Health and Care Bill

Baroness McIntosh of Pickering Excerpts

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

[Lord Shinkwin (Con)]

My Lords, I too thank my noble friend the Minister for Amendments 36 and 157. I shall also speak in support of Amendment 59 in the name of the noble Baroness, Lady Hollins. Before I do so, I hope your Lordships’ House will allow me to take this opportunity to thank the healthcare professionals at Guy’s and St Thomas’s, who recently looked after me so well following major surgery. Some noble Lords may have noticed my absence. I have had half my leg rebuilt and am now the proud, if involuntary, owner of a Meccano set inserted by my excellent surgeon, Marcus Bankes, and his registrar, Christian Smith. I apologise in advance if any noble Lord seeks to intervene and I dare not sit down to take their intervention as I am not sure I would be able to get back up again.

Although the pain was excruciating and the morphine, which I am weaning myself off, very welcome, it saddens me to say that that pain was compounded by the way in which I received no support from your Lordships’ House. I might as well have been dead. It reminded me that this wonderful institution remains a place whose rules and modus operandi were designed by and for rich, non-disabled men. I will say no more on the matter now, but it is clear to me that this needs to change if we are to become a stronger, more diverse, more representative House. If we do not want to be consigned to the past, we must stop living in the past. The appalling way we treat Members whose disability enforces temporary absence from your Lordships’ House is indefensible and cannot continue.

Returning to the substance of the amendments under discussion, I am hugely grateful that the Government have listened to concerns I raised at Second Reading and others raised, in my absence, in Committee. All credit goes to noble Lords for the strength and the passion with which they did this, and to the Minister for so obviously listening and taking their concerns on board. Taken together, Amendments 36 and 157 should make a real difference to the lives of all babies, children and young people in this country, particularly those with speech, language and communication needs. I should declare at this point my interest as a vice-president of the Royal College of Speech and Language Therapists. I know the Minister and his colleagues across government, not just in the Department of Health and Social Care but also in the Department for Education and the Ministry of Justice, share my ambition and the ambition of other noble Lords in wanting children and young people with communication needs and their families to have the best possible level of support so they can realise their potential.

To help deliver that ambition, I ask my noble friend to reflect on four things. First, I would be so grateful if he would look kindly on Amendment 59, so ably spoken to by the noble Baroness, Lady Hollins. This would help to close any potential accountability gap and considerably strengthen the provisions of Amendment 36.

Secondly, will the Minister pledge to ensure that all the guidance to the Bill specifically references children’s speech, language and communication needs? The statutory guidance and accountability lead for SEND is a very positive development, but it is not sufficient. The vast majority of children with communication needs do not have an education, health and care plan. This includes children with developmental language disorder—over 7% of all children—those who stammer, and those with speech-sound disorders. The guidance must, therefore, ensure that the needs of those children are supported. A model that the Government have already established for this is the statutory guidance to the Domestic Abuse Act, where speech, language and communication are listed as a specific intersectionality.

Thirdly, will the Minister agree to meet the chief executive of the Royal College of Speech and Language Therapists to discuss how the guidance on the Bill can best capture those issues? Fourthly, on Amendment 157, can the Minister reassure the House that the report will include commitments to act to improve information-sharing? Finally, may I reiterate my huge thanks to my noble friend the Minister, and say how pleased I am to be able to do so in person, in your Lordships’ House? It is good to be back.

[Baroness McIntosh of Pickering (Con)]

My Lords, I welcome my noble friend back and commend him for his bravery. We came into the House at the same time, and he is a source of constant inspiration to us all; I have endless admiration for him. I apologise to the House for having omitted to declare my interests when I spoke for the first time on Report on Tuesday. I refer to my entry in the register of interests, and in particular to the fact that I work with the board of the Dispensing Doctors’ Association. I am also a patron of the National Association of Child Contact Centres and a co-chair of the All-Party Group on Child Contact Centres and Services.

I again commend my noble friend the Minister for summing up and assessing the mood of the House and tabling the amendments today; I am grateful to him for that. I also support the noble Baroness, Lady Hollins, and her Amendment 59, which is very appropriate. I hope my noble friend will look favourably on it, and I pay tribute to the work of the noble Baroness. One of her remarks earlier on Report which struck a chord with me was about the shortage of psychiatrists and other mental health professionals, particularly for those in the age group affected by these amendments.

I endorse and support the amendments in the name of my noble friend Lord Farmer. He refers in particular to the family hubs, and I make a plea to the Minister to recognise, as part of a family hub, a child contact centre. Centres are usually manned by volunteers, and they do fantastic work—not necessarily in keeping families together, because, unfortunately, their role largely comes into play when families have broken, but they play a fantastic role in maintaining contact with the absent parent.

Obviously, in these constrained times, the budgets of all organisations come under increasing scrutiny and pressure, so I urge the Minister to use his good offices to speak to those in the Ministry of Justice and the Department for Education to ensure that the budget for child contact centres will be renewed not only for two years but for three years—the period promised earlier. Those centres do fantastic work, under great constraint, and I am proud to be associated with them. I wanted to use this opportunity to support the amendments and to urge my noble friend the Minister to use his good offices in this regard.

Health and Care Bill

Baroness McIntosh of Pickering Excerpts

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

[Lord Kamall (Con)]

My Lords, in moving Amendments 4, I shall also speak to Amendments 23, 58 and 79 in my name. Before I start, I really should acknowledge the contribution and engagement of a few noble Lords, in particular the noble Lords, Lord Sharkey and Lord Patel, and my noble friends Lady McIntosh and Lady Blackwood for their constructive engagement with me and my officials.

