Health and Care Bill

Baroness Hollins Excerpts

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

[Baroness Hollins (CB)]

My Lords, I welcome all the amendments in this group. The importance of parity between mental and physical health is key, and I am grateful to the Minister for confirming that that is the intention behind the Government’s amendments. The explanatory component of the amendment is important, but a question remains over what precisely constitutes mental health spending. I would be grateful if the noble Lord could clarify this. For example, will the report on the expected change and expenditure by NHS England and the ICBs, and the comparison with the previous year, include other aspects of mental health investment not covered by the mental health investment standard, including dementia and learning disabilities? Will the Minister consider identifying in the report whether each ICB has increased the proportion of spending on children and young persons’ mental health, with details of any failure to increase spend?

Turning to Amendment 184, tabled by the noble Baroness, Lady Tyler, to which I also added my name, Dr Adrian James, president of the Royal College of Psychiatrists, said:

“These new standards will help patients get the treatment they need when they need it by setting more rigorous standards and generating vital data, helping to put mental health on a more equal footing with physical health. The standards will only have this impact if matched with similarly ambitious investment and action on the workforce crisis to ensure that no-one has to wait too long for the treatment they need. It’s vital the government provides further clarity on how it will support the implementation of these standards as part of the broader recovery from COVID-19.”


I would add that the range of treatments available in all localities needs to be thought about very carefully by ICBs, just as in surgical teams the right specialist expertise is required for each condition, with reasonable adjustments being made for people who have difficulties in accessing specialist services. I include here, of course, people with learning disabilities. It would be unfortunate if waiting times simply led to an increase in medication clinics, rather than the development of a gold standard treatment in mental health, which would include appropriate skills and psychotherapeutic help alongside appropriate social prescribing.

[Lord Davies of Brixton (Lab)]

I want to reiterate a couple of points on this issue that I made at earlier stages of the Bill. I welcome all these amendments, and I am glad about the movement from the Government and that they have recognised the issues raised. Obviously, the key issue here is funding, and a move to better funding for mental health services within the health service is clearly important. It is also important that mental health is referred to in the legislation, and good that the standards have some statutory backing.

I have to express one concern: waiting times and access are important in and of themselves, but they are not a direct reflection of the standard of care. We need to do more work to understand how we can measure the standard of care being delivered by our mental health services. I have mentioned the issue of the differential mortality. I am sure that there are other issues, but mortality is something that I know a little bit about; those other issues could be brought in so that we directly assess the output as well as the input.

These amendments are important and will address the way in which mental health services suffer because of a lack of esteem. However, they are only treating the symptoms of this lack of esteem. We need to understand a lot more about why mental health, in all sorts of subjective ways, has not achieved a parity of esteem within medical culture as a whole. It is a deep-seated problem which needs to be addressed. The money and standards are important, but we need to understand a lot more about this differential level of esteem and how it can be addressed at its heart—not just by addressing the symptoms.

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[Baroness Meacher (CB)]

My Lords, I support Amendments 9, 10, 14 and 32 and will speak to my Amendment 11, which follows on quite nicely from the contribution of the noble Lord, Lord Bradley. It refers to mental health, public health and secondary care services as vital to be represented on ICBs.

As drafted, the Bill leaves the membership of ICBs very much up to local decision-making. The Minister’s Amendment 31 does not change that; it leaves it up to the ICB to decide what it should look like. My concern is that ICBs may be dominated by managers from a range of organisations, perhaps including private sector health bodies. If such ICBs are established—they are being created as we speak—the Minister’s amendment simply enables them to reproduce themselves over time. There will be a degree of transparency over time, but the amendment ignores key sectors and the need for significant clinical inputs to these boards.

Amendment 31 usefully provides an opportunity for statutory guidance to achieve important objectives. In his letter, the Minister made it clear that statutory guidance will clarify that the ICB’s annual report will cover ICB duties in relation to child safeguarding. I very strongly welcome that. Can he include mental health and public health alongside child safeguarding as very particular services that are too often neglected and really need to be represented on ICBs? If he can agree to include those key services in the statutory guidance, as he has included child safeguarding, I would be very content.

Why are these services so important? As I said in Committee, having chaired a mental health trust for nine years, I am acutely conscious of the importance of high-quality and available child mental health services in particular. Across the country at present, the scarcity of such services means that vast numbers of children with quite severe mental health problems simply never get a psychiatric service at all while they are children. These untreated children will have severe problems for the rest of their lives because of that lack of treatment. It is therefore crucial to have a psychiatrist, who will be very conscious of this, on these ICBs—any psychiatrist will be aware that you have to intervene early if children display mental health problems. That is why I feel so strongly about that; I have watched it happen over years.

Another highly significant field being neglected as ICBs are being formed is public health. As many noble Lords know, I am conscious of the huge impact that effective public health responses could have on drug addiction. Police services are increasingly aware of this and are diverting addicted young people to treatment and away from the criminal justice system. However, this approach assumes that treatment services are available in every urban area, but they are not—they have been dropped or cut. Having a public health consultant on every ICB is crucial if these difficult matters are to be properly dealt with and treatment centres are not just closed because they are inconvenient, or whatever the case may be.

The Government hope to control the growth in knife crime through punitive, serious violence reduction orders. We know from all the research in the field that they simply will not work. The Durham, West Midlands and other police services are way ahead of the game, and more and more police services are following them in showing how best to ensure that violent young people caught up in county lines gangs can be diverted into education and work and away from the criminal justice system. However, that assumes that there are treatment facilities available; otherwise it simply cannot happen. Again, please can the Minister include a public health professional consultant on the ICBs as a recommendation in the statutory guidance, as he has done for child safeguarding. I beg to move.

[Baroness Hollins (CB)]

My Lords, I will speak to Amendments 14 and 32 in my name and that of my noble friend Lady Watkins. I want to give an example from my experience; I declare an interest here as independent chair of an oversight panel, reviewing for the Department of Health and Social Care the use of long-term segregation for children and adults with learning disability and/or autism detained under the Mental Health Act. I have seen the impact of very poor and unaccountable commissioning for this group, with very costly mistakes—costly in money and in terms of lives lost and lives destroyed—because of a failure of commissioning appropriate health and social care in the community.

Some commissioners, frankly, do not have the competencies to do their commissioning job safely. I make this point because—while I appreciate the value of Amendment 31 and its requirement that ICBs would have skills, knowledge and experience, keep them under review and take action if they consider that members are failing in some way—as the noble Lord, Lord Bradley, put it, it is rather looking backwards, or marking their own homework, as I might put it, when they do not know what they do not know. This is the problem and why these amendments propose going a little further.

I welcome the Minister’s statement that ICBs will be required or expected to have the appropriate skill mix and experience necessary to deliver all their functions. I understand that the Government will issue regulations regarding fit and proper person tests, which will apply to ICBs when established, including adherence to the Nolan principles, Without the inclusion of the specific skills and expertise required, however, there will be little oversight or accountability of commissioning competence.

I would like the Minister to think again, and to commit to regulations and guidance that set out the criteria and standards that members of ICBs must possess, recognising the responsibilities that they will have and the impact of their decisions on the health and well-being of some of the most vulnerable people in our society. Commissioners take decisions of extraordinary influence; they spend large sums of public money. Civil service appointments are made in accordance with a competency framework. There is no reason why commissioners should be exempt from meeting specific eligibility criteria—and not just in the clinical sphere but in the commissioning sphere, for which there is currently no professional competency laid out.

To give another example, later this month I will be sponsoring the Second Reading of the Down Syndrome Bill, the Private Member’s Bill from the other place that will require relevant authorities, including the NHS, to take account of the specific needs of people with Down syndrome. During the Committee stage of the Down Syndrome Bill, the Minister committed to

“having a named lead on integrated care boards who will be responsible for the implementation of the guidance in practice.”—[Official Report, Commons, 2/2/22; col. 642.]

Thus, representation of learning disabilities and autism interests on ICBs would be within the context of the duty of ICBs to ensure that they have the necessary skills, knowledge and experience. Much will depend on the guidance issued by the Secretary of State under that Bill, which would fulfil similar obligations, I hope, to those of the autism strategy and the Autism Act 2009.

I reassure the Minister that I and other noble Lords recognise the challenge that the Government have in seeking to ensure that the new ICBs comprise people with the correct skills to enable the board to carry out its functions, but these amendments ask for a slightly stronger approach. I ask the Minister to assure the Chamber that guidance and regulations will address the requirement for criteria to be specified.