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.

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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.

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[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.

Health and Care Bill

Baroness McIntosh of Pickering Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness McIntosh of Pickering (Con)]

My Lords, I refer to my declaration of interest in the register: I currently work with the Dispensing Doctors’ Association and my father was a dispensing doctor. I congratulate my noble friend the Minister on introducing the Bill, which I broadly support—particularly its emphasis on greater collaboration between GPs, hospitals and local authorities.

If I can paraphrase the noble Lord, Lord Stevens, whom I congratulate on an excellent maiden speech, I agree that all health services are local. However, I disagree with him on his support for the fluoridation of the water supply, and refer him to the case of the petitioner, Mrs McColl, against Strathclyde Regional Council. You might say that I cut my legal teeth on this case because I spent nine months as a Bar apprentice and the remaining time as a devil; my devil master was one of the advocates for Strathclyde Regional Council. Crucially, Mrs McColl had dentures; she had no teeth. She argued that fluoride is a carcinogen and that the action Strathclyde Regional Council sought to introduce, which the Bill also seeks to introduce, was unsafe, ineffective and illegal. I agreed with her. She won her case. I cannot see how it is appropriate to prescribe such an interventionist action that could be achieved by other means: either regularly brushing children’s and adults’ teeth with toothpaste containing fluoride or reducing sugar in the diet. So, on that, we will disagree, but I warmly welcome the noble Lord to the House and congratulate him on his excellent maiden speech.

I am grateful to my noble friend the Minister for the meeting we had to discuss these issues, at which he heard me argue that the NHS and the Department of Health and Social Care tend to be urban-centric. A lot of that has been proved in many of the speeches this evening. Dispensing doctors have a unique role to play. They are general practitioners who are permitted to dispense medicines—in effect, a GP and a pharmacy rolled into one—for patients who would otherwise have difficulty accessing one or both, not least due to the distance from their home. All these services are in rural areas only. I pay tribute to the role that dispensing doctors play as an integral part of the health service in rural communities, building strong relationships with their patients. They are crucial to the delivery and promotion of preventive services and well-being, which is so dear to the heart of the Conservative manifesto.

I will focus on delivering healthcare and social care in a rural setting. I urge my noble friend to confirm that he will redress the inequalities already identified in this Bill, particularly by the right reverend Prelate the Bishop of St Albans, to restore the balance in favour of spending on rural areas as opposed to urban areas and in favour of spending on primary care as opposed to secondary care. Does he share my concern that the ICSs will be full of secondary care practitioners and that primary care practitioners may not be as well represented as they might be?

I share the concerns expressed by others this evening about the number of GPs, many of whom are facing retirement in the next five or 10 years and have real concerns about their pensions. Again, I regret the fact that the Government—as shown both this evening and with the Health Secretary’s acceptance to the health Select Committee next door in the other place—have not kept their commitment to increasing the number of doctors in the next four, five or six years. That is deeply regrettable.

Will my noble friend the Minister use this opportunity to redress the balance in spending between urban and rural areas? Rural areas are facing issues with isolation and the distance that patients have to travel to access healthcare; they also have disproportionately higher levels of older people with chronic conditions. This is a golden opportunity to address these issues; I warmly invite my noble friend to do so.

Coronavirus Act 2020 (Early Expiry) (No. 2) Regulations 2021

Baroness McIntosh of Pickering Excerpts

Tuesday 30th November 2021 Grand Committee

[Baroness McIntosh of Pickering (Con)]

My Lords, I welcome the opportunity to debate the provisions in the regulations before us and I congratulate my noble friend on bringing them forward. I thank him for the meeting that I had in the last 10 days with him and his team, which was most useful. I endorse enthusiastically his invitation for those who have not yet been vaccinated to come forward. This would be an opportunity to ask where we are, particularly with those under 18. Have they had their second vaccinations and at what age will the vaccine programme be rolled out?

I remind the Committee of my interest as an adviser to the Dispensing Doctors’ Association, which may or may not pertain to the comments that I make this afternoon. I seek my noble friend’s guidance on whether one area that I am particularly interested in, as I know are all general practitioners, is covered in the provisions before us. If it is not, can he write to me? I understand that one of the reasons why GPs are unable to have as many face-to-face appointments as they would wish is that they have been constrained by the regulations passed by both Houses of Parliament. I cannot remember whether the provision was in the original Act or in supplementary regulations in the form of statutory instruments that we have adopted. However, I understand that specific regulations regarding the square footage or meterage of a waiting room were set out at the beginning of the pandemic, limiting the number of patients who could be accommodated in person in a waiting room during the pandemic. I think that it was the same for dental practices.