We have seen the power of research as we have made our way through the pandemic, and research will continue to be essential. I agree that research needs to be embedded in the very DNA of the NHS. Earlier this week, I chaired a round table with a number of research charities and other stakeholders, and we all talked about the importance of embedding research into the NHS. A bit like the challenge I had when I was in academia, when you wanted more time for research but at the same time were told to get on with your day job of teaching students, likewise many clinicians are under the same pressures in terms of the day-to-day delivery of healthcare while wanting time for research.

We know that informed research helps to improve healthcare and health outcomes. It brings benefits to patients, staff, the NHS and the wider economy. We believe that integrated care boards will play a leading role facilitating and enabling research and fostering a culture and environment for research to flourish. To this end, the Bill currently places a duty on each ICB that it

“must, in the exercise of its functions, promote … research on matters relevant to the health service, and … the use in the health service of evidence obtained from research.”

I have, however, heard clearly from noble Lords that they want to see a step change in research. That is a request, or a plea, that I agree with, so rather than directly funding or conducting research, ICBs will primarily facilitate and enable it. However, ICBs will also have the power to conduct, commission or assist the conduct of research. This could include hosting or being a collaborating partner in research infrastructure.

I also heard from noble Lords, particularly the noble Lord, Lord Sharkey, that it is not clear what a duty to promote research should involve. To that end, I have tabled Amendments 4, 23 and 79 to clarify that the meaning of “promote” includes “facilitate”. I once again thank the noble Lord, Lord Sharkey, for his engagement. This highlights that facilitation is a subset of the range of activities meant by promoting research while retaining the breadth of a duty to promote research.

The duty is broad and could be met in a number of ways. For example, when exercising its commissioning functions, an ICB may select providers which have a proven track record of being research-active or can demonstrate the intention and capability to participate in research. The provision is also flexible so that bodies can develop the processes and structures that work most effectively, but we anticipate that ICBs would have dedicated research offices or teams to support their role in research and to encourage the conduct of research.

To ensure that research is fully embedded in local systems, we expect ICBs to consider research when preparing, with the responsible local authority, a joint strategic needs assessment articulating local research needs where they identify them. We would also expect ICBs to ensure that the joint local health and well-being strategy sets out how research needs can be met by the ICB. We have tabled Amendment 35, which is to be debated in the next group, to ensure that the research duty, along with other duties, is given particular consideration during ICBs’ planning of their strategies. We have also tabled a package of amendments to provide increased transparency, accountability and oversight of the research duties.

During the debate in Committee, my noble friend Lady Harding remarked that

“what gets measured gets done”.—[Official Report, 24/1/22; col. 47.]

We agree. Amendment 4 requires NHS England’s business plan to explain how it proposes to discharge its research duty and requires its annual report to contain an assessment of how effectively it discharged this duty. We have tabled similar amendments for ICBs. Amendment 55, also to be debated in the next group, would require that ICB annual reports must explain how the ICB has discharged its research duty. Amendment 58 would require that the NHS England’s performance assessment of each ICB includes an assessment of how well it discharged its research duty. I beg to move.

[Baroness McIntosh of Pickering (Con)]

My Lords, I take this opportunity to thank my noble friend for listening and acting in the terms set out in the amendments in this group, which I support on research as far as they go. I have to express my disappointment that my noble friend has not seen fit to extend his bonhomie to NICE. I have therefore tabled Amendment 29, and I am delighted to have the support of the noble Lords, Lord Hunt of Kings Heath and Lord Patel. As set out by the noble Lord, Lord Kakkar, our thoughts are with the noble Lord, Lord Patel, who is unable to be with us today, and we wish him the speediest possible recovery. It is a great shame that he cannot be here today because we would all wish to pay tribute to his work historically as the forerunner of NICE. We are grateful to him for it. It is a great disappointment to me that he is not able to be here in person.

I also support Amendments 171 and 178 in the name of the noble Lord, Lord Hunt, but I shall leave the noble Lord to set them out.

My noble friend has set out that the government amendments set a responsibility on integrated care boards to respond annually and to measure the research work that they have done. Quite frankly, I am a little concerned and gobsmacked as to why my noble friend is not insisting that integrated care boards do the same as regards NICE. The key provision of my Amendment 29 is:

“Within 28 days of any medicine or device receiving market authorisation from NICE, an integrated care board must update its formulary to include that medicine or device.”


I have set out other provisions, but the other one to which I draw attention is in proposed new subsection (3), which says that every year an individual ICB must report

“in a publicly accessible format”—

to me that would mean it being accessible on its website—

“all medicines and devices that have been added and removed from their formulary over the previous year and maintain an active list of all medicines and devices available on their formulary.”

Vaccination: Condition of Deployment

Baroness McIntosh of Pickering Excerpts

Thursday 3rd February 2022 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for raising that point. It is really important to note that, when engaging in debates such as this, it is sometimes easy to forget patients, and we should not do that. The health service should be all about patients; it should be patient-centred. I understand the concerns. One of the reasons that we originally introduced VCOD, particularly for care homes and then more widely, was that patients were very concerned and relatives of patients were concerned about their loved ones—they were terrified, given the early outbreaks that we saw in care homes. On the particular consultation, I am afraid that I do not have the information with me, but I will commit to write to the noble Baroness.

[Baroness McIntosh of Pickering (Con)]

I thank my noble friend for answering questions on the Statement here this afternoon. One thing that struck me when I read through it was that

“Incredibly, over a third of the UK’s total number of covid-19 cases have happened in just the last eight weeks.”—[Official Report, Commons, 31/1/22; col. 71.]


Taken together with the point raised by one of the noble Baronesses on the Front Benches—that the Government are planning to stop publishing the level of Covid infections and deaths, and to stop testing from the end of March—what reassurance can he give us this afternoon that the Government will know where the infection is and what the level of infection is? Against that background, how does my noble friend expect to protect the NHS and care homes at that time?

