Health and Care Bill

Debate between Baroness Harding of Winscombe and Lord Kakkar

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

[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

Debate between Baroness Harding of Winscombe and Lord Kakkar

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

[Baroness Harding of Winscombe (Con)]

My Lords, I also rise to support the noble Lord, Lord Mawson, in his amendment, and congratulate him and his colleagues on the extraordinary work they have done.

I support the Bill precisely because integration will be key to delivering the health outcomes that we all seek. But I worry that, if the Bill is just rearranging the organisational deckchairs, with exactly the same people in different organisations with different three-letter acronyms, we will not change anything at all.

I think that, over the course of the nearly three days we have spent in Committee and on Second Reading, there is cross-party agreement on the nature of the problem we are trying to solve. In each debate we have had over the last two and a half days, whether on health inequalities, mental health, the social determinants of health, or person-centred digitally enabled care, there has been extraordinary cross-party agreement on the nature of the problem. As the noble Lord, Lord Clement-Jones, said, we are debating and disagreeing more on the means to the ends than anything else.

One of the means to the ends is local—genuine local ownership and leadership. Like many in your Lordships’ House, I have made the pilgrimage to Bromley by Bow and I have also been to St Paul’s Way. When I first joined the NHS, about five years ago, I was told to go to Bromley by Bow, and I was told by a number of NHS insiders how brilliant it was, but how impossible it was to replicate anywhere else. “Go and have a look at it, Dido,” they said, “because you’ll be amazed and impressed, but no one’s worked out how to spread it”.

What I have actually discovered, as we have heard today from people with far more experience of place-based leadership than I have, is that brilliant though Bromley by Bow is, it is not alone. There are fantastic place-based leaders in communities across the country. It is those local groups and leaders who we owe the exit from Covid to more than anyone else, I suspect.

I have had the privilege of working alongside them. I have been to north-west Surrey with the noble Lord, Lord Mawson, but also to Wolverhampton, to the Guru Nanak Sikh gurdwara, one of the first local testing sites for NHS Test and Trace. I have been to Gloucester and spent time with Gloucester FM, a local community radio station that for the first time in its existence got funding to run an advertising campaign to encourage people to come and get vaccinated in the local community. That was the first time it had succeeded in working collaboratively with the local NHS.

I have been across the country in the last two years talking to people from groups who feel excluded. Whether it is the Roma Gypsy community, Travellers, refugees, taxi drivers or faith leaders from a whole host of communities, all have told me—in both my previous role as chair of NHS Improvement and as executive chair of NHS Test and Trace—how in different ways they felt excluded not just from the NHS but from society in general. They also said, generally to a man and a woman, how hard the NHS is to work with when you are from a small, outside local group, as those of us who have worked in the NHS know.

It is with that knowledge base that I wholeheartedly endorse the spirit of the amendment of the noble Lord, Lord Mawson—but with a “but”. I have been consistent in the last two and a half days of Committee in being nervous about adding specific roles and experiences to what is now a growing list of characteristics and past experience we would all like to see in this new three-letter acronym NHS entity, the integrated care board.

I would like to post a question to the Minister. It is clear that we need these local voices—the grit in the oyster, as my noble friend Lady Cumberlege described it; the difference that the noble Lord, Lord Crisp, is referencing; people from outside the system—if this new reorganisation is going to be anything more than a rearranging of the deck chairs. How will we ensure that those local voices are genuinely heard in an integrated care board?

[Lord Kakkar (CB)]

My Lords, I rise to support the amendment in the name of my noble friend Mawson and others, and in so doing congratulate him on his thoughtful introduction. It is clear that one of the most important aspects, and the purpose, of this Bill is to ensure integration at a local level. But the purpose of that integration must surely be—as has been confirmed by the Minister—to improve health outcomes for the entire population. It is well recognised that that can happen only if the social determinants of health in local communities are addressed appropriately and effectively, in a way that our health system has not been able to do to date.

If we accept that to be the purpose, then local integration—that focus on and understanding of the social determinants of health—and responding to local needs must be secured in the organisation of the integrated care systems and their boards. As we have heard from the noble Lord, Lord Mawson, and others, to achieve that, one must not only understand, appreciate and hear the local voice, but be clear that the culture that is established in these systems is responsive to those voices and is determined to act on them and the understanding of the local situation—particularly those social determinants that extend far beyond what has been and can be delivered through healthcare alone—and focus on other issues such as housing, education and employment. It would be most helpful if the Minister, in answering this debate, could explain how that is going to be achieved in the proposed construction of the integrated care boards.

Of course, one recognises that Her Majesty’s Government are deeply committed to this agenda. But it is clear that if these boards are not constructed in such a way that they can change the culture and drive, in an effective and determined fashion, a recognition of those social determinants and create opportunities at a local level to address them, much of the purpose of this well meant and well accepted proposal for greater integrated care at a local level will fail.

Health and Care Bill

Debate between Baroness Harding of Winscombe and Lord Kakkar

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?