Are these provisions still in place? If they are not part of these regulations, I would be grateful if my noble friend could write to me. It could be extremely important to advise the public that that is why doctors are not able to see as many patients physically as they would wish to do. I am sure that the regulations were brought in for good reasons—that we should not be mixing and should be masking and that we should respect the ventilation to which my noble friend referred, while self-distancing—but it is important that patients understand the constraints under which general practitioners have to operate.

To turn to the specific remit of the regulations before us, my noble friend just stated, and I think that it is on page 5 of the Explanatory Memorandum, that the Government are minded to expire and lift the regulations relating to the power in Schedule 22

“to provide powers to issue directions relating to events, gatherings and premises in England and Northern Ireland respectively.”

With the greatest respect, mindful of the fact that we might have difficulties once we know more about the omicron variant, is this the right time to be lifting those restrictions? Can my noble friend put my mind at rest that powers exist elsewhere, either in subsequent regulations or still in the original Act? It seems a little premature to be expiring those provisions at this time.

--- Later in debate ---

[Lord Kamall (Con)]

I apologise if I was not clearer before. I thank the noble Baroness for taking advantage of the opportunity to ask that question and finding the urge to do so irresistible. On theatres and cinemas, one of the things that was put to us was that in a restaurant, you are constantly taking a mask on and off, whereas in a cinema or theatre you are not really eating that much. Okay, you might well go to buy your ice cream—I do not know whether they still sell ice cream and jelly babies in theatres, or whatever it used to be; this will look very odd in Hansard when someone reads it—but you are not constantly doing and you are more or less constantly wearing your mask. However, I will take that back. It is a fair point, and one thing that I do when I am being briefed is to challenge because I know that noble Lords will rightly challenge me on this issue.

In response to the comments by Jenny Harries, I hope I have been clear that we take advice from a range of advisers and there is not yet consensus, but we have been relying not just on making mask mandatory when necessary as a precaution, but at the same time on people’s individual behaviour and them acting responsibly. It is about getting that balance right. We listen to Dr Jenny Harries, but she is one of a number of experts whom we listen to. We weigh up the different views; it is as simple as that. As we have been clear, there is no one trigger for any of these measures. We always consider a range of measures, including capacity in the NHS, the trends et cetera. I have listed them in previous debates. It is not one person whom we listen to. We listen to a range of experts.

[Baroness McIntosh of Pickering (Con)]

Will my noble friend undertake to write to me about waiting facilities in GP waiting rooms? That would be helpful. I am also prompted by a question that I do not think he responded to from the noble Baroness, Lady Brinton, on the welfare aspects of staff shortages in meat-processing plants and the massive cull of pigs. While I appreciate it might not be the direct responsibility of his department, this is an animal welfare disaster about to happen.

One thing that I did not like to raise—I am sure it will go no further than the Grand Committee, which is why I feel confident to raise it now—is that my noble friend will be aware that there is PPE equipment which was deemed not fit for use, but it is in the system and is, to a certain extent, clogging up the supply chain by taking space which should be used for other goods. Will he undertake to use his good offices to look into this? Perhaps we could have a word about it afterwards because it is contributing to shortages and delays in the supply chain, particularly in storage terms.

[Lord Kamall (Con)]

First, I apologise for missing that point earlier. Regarding the supply chain provision, an SI was laid under the draft affirmative procedure on 21 April 2021. It was debated and approved by both Houses, came into force on 16 July and expired the provision. As the noble Baroness rightly acknowledged, some of her questioning was not within the scope of these regulations. However, given that she has asked a question, I will endeavour to find out the answer. Clearly, that will include going across departments, so I hope that she will be patient as I try to get that answer as quickly as possible.

On GP access, we recognise the pressure that general practitioners are under, especially in the upcoming and challenging winter period. We are investing £250 million in the winter access fund to improve GPs’ practice capacity. I will take the noble Baroness’s specific question about square metres and areas back to be answered; I hope she understands that I do not have those facts to mind.

The issue of measures was also raised. We must remember that one of the counterpoints put is that the country is in a very different position to the one it was in last year, due to the vaccination programme. Some of the restrictions that might have seemed appropriate last year are not as appropriate this year because we have reduced the link between cases and hospitalisations, as well as between hospitalisations and deaths. Clearly, we have the vaccine. I am sorry if I sound like a broken record but we continue to push the vaccine because it helps to break that link; it is part of the reason why we will not have to go back to some of the restrictions—those similar to last year’s—that many noble Lords are pushing for.

All I will say is that the Government’s autumn and winter plan set out how we will sustain and strengthen some of the progress made so far. We all know that winter will be a challenging period, but more so over the next few months. We all have a role to play in fighting the virus. There is much that government can do but sometimes, even when we mandate things, we know that there will be people who do not obey, so we must get the balance right and decide how to get the appropriate enforcement. Together, we believe that we can protect the progress that we have made, protect the NHS in the months ahead and help friends, loved ones and ourselves by being vaccinated against Covid-19, getting a flu jab if eligible and sticking to the advice on how to keep safe.

I thank noble Lords for their contributions to this debate and previous ones on the Coronavirus Act; I also thank them in advance for future contributions. I welcome noble Lords’ expertise and contributions, and I commend the regulations to the Committee.

NHS England: Waiting Lists

Baroness McIntosh of Pickering Excerpts

Tuesday 16th November 2021 Lords Chamber

[Lord Kamall (Con)]

The noble Lord made a very perceptive intervention last night when asking us to think outside the box, and I gave an example of someone who I know suffers from asthma and forgot to take his blue inhaler with him to another city. His wife went to a number of places to try to get an inhaler from the pharmacy and from A&E, while telling him to stay in his hotel room. In the end, he was told that the only way to get an inhaler was to call the ambulance. We need to think outside the box and be more creative about when those situations occur—it is not necessarily political, but we need to be creative.

On technology, one of my jobs is Minister for Technology, Innovation and Life Sciences. I have been forceful, when talking to the NHS, that we have to digitise and share data. I accept that there are some concerns over sharing data, but the way to have an NHS that is fit for purpose is to make sure that we digitise and share data.

[Baroness McIntosh of Pickering (Con)]

I refer to my work with dispensing doctors. Will my noble friend join me in paying tribute to all the workforce of the NHS? Does he recognise that they are absolutely exhausted? The BMA has forecast that thousands of doctors will leave the profession in the next few years. Will the Government undertake to reinstate the commitment to have 6,000 more doctors by 2024?

[Lord Kamall (Con)]

In our conversations with the NHS, we are talking about the workforce plan. We are looking at ways to improve the way in which the NHS and social care plan for their workforce. We have committed to continuing to reflect very carefully on points made by noble Lords across the House. honourable Members in the House of Commons and many stakeholders. It is important that we value the workforce of doctors, nurses and other healthcare workers whom people often forget about. We should also value all those other workers who have provided services to us during lockdown, such as delivery drivers, postal workers, Amazon workers et cetera. They have all played a vital role, and we should not forget the role of civil society organisations.

Alcohol Duties

Baroness McIntosh of Pickering Excerpts

Tuesday 2nd November 2021 Lords Chamber

[Lord Kamall (Con)]

The World Health Organization and a number of other organisations have criticised the current system of taxation of alcohol, and urged the Government—and the EU when we were a member of it—to move toward taxation based upon the volume of alcohol. To answer the noble Baroness’s specific question, there are no current plans to implement minimum unit pricing in England, but the Government continue to monitor the impact of minimum unit pricing as evidence emerges from Scotland and Wales. It has been in place in Scotland for more than three years, and the Scottish Parliament will not consider its extension until April 2024. In all my conversations with various public health experts, one of the things that they make quite clear is that this has to be evidence-led, and we want to look at evidence from elsewhere.

[Baroness McIntosh of Pickering (Con)]

I declare my interest as chairman of the PASS Proof of Age Standards Board. I also chaired the Select Committee on the Licensing Act 2003. Does the Minister agree with the Committee when it said:

“It is in our view unarguable that an increase in the price of alcohol will decrease consumption.”?


Does he further agree that, by increasing the taxation on stronger alcohol as the Budget aims to do, that will have a better chance of reducing alcohol intake and dependency than the minimum unit pricing that we have seen in Scotland?

[Lord Kamall (Con)]

I thank my noble friend for that very important point. This is why the new system of taxation has been introduced. It will more directly align the volume of alcohol with the taxation on it. That will feed through to higher prices for drinks with higher alcohol content.

Health Protection (Coronavirus, Restrictions) (Steps etc.) (England) (Revocation and Amendment) Regulations 2021

Baroness McIntosh of Pickering Excerpts

Tuesday 14th September 2021 Grand Committee

[Baroness Barker (LD)]

My Lords, I am speaking in this debate because my noble friend Lady Brinton cannot be in her place to take part. We have the technology to enable remote participation in debates in the Moses Room, but the House authorities have not yet permitted that for contributions in Grand Committee, so virtual participation in these proceedings is unfortunately not possible, even though we have seen in this last week that the very few participants who need to take part remotely can be managed very effectively without recourse to extensive speakers’ lists.

It is also a loss to the Committee, because my noble friend Lady Brinton cannot take part for one very important reason, about which she has been quite public: she is clinically vulnerable, and one thing she cannot do is travel on public transport, which she cannot do because people are not wearing masks. Of all people, she should have been able to be here to make that point.

Yet again, these SIs were tabled very late. They came in just before the recess in late July, so yet again we are back to debating things that are long in the past. We have repeatedly asked the Government to respect the House and timetable SIs when they are not genuinely urgent. However, these are, as the noble Lord, Lord Hunt of Kings Heath, said, quite pertinent in view of the Statements being made this week.

This statutory instrument mostly deals with the revocation of statutory instruments on 21 July, which confirmed a number of the changes in the Prime Minister’s so-called freedom day. However, there is one extension, in Regulation 4, to the expiry date of the Health Protection (Coronavirus, Restrictions) (England) (No. 3) Regulations, which are now to end on 27 September. The Explanatory Memorandum says that this

“will ensure that local authorities retain powers to respond to local serious and imminent public health threats as a result of the spread of coronavirus. The No. 3 Regulations will continue to act as an important public health tool for local authorities in their local coronavirus outbreak management, compliance and enforcement activities. This is particularly important in light of the revocation of the other restrictions mentioned above”.

As we have said all the way through this pandemic, it is important that local authorities have the power to manage local outbreaks. Simply extending that power in law, but not making sure that they have the resources, will not work. As epidemiologists have said to us in terms, there will inevitably be points when it is important to close all the pubs in a certain area, simply because an outbreak has to be contained. While we welcome that, it behoves the Minister to say something about local authorities such as Croydon, which is insolvent, and how it will have the resources to manage this significant and enduring public health problem.

We regret the removal of face coverings on public transport and other crowded venues. I can say, as somebody who travels on the London Underground every working day, that fewer and fewer people are wearing masks and, as more and more people are on the Tube, I am certain we will see a spike in infections as a result. I also point out to noble Lords that the bad messaging on this does not help. There is genuine confusion. One of my colleagues was on a train to Scotland in the summer and, when it got to the border, there was an announcement that the law now required everybody on that train to wear a mask, and they did, as they should have done all the way.

It is now clear that the Government, and in particular the Prime Minister, have been so desperate to place emphasis on the vaccination programme as our primary defence that they have forgotten to look at the role of other mitigations against the disease. Although we support the passing of these regulations, we need to make the messaging clearer as a matter of urgency, so we can avoid the confusion that is now prevalent among people in England.

[Baroness McIntosh of Pickering (Con)]

My Lords, I welcome the regulations and congratulate my noble friend on bringing them before us. To a certain extent, my comments echo those that have already been made by previous speakers. I was fortunate enough to visit my family in Denmark and Scotland this summer, and the guidance in each place was much clearer. Speaking as an older person, I prefer to keep my mask on, on all forms of public transport. I am sure my noble friend will recognise that one of the reasons why there was not a high incidence of flu last year was, in large measure, because we followed the example of the Asians after the SARS epidemic in the late 2000s of masking up. Even the common cold was kept under control.

I understand the Department of Health and Social Care’s concern about a high incidence of flu this year, but I am sure we can encourage people to mask up, particularly in areas of close proximity. The noble Baroness, Lady Barker, mentioned the Tube. I am still reluctant to go on the Tube at busy times, but even the trains on the east coast main line are incredibly busy now, and you can find yourself next to someone who you are not normally accustomed to seeing.

To me, wearing a mask is not an infringement of my liberty; it is my passport to health and keeping safe. I hope that it will keep others safe as well. Does my noble friend imagine that the guidance will be revisited? It is in stark contrast to what has applied in Denmark and in Scotland.