[Lord Kamall (Con)]

I thank my noble friend for her question. I will be frank with her: I was not aware that the Government intend to stop publication, so I will have to go back to the department and double-check whether that is indeed true or whether it is a qualified statement. I commit to write to all noble Lords, given that it seems to be what we have heard. Clearly, as we are told, we follow the evidence, and the scientists continue to follow the evidence, so I would expect that data to continue to be collected. The best answer I can give at this stage is that I will go back to the department and investigate, and will write to noble Lords.

Personal Protective Equipment: Accounting

Baroness McIntosh of Pickering Excerpts

Wednesday 2nd February 2022 Lords Chamber

[Lord Kamall (Con)]

The noble Lord asks a detailed question, so I hope noble Lords will forgive me if I try to respond in some detail. If you look at the breakdown of the writedown, you will see that, first, about £4.6 billion was attributable to changes in global prices following the point of purchase in a highly inflated market—noble Lords will remember that even toilet rolls went up at one time. As the noble Lord rightly says, the £673 million was for stuff that had failed the quality testing or technical insurance. The £2.6 billion was for stock that will not be used for its intended purposes but can be repurposed. We are also looking at stock in excess of the current forecast requirements, which can be stockpiled, and we are also introducing a tender for testing to see whether the life of some of that stock can be extended.

[Baroness McIntosh of Pickering (Con)]

My Lords, can I press my noble friend a little more closely on one issue? I speak as president of the UK Warehousing Association. I am grateful to my noble friend for his explanation. What timetable do the Government have to remove this redundant PPE equipment from the warehouses in which it is currently situated to enable stock to be stored in those warehouses which really needs to be at this time?

[Lord Kamall (Con)]

There are different ways; some of it is about stockpiling stuff that is still useful and which we would use in future anyway. We are looking at research into testing whether the life of some of our stock can be extended—we are working with some of the best scientists on that. We are also looking at where we can give stock away or sell it on, as all the stock we are passing on meets WHO standards. To give noble Lords one example, we bought lots of latex gloves; usually we do not buy latex gloves in this country because of allergies and, now that we no longer need them, we can give them to a country such as Syria.

Health and Care Bill

Baroness McIntosh of Pickering Excerpts

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

Moved by

[Baroness McIntosh of Pickering]

78: Clause 20, page 17, line 14, at end insert—
“14Z39A Duty to review latest innovations with a view to local commissioning (1) Integrated care boards must review all new—(a) medicines,(b) medical devices, and(c) other health care solutions that may benefit the local population.(2) Integrated care boards must—(a) appoint a dedicated innovation officer to their board, and(b) develop and maintain a system to keep up to date with medicines and devices innovation and review suitability for patient usage, including engagement with the relevant—(i) academic health science network, and(ii) local pharmaceutical committee.”Member’s explanatory statement
This amendment would mandate ICBs to monitor and assess innovation for the benefit of the local population.

[Baroness McIntosh of Pickering (Con)]

I have four amendments in this group; I will speak to each in turn and look forward to hearing what the noble Lord, Lord Sharkey, says on his two amendments.

I thank the noble Lords, Lord Hunt of Kings Heath, Lord Patel and Lord Kakkar, for supporting Amendment 78. It looks at innovation, recognising that it is an ongoing iterative process that every ICB should be aware of to ensure that patients have access to the most efficient and effective healthcare solutions of the day. To that end, is purpose is to oblige integrated care boards to formalise the obligations of the board to horizon-scan for the latest innovations, as approved by regulatory bodies, to cover their population.

This new clause would require the appointment of an “innovation officer”, or potentially identifying an officer to take up that role, and place an obligation on the board to constantly review innovative medicines and devices, as they become available. This is a separate and additional duty to that to promote research.

--- Later in debate ---

[Baroness McIntosh of Pickering (Con)]

My Lords, I am grateful to all who have contributed to what has been an excellent debate. I welcome my noble friend’s offer to have further discussions, which I am sure will be taken up actively by all those concerned.

However, there seems to be a bit of a mismatch between my noble friend’s reply and the very real concerns expressed across the House, including by the noble Baroness, Lady Merron, in summing up. The noble Lord, Lord Kakkar, said that there was insufficient emphasis and obligation for integration, and that the whole country would benefit from wealth creation—a point well made by my noble friend Lady Neville-Jones as well.

I was very moved by the reference of the noble Lord, Lord Patel, to the loss of status and standing of teaching hospitals. My father, a GP, always used to say that if you want something done, have it done in a teaching hospital. My late uncle was a surgeon at the Royal Infirmary, where his students rather fondly called him “Mack the Knife”—I hope for positive reasons, because he used it skilfully, but unfortunately it is too late to ask.

We need to press my noble friend further on strengthening the obligation and making it much firmer in the Bill. Is he prepared to move in that direction? I would like to say how proud I am to be British and living in a country where we have such a strong record on research and the data available. My noble friend the Minister did not respond on where we are with clinical trials—my noble friend Lady Neville-Jones and I particularly asked him about that—and I would be very grateful if he could write to me separately. On the basis that we can have further discussions on this, I beg leave to withdraw my amendment at this stage.

Amendment 78 withdrawn.

Health and Care Bill

Baroness McIntosh of Pickering Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

My Lords, I am delighted to follow the noble Baroness, who speaks with such knowledge and authority on these issues. I will speak to Amendment 110, but first I will make some comments on the amendments spoken to by the noble Baroness, Lady Masham, and my noble friend Lord Black.

The noble Baroness, Lady Masham, highlights the difficulties that those of us living in rural areas have. I regret to see the downgrading, in particular, of the Friarage Hospital in Northallerton, where my father, for one, was treated to great effect. I associate myself with the comments of the noble Baroness, Lady Masham. I know that the Minister is familiar with these arguments now, because he very kindly spent an hour with his team listening to me on these issues. Whereas before, national health policy used to recognise and measure rural health policy, particularly as regards rurality and sparsity of population, those markers have now gone.

The House will be familiar with my work with the Dispensing Doctors’ Association. I regret the fact that, whereas my father and my brother in their time would have been rewarded by the number of patients that they had on their list, and by the distance they had to travel from the surgery to visit patients in their own homes or when called out to an emergency, that has now gone. Much of the bread-and-butter income, as I understand it, for dispensing doctors and pharmacists in rural areas is made up from dispensing. So a separate argument to be had on another day is how, from the beginning of April, I understand, those reimbursements are going to come under the cosh. I will just leave that with my noble friend; I will ask for a separate meeting with him on that. I pay tribute to the work that dispensing doctors do in rural areas under these pressures and I am delighted to be working with them in this regard.

My noble friend Lord Black spoke eloquently on osteopenia. There is a cohort of people—mainly women—who, like myself, are diagnosed with osteopenia. I had not been in the House very long when, having broken one bone six months previously, I broke another. I was sent to the fall clinic where, unsurprisingly, we were mostly women being tested to see how likely we were to have a fall and break a bone. When my noble friend said that many women could die within a year of breaking a hip, I recalled that I was told that I had an 11% chance of breaking a hip. The good news, I suppose, is that I have an 89% chance of not breaking a hip, and that is something I cling on to.

I was put on a course—as I am sure others have been as well—of very strong vitamin D tablets. Since I completed that course, I have had no further treatment, but also no recommendations as to how to prevent the condition—in my case, and I am sure in the cases of other women—deteriorating into osteoporosis. I will just leave the Minister with the thought that, given the seriousness of the condition, those who are on the cusp of descending into osteoporosis itself should perhaps be given greater guidance.

Amendment 110 is intended as a probing amendment, and I am delighted to see that the noble Baroness, Lady Bennett of Manor Castle, has lent her support to it. I am very grateful to her for that. We had many debates on domestic abuse in the context of that Bill, now an Act, but domestic abuse remains a scourge in our society. While it is recognised as a crime, it is most often manifested initially in a GP’s surgery, not at a police station. In the context of the noble Baroness, Lady Hollins, describing the Bill as essentially an integration exercise, I believe it is important to see and recognise a victim of domestic abuse in a safe place or a safe haven—in a setting with trusted professionals, such as a GP’s surgery.

I am sure that the Minister will share my concern that there is currently no training for GPs or other health professionals enabling them, or expecting them to be able, to spot or treat an individual suffering from mental or physical abuse or to instruct them on how to engage with the police. Does he share my concern that that is indeed the case? I understand from Anne Marie Morris, my honourable friend in the other place who moved this amendment at that time, that Devon is the only health system to have a dedicated individual on the CCG board and a health and care strategy for victims of abuse. That strategy has improved health and care outcomes through training and other interventions. Surely, this should be rolled out nationally for other local health services to benefit from.

While it is welcome that the Government have agreed to take this issue into account—and I understand that the amendment was agreed in the Commons—I urge the Minister and the department to go further. ICBs should be mandated to have a strategy to deal with domestic abuse. I am sure that the Minister would agree that, if it is not mandated, it probably simply will not be done. Additionally, the role of the domestic abuse and sexual violence lead on the ICB is essential to spearhead the work in this area and to provide essential expertise. As there is only such a lead at the moment in Devon—who does fantastic work which can be seen first hand, and has been seen to help a number of related pilots roll out in that area—I would like to see this work rolled out throughout the country.

Amendment 110 therefore sets out a duty to prepare a strategy to support victims of domestic abuse using the services set out in that amendment. It asks for various consultations to take place not only with the local authority for the area within the integrated care board but with the domestic abuse local partnership board and other persons whom the integrated care board considers appropriate. I humbly submit that this is a gap in the Bill at the moment that Amendment 110 would fill.

[Baroness Barker (LD)]

My Lords, I will speak to my Amendment 297J in this group, but I will preface my remarks by returning to the purpose of this Bill. The stated purpose of this Bill is to promote integration of health and care services in order to reduce health inequalities and to promote better outcomes. I have chosen, in this amendment, to speak on the issue of HIV and AIDS services. I have spoken in previous debates about access to sexual and reproductive health services such as contraception and abortion. They are two services which we would do well to look at in considerable detail, because they are services addressing issues that cannot alone be solved by the National Health Service. They are services which will only be solved by not only integration but collaboration between health and social care. Having, like many Members of this House, discussed these issues for many, many years, I come back to the point made by the noble Baroness, Lady Thornton, the other day, that we are trying to seek integration and collaboration between two fundamentally different services. One is organised as a national and essentially top-down system, and the other is organised on a local and democratically accountable basis, with a completely different ethos.

At this point it is worth us taking advantage of the presence of the noble Lord, Lord Stevens of Birmingham, and noting what he said the other day about the National Health Service. He said—and I paraphrase—that one of the best ways to ensure that the National Health Service does what we expect it to do is to ensure that it has resources, and he is absolutely right. Would that people took the same attitude to social care—but they do not, and in the matters of both sexual health services and HIV services, we see in graphic and demonstrable terms the failure to do just that.

Turning to HIV services, it is important to note that although, overall, we have a very good story to tell on HIV in this country, and a reasonably good story to tell in the last few years as we are on a path towards the complete ending of transmission by 2030, we do have some problems. Last year, the number of people living with HIV in the UK rose to 106,000. In 2020, the number of people being tested at clinics decreased by 30%, and more so in black and minority communities, where late diagnosis, with all its complications, remains stubbornly high. However, there was a very great increase in online testing. HIV is an area in which there have been and will be, over the next few years, huge technological changes in diagnosis and treatment, which the NHS and social care should be up to speed with if we are to get to the stated aim of ending transmission by 2030—which we can do. The problem is that, at the moment, we have an increase in the rate of late HIV diagnosis—it was up to 42% in 2019—and we know the concomitant costs that that presents for the health service.

Anyone who has spoken to anybody involved in HIV services, be it in social care, local authorities or the NHS, will have heard exactly the same story since 2012. Just look at commissioning. HIV testing in sexual health clinics and community settings is commissioned by local authorities; HIV testing in GP settings, where it is clinically indicated, is commissioned by NHS England; HIV testing in GP settings as a public health intervention is commissioned by local authorities; HIV testing in secondary care, where it is clinically indicated, is commissioned by CCGs; HIV testing in secondary care as a public health intervention is commissioned by local authorities—keep with me, my Lords. Home testing, which is increasingly popular, is commissioned by local authorities and by Public Health England, for some periods, at some times in the year. Is it any wonder that it is a mess? We are not taking advantage of any of this and we are letting people down. The fragmentation in this area—even for people who have HIV, who are some of the savviest patients the NHS comes across and who are up to speed, sometimes in advance of their clinicians—is really difficult and does not make sense on any level; it does not make sense on a public health level or an individual level. I do not need to go into great detail, as noble Lords can work out for themselves all the consequences of that.

It is quite interesting to talk about one piece of work that the All-Party Parliamentary Group on HIV/Aids did. We did some in-depth research in south-east London, where there are some of the most advanced integrated care services for HIV. Even there, where there is very high prevalence and they know, largely, what they are dealing with and the populations where this is the biggest problem, they struggled to make sense of this fragmented commissioning picture.

I am not asking that all this funding be put into the NHS—most definitely not, because we all know that once money goes into the NHS, it never comes out again. I think there is a case to be made for increasing budgets, not least the budgets of local authorities, which have been slashed, in order for them to carry on doing what is important, which is getting to people long before they are anywhere near being any kind of medical priority.

What I am asking for in this amendment is a formal duty to collaborate. I have no doubt that the Minister will say that that is not necessary, but we cannot carry on as at present: we are badly wasting resources when we should not be. We have enough knowledge in this Committee of the levers that make decision-makers and commissioners change what they are doing, not least when they understand that there are new and more efficient ways to meet the needs of the population. I propose this amendment with no great sense of hope, but, if he does not accept it, I hope the noble Lord will at least understand that we cannot continue with this inefficient way of dealing with known issues. We must stop failing people when we could be sorting out the issues.

--- Later in debate ---

Moved by

[Baroness McIntosh of Pickering]

54: Clause 16, page 14, line 47, at end insert—
“3AA Duty of integrated care boards to commission approved treatments(1) This section applies where—(a) a treatment has been approved by the National Institute for Health and Care Excellence,(b) an integrated care board has not arranged for the provision of that treatment under section 3 or 3A, and(c) a clinician has recommended that treatment for a person for whom that integrated care board has responsibility.(2) The integrated care board must arrange for the provision of that treatment to the person for whom it has responsibility.(3) In subsection (1) “clinician” means a medical professional employed by or acting on behalf of an NHS Trust, NHS Foundation Trust or primary care service from whom the integrated care board has arranged for the provision of services.”Member’s explanatory statement
This amendment would require an integrated care board to arrange for the provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area.

[Baroness McIntosh of Pickering (Con)]

My Lords, I will speak particularly to Amendments 54, 74 and 97 in this group. I warmly thank the noble Lords, Lord Patel and Lord Hunt, for lending their support to all three amendments, and the noble Lord, Lord Warner, for supporting Amendment 74. I pay particular tribute to the noble Lord, Lord Patel, and his historic work prior to the setting up of NICE; it was a great contribution that deserves to be recognised.

We are all aware of the procedure that, when a medicine is approved, it goes through two processes. First, it goes to the Medicines and Healthcare products Regulatory Agency, known as the MHRA, a body which checks whether a drug is safe and effectively does what it says on the tin. It then goes through a separate process run by the National Institute for Health and Care Excellence, known as NICE, which looks at cost-effectiveness and value for money. After those two hurdles have been passed, the medicines should, theoretically, be accessible to anyone. That is very clear in the NHS constitution, which explains that there is a legal right for people to have access to NHS NICE-approved drugs if it is right in their particular circumstances that they should. Indeed, the NICE guidelines say very clearly that there should be automatic adoption within 90 days of approval, if clinically appropriate and relevant.

For a drug then to be prescribed, it must not only have been approved by NICE but go on to the approved list of drugs in the local health authorities, called a formulary. The problem is that somebody must put the drug on the formulary and, currently, while in theory there is a system under the NHS NICE guidelines, this does not actually happen. Sadly, this results in a postcode lottery where some areas have the product on their formulary and others do not. Sometimes this is a process failure, but sometimes it is to avoid budget overspends. Therefore, I would say that it is at the patient’s expense that they are deprived of the drug.

To give an example of the problem, there is currently a drug for multiple sclerosis that patients are still waiting after 150 days to see go on to the formularies in around 25% of the local health systems across the country. There is a state-of-the-art flash monitor for type 1 diabetes, but the uptake across the country varies between 16% and 65%. What is most worrying is that those parts of the country with the greatest levels of deprivation have the lowest level of uptake.

I make a plea to the Minister: in my view, ICBs should be required to ensure that all NICE-approved medicines and devices are available and promoted to their population, because the cost of these drugs is covered by the VPAS reimbursement scheme agreed between the NHS and the pharmaceutical industry. If a treatment is unavailable in one ICB footprint, they should be required to commission the required treatment from another ICB. The Government should also promote uptake through the ICBs of NICE-approved medicines and report uptake of new medicines annually.

Amendment 54 would require an ICB to arrange for provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area. Amendment 74 would require ICBs to ensure that all NICE approvals are available and promoted to their population via a publicly accessible format, normally online, and to report on their uptake annually. Amendment 97 would mandate integrated care boards and healthcare providers, notably hospital trusts, to update their formularies to include all NICE-approved medicines or devices within 28 days of market authorisation, to ensure they are available for healthcare practitioners, through either their physician, for example, or prescribing pharmacist, to make available for suitable patients.

I thank those who submitted briefings to me while I was preparing for today, notably JDRF, which makes a number of recommendations on this issue, particularly in regard to type 1 diabetes. These aim to reduce inequalities, remove the postcode lotteries to which I referred and make sure that treatments, such as those for type 1 diabetes, are uniformly available across the piece. I also thank EMIG, a pharmaceutical trade association for small and medium-sized companies, for its briefing. It says that the uptake of NICE-approved medicines is critical for NHS patients to benefit from the latest and most promising innovations. Finally, I am grateful to Vertex Pharmaceuticals, which submitted a briefing that again supports the conclusions reached. Among the proposals it highlights is the introduction of a modifier to take account of the severity of a disease and efforts to more fairly consider uncertainty in the evidence for highly innovative and complex treatments for rare and severe diseases, including through greater use of real-world evidence.

On this small group of amendments, I look forward to hearing what the noble Baroness, Lady Finlay, has to say in connection with her neat, simple amendment, which would strengthen what we are proposing to do here. I urge the Minister and the department to address these postcode lotteries and make sure that NICE does not just make the guidelines but ensures that treatments reach the formularies and ultimately the patient in question. I beg to move.

[The Deputy Chairman of Committees (Lord Russell of Liverpool) (CB)]

My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite her to speak now.

--- Later in debate ---

[Lord Kamall (Con)]

Perhaps I may suggest, following the interventions of both noble Lords and their experience of being Health Ministers and of NICE, arranging a follow-up meeting with them to discuss this matter in more detail so that I can understand the situation more. As I am sure noble Lords will appreciate, I have been in this job for only four months and am still learning an awful lot. In fact, I am learning far more in this Committee than I have in my first four months. That shows that sometimes there is no substitute for learning on the job.

NICE has a suite of more than 300 guidelines and, as the noble Lord, Lord Stevens, said, more than about 1,900 medicines, spanning the whole of health and social care. It makes dozens of recommendations that can be complicated. We do not think it proportionate or feasible to require compliance with NICE guidelines but, given what I have just mentioned, I should like to consult previous Health Ministers with experience in this area and perhaps have further discussions to see what is relevant in the future.

I shall end with the CQC reviews of ICSs. We will look more broadly at the entire system of how the ICS areas are performing. A requirement for the CQC to specifically consider compliance with NICE guidelines as part of these reviews risks adding a considerable burden to this process. I can, however, assure the Committee that the Government expect the healthcare system to take NICE’s recommendations fully into account, subject to what noble Lords have told me about the performance of some CCGs. I am also aware that NICE works closely with system partners to support implementation where possible. It is probably best henceforth for me to have those conversations with the two noble Lords and any others with experience of this matter. There are more than two former Health Ministers in this House and we should have those conversations.

Let me see if I can answer some of the specific questions. As regards VPS—how do I put this in the most diplomatic way?—I have been asked to look at that issue. The industry has complained, for example, because we also have therapeutic tendering at the same time as expecting this. I am grateful to my right honourable friend the Secretary of State for asking me to look into this issue in further detail. I have asked what would happen, for example, when some of the life sciences companies ask whether it makes the UK less attractive in some ways. I am assured that it does not but I am looking into this issue as part of the life sciences aspect of my portfolio.

I think that I have covered all the questions but all that I ask at the moment is to let me have further conversations. That is probably best. In that spirit, I ask noble Lords to consider withdrawing or not moving their amendments.

[Baroness McIntosh of Pickering (Con)]

My Lords, I am grateful to all who have contributed to this debate and for the number of issues that have been raised.

At the outset, the noble Baroness, Lady Brinton, highlighted and a number of us focused on the hurdles—as the noble Baroness, Lady Merron, described them—to be overcome. However, there has been a lot of focus on the problems of the budgetary challenge. It would be incumbent on my noble friend the Minister to meet not just with the two noble Lords he highlighted but the drafters of the amendments: myself, the noble Baroness, Lady Finlay, the noble Lords, Lord Hunt and Lord Warner, and the noble Lord, Lord Patel, who sat so patiently through the whole of today’s proceedings and had to leave before this discussion was reached. As he had such success in the mental health meeting, I hope that we replicate that and take up a number of the issues raised here.

Health and Care Bill

Baroness McIntosh of Pickering Excerpts

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

[Baroness Hollins (CB)]

My Lords, I start by declaring my interests as a past president of the Royal College of Psychiatrists and a former consultant psychiatrist and clinical academic at St George’s, University of London. I thank Mencap and the Royal College of Psychiatrists in particular for the discussions I have had with them about this group of amendments.

I will not list all my amendments and those I am supporting in this group. I say to my noble friend that this is not just a spine-stiffener; it is a reminder, because we forget about mental health. We still forget to think about it and talk about it. One of the things I often do in my career is put my hand up and say, “By the way, what about mental health?” The noble Earl, Lord Howe, will remember the debate 10 years ago; I will come back to that.

The issues covered in these amendments are not new, because the World Health Organization definition of health is about a complete state of mental, physical and social well-being. It is not just about disease and infirmity. Noble Lords may not be aware—I heard this only recently—that a psychiatrist represented the United Kingdom at the first WHO meeting, which is probably one of the reasons why mental health was included at that stage.

These amendments would require the Secretary of State and all NHS organisations to prioritise physical, mental and social well-being. The idea is simply to replicate the parity of esteem duty as introduced in the Health and Social Care Act 2012. I re-read some of my speeches on that Bill, and I can see that I was persuaded to withdraw some amendments similar to those I am speaking to today. While a significant first step, that legislation ensured only that the Secretary of State for Health and Social Care would promote parity of esteem. What we have seen since then is a better understanding of the importance of mental health and mental health services, but there is still a gulf between the financing and delivery of these two equally important services, with physical health continuing to dominate. Of course, they should not really be separate, because there is no health without mental health. Integration is fundamental; we debated that at length in 2011-12 too.

The Royal College of Psychiatrists referred me to data published by NHS Digital last year. In March 2021, there were more than 400,000 referrals to mental health services—the highest ever recorded in a calendar month, and 36% higher than the beginning of the pandemic in March 2020. The pandemic has indeed shown us the importance of good mental health for the general population, including, of course, children and young people and health and care staff.

One of my amendments is on the duty of parity of esteem, and others insert “physical and mental” in multiple places to embed the fuller meaning of “health” in the Bill. I am grateful to noble Lords who are supporting this.

I want to focus on my Amendment 99, which places the duty to ensure parity of esteem at the integrated care system level. We cannot really leave it to chance; history tells us that this would lead to a suboptimal priority for mental health services. The duty that has been in place at national level for the Secretary of State has been so valuable that we can and should replicate it at a local level. Consider a recent survey by the Royal College of Psychiatrists in which two-thirds of respondents said that their ICS had not worked towards parity of esteem effectively. Fewer than one in 10 thought that their local area was effectively promoting parity of esteem.

But if a population health-based approach is core to ICSs’ planning and decision-making, I suggest that we need stronger legislative levers to support them to address mental health. Mental health is a key population need across the country. We cannot presently meet demand. No population health approach is complete without the inclusion of mental health, and yet we consistently see the imbalances in place. The new ICSs, bringing together commissioning and provision, could be a huge opportunity to get it right—or, certainly, a lot better—for mental health.

At present, there is no assurance in the Bill that mental health will be given equal precedence with physical health in integrated care systems or even by NHS England. My proposed duty for ICSs would help to ensure parity and repeat the success of the duty on the Secretary of State in the 2012 Act—not only that, but such a duty also increases focus at service level and would make sure that ICBs are looking closely at how they are providing for people at risk of or with a mental illness.

The trouble is that it is not easy to determine the best way to achieve this. As it stands, the Bill does not address parity at all. There are other similar amendments. Would putting this duty at the local level ensure that the next step in the battle for parity of esteem will be closer to the everyday experience of people who have struggled for far too long to access mental health services? Developing good integrated care cannot be just about meeting a person’s physical health. We must think more holistically about people’s psychological and social well-being, as mentioned by the noble Lord, Lord Howarth.

Turning to the amendments tabled by my noble friend Lord Stevens, which would strengthen transparency in mental health spending, he has a unique insight into the NHS and could not be better placed to advise on what improvements are needed in funding of our mental health services, particularly in accountability and transparency. The resourcing of mental healthcare is one—admittedly, only one—indicator of whether we have a chance of meeting the need and, we hope, preventing illness developing in the first place. We know that change is needed. There have been improvements in financing mechanisms. My noble friend mentioned the mental health investment standard. This feels important in light of the most recent spending review, in which, although there was a large funding injection for the NHS, mental health seems to have lost out again.

One wonders whether anyone remembered to ask the Treasury for additional funding for mental health. Having worked in mental health for so long, perhaps I may be forgiven for suspecting that it may have been forgotten once more. Last year’s uplift for mental health due to the pressures of Covid-19 was welcome but it was non-recurrent and those pressures have not gone away. Recent estimates from different charities that I have spoken to suggest that the overall share spent on mental health could go down in the coming year. We need these amendments to the Bill to make it clear that only when the Government and the NHS genuinely have mental health at the forefront of their efforts and are truly committed to parity of esteem, even in difficult circumstances, will we make good on the purpose of the NHS when it comes to the needs of people with mental illness in our society.

[Baroness McIntosh of Pickering (Con)]

My Lords, I am delighted to speak to this group of amendments, and I associate myself very closely with the remarks of the noble Lord, Lord Stevens of Birmingham, and the noble Baroness, Lady Hollins. I declare my interest in working for the Dispensing Doctors’ Association. I speak particularly to Amendment 263, in my name and that of the noble Baroness, Lady Tyler of Enfield, and Amendment 138, in my name and those of the noble Baronesses, Lady Tyler, Lady Watkins of Tavistock and Lady Bennett of Manor Castle.

All of us are touched by knowing or learning of those who suffer from mental health problems, and I express my disappointment as well to see that there has been no parity of esteem or parity of funding between physical and mental health. I urge my noble friend the Minister, when responding, to give a commitment, in the context of the Bill, to ensure that the role of the ICS and the other bodies under the Bill will make this happen for the first time in reality.

There are particular issues, as I have seen closely, primarily as an MP but also previously as a shadow Minister. In rural areas, particularly in isolation and where there are pockets of poverty, poor mental health is suffered particularly by those on low incomes and pensioners. The farming community, especially in times of hardship, has great difficulty in communicating anxiety and mental stress. Undoubtedly, the current pandemic has taken its toll, not just in terms of self-isolation quarantine but because many businesses, particularly small businesses, have collapsed, often through no fault of those who set them up.

The background to Amendments 138 and 263 is very closely associated with that of the others in this group. I thank and pay tribute to the excellent work of Anne Marie Morris, who moved these in the other place and is chair of the All-Party Group on Rural Health. I commend her work in this regard. As has been indicated, Governments of all persuasions over recent years have spoken regularly about their desire to achieve parity of esteem between mental and physical health, including in the NHS 10-year plan. However, for this to be meaningful, there must be a legal obligation in the Bill to that effect, supported by reporting mechanisms on inputs to the mental health system, in terms of money, people trained and training places, as well as outputs resulting, including the number of mental health appointments or services made available, uptake of those appointments and the outcomes—namely, the number of patients discharged from care.

Public Health: Night-time Working

Baroness McIntosh of Pickering Excerpts

Thursday 6th January 2022 Lords Chamber

[Lord Kamall (Con)]

I think all your Lordships would agree on the incredible dedication of our medical and health and social care staff, before and particularly during the pandemic. We have to remember that a lot of these conditions are governed by the Health and Safety Executive guidance on managing health and safety risks, which includes guidance on shift work and fatigue, to make sure employees are treated with as much dignity and respect as possible.

[Baroness McIntosh of Pickering (Con)]

My Lords, the Wilf Ward Family Trust is a charity that looks after severely disabled adults in north Yorkshire. Following the court case last year over pay for sleep-in shifts, it has had great difficulty in filling these roles and reaching an accommodation with the staff. Could my noble friend look into this—perhaps I could have a word with him afterwards—to see if that situation has been resolved to the satisfaction of both the adults in care and those providing that care?

[Lord Kamall (Con)]

As my noble friend will appreciate, I cannot comment on the details of a specific case, but I would welcome a conversation with my noble friend. The general issue has to be that we make sure that patients are treated as well as possible but that staff and employers are treated with as much as dignity as they deserve.

Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) (No. 2) Regulations 2021

Baroness McIntosh of Pickering Excerpts

Tuesday 14th December 2021 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I wish to make some comments about the actual substance of this statutory instrument, although I will start by saying that I have a lot of sympathy with what has already been said about the lack of proper parliamentary scrutiny and indeed the lack of an impact assessment, which is extremely regrettable.

As I have said in your Lordships’ House before, I am very sympathetic to the overall principle that both front-line health and care workers should be vaccinated. However, as I have always said, it must be handled in the right way, particularly given the absolutely acute pressures that both health and social care are under and will be over the winter months. It is absolutely critical that the right amount of help and support is made available to health and care workers who are genuinely vaccine hesitant—and that means things such as one-to-one conversations during work time in which they can express what their concerns are and, I hope, get additional information.

I know very well from personal experience that care homes that, for example, have brought GPs in to have one-to-one conversations, taken the concerns that care workers have expressed seriously and tried to explain why it would be a good idea to have the vaccine, have had an awful lot of success, and I am concerned that there is not enough focus at the moment on that help and support. It was very regrettable—this point was raised by the Secondary Legislation Scrutiny Committee —that the draft Explanatory Memorandum made no reference to any lessons learned from the rollout of the earlier care home regulations, as well as being silent on what contingency plans the department had to cope with the expected staff losses when the regulations take effect. I know that those staffing issues will be particularly acute in London, where I live.

I recently had a helpful meeting with Healthwatch, which shared with me some very good research. It commissioned an organisation called Traverse to undertake in-depth conversations with a range of people, mainly of African, Bangladeshi, Caribbean and Pakistani ethnicity, to understand the reasons for their vaccine hesitancy and what can be done about it. Although the research was carried out with the groups I have specified, I suspect that the conclusions drawn in the report have more widespread application.

I found it interesting that the attitudes expressed were incredibly personal to the individual. One of the lessons learned is that you cannot lump all this together and say, “This is the issue for this group”; you have to think very carefully about individual concerns. There was most clearly, as we know, a lack of trust, which featured strongly in terms of the vaccine, and there was very strong distrust of those who had any possibility of standing to gain commercially from the rollout, which I thought was an important point. Probably most notable of all, people said that they trusted most of all front-line healthcare workers to talk about Covid and the vaccine and had less trust in very senior people in the NHS or Public Health England, who were perceived to have less tangible experience. That interesting document ends with very seven practical tips: ways to try to encourage health and social care workers to become less vaccine hesitant.

I end by asking the Minister whether he is aware of this document—if he is not, I am very happy to send it to him—but, more generally, what steps the Government and NHS England have taken to promulgate this sort of important and practical good practice and advice?

[Baroness McIntosh of Pickering (Con)]

My Lords, I echo the words of my noble friend the Minister in introducing the regulations before us in praising the heroic efforts of the whole health service: the volunteers, nurses, doctors and pharmacists—everyone involved. The vaccination programme is essential, but I hope that GPs and practitioners will have the vaccines in time to roll them out. My noble friend is aware of my work with the Dispensing Doctors’ Association.

Covid-19 Update

Baroness McIntosh of Pickering Excerpts

Wednesday 8th December 2021 Lords Chamber

[Lord Kamall (Con)]

The noble Baroness makes an important point. Let us hope that the NHS will fix it. As the NHS says, it is aware of the issue and will try to fix it and update as soon as possible. But, clearly, if that is not possible, we will have to update the guidance, and I will take that back to the department.

[Baroness McIntosh of Pickering (Con)]

My Lords, I think that my noble friend said that the peak of the omicron infection rate is expected in January. Will he confirm that the lateral flow testing will last through January to March if that is the case? Will he join me in congratulating the Dispensing Doctors’ Association, with which I declare my interest as an adviser, on rolling out specifically the programme to which my noble friend Lord Naseby referred of vaccinating the housebound? Can he look into the fact that the Covid pass that is issued reflects only two vaccines and not the booster vaccination?

[Lord Kamall (Con)]

I pay tribute to my noble friend for making us aware of the dispensing doctors, and for making people like me, who are much more urban-centred, aware of some of the issues in rural areas. On the Covid pass, up to now, in most countries it has not been a requirement to have the booster shown in order to travel. Clearly, all countries will now be updating their travel requirements and restrictions. I am afraid I have a terrible short-term memory. What was the first question?

[Baroness McIntosh of Pickering (Con)]

Lateral flow tests.

[Lord Kamall (Con)]

Yes. Given the advice on testing, especially if you are pinged and have to test, clearly we will make sure that there are sufficient tests available.