Health and Care Bill

Baroness Merron Excerpts

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

Moved by

[Baroness Merron]

2: Clause 1, page 1, line 5, at end insert—
“(1A) The Board of NHS England must be made up of—(a) a Chair appointed by the Secretary of State;(b) five other members so appointed of whom—(i) one must be appointed to represent Directors of Public Health;(ii) one must be appointed to represent the Local Government Association;(iii) one must be appointed to represent the interest of patients;(iv) one must be appointed to represent the staff employed in the NHS; (v) one must be appointed to represent the integrated care partnerships;(c) one further member appointed by the Secretary of State after being recommended by the Health Committee of the House of Commons as a person with appropriate knowledge and experience;(d) executive members as set out in Schedule 1 to the Health and Social Care Act 2012.(1B) In making the appointments in subsection (1A)(a) and (b) the Secretary of State must have due regard to—(a) the need to ensure diversity and equality of opportunity; and(b) the need to ensure that no person who could be perceived to have a conflict of interest by virtue of their current or recent employment or investment holding in any organisation with any role in the delivery of services to the NHS may be considered for appointment.”Member’s explanatory statement
This amendment requires changes to the membership and composition of the Board of NHS England to reflect its new role under the Bill.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley, for their support.

This amendment seeks to define the composition of the board of NHS England to better align it to the new requirements set out elsewhere in the Bill. There must not be any doubt as to why board members have been appointed. In other words, their appointment must be made on their ability to contribute and add strength to the board, rather than—perhaps—because of those whom they already know. Key factors in the appointment of board members need to be an independent assessment of their value and meeting a fit and proper test of freedom from conflict of interests—things that I hope we would all agree on in your Lordships’ House.

Beyond that, we must also look at what the new NHS England board will be required to do. Other parts of this Bill deal with the powers and duties of this new version of NHS England, originally the NHS Commissioning Board. This is the clearest demonstration of the reversal of the 2012 Act, as the new NHS England bears no resemblance to its original predecessor—and that is a good start. The new NHS England will of course be an amalgamation of the old NHS England, Monitor and the NHS Trust Development Authority. It will commission some specialist services. It will be the regulator of a market that no longer exists. It will performance manage both commissioning for integrated care boards and provision of services by trusts and foundation trusts.

This is indeed a wide range of responsibilities, and how it sits with roles within the department unfortunately remains as vague as ever, with the ability of Ministers to micromanage depending on other parts of this Bill. However, the most crucial policy change is that the new NHS England will sit at the top of a system based on the integrated care boards being the major commissioners of services. The Explanatory Notes and the government pronouncements about these new integration bodies strongly assert their role as driving the reintegration of the NHS, repairing the worst of the fragmentation caused by the 2012 Act and dealing with aspects of previous legislation which had a somewhat market-centric view of our NHS.

This purpose drives what we now need from the new board members of NHS England. Those new board members must chime with this new philosophy of partnership and collaboration rather than markets and competition. In the new world, the NHS will still be bound, as it always has been, by its core principles: comprehensive, universal, free, and funded from general taxation. Board members need a demonstrable record of commitment to these principles. They should also have a commitment to the new values, which favour a stronger role for patients and the public to have influence, a view of the NHS as contributing to reducing inequalities and improving well-being, not simply being a sickness service, and greater alignment of NHS services provided through local government. The current make-up of the board is a chair and five other non-executives, all appointed by the Secretary of State and then the appropriate executive directors. Given the huge importance of the NHS, it is appropriate of course that the chair and at least some of the non-executives are appointed by the Secretary of State. This amendment deals only with the remaining non-exec members.

--- Later in debate ---

Amendment 3 (to Amendment 2) withdrawn.

[Baroness Merron (Lab)]

My Lords, the noble Earl, Lord Howe, hoped that his comments would be helpful and I reassure him that he is always helpful in the comments that he offers. Today, of course, is no exception.

As my noble friend Lord Howarth said, this has been a very interesting debate and it has certainly stimulated many angles of consideration. At a minimum, that has been extremely useful because what binds us all together in this debate, whether or not we agree with the amendment, is the wish to see the new NHS England perform to the highest order in terms of not only confidence but effectiveness. I know that we all want to move in the same direction.

Clearly, we have heard differences of opinion. I am grateful to the noble Baroness, Lady Walmsley, for speaking further to the point about representation. I say to my noble friend Lord Howarth that I did not interpret her as having reservations; her concerns were more about clarification, and I share them. The intent of the amendment was not that people should be consulting back and be a straightforward linear representative, but that they should represent and come from the area which we were discussing. The noble Lord, Lord Patel, made a particularly strong case for the importance of influence in public health; that was echoed by my noble friend Lord Brooke. We are all keen, I am sure, to see the ability to promote good health and well-being such that the NHS, as I said in my opening remarks, should not be focused entirely on dealing with ill health, important though that obviously is.

It is important that we get the right people in place to build the right team. It is crucial that they work together. I am sure that many noble Lords who are non-executives on boards know that a successful board is one that invites challenge, dissent and the widest range of voices. I certainly hope the new NHS England board will do this.

As the right reverend Prelate the Bishop of London so clearly put it, it is too easy for patients’ voices to be forgotten—this must not be the case. I know the noble Earl, Lord Howe, will do his best to ensure that those voices are well heard. Certainly, we in this House will continue to pursue that.

The areas outlined in the amendment from which we had hoped to seek representation remain as important as ever after this debate. I am sure that the noble Earl, Lord Howe, and the Minister will reflect on them in the context of the debate. I thank the noble Lord, Lord Mawson, and the noble Baroness, Lady Harding, for providing challenge, as is quite right and proper. I look forward to the new board of NHS England doing the job we all want it to do. In view of our debate, I beg leave to withdraw my amendment.

Amendment 2 withdrawn.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I feel that today’s debate on this important group of amendments should carry much weight because, at its core, this is about treating people as whole people and seeing them as physical, mental and social beings. Our welfare on each of those fronts is absolutely key to the others. It is not possible simply to treat one without regard to the others, and it is crucial that we enhance people’s well-being across our whole complexity as human beings.

I am glad to speak to this group of amendments because, as we have heard across all sides of the Committee throughout today’s debate, the reality is that, despite the best efforts encapsulated in the mandate, and many times in policy, we find that competing priorities, an avalanche of guidance and instructions, and events—the pandemic has been referred to several times, of course—mean that mental health services can be, and indeed have been, relatively left behind. As the Centre for Mental Health reports:

“Mental health problems account for 28% of the burden of disease but only 13% of NHS spending.”


In the debate today we have also asked ourselves: where is the accountability? For example, we know that in many clinical commissioning groups the actual spend on mental health was below what it was supposed to be, yet there have been no consequences. We need to address not just the finances but the mechanisms around it and the impact on individuals.

The founding National Health Service Act 1946 rightly spoke of a comprehensive health service that secured the improvement of both physical and mental health, and subsequent Acts, quite rightly, have confirmed this. In operational terms, the Government require NHS England to work for parity of esteem for mental and physical health through this NHS mandate, but we know, and have heard again today, that this requirement falls down when we go to a local level.

One way or another, we will all be familiar with a whole range of stories of people who have not been able to access treatment in a timely manner or who find that they are pushed around a system with very little effect and discharged from care before it is appropriate, with consequences that are all too clear to see. It is difficult to overestimate just how challenging this is, not just for the individuals but for local commissioners, because they face competing pressures in trying to deal with this.

As has been emphasised, this group of amendments is about not just getting on the road to financial parity, important though that is, but changing the culture and the whole means of monitoring and implementation, so that disparities can be addressed—indeed, if possible, so that difficulties can be headed off at the pass. It is a well-worn phrase, but it sometimes seems that mental health is a Cinderella service—the one that can be cut first, to the benefit of the more visible services. Some of the recent statistics show that one in four mental health beds has been cut in the last decade, while just last year 37% of children referred by a professional to mental health services were turned away. That is a shocking statistic that we need to move away from.

I thank noble Lords for promoting these amendments and for their contributions illustrating what they mean and the reason we need them today. The noble Lords, Lord Stevens and Lord Patel, made timely points about the impact of the pandemic. If this is not a moment for focusing more on mental health, I do not know what is. The challenge we have and the difficulty presented by the pandemic is that while there is a focus on cutting waits for operations—and we know that is important—this could be a reason for mental health services to get somewhat lost, when in fact the pandemic reminds us of the importance of mental health and the need for the NHS to meet the needs that there now are.

The amendment by the noble Lord, Lord Stevens, encourages and directs the actions necessary for transparency on expenditure. I recall that they were referred to in the debate as legislative levers, and that is indeed what they can be. For me, they encourage not just accountability and transparency but actual action and change—the change we need to see.

The noble Baroness, Lady Hollins, referred to parity of esteem having to be applied locally, not just at a higher level. That is the only way we will see a difference in mental health services and improve the mental health of people in this country.

The noble Lord, Lord Crisp, made reference to the fact that legislation is trying to catch up with where we are as a society, and the noble Lord, Lord Warner, referring back to the meeting he attended, said that the public are well ahead of the game. I believe that is true. Indeed, as the noble Baroness, Lady Watkins, said, we have to prepare for tomorrow. It is not satisfactory that we stay stuck in today, or indeed in the past.

In my view, these amendments move us on. They bring mental health services into real parity with physical health services, but they also connect mental and physical together. I hope they will find favour from the Minister.

[Lord Kamall (Con)]

I begin by thanking all your Lordships for the wide-ranging debate. I want to say how much more I learn, listening to the contributions in each of these debates, before I stand up to speak. I thank all noble Lords for their contributions. As the noble Baroness, Lady Merron, says, this debate carries some weight for our understanding that social, mental and physical well-being are equally important. We should not seek to suggest that one takes precedence over another. I also thank the noble Lord, Lord Stevens, for kicking off this debate with his encouraging and not critical amendments; I take them in that spirit.

Following on from that, and before I go to some of the specific amendments, I will just reflect on some of the contributions made thus far. I first thank the noble Lord, Lord Howarth, for raising social prescribing. I know we have discussed this a number of times since I became the Minister, with particular contributions from the noble Baroness, Lady Greengross, on the importance of art and music in helping to unlock the mind and touch the soul.

As has been made clear, social prescribing is a key component of the NHS’s universal personalised care, and I know that, crucially, this can work well for those who are socially isolated or whose well-being is impacted by non-medical issues. The NHS has mechanisms to ensure that social prescribing is embedded across England: for example, the primary care network directed at enhanced services specification outlines that all PCNs must provide access to a social prescribing service.

I also thank the noble Lord, Lord Patel, for raising the importance of the mental health of children and for making sure that we do not forget, even within mental health, that many sections of our society can quite easily be forgotten.

I agree with the right reverend Prelate the Bishop of London: we have come a long way. I remember as a child in the 1970s going to visit my uncle who was a psychiatric nurse at Claybury Hospital and looking at the patients, with the innocence of a child, and thinking, “These people don’t look ill to me.” We have come far since then. I remember the Rampton hospital scandal in the late 1970s, where the patients were treated appallingly, almost not as humans, and with a lack of dignity. The fact that today we are discussing the parity of mental with physical health shows how far we have come as a society.

We also spoke about loneliness and isolation. The noble Baroness, Lady Watkins, and I have had conversations about loneliness and some of the civil society projects that, for example, bring together lonely older people with children from broken homes so that both can benefit and learn from each other. I remember a story that I have mentioned in the past: in one of the projects I visited, a rather old man said, “I lost my wife five years ago and I had almost given up on life. The fact that I am now working with children from broken families and am almost being a mentor to them gives me a purpose to live—a reason to get up in the morning. I have no longer given up on life.” There are so many of these civil society projects, and no matter how we legislate, sometimes those local projects get to the nub of the problem in their local communities.

I have to pay attention when not only two former NHS chief executive officers but the former Chief Nursing Officer speak in the debate. The noble Lord, Lord Crisp, talked about the focus on outcomes, not inputs and how it is important to make sure that we are not gaming the system, mentioning mental illness and mental health but not doing anything effective about it.

Autism was mentioned by the noble Lord, Lord Warner, a former Health Minister. We are fully committed to improving access to and provision of health and care services for autistic people and people with a learning disability. I know that we have had at least one debate on the treatment of patients with autism and sometimes the terrible conditions they experience. That just shows how important this is.

I am trying to say that in many ways that the Government are absolutely committed to supporting everyone’s mental health and well-being and to ensuring that the right support is in place for all who need it. I therefore welcome the amendments which look to ensure parity of esteem across physical and mental health. I assure noble Lords that we support the sentiments behind these amendments and take mental health seriously.

Indeed, one of the considerations in weighing up the many arguments for further measures in response to Covid—from those who were asking for lockdown, for example—is that we also had to recognise that there was a mental health impact to lockdown. As a Government, we had to look not only at the societal and economic impacts but the mental health impacts within health considerations.

On the amendments, I will first address those tabled by the noble Baroness, Lady Hollins—I add my voice to those of the many noble Lords who have paid tribute to her work over many years in promoting this issue and ensuring that we take it seriously. I also pay tribute to the noble Baroness, Lady Walmsley, for making sure that we are informed about this. These amendments would explicitly reference both mental and physical health and illness in certain provisions of the Bill. I understand that the intention is to ensure that due attention is given to both “mental and physical health” and “mental and physical illness”. Indeed, you cannot separate mental and physical illness, as the noble Baroness, Lady Jones, said. We have moved way beyond “Pull yourself together, man” or a stiff upper lip attitude. We see how mental health plays a role, for example, in terrorism, with those who are recruited to be terrorists, or in those with eating disorders, or the number of people in prison who suffer from mental health issues. It is important that we fully recognise that.