doing here today.

Nursing: Recruitment

Baroness Harding of Winscombe Excerpts

Wednesday 26th October 2022 Lords Chamber

[Lord Markham (Con)]

We appreciate that recruitment is an ongoing process, and while I think the whole House would agree a 29,000 increase is a good record—up 9,000 in the last year alone—we cannot rest on our laurels. Vacancies of 50,000 is partially a function of a full-employment economy, which I think we would all support. We are showing that our recruitment is working and, as I say, we are over half way towards our target of 50,000 more nurses.

[Baroness Harding of Winscombe (Con)]

My Lords, a few months ago, the Secretary of State but two said that the NHS long-term workforce strategy would include numerical assessment of both supply and demand of nurses and other clinical professionals but that publishing those details would depend on cross-government agreement. There was broad agreement in this House, in June, that those numbers should be published. Could my noble friend the Minister put on record his support for publishing NHS workforce supply and demand numbers? If he does not feel able to, could he explain how we will know whether 50,000 is the right number of nurses?

[Lord Markham (Con)]

There is a long-term workforce strategy plan being put together, as I think we know, and that builds on the NHS people plan of 2020, which has seen this increase in numbers. I will find out where we are with that, and the details behind that, and write to my noble friend.

Health and Care Bill

Baroness Harding of Winscombe Excerpts

Consideration of Commons amendments
Tuesday 26th April 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise very briefly to offer Green support for both Motions A1 and D1. Motion D1 has already been very amply covered, most notably by the noble Baroness, Lady Campbell of Surbiton, so I will just address my remarks to Motion A1.

I know that many Members of your Lordships’ House feel as though we do not want to be political about things—I might have thoughts about that—but this is not a political amendment at all. As the noble Baroness, Lady Merron, said, more than 100 of our major healthcare organisations have expressed support for this workforce planning approach. Just a couple of hours ago, and this addresses your Lordships’ House directly, the British Heart Foundation put out a press release saying that, without this amendment, it is

“unclear how ambitious targets laid out in the Elective Recovery Plan and other NHS delivery plans can be met.”

The chief executive said that

“the Government has missed an open goal by failing … to address the workforce shortage”.

In addition, just yesterday the King’s Fund put out a report saying that the Government—they can welcome this—are “on track” to meet their target of “50,000 extra nurses” by 2024. However, the King’s Fund points out that the level of vacancies is still the same as it was when that promise was made. Just plucking figures out of the air and going, “Hey, we’ve got this great figure”, is not enough; we need to plan for the future. That is why this amendment is absolutely crucial for our NHS.

[Baroness Harding of Winscombe (Con)]

My Lords, I rise very briefly to speak to Motion A1. I will first thank my noble friend the Minister for his fantastically collaborative approach on the Bill. I am particularly delighted to see the Government’s proposals on reconfigurations, so I thank him very much for them.

On workforce, I fear that there is almost nothing more to be said. Throughout the passage of this Bill, at every stage in this House and across all sides, we have all been clear that if we do not resolve the workforce issues—the people issues in the NHS—everything else is for naught. Yet we come to end of this process and there have been no changes at all. It is with great sadness that I speak today because I feel that, despite the great work that has been done and all the best intentions, things will not improve. I would love to believe that I am wrong, that my noble friend the Minister is right and that the workforce elements of the Bill are sufficient, but I am afraid that the evidence of the last 20 years is that they are not.

Health and Care Bill

Baroness Harding of Winscombe Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, I will speak in support of Motion B1 on workforce planning and Motion C1 on the Secretary of State’s powers on reconfiguration. As the noble Baroness, Lady Cumberlege, has just reminded us, there is a huge groundswell of support for the need to do proper workforce planning in the NHS, but the fact is that today we do not need to relitigate the fundamental arguments, because your Lordships have already decided, by a margin of 171 to 119 votes on 3 March, that that is indeed what is required.

Of course, if the facts change, we should change our minds. Have the facts changed since 3 March? Have we seen the long-awaited detailed workforce plan for the health and social care sector that has been promised yet suppressed for the last six years? Regrettably, we have not. Have we even had concrete commitments to the detailed, costed and quantified five, 10 and 15-year outlooks that will supposedly be forthcoming in the spring? No, we have not had commitments that those numbers will be able to be produced without fear or favour, or Treasury veto.

However, we have before us two new data points. One is the survey of 650,000 NHS front-line staff, half of whom—52%—are now telling us that they cannot do their jobs properly because of a shortage of staff in their local service. The second data point is the results of the British Social Attitudes survey, telling us that nearly half of our fellow citizens have noticed that fact; they too believe that one of the fundamental problems standing in the way of performance by the health service is the shortage of staff.

If the Government are not inclined to listen to the hundred or so organisations that have supported this amendment or, indeed, to the results of surveys of front-line staff or the public, perhaps they will listen to a commentator from the Spectator:

“The lack of workforce planning by the Government—and its continual refusal to commit to it—means satisfaction from patients and staff is likely to plummet still further.”


I do not believe the Government want that. Nobody wants that, which is why we should take this opportunity to listen to the clear message that we have been sent by patients, staff and the public.

I turn briefly to Motion C1 on the Secretary of State’s powers on reconfigurations. There is an obvious read-across between the discussion on workforce and the discussion on reconfigurations. In the real world, it is often staff shortages which give rise to concerns about the safe provision of services, hence the request for reconfigurations. In these circumstances, and coming just a few days after the Ockenden review of maternity safety, it is all the more dangerous that the new powers in Clause 40 and Schedule 6 would allow the Secretary of State to suppress changes needed to keep patients safe and to pre-empt and override the concerns of local clinicians, local patient groups, local authorities and even the Care Quality Commission.

There could be safeguards but, unfortunately, to date at least—perhaps, depending on what we do today, this will resurface after Easter—we are being asked to support the original text of the Bill, which has taken no account of any of the concerns that have been raised in both Houses during its passage. Instead, on the reconfiguration powers, today the Government are essentially praying in aid an argument not on the substance but on the merits of democratic oversight by the Secretary of State. This is despite the fact that previous Health Secretaries have managed democratically to supervise the National Health Service without requiring these new powers, despite the fact that former Health Ministers—Conservative Health Ministers, Labour Health Ministers and Liberal Democrat Health Ministers—all oppose these measures and have spoken out, including in your Lordships’ House, and despite the fact that democratically elected Health Ministers in just about every other European country have never sought and do not possess these types of powers.

If the Government want to argue Motion C on the crucible of democratic oversight, it seems that by that logic they should indeed support Motion C1 tabled by the noble Baroness, Lady Thornton, which further enhances the democratic oversight of the use of these proposed new powers, giving Parliament the ability to scrutinise these types of interventions. Therefore, for those reasons, frustratingly, perhaps, I find that we are in a position where Motions B1 and C1 are still necessary.

[Baroness Harding of Winscombe (Con)]

I rise to congratulate my noble friend Lady Cumberlege on her excellent speech and to support her on Motion B1. Addressing workforce shortages in our health system is a wicked problem. It is complex and complicated and it is a problem that is shared by every healthcare system in the world. I have no doubt that my noble friend the Minister and the Government are sincere in their belief that they are doing a lot to address the problem but, as my noble friend said, the problem is that we do not know its scale. Until we do and we are open and honest about the complexity and size of the problem. we will not be able to move forward.

Sadly, this ought to be one of the reasons why the NHS is the best healthcare system in the world. It, above all other healthcare systems, ought to be able to do this sort of long-term, complex, detailed planning as a single-payer, state-provided system. Most developed countries do not have those benefits, yet today we are in a place where the Government appear to be saying that we should just keep doing what we have always done. There is a basic maxim in life that if you always do what you have always done, you will always get what you have always got. The reality is that unless we are willing to bend and change, we will not get any meaningful, sustained solutions to this burning problem. My noble friend Lady Cumberlege has bent and changed and has adapted her amendment to try to address what I know were some of the major concerns of the Government about the risk of a verified, firm and unwavering false certainty in a forward forecast and the need to recognise that this is a complex problem where there is likely to be a range. If we are not open and honest about that, we will never really address the issues.

This is a wicked problem that requires us to be brave enough to admit that we do not have all the answers. That is the courage we would need to see in publishing a workforce plan and is why I support Motion B1.

Health and Care Bill

Baroness Harding of Winscombe Excerpts

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

[Baroness Tyler of Enfield (LD)]

My Lords, I will be exceptionally brief and make two very quick points, but first I need to apologise for, when I spoke earlier, omitting to mention my registered interest as a non-executive director of the Royal Free London NHS Foundation Trust.

I very strongly support Amendment 80, moved so ably by the noble Baroness, Lady Cumberlege, and pressed so very cogently by the noble Lord, Lord Stevens, and others. It is absolutely fundamental to everything that the Bill is designed to achieve, and we will not achieve those things unless the workforce is addressed.

In relation to Amendment 111 in the name of the noble Lord, Lord Hunt, I say that it is so important that we have a review into the distribution of GPs in England. I was very concerned when we debated in Committee the huge variation in list numbers in different parts of the country. The biggest lists were in the most deprived areas. If you track that back to the debate we were having on health inequalities, where there was a huge consensus across the House, it is clear that we are never going to fundamentally tackle health inequalities unless we have far greater equality in things like the size of GPs’ lists.

[Baroness Harding of Winscombe (Con)]

My Lords, I also support my noble friend Lady Cumberlege and Amendment 80. The noble Lord, Lord Stevens, made two points: I would just like to add a third to his argument. He argued that workforce planning needs to happen. There is no large employer of people that does not plan its workforce other than the NHS. We need to do it, and I do not think anyone in this Chamber is going to disagree. He also said that this would not happen without legislation. I will not repeat the points I made at Second Reading or in Committee, or those that he just made so eloquently.

My third point, which I would like to add, is very much addressed to my noble friend the Minister. It is that this amendment will not bring the downsize that the Treasury truly fears. This is actually an amendment of sound management that enables the NHS to manage finances and people better. While there will be more money spent on training, this is actually the way to control the costs of the ever-growing demand for health and social care. If you do not plan, you cannot control the costs. This is actually the way to do the very thing that the Treasury is most concerned about.

Far from locking in old, established ways of working, this is also the way to drive transformation because, unless we are honest about the ever-growing demand for clinicians of every profession, we will not face the fact that we will need to change the way those clinicians work together as medicine and science evolve and all of us age. This is a way to deliver the very thing that the Treasury most wants: control of the finances and transformation of our healthcare services.

With that, I add one final point, and I hope noble Lords will forgive me for repeating what I said in Committee. There is another reason why we need to do this now. Our NHS people are exhausted, and they have lost hope that we understand what it is really like on the ground for them. By passing this amendment, we will give them hope; we will show them that, collectively and cross-party, we really understand that it is they who make our wonderful, precious health and care system work, and we are committed to helping them going forward.

[Baroness Finlay of Llandaff (CB)]

My Lords, I must declare my interests: I am a fellow of the Royal College of Physicians, the Royal College of General Practitioners, the Academy of Medical Sciences, and the Royal College of Physicians of Edinburgh, which is affected by Amendment 168. I am an honorary fellow of the Royal College of Emergency Medicine, president of the Chartered Society of Physiotherapy and an observer on the Medical Schools Council. All those organisations have a vested interest in this amendment.

Very simply, this amendment just makes sense for the future. Without it, the cost of healthcare to the nation will rack up and never come under control. The talk about people working in the NHS is a fallacy. What matters is whole-time equivalents and the competencies of those people with whole-time equivalents. While it is absolutely right to say that it might take 15 years for somebody to come through training as a specialist, what is not understood is that, as soon as people qualify, having left their undergraduate training, they are then on the job. They are learning on the job, working incredibly hard and contributing, but they do not have the competencies developed. That is what takes a long time. The modern techniques that get things done much more quickly and that deal with more patients—laparoscopic surgery having been an example—are highly skilled, but highly efficient.

We have a shortage of 1,400 anaesthetists. Without anaesthetists, you cannot have good maternity services, you cannot operate and you cannot have good emergency services. They are absolutely essential to the whole running of secondary care. Then, of course, in primary care, we have the gaps as well, so the specialist training is really important.

As well as that, this cannot be handed over to algorithms on a computer and left to IT, because of the need for personal interaction between the clinician and the patient and their family. I do not believe that this will be replaced by AI. However, many jobs performed currently will be taken over by AI, freeing up clinicians to become even more specialist competent.

Building on the comments of the noble Baroness, Lady Harding, I remind the House that poor care overall is more expensive than good care in the long term. It is a very short-term view to think that you can provide poor care; in the long term, you really do stack up debt. Stopping workforce planning will not avoid costs at all; all it will do is move the costs from one year further into the future and create bigger problems. Although I hesitate to say it, I think it will also fuel the whole litigation culture.

Amendment 80 is absolutely essential. If it is accepted by the Government, or passed by this House, then Amendments 81 and 82 would fit very neatly into the criteria against which such reports are to be written on the workforce. I remind noble Lords who might be unaware of this that the royal colleges already collect workforce data. Verification of data collected from integrated care boards and areas will not be difficult, because you will simply see how the figures match up. The figures will be reported centrally, and planning can take place. The amendment of the noble Lord, Lord Hunt, is so straightforward; I cannot see why we want to rack up costs further by not putting it through. Vacant posts cost money, they do not save money. By putting that through, we will have more efficient appointment procedures. This is an historical anomaly which could be corrected easily.

Relying on bank staff is really dangerous. Mistakes happen much more often when staff come in who do not know the place, the team or who to call. You would never field a sports team consisting of a bunch of people brought together to play at a high level who had never played before. Yet, what we are doing in our NHS is bringing in bank staff who often do not know the hospital or the team. They do not know the strengths of the other people in the team, so they do not know to whom they can delegate. I hope that the House will approve Amendment 80 if the Government are too short-sighted to just accept it.

Health and Care Bill

Baroness Harding of Winscombe Excerpts

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

[Lord Hunt of Kings Heath (Lab)]

My Lords, before the noble Baroness, Lady Walmsley, speaks, I congratulate her and the Minister on Amendment 31. I also want to ask a question. It very much looks as if the integrated care board is marking its own homework, because the duty to keep the experience of members under review is placed on an integrated care board. It is then for the integrated care board itself to make a judgment as to whether it

“lacks the necessary skills, knowledge and experience”.

Quite clearly, any board that has already appointed a group of members is almost certain, in undertaking its review, to come to the conclusion that it was altogether wise in appointing the members with the balance it did. Who is going to monitor this? Who is going to check?

What if you are a local nursing body concerned that nursing issues are not being debated and reflected enough within an integrated care board? What do you do? Who do you go to? As far as I can see, apart from judicial review proceedings there is absolutely no way you can get any change. That is why—and I pay tribute to the noble Baroness, Lady Walmsley, for her work on this—you need amendments like my noble friend Lord Bradley’s to make some specification in relation to those critical areas where it is essential that the board has members with the relevant experience.

My second point for the Minister is this. In introducing her Amendment 9, my noble friend Lady Thornton essentially said that the Bill already lays out constraints on integrated care boards in relation to potential conflicts of interest. All she seeks to do is to extend that to sub-committees of the integrated care board, including place-based committees, which will commission a huge amount of health service provision in future. For the life of me, I cannot see how those sub-committees can be constituted under any different principle from that of the integrated care board itself. Unless the Minister really comes up with a convincing answer on this, I think the House should make its views clear.

[Baroness Harding of Winscombe (Con)]

My Lords, as this is my first contribution on Report, I begin by declaring my interest as the recently stepped-down chair of NHS Improvement and NHS Test and Trace.

I commend the noble Baroness, Lady Walmsley, and my noble friend the Minister and support Amendment 31. In Committee, we debated in considerable detail the constituent elements of the ICBs. I think it hugely important that integrated care boards have a loud, strong, forceful voice for mental health, public health and prevention in all its forms, but I also think it really important that we enable a board to be a proper board.

The noble Lord, Lord Hunt, questions whether a board would ever assess its own competence and members. Any really good, functioning board in the public and private sector views that as one of its primary obligations. The first line of defence to ensure that a board is performing well is whether it is actually doing an assessment every year of whether it has the appropriate skills. Yes, you should have second and third-line assessments through the CQC and NHS England, but it is the role of a board, and we should let them do that. I believe that Amendment 31 holds these boards to account to do that.

The amendments we have already debated today, enshrining the obligations around public health, health inequalities and mental health, ensure that that is the clear objective of those integrated care boards. I encourage my noble friend the Minister to hold firm and support his amendments and not the others.

[Baroness Walmsley (LD)]

My Lords, I thank noble Lords who have expressed their support for Amendment 31 and my role in it; it is very kind.

I go back to how this arose. It is to some extent influenced by what the noble Baroness, Lady Harding, said in Committee. It was quite clear that many noble Lords were very concerned that appropriate levels of skills, knowledge and experience were on an ICB so that it would be able to carry out all the functions that the Bill puts upon it; not perhaps just the list that the noble Lord, Lord Kamall, mentioned, because it was not intended to be an exclusive list. The amendment actually says:

“in order for the board effectively to carry out its functions”.

I think there it means all of its functions.

It was quite clear in Committee that the Government had set their face against prescribing all the different people who should be on a board. But there had to be a way of making sure that the board had all the necessary commissioning skills, and the knowledge and experience of all the areas of health services which that board had to deliver. The board had to have the duty to make sure it could do all of those things—perhaps without prescribing everything, which the Government are determined not to accept.

The solution came to me not just because of what the noble Baroness, Lady Harding, said but because of what my noble friend Lord Thurso said to me in private—not on the Floor of the House. He is a very experienced board chair. He called my attention to the National Audit Office advice on best practice in this respect and a paper on NHS leadership, which recommends something very similar: that the board must have the duty to make sure it has all the skills, knowledge and experience to carry out all its functions, keep that under constant review and report on what it has done and how.

It is inconceivable to me that, if ICBs had this duty, there would not be somebody who knew everything that needed to be known about mental health and public health to effectively commission those services. The duty to report is very important, to keep this in constant review every year and to report in its annual report on how it makes sure that it has got all those skills and that experience. I think the CQC would look very carefully at whether the board had actually carried out the duty put upon it by Amendment 31. If there were any gaps in a service which the board had to carry out, and it did not have the right skills, knowledge and experience to do that, the CQC would be very critical. I commend this amendment to your Lordships.

I will also say in concluding that on these Benches we also support Amendment 9. The noble Lord, Lord Bradley, had a very good point. The amendment in the name of the noble Lord, Lord Kamall, which I am supporting, is retrospective because it requires that, by the end of when an annual report comes around, the board has to show what it has done in respect of providing the right people to make the right decisions. From day one, what this House has done on mental health and how important it is, with the Government’s co-operation, is right.

Health and Care Bill

Baroness Harding of Winscombe Excerpts

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

In finishing, I make one further observation. Beyond the health gain that drives a research strategy applied across the entire NHS, there is a broader wealth gain for society and our economy. It is well recognised that after financial services, the field of life sciences represents one of the most important economic sectors in our country. To fully mobilise that opportunity, we need to ensure that, while its primary objective is to secure high quality, effective and safe care for all patients, every part of the NHS is also mobilising that public investment to ensure that what can be done to promote research and innovation, is being done, so that the second opportunity—driving wealth creation in our country—is also achieved.

[Baroness Harding of Winscombe (Con)]

My Lords, I rise to speak on behalf of my noble friend Lady Blackwood of North Oxford and the noble Lord, Lord Patel, neither of whom are, sadly, able to be here today.

[Noble Lords]

Oh!

[Lord Kamall (Con)]

The noble Lord has recovered.

[Baroness Harding of Winscombe (Con)]

I am sorry—the noble Lord, Lord Patel, is here. I meant to say the noble Lord, Lord Bethell. I apologise for my senior moment.

I will begin again. I rise to speak on behalf of my noble friends Lady Blackwood and Lord Bethell, neither of whom is in their place. I should, out of an abundance of caution—particularly given how well I have spoken so far—declare the interests of both my noble friend Lady Blackwood and me, as the present and past chairs of Genomics England.

In speaking to Amendments 79 and 196, we wish to support the noble Lords, Lord Sharkey, Lord Kakkar and Lord Patel, in calling for trusts and integrated care boards to have a duty to conduct research and to report on the steps they have taken to deliver it. We know that there are excellent research-active NHS organisations in the UK, ranging from our acute tertiary university hospitals, such as Oxford, to our district general hospitals, such as Portsmouth.

There are many initiatives to promote research, such as Saving and Improving Lives: The Future of UK Clinical Research Delivery, which sets out a bold and exciting vision. In particular, my noble friends and I await with interest the Find, Recruit and Follow-up service, which plans to use digital tools to identify patients who may be suitable subjects for research. When speaking to patients, one of the refrains that we all hear most often is that they find it hard to find suitable clinical trials, and we welcome any initiative that can make it easier for patients to take part in clinical research.

As well as supporting patients in finding trials, we need to make it as easy as possible for them to participate. In some cases, the pandemic has accelerated a move towards remote monitoring tools—wearables and other devices that allow individuals to participate in trials while reducing the number of visits they have to make to hospitals. We welcome the NIHR remote trial delivery toolkit, which makes recommendations on how some of these positive practices can be continued and so broaden participation and promote patient retention in a beneficial way.

My noble friend Lady Blackwood, as a rare disease patient herself, knows that clinical research is often the only way for patients to get access to innovative treatment. Yet we are saddened to see, in the annual NIHR publication on initiating and delivering clinical research, that some trusts are still not delivering trials every quarter. We continue to see a large disparity in the number of trials being offered in each trust, which leads to a postcode lottery. Those individuals fortunate enough to be under the care of a research-active hospital have an increased chance of being recruited on to a trial, and therefore have better outcomes than patients under the care of less research-active hospitals.

Patients admitted to more research-active hospitals also have more confidence in staff and are better informed about their condition and medication. And as the noble Lord, Lord Davies of Brixton, has said, there is very clear evidence that research-active trusts deliver better outcomes—in part, I am sure, because of their ability to retain and energise staff, as the noble Lord, Lord Kakkar, has mentioned.

The last couple of years, however, have been challenging for the health research community. In 2020, the Association of Medical Research Charities predicted a £320 million shortfall in research spending, forcing many medical research charities to make tough choices about which projects to prioritise. Data also suggests that the UK has been slower to return to pre-pandemic levels of commercial clinical research compared with other European countries.

The Life Sciences Vision sets out the Government’s objective to be a science superpower, but this requires research to be embedded in every part of the NHS, including primary, community and mental health services. That will happen only if NHS organisations, including the new integrated care boards, have a duty to conduct research, as these amendments propose.

In addition, we all know that what gets measured gets done, which is why these amendments place a duty on trusts and ICBs to report the steps that they are taking to deliver clinical research in their annual reports or forward plans. This not only enables progress to be tracked but helps patients understand what research is being done in their area and will encourage NHS organisations to invest in research that meets the needs of their local communities and—

[Lord Lea of Crondall (Non-Afl)]

I am sorry to intervene. I am fascinated by everything that is being said but, given the cliché that money does not grow on trees, I am a bit surprised that we have not heard as much as we might have about international collaboration. Is that not a big deal? How would that be measured, as it were, as compared with the issues that the noble Baroness, Lady Harding, has already raised?

[Baroness Harding of Winscombe (Con)]

I personally believe that international collaboration and engagement in research across all parts of the United Kingdom go hand in hand. It should not be either/or; it is a combination, and we need to do both. The amendments that I am speaking to call for every NHS organisation to participate and become research active.

Finally, and briefly, I urge the Minister to embrace this opportunity to embed what is genuinely cross-party support for clinical research in legislation. We all want to put the UK on the path to being the best place in the world to participate in health research. We will do that, as the noble Lord suggests, by collaborating internationally, but we will address the health inequalities that we have all spoken about over the many days of Committee only if all NHS trusts have a duty to conduct research.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I agree with the thrust of all these amendments. Most of the discussion has been about research—encouraging research in clinical trials within NHS trusts and foundation trusts—but I want to speak in support of Amendment 78, in the name of the noble Baroness, Lady McIntosh, which looks at the issue of commissioning and the role of integrated care boards, because I believe that it is just as important to ensure that integrated care boards have in mind the need, through their commissioning policies, to encourage innovation. In our last debate on NICE, last week, we discussed the same issue, which is the fact that the reason NICE exists is that there are many innovative new medicines and treatments coming on stream, many of them developed in the UK, which the health service has found difficulty in adopting more generally.

The noble Baroness’s Amendment 78, about ICBs, is designed to encourage the ICB boards to consider that they have a responsibility in relation to innovations. It also proposes that integrated care boards must appoint a dedicated innovation officer to the board. I do not want to open up the issue raised by my noble friend Lady Thornton as we went into Committee, but we come back to the issue of the composition of ICB boards. She referred to guidance issued by NHS England a few days ago, which is not obtainable in the public domain. It is obtainable through something called “NHS Net”, but the Library has not been able to get hold of it. It is a bit much that advice on the contents of the Bill has been given out which we cannot even see. I hope that, as part of his response to my noble friend Lady Thornton, the Minister will look into that.

On the question, “Why add another postholder to the board of an ICB?”, I point to the Nuffield Trust report, which says that no organisation in the health service at the moment—or very few places—has someone with a direct responsibility for encouraging innovation. The Nuffield Trust thinks that having chief innovation officers with broad oversight could make what it calls a fundamental difference. I refer the noble Lord to research by the ABHI, which is essentially the trade association for medical devices. It showed that fewer than 20 NHS trusts across the UK have a member of their board with explicit responsibility for the uptake of innovative technologies.

Sometimes one must be wary of having a board appointment that may seem to be a token appointment. However, when it comes to commissioning, having someone around the table who is constantly reminding the board that through commissioning we must encourage and invest in innovation, would be very helpful. The slew of amendments tabled by the noble Baroness, Lady McIntosh, is valuable in getting that message across.

[Lord Patel (CB)]

My Lords, I am seriously concerned, for my sake, that I am invisible to the noble Baroness, Lady Harding—which I regret, but I will tease her about it.

[Baroness Harding of Winscombe (Con)]

My Lords, I fear that is my blindness and my problem, not his. I am very sorry.

[Lord Patel (CB)]

My Lords, I am only teasing.

I declare an interest as a fellow of the Royal Society of Edinburgh and of the Academy of Medical Sciences, and as a professor emeritus at the University of Dundee, where I have spent all my life bar the first 18 years. I say this because we have lost something in the United Kingdom. A key strength of our academic clinical departments was a worldwide reputation for conducting health service-related research. We were second to none, and I mean that. We have lost that because we have changed the environment. People who work in clinical academic institutions—our so-called teaching hospitals—no longer have the environment to promote that. It was the duty of those of us who worked in clinical academic departments to grow the next generation of academics. It was important that we were all involved in conducting clinical research that produced innovation, better care for patients and a first-rate, first-class, internationally renowned next generation of academics. We do not have that any more, and anything we can do through this Bill to bring that back would be a major plus.

I will speak to the amendments tabled by the noble Baroness, Lady McIntosh of Pickering, and the noble Lord, Lord Sharkey. Much has been said, excellently, and I will try not to repeat it, but a strengthened research mandate through this Bill could support patients, clinicians, NHS organisations and research. The patient benefits from increased research activity have already been mentioned, but there is a significant variability across the UK in the opportunity for patients to engage in research. A strengthened mandate could support ensuring that all patients can access clinical trials and their associated benefits. Therefore, wider changes are needed to increase the competitiveness of the UK as a destination for research, particularly through the proposed changes to clinical trials legislation, and through increases in Department of Health and Social Care and NIHR funding.

This could include measures to support faster approval timelines and closer multiagency collaborations. Clinical research has clear benefits to patients, as has already been mentioned. NHS trusts with higher levels of research have a higher rating from the CQC and better outcomes, as have already been said. During Covid, the UK has demonstrated its potential with the success of Covid-19 research, with 68 commercial Covid trials launched in the UK in 2020—the third-highest globally, beating the United States and the rest of Europe.

How did we manage to do that? It is because, during the emergency, we set up methodologies that allow patients to be involved in trials more quickly by creating a voluntary registry, where patients themselves volunteer to take part in research. I also note the clinical recovery trials that we set up—some noble Lords might have seen the article in the Times, with Sir Martin Landray suggesting that we follow that process in the future to try to find treatments for other common diseases. If we do that, we will lead globally. The NHS has the capacity to do that, but it now requires the will and the leadership from the centre to drive that. The clinical academics will be up to it—they just want to be given a chance. Let us do that, because we have demonstrated that we can.

--- Later in debate ---

That is why I have tabled Amendment 285, which talks about establishing an office of health and care sustainability which would bring together the issues of money and workforce planning. It basically implements a recommendation from the 2017 Select Committee report and is based on the experience of the Office for Budget Responsibility. The noble Lords, Lord Patel and Lord Kakkar, have tabled a similar but slightly less detailed amendment with Amendment 286. Between now and when we reach those amendments, we need to consider whether we are confident that amending the Bill to rely on the Secretary of State doing the right thing, without some independent outside influence, is the right way forward. We want to give the Secretary of State the job, but we also want to ensure that he does it. I mention, if I dare, that the amendment proposed by that 2017 report was put to Jeremy Hunt, who did not act on it—though I am pleased to see that the sinner has repented and decided that there was perhaps some merit in having a national body to look at this kind of issue.

[Baroness Harding of Winscombe (Con)]

My Lords, I add my voice in support of Amendment 170, so ably and brilliantly introduced by the noble Baroness, Lady Brinton, my noble friend Lady Cumberlege and the noble Lord, Lord Stevens.

At Second Reading, I spoke of my personal experience along the timeline set out by the noble Lord, Lord Stevens, as the person charged with developing the 2019 people plan with said absence of numbers. I do not wish to go into more detail on the history; I would rather spend the brief time I have available talking a bit more about why I think this amendment is needed and attempting to pre-empt some of the potential objections which I suspect will come from my noble friend the Minister.

A number of people have alluded to it, but we should be under no illusions that this is the most important debate we will have on health and social care. All our fantastic, lofty ambitions for our health and care system are for naught if we do not have the people to deliver them—and we should be under no illusions that we do not have them today.

I add my voice to those of the noble Baroness, Lady Hollins, and my noble friend Lady Verma: there is undoubtedly an important point about ensuring that healthcare assistants, nurses and managers in social care are paid appropriately. We also need to face the fact that we do not have enough people working in health and care in every single role in the system.

This is not a UK-only problem. As the noble Baroness, Lady Brinton, and the noble Lord, Lord Patel, said, this is a global issue. We cannot rely on people from outside the UK alone to solve our problem; we have to solve some of this ourselves. We undoubtedly need more people, but I would argue that we also need to work differently; we need both more and different. We need to address the way we work in health and social care, which is at the heart of this Bill. We need to embrace new professions and do the forward planning to make that possible, whether that is recognising sonographers as a registered profession; pushing forward on physician associates, where we are some 10 years behind other countries in the world; or developing an approach to credentialling which enables our clinicians to have more flexible careers, as science and technology change through the course of their lives. All of these ways to work differently from the way we operate today are as important as having more people. Neither more nor different is possible unless we start by being honest about the size of the problem, which is why Amendment 170 is so important.

I believe there are two substantial disincentives for this amendment being accepted. A number of your Lordships have alluded to the first one: anyone running a large people-based organisation is always tempted to focus on the urgent today and not invest in training and development for the future. It is just too tempting for the NHS, as well as the Secretary of State and undoubtedly the Treasury, to want to retain the flexibility to focus on the short term and raid the training budget for the future. Any one of us who has run any organisation knows that that is a human temptation. This does not make them bad people and it is not party political; it is just the reality of running a large organisation. That is why legislating to force transparency is so important.

The second major disincentive relates to a view that I suspect has been held in the Treasury for the best part of 20 years and which is counter to most economics. It is a belief that the way to control workforce costs in the NHS is to constrain the supply. I am not a brilliant economist, but most economics is the other way round: the way to reduce the cost is to increase supply. I have no doubt that it is quite a strongly held view in Her Majesty’s Treasury that the way we control workforce costs in the NHS is by constraining the supply. The reality is that that market mechanism is completely failing.

You have to look only at the costs the NHS is paying for locum, agency and bank staff. A recent Getting It Right First Time report, published last autumn, stated that 27% of workforce costs in emergency departments are for locum, bank or agency staff, which tells you that they are not properly staffed. If you are a young junior doctor in your third year in your career and you work as a locum for one week, you will earn £5,800, but if you work for the NHS for one week, you will earn £3,300. We should not be surprised that junior doctors with large student debts want to work as locums, yet we also know that that materially reduces their fulfilment and the quality of the care they deliver. The economic incentives are not working, despite the deeply held view that if we constrain the supply the NHS will somehow magically transform itself.

That is why we need to put this in the Bill. We do need more people, but we also need to drive incentives for transformation, and we will do that only if we face into the challenge. Those working in higher education can plan only if we give them a signal, and transformation teams can challenge the way we work only if we are honest about the need for that transformation.

One final reason I really urge my noble friend the Minister to accept this amendment is that our wonderful people, who have worked so hard in health and care over the last two years, need hope—and we can send them the strongest signal of hope that we really hear them, that we really understand the people challenges that they face, by putting this in the Bill.

[Lord Kakkar (CB)]

My Lords, I support Amendment 173 in the name of the noble Baroness, Lady Merron, to which I have added my name, and I broadly support the amendments in this group.

Many noble Lords have identified the question of workforce as the most important single issue that the Bill has to address. Without effective workforce planning, the NHS, as we have heard—and, indeed, the care system—is in peril. Previously, our country and the National Health Service have depended on overseas doctors and nurses to come and fill large numbers. That has been the principal basis of workforce planning for many years—indeed, decades. But that is no longer a viable option. The World Health Organization has estimated that, globally, there will be a shortage of some 18 million healthcare professionals by 2030. That will be a particularly difficult challenge across the globe, and it means that we can no longer depend on importing healthcare professionals to meet our ever-increasing needs. This is well recognised by all who are responsible for the delivery of healthcare and, indeed, by Her Majesty’s Government.

The question is: how can we dependably plan for the future? Unfortunately, it has to be accepted—indeed, it has been accepted in this debate—that planning to date has failed miserably. That is not a malicious failure, but it is a reality, and one that we can no longer tolerate. That is why amendments in this group that deal with the requirement for independent planning and reporting on a regular basis to provide the basis for determination and projecting future health and care workforce needs, are appropriate—indeed, essential.

My noble friend Lord Warner raised a separate issue about a group of amendments that will come later in the Committee’s consideration, which propose the establishment of an independent office for health and care sustainability. This is a recommendation of your Lordships’ ad hoc Committee on the Long-term Sustainability of the NHS and adult social care, chaired by my noble friend Lord Patel. It is this emphasis on ensuring that there is independent, long-term planning and projection that can provide the fundamental and accurate foundations for workforce planning. We need a broader assessment of what the demand for healthcare will be, and that demand is complex and driven by not only demographic change but changes in the way that we practise, changes in expectations, adoption of technology and changes in working practices. That all needs to be brought together to provide the foundations for planning. Without this emphasis and this obligation secured in the Bill, the NHS and adult social care in our country will not be sustainable.

I very much urge the Minister, in considering this group of amendments, to help your Lordships understand why it would be wrong to secure this emphasis in the Bill. If Her Majesty’s Government are unable to secure this emphasis in the Bill, how can they reassure noble Lords that the failures in planning that have dogged NHS performance with regard to workforce over so many years will not be repeated in the future?

Health and Care Bill

Baroness Harding of Winscombe Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness Whitaker (Lab)]

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

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

[Baroness Harding of Winscombe (Con)]

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

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

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

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

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

Health and Care Bill

Baroness Harding of Winscombe Excerpts

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

[Lord Kakkar (CB)]

My Lords, I first join other noble Lords in thanking the noble Baroness, Lady Thornton, for the thoughtful way in which she introduced this group of amendments. I support Amendment 14, in the noble Baroness’s name, and Amendments 65, 94, 186 and 195 in the name of my noble friend Lord Patel. This is a vital group of amendments, as your Lordships have already heard, because it is focused on inequalities. Clearly, no society, Government or Parliament can tolerate the inequalities that we see in both clinical outcomes and access to healthcare that have remained despite our remarkable healthcare system and the NHS. It is for that reason that it is absolutely right that, in the opportunity afforded by this Bill, inequalities are properly addressed.

More worrying is that, despite this country’s substantial investment in healthcare and the development of health systems over the past 70 years, these disparities in outcomes and access to healthcare described geographically and across different ethnicities and socioeconomic groups have continued to grow. That is despite all the success we have seen more broadly in delivering healthcare, addressing prevention and improving treatments.

It is also right to recognise that inequalities in outcomes and access to healthcare are best addressed at the local level. Through a focus on integration in not only the capacity of services but the capacity to integrate the development of policy and its execution across healthcare and through local government and the other elements of the state—education, employment, housing and so on—we will have the greatest opportunity to address social determinants of health. There has probably been no other health Bill presented to this Parliament since the creation of the NHS that provides the greatest opportunity to take that combined and collective approach.

It is therefore quite right that one turns attention to the triple aim. This is a laudable addition to the Bill, with an absolutely appropriate focus on promoting health and well-being, ensuring access to quality care for all citizens and ensuring the appropriate and effective utilisation of healthcare resources. Why not add to that triple aim a fourth clear objective to address issues of inequality? The triple aim does not mandate action, but it provides the context in which a framework should be developed locally, cognisant of the healthcare needs of the local population. An ideal framework would ensure that we drive collaboration and co-operation as required to focus activity and the allocation of resource and establish a local vision and determination to address health inequalities.

To fail to take this opportunity would be disappointing and, quite frankly, unacceptable. As we have heard in this excellent debate, if we fail to address these inequalities not only will they have a continuing and profound impact on health outcomes and access to healthcare for large numbers of our fellow citizens, but there are broader societal and economic consequences of continuing to accept inequalities in healthcare. I hope that, in answering this debate, the Minister will be able to confirm that Her Majesty’s Government are prepared to consider this issue and will put inequalities the heart of this Bill in the triple aim—becoming a quadruple aim—and will ensure that, at a local level, data collection and reporting become a primary focus of healthcare systems.

[Baroness Harding of Winscombe (Con)]

My Lords, I begin by declaring my interest as the recently departed chair of NHS Improvement. I support these amendments, especially those that seek to extend the triple aim, such as Amendments 14, 65 and 94, as the noble Lord, Lord Kakkar, just set out so eloquently. It seems there is no disagreement in the Committee about the importance of addressing health inequalities. Anyone who has lived through the past two years can see that plainly and clearly, as Covid has so cruelly highlighted the health inequalities in this country. The question is how we make sure this Bill genuinely tackles the issue that we all agree about so passionately. Why is it important, as just set out by the noble Lord, Lord Kakkar, to put the duty to address health inequalities in the Bill?