Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 2 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Lord Eatwell (Lab)]

My Lords, I rise to give my strong support to Amendment 108, and I do so because of the terms of the genocide convention to which this Government are committed and are obligated to support. It is important for the House to note that genocide is not defined solely as mass killing. It is also defined as

“causing serious bodily or mental harm … deliberately inflicting … conditions of life calculated to”

destroy the protected group

“in whole or in part … imposing measures intended to prevent births”,

and

“forcibly transferring the children of the group to another group.”

The Government are a signatory to the genocide convention, and I think the noble Earl, Lord Howe, is obligated by that signature to support this amendment.

[Baroness Merron (Lab)]

My Lords, it is impossible to turn away from the connection between procurement of products and services and the message and support that such procurement may give to those who seek to exploit, oppress, damage and murder.

I thank the noble Lord, Lord Alton, for introducing this amendment, in the name of the noble Lord, Lord Blencathra, who we wish well. Genocide and the abuse of human rights do not respect the imposed boundaries of government departments, and that is why it is appropriate that these amendments, which have extensive support both inside and outside your Lordships’ House, have been tabled today. Amendment 108 has cross-party support and if the will of the House is tested, we on these Benches will support it.

The NHS is the biggest single procurer of medical products in the world. It has a huge amount of leverage to be a force for good or otherwise when it comes to ethical procurement. It can starve abusive regions of resources. It can also remove a veneer of acceptability from those regions.

If we are serious about being global Britain and a force for good in the world, we need to act as such. It is surely wrong that, for example, we are using bandages which have been produced by forced labour. We must hold the Government to their commitment to provide guidance and support to UK government bodies to use public procurement rules to exclude suppliers where there is sufficient evidence of human rights violations in any of their supply chains. As expressed by my noble friend Lady Kennedy, this is about giving the Minister the opportunity to act. It is about focusing minds. I hope that the amendment will find favour with the noble Earl.

In Committee, my noble friend Lord Collins spoke of the need not to be tied down by a very strict legal definition of genocide. He also emphasised that we must focus on broader human rights issues. As the noble Lord, Lord Alton, said, we need to take a comprehensive, joined-up approach. Amendment 108 gives us this opportunity.

I thank my noble friend Lord Hunt for continuing to press home the need for action, as outlined in Amendments 162 and 173. We heard explicitly and movingly about the realities of how this affects people’s bodies, alive and dead, and the distaste and abuse related to it. It is surely right that UK citizens are safeguarded against complicity in forced organ harvesting as the result of genocide. Countries such as Spain, Italy, Belgium, Norway and Israel, among several others, have already taken action to prevent organ tourism in respect of China. We have the opportunity to do so today.

I hope that the noble Earl will feel able to accept these amendments. I am grateful to the noble Lord and his officials for the opportunity to discuss these matters. I hope only that your Lordships’ House can assist in improving this aspect of the Bill by taking action, as we should, about genocide and the abuse of human rights.

[Earl Howe (Con)]

My Lords, the amendments in this group bring us to three discrete topics which are nevertheless linked by a common thread—that of human rights. Because they engage us in issues of great sensitivity, I begin by saying something that may sound unusual. There is probably no one in this Chamber who is not instinctively drawn towards these amendments. All three are honourably motivated. In pointing out any shortcomings, I would not want noble Lords to think that the Government did not understand or sympathise with why they have been tabled.

I will start with the issue of organ tourism. Like the noble Lord, Lord Hunt, I find it abhorrent that individuals exist who are in the business—often the lucrative business—of sourcing human organs from provenances that are both illegal and supremely unethical. They then entice desperate and seriously ill people to go to a foreign country to have such organs transplanted within them. This idea is unconscionable. As far as we can, we should have no truck with it. The Human Tissue Act already prohibits the giving of

“a reward for the supply of, or for an offer to supply any controlled material”

in any circumstance where a substantial part of the illicit transaction takes place in England, Wales or Northern Ireland.

The Modern Slavery Act makes it an offence to arrange or facilitate another person’s travel, including travel outside the UK, for the purposes of their exploitation, which includes the supply of organs for reward in any part of the world. The law as it stands addresses a substantial element of potential criminality. How widespread is this criminality? What do we know about the scale of organ tourism as it relates to UK residents? I have obtained some figures from the department. In 2019-20, the last reporting year before international travel was curtailed by the pandemic, a total of 4,820 organ transplants took place in this country. At the same time, NHS Blood and Transplant data shows that only seven UK residents received a transplant abroad, many if not all legitimately, and had follow-up treatment in the UK.

Therefore I am thankful to say that the scale of the problem of illicit organ tourism, as it relates to UK residents, is small. If the noble Lord, Lord Hunt, were to say to me that one such case is one too many, I would agree, but the House should not support this amendment, because it is not right to support an amendment that could cause vulnerable transplant patients who receive a legitimate transplant overseas to face imprisonment because they may not have the right documentation. That is what the amendment could lead to. Checking such documentation and creating individually identifiable records for every UK patient who has received a transplant overseas would put healthcare professionals in an invidious and inappropriate position by blurring the line between medic and criminal investigator.

More to the point, it could also prevent those who legitimately receive an organ transplant abroad—particularly those from minority-ethnic backgrounds—from seeking follow-up treatment, for fear of being treated as a criminal suspect. Following that thought through, I say that the effect that this amendment could have in exacerbating health inequalities is likely to be far greater than its effect in deterring transplant tourism, especially, as I have emphasised, because there are already legal provisions in place covering most cases of organ tourism.

I listened with care to the noble Baroness, Lady Finlay, particularly regarding her examples of the exhibition that she went to. I join her in being somewhat incredulous that there could be consent to some of the exhibits that she witnessed. However, where consent has been obtained, it must be unequivocal. As I emphasised, the law as it stands now prohibits the exhibition of bodies or body parts where express consent cannot be fully demonstrated. I undertake to speak to the Human Tissue Authority, to see that, should there be another exhibition of this kind proposed, there is full transparency in the form of labels under each exhibit making clear how consent was obtained and what it consisted of.

Targeting those who receive an organ, rather than the traffickers and their customers who initiate or negotiate the arrangements, risks imprisoning vulnerable patients who may have been misled as to the provenance of their organ. That would be disproportionate. The Government’s view remains that the best approach is to continue targeting traffickers and their customers, while doing all that we can to help UK residents who are in need of an organ by focusing our efforts on improving the rates and outcomes of legitimate donations.

--- Later in debate ---

[Lord Kakkar (CB)]

My Lords, I declare an interest as a member of your Lordships’ ad hoc Select Committee on the Long-term Sustainability of the NHS. My noble friend Lord Warner has very clearly introduced the arguments summarised at that time, when your Lordships’ committee made its report, strongly supporting the establishment of an independent office for the sustainability of health and care, and I shall not repeat those arguments.

What was striking was Her Majesty’s Government’s response to that report and, indeed, to recommendations 32 to 34 in that report, which dealt with that specific question. To summarise, Her Majesty’s Government felt that that office was unnecessary and that the Office for National Statistics had much of the data publicly available to assist in this long-term planning activity. Clearly, that is not the case; it has not happened, and it is unlikely to happen.

It is essential, as we have heard, that such an office is established not only to deal with questions of workforce—my noble friend has identified the interview given by the right honourable Jeremy Hunt on the question of an independent office for questions of workforce—as sustainability of health and care goes far beyond workforce. A very careful and appropriately defined methodology and expertise needs to be brought together to ensure that we can plan on a definite basis and achieve the sustainability that every Member of your Lordships’ House clearly regards to be essential. I therefore hope that Her Majesty’s Government accept this amendment.

[Baroness Merron (Lab)]

My Lords, five years have passed since the ad hoc Select Committee on the Long-term Sustainability of the NHS, under the chairpersonship of the noble Lord, Lord Patel, recommended an office for health and care sustainability. I thank the noble Lord, Lord Warner, for bringing this amendment before your Lordships’ House. This is a clear direction to put sustainability at the heart of planning and is long overdue. So we on these Benches support the amendment, and I hope the Minister will accept this amendment as a way forward.

[Baroness Penn (Con)]

My Lords, I thank noble Lords for bringing this debate before the House today. As mentioned in the debate in Committee, the specific functions described in Amendment 112 are crucial functions that the Government are committed to ensuring are discharged. This commitment is underlined by the fact that there are already bodies and mechanisms in place to fulfil these functions. These are core components of the Government’s commitment to evidence-based health provision. This commitment has been made clear in many of the Bill’s provisions, in our wider programme of public health reform and in the proposals set out in the Government’s plan for health and care.

The amendment makes recommendations on both appraisal and scrutiny of funding and of social and demographic trends. With regard to the monitoring of trends, the department already publishes data relating to disease profiles, which incorporates demographic trends where relevant. This is supported by independent academic modelling from the Care Policy Evaluation Centre, CPEC, to produce projections of the long-term demand on adult social care services. As for funding, noble Lords will also be aware that successive Governments have used the well-established spending review process to set public service budgets. This takes into account the needs of service users, but crucially also considers the fiscal context and how healthcare expenditure balances with the range of priorities across government.

As noble Lords have noted, aligned to those spending decisions, the Office for Budget Responsibility already scrutinises the Government’s fiscal approach and our management of fiscal risks. For example, in October 2021 the OBR provided an independent analysis of the Government’s reform to the funding of adult social care in England and has announced that it will provide more analysis of the long-term implications in its next fiscal sustainability report. There is also, as noble Lords will know, a wide range of highly influential non-governmental bodies dedicated to the kinds of functions proposed for this new body—the King’s Fund, the Health Foundation and the Nuffield Trust to name just three. All of these contribute richly to the public debate on financial sustainability and on the size and composition of the workforce, as well as other related issues, and to the ability of this House to scrutinise government decisions on spending and policy.

The Government therefore do not think that the creation of a further body would add value. At this crucial time for the health and care system, we must proceed with the reforms we have outlined. For these reasons I hope that the noble Lord, Lord Warner, will feel able to withdraw his amendment.

Eating Disorders

Baroness Merron Excerpts

Tuesday 1st March 2022 Lords Chamber

[Lord Kamall (Con)]

I think the noble Baroness is being unfair in suggesting that the Government are not taking this issue seriously. In the conversations that I have had in the lead-up to this Question, it has been quite clear that they are taking it very seriously. They recognise its granularity and the differences in types of eating disorder. As the noble Baroness rightly said, people quite often associate eating disorders with adolescents or young females and young men, but binge eating disorders in particular can occur among adults who are 30 or 40 years old. The Government are looking, first, at education. Secondly, they have made a number of investments in adult and children’s services relating to mental health, including eating disorders.

[Baroness Merron (Lab)]

My Lords, there has been a 72% increase this year in the number of children and teenagers referred for urgent support for eating disorders, but a new, dangerous issue has emerged, that of specialist mental health services with no capacity having to bounce back even those who are at risk of suicide, self-harm and starvation to GPs, who, as we have heard, often have no specific training to deal with this. Can the Minister apprise your Lordships’ House of what assessment has been made of the incidence of this so-called bounce-back? Will he commit to tackling it by various means, including a recovery plan for mental health services that has a focus on children and young people and ensures that there is a trained workforce to deliver this support?

[Lord Kamall (Con)]

The noble Baroness’s suggestions are reasonable, and I think that many noble Lords would agree that it is important that we tackle this on a number of levels. For example, under the NHS long-term plan, extra funding has been going to children and young people’s community eating disorder services every year, with £53 million per year invested in 2021-22. That will increase the capacity of 70 new or improved community eating disorder teams covering the whole of the country. In response to Covid and to help meet the waiting time standard, we have invested an extra £79 million in 2021-22 to significantly expand children’s mental health services. In addition, as part of the additional £500 million that we announced in 2021-22, some of this is also being done via the mental health recovery action plan. NHS England and NHS Improvement have announced a further £40 million in 2021-22 to address the impact of Covid on children’s and young people’s mental health. These are some of the different ways in which we are addressing this very serious issue that a number of noble Lords have quite rightly raised.

Health and Care Bill

Baroness Merron Excerpts

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

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for listening very carefully to what noble Lords from across the House have been saying about the need to recognise the parity of esteem between physical and mental health, and for giving us some reassurance that the funding for mental health will increase in the future. A lot of mental distress has been caused by the fact that many patients suffering from mental ill health have not been able to reach the threshold for access to services. The reason for that has been a shortage of resources and a properly trained workforce which can deliver the therapies required. At the end of the debate, I hope that the Minister will be able to assure us that those resources will be made available.

My noble friend commented that she hoped that the new standards would not have the unintended consequences of transferring delays from the initial diagnosis to further down the treatment pathway. That is a very important consideration. We will talk about the importance of increasing the NHS workforce later in our debates. However, will the Minister consider how focusing increased resources on early intervention and prevention will save both money in the end and a lot of distress, as dealing with it early will save patients having to go into more intensive therapies further down the track? It is very important that any increased resources—or, at least, much of them—are focused on early intervention and prevention. I hope the Minister can reassure us of this.

[Baroness Merron (Lab)]

My Lords, if the role of your Lordships’ House is to improve the Bill, I feel that this set of amendments will achieve this. I am grateful to the Minister and his officials for responding to the points which were made so powerfully in Committee and in meetings outside this Chamber. The range of amendments will take us further.

The Minister talked about the introduction of transparency and accountability, which are key in the efforts to improve the provision of mental health services. However, of course, improving transparency and accountability is not an end in itself; it is purely a way of getting us to the right place. What will be important is what this delivers. A step along the way to improving mental health services is definitely being made, but there is an awful lot more to do. For example, the Centre for Mental Health estimates that some 10 million additional people, and that includes 1.5 million children and young people, will need mental health care as a result of the pandemic. It would of interest to understand a little more about how the Government intend to make progress on this once the Bill receives Royal Assent. Will we see a recovery plan in the area of mental health services, backed by a long-term workforce plan, something which we will return to later?

On the policy to bring practice into line with aspiration, and on the funding for and redoubling of effort towards achieving parity, while we are talking about this on a national level, it would also be helpful for the Minister to clarify that it applies to all areas of the Bill’s implementation and that the new bodies set up by the Bill will be expected to treat mental health equally from the outset. For example, it would mean ensuring that the decisions about resource allocation, capital spending, waiting times and priorities were all taken on the basis that mental health must be valued equally with physical health.

The noble Baroness, Lady Tyler, was right to point out that we do not start in a neutral position, because we know that waiting times are considerable, standards of services need massively to be improved and the workforce needs to be strengthened in order to deliver those services. It is therefore extremely important that the Minister in putting forward these amendments undertakes to see the job through, so that we do not just have transparency and accountability for their own sake but we deliver for the many millions who will rely on those services.

[Lord Kamall (Con)]

My Lords, I once again thank not only noble Lords who spoke in this debate but those who engaged with us throughout the process. As the noble Baroness, Lady Merron, said, if the role of this House is to improve the Bill, we have learned much. As a relatively new Health Minister, I have learned so much from the various meetings that I have had with noble Lords, not only on this issue but on many others across the health and care spectrum.

I thank noble Lords who have engaged with me personally but also with my officials to make sure that we closed the gaps as much as we could. I am pleased to hear support from your Lordships for the package of amendments that I have brought forward, and I am grateful.

I stress that this package of amendments should be considered alongside the amendment placing a duty on ICBs to have an appropriate skill mix and experience necessary to deliver all their functions—I hope that noble Lords will look at those in that context—as we expect skills pertaining to the delivery of mental health services to be considered when meeting this duty at the ICB level as well as below that at place level. Many noble Lords have discussed the importance of place.

Amendment 184 would require the Government to report on our plans to improve mental health standards. Access to services is at the heart of the mental health commitments in the NHS long-term plan. The department, NHS England and NHS Improvement regularly report performance against existing waiting time standards in mental health, including improving access to psychological therapies services, children and young people’s eating disorder services and people experiencing a first episode of psychosis.

As noble Lords have acknowledged, last week NHS England and NHS Improvement took another step to strengthen mental health standards, publishing a consultation response following the mental health clinically led review of standards consultation. As noble Lords will know, this sought views on the proposed introduction of new measures, including five new waiting time standards, to support our ambitions to ensure that patients have timely access to community mental health care.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 2 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Baroness, Lady Finlay, without whom this amendment would not have been laid by the Government —although I pay tribute to the Government for listening to her. As she said, it could be game-changing—I say “could be” because unless the resources are made available for these services and for training enough of the health professionals needed to carry them out and make them available everywhere, it will not be game-changing. I would like a reassurance from the Minister that adequate resources will be made available so that, as appropriate, ICBs can carry out the duty that will be put on them.

I was horrified to hear the noble Baroness, Lady Meacher, mention a hospice with half its beds empty. I hope additional resources will be provided for hospices. I clearly remember somebody saying in Committee that you would not expect to have a coffee morning or a cake bake to treat a broken leg; you should not have to do the same sort of thing for services at the end of life. I hope the Minister will bear in mind the possibility that additional resources should go there.

We have heard that services are patchy across the country, and I suggest that the worst patchiness is in services for people dying at home. I know it is not easy to provide 24-hour services and advice to a family doing their best to try to care for somebody dying at home, but it must be done. I am afraid I know friends who have had a very bad experience of that. The person at the end of life had a bad experience, and the family have never forgotten it. As the noble Baroness, Lady Finlay, has often told us, it is possible for everybody to have a good death if the right services are provided to them. That means a good experience too for the family, who simply want to know that they have done the best and that that has been enough.

[Baroness Merron (Lab)]

My Lords, from these Benches I am very glad to continue our support for palliative care being part of a comprehensive health service—literally from the cradle to the grave—no matter who you are, your age or where you live. I join other noble Lords in paying tribute and giving appreciation to the noble Baroness, Lady Finlay, for her assistance and professionalism over many years. I hope that the real tribute to the efforts of the noble Baroness will be in the delivery of real change to the quality of people’s lives—and their deaths. I add my appreciation to all the charities and hospices that have also been a force for good in seeking this change.

I welcome the government amendment in this area and, in so doing, I simply say to the Minister that I hope the Government have heard the number of questions asked today. Clearly, there is concern about the words “appropriate” and “reasonable”, and I will add a few questions to those already put to explore that further. I am sure the Minister understands that noble Lords are simply trying to ensure that what is intended will actually be delivered.

Can the Minister confirm how the Government’s expectations will be conveyed to ICBs, and how they will understand what is expected of them in terms of the nature of palliative care services that they would be required to commission? It would also be helpful if he could commit to providing a definition of “specialist palliative care” services, referring to the amendment tabled by the noble Baroness, Lady Finlay, so that we can see a consistent standard in provision of services across the country. My final question is: can the Minister confirm that it is the Government’s intention to communicate to all ICBs that they should fulfil the true requirements of this amendment, and can he tell your Lordships’ House how this will be monitored?

The right reverend Prelate the Bishop of London and other noble Lords have made it clear that we would like the matter settled by the amendment, but it is not entirely. I hope that the Government will not lose the opportunity to really make the transformation so that we can all expect, and have, a good death, as we would want to have a good life.

[Earl Howe (Con)]

My Lords, I am very grateful to all noble Lords who have spoken in this important short debate, but, in particular, I express my thanks to the noble Baroness, Lady Finlay, for the illumination that she shed on the reality of well-functioning palliative care services from her personal perspective.

Without repeating what I said earlier, the Government recognise and understand the strength of feeling on the issue of variation among access to palliative care services. I understand the line of questioning posed by a number of noble Lords on the strength of the imperative implicit in the government amendment. The noble Baronesses, Lady Brinton, Lady Meacher and Lady Walmsley, and the noble Lord, Lord Hunt, all had questions on that theme.

The first thing for me to say is that I agree with the noble Baroness, Lady Finlay: this is a game-changing amendment because it would specifically require—that is the word—integrated care boards to commission such services or facilities for palliative care, including specialist palliative care, as they consider appropriate for meeting the reasonable requirements of the people for whom they have responsibility.

Questions have been asked about the word “appropriate”. I do not think any other word could be fitted into this context; you have to talk about what is appropriate when the extent of need and the requirements of the local population inevitably vary according to the locality. It is for the board to judge what is appropriate to meet that need in the local area and what is appropriate to the nature of the palliative care provision that may exist in an area: for example, whether it is a hospital, a hospice, social care hospices or hospices at home—all the panoply of palliative care provision that noble Lords will be familiar with. My noble and learned friend Lord Mackay of Clashfern made a very helpful intervention on that issue, for which I thank him.

We therefore expect palliative care to be commissioned by every ICB. It will be for them to allocate resources to meet the needs of their population that they identify but, on funding more broadly, the House will know that there is a multifaceted funding pattern in the palliative care field. Palliative and end-of-life care services are delivered by services and staff across the NHS, social care, the voluntary and community sector and independent hospices.

We recognise the vital role that hospices and other voluntary organisations play in the delivery and funding of palliative and end-of-life care and continue to engage proactively with our stakeholders on an ongoing basis to understand the issues they face. Those are not bald words; as part of the NHS Covid response, over £400 million has been made available to hospices since the start of the pandemic to secure and increase additional NHS capacity and enable hospital discharge.

The noble Baroness, Lady Brinton, asked me about statutory guidance. A range of guidance is already available to commissioners about the provision of palliative and end-of-life care, including detailed, evidence-based guidance from the National Institute for Health and Care Excellence. We will continue to keep the guidance under review. NHS England and NHS Improvement have also made funding available to seven palliative and end-of-life care strategic clinical networks, which will support commissioners in the delivery of outstanding clinical care, with sustainability of commissioning as a guiding principle.

The noble Lord, Lord Howarth, and my noble friend Lady Fraser touched on transparency and reporting. I point to our later amendments requiring ICBs to set out how they intend to commission services and report on that in their annual reports. That will of course include palliative care. I can also give an assurance that we are not only looking at the guidance currently but will continue to keep the range of guidance available to commissioners under review.

In answer to the noble Baroness, Lady Merron, on the Government’s expectations in this area, I can say only that our expectations as of now are set out in this amendment and in the guidance we will issue, and the assurance that we will engage with in our dealings with NHS England.

I hope I have been able to reassure the House that the Government are absolutely committed to ensuring that people receive high-quality palliative care if and when they need it. I invite the House to support Amendment 16.

Covid-19: Lateral Flow Tests

Baroness Merron Excerpts

Thursday 10th February 2022 Lords Chamber

[Lord Kamall (Con)]

That is a valid question and if the noble Baroness could write to me, I will respond.

[Baroness Merron (Lab)]

My Lords, in addition to the need to improve the approval process for lateral flow tests, when can we expect to see a real plan for living well with Covid? Will this include proper provision for better sick pay, improved testing and those who are clinically vulnerable.

[Lord Kamall (Con)]

Clearly, the noble Baroness raises a number of important considerations for when we come up with a living with Covid strategy. At the moment, we are consulting on it to make sure that we have an appropriate strategy that covers many of the issues she referred to.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to follow everyone who has spoken in this group. I thank the noble Baroness, Lady Chakrabarti, for so powerfully and clearly introducing this amendment, to which I was pleased to attach my name. The case has been overwhelmingly made, so I will not go over the same ground but will add a couple of points and draw some things together.

It is interesting that we started the day with the ARIA Bill. Concern was expressed from several quarters of your Lordships’ House about public money going into ARIA and whether we would see public returns from that money. As the noble Baroness, Lady Chakrabarti, said, what we have seen so often is the socialisation of costs and the privatisation of profits in so many areas of research and knowledge.

I draw to the attention of any noble Lord who has not seen it a very useful briefing on this amendment prepared jointly by Just Treatment, STOPAIDS, Global Justice Now and Universities Allied for Essential Medicines. That brings out two points, and it is worth looking at the national and the international. We have tended to focus on the international. Nationally there are some fascinating figures. The NHS pays more than £1 billion a year for medicines, but two-thirds of the upfront costs of producing those medicines come from public funding.

That is the national side. Looking at the international side, we have talked about and focused very much on Covid, but we really need to think about the fact that we are now in the age of shocks, in a world that is environmentally extremely disturbed. That is certainly a factor in the appearance of Covid; we have seen SARS and MERS, and there is Ebola out there. We need to build resilience into our world. We are talking about changing so many different things, and whether it is supply chains, medical supply chains specifically, or anything else, we really need to think about preparing for that different world, with the focus on resilience, rather than on private profits as it has been.

The noble Lord, Lord Crisp, asked an interesting question: why do we see the UK, the EU and Switzerland lining up against the rest of the world? The answer is there in profits, in an ideology that says, “We have to organise everything for private profits and somehow the benefits will trickle down.” It is interesting that today Michael Gove has gone on the record as saying that trickle-down has not worked; it is a failed ideology. Of course, there is also the impact of those profits being fed into our political system and the influence that that money and that lobbying have.

I will finish with this final thought. The noble Baroness, Lady Chakrabarti, said—and I think this reflects what other noble Lords, particularly the noble Baroness, Lady Lawrence, and the noble Lord, Lord Crisp, said—that we have been utterly wicked in our behaviour towards the global south in the Covid pandemic in failing to ensure that it has crucial vaccines. We have also, as has become obvious with omicron, spectacularly shot ourselves in the foot. I say to those who will not accept moral arguments for this amendment: please look at the practical self-interest. No one is safe until everyone is safe.

[Baroness Merron (Lab)]

My Lords, I thank my noble friend Lady Chakrabarti for raising the crucial matter of countries and peoples left behind in terms of the opportunity to have a necessary vaccination programme available to them. My noble friend Lord Campbell-Savours spoke of the importance of supporting innovation, which is one of the ways in which we can ensure that, while my noble friend Lord Howarth rightly said that the subject requires exploration outside of the Health and Care Bill—something also commented on by the noble Lord, Lord Crisp, who emphasised, as do I, the need for the political will to make progress.

There is no doubt, as we have heard today, about the gravity of the issues at stake and the need to resolve them. It is the case that where public funding is provided there must be conditionality, although of course that may be complex to refine into legislation. There are of course additional issues when funding is also coming from the private sector along with a need to ensure a balance of interests. It would certainly be helpful to have a stipulation that avoided placing undue bureaucracy and restraint on smaller developments and small-scale research. We do not want to see the pace of research slowed down with researchers tied up in lengthy proposal writing, contract negotiations and legal agreements.

As my noble friend Lady Lawrence has said, we know that the pandemic is not over until it is over everywhere, so the amendment raises the opportunity to explore whether the immediate waiver of intellectual property rights would mean an end to the pandemic everywhere. It is relevant to assess what contribution or otherwise intellectual property rights make to the promotion of technological innovation and the transfer and dissemination of technology. There is an advantage for producers and users of technological knowledge and the consideration of rights and obligations, and that needs to be considered in the round.

In respect of the response and actions to a pandemic declared by the World Health Organization, while I understand the intention behind the amendment, in order to be consistent I would comment with some caution about the Secretary of State being compelled to immediately take actions, particularly without any form of oversight—something that we will return to later in Committee.

However, I hope that today we can obtain some reassurances from the Minister about the Government’s intentions and plans in order that we can find a way forward so that low-income countries and their peoples have access to vaccines both now and in future.

[Lord Kamall (Con)]

I thank the noble Baroness, Lady Chakrabarti, for bringing this debate before the Committee today and for the heartfelt speech that she gave. The noble Baroness will be aware of the view of this Government following her recent Question in the House on the subject of patient waivers. As my noble friend Lord Grimstone set out, the Government remain open to all initiatives that would have a demonstrably positive impact on vaccine production and distribution. However, we believe that waiving intellectual property rights would have the opposite effect. Doing so would dismantle the very framework that helped to develop and produce Covid-19 vaccines at the pace and scale now seen. It would risk undermining the continued innovation in vaccines and technological health products that is required to tackle a virus, especially as it mutates and evolves, so we believe that doing so would be a mistake.

Instead, the success of the Covid-19 vaccine rollout vindicates the value of public and private co-operation. While university research departments are great at research, large-scale manufacturing and global distribution are not their function, so we recognise the importance of their working with partners with expertise in this area.

The intellectual property framework is key to those efforts. It has incentivised the research and development that has led to the development of Covid-19 vaccines. It has given innovators the confidence to form more than 300 partnerships, an unprecedented number, and has contributed to the production and dissemination of vaccines and other health products and technologies across the world, with global Covid vaccine production now at nearly 1.5 billion doses per month.

I share the noble Baroness’s intention that research funded through taxpayer finances should benefit the taxpayer, but we do not consider that that is best achieved through particular constraints in primary legislation. Research contracts afford greater flexibility and more powerful levers than the amendment, through provisions such as those requiring the dissemination of intellectual property for patient benefit, revenue sharing with the Government of commercialised intellectual property, and requirements around access to medicines in the developing world. Contractual protection mechanisms in funding arrangements can also ensure that intellectual property funded by taxpayers results in the creation of taxpayer benefit.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this group rightly began with an amendment about adequate provision in dentistry. As we have heard, there is currently a massive shortfall in provision of NHS dentists and indeed dentists as a whole, so much so that a charity called Dentaid, which normally works in the third world, is now working in Dewsbury and Batley—and possibly in other parts of the country that I am not aware of—because people cannot get free dentistry. The situation is made worse by the backlog of treatment caused by the pandemic, whereby dentists were at first unable to see patients and later had to reduce the number of aerosol-producing treatments they could carry out each day.

I have no doubt that the condition of the nation’s teeth has deteriorated during the past couple of years. Nearly 1,000 dentists left the NHS between 2020 and 2021, according to the BDA. However, problems with access to NHS dentistry predate the pandemic. Government spending on dental services has fallen by a third in real terms in the last decade, and the £50 million one-off injection of funding announced recently will barely make a dent in the unprecedented backlog that NHS dentistry now faces.

However, it is also well proven that fluoride, however administered, can strengthen tooth enamel and help teeth to resist decay. The 2018 report from Public Health England made that clear and did not report adverse effects. In Clauses 147 and 148, the Government intend to ensure that the whole country has access to drinking water with at least 1 milligram per litre of water, the level believed to be most effective in reducing tooth decay without the unwanted effects mentioned by the noble Lord, Lord Reay, and without waiting for local authorities to initiate schemes. I have to say that I believe Public Health England rather than the noble Lord.

I am always in favour of prevention and of reducing health inequalities, and it is claimed that this measure would do both, but there are some issues which I wish to probe. Currently only two areas in the country, Hartlepool and Braintree, have the optimum level of naturally occurring fluoride in their water. Other areas, covering about only 10% of the population, mainly in the north-east and Birmingham, already have schemes initiated by the local authority. I accept that a number of costly and bureaucratic barriers have been identified to more local authorities initiating such schemes, and I understand these clauses are an attempt to overcome them by making national regulations. These would remove some of the consultation costs from local authorities. However, some local authorities are reluctant to give up their local autonomy on this issue and believe their residents should be consulted before fluoridation occurs. This must be considered.

I have some questions for the Minister, which fall into two categories. The first is about costs and where they fall. We are told in the impact assessment that current schemes will not be affected, and existing and future capital costs will continue to be borne by the Department of Health and Social Care. What will be the additional burden on the funding of the Minister’s department of bearing the capital costs for every area in the country? I understand that regulations will allow for future costs to be shared by his department with water companies. What impact is that expected to have on the water bills paid by households, since the companies will undoubtedly try to pass it on to customers?

Water companies can well afford to pay these costs themselves, rather than take the money from the health budget. This is clear from the eye-wateringly high earnings of their leading directors. We know from a briefing from Yorkshire Water that the costs can be considerable. A few years ago, it did a feasibility study when only one area—Hull City Council—was looking into fluoridation. At the time, it estimated the capital cost to be £1.6 million to £2 million and the annual operation costs to be approximately £330,000 per year. These costs would have fallen on Public Health England and the local authority at the time, but under the new proposals they would be covered by the Department of Health and Social Care.

Over recent years, capital investment in water and sewerage services has been covered just by income from water bills, but investment in infrastructure has not been adequate, since we still have raw sewage being discharged into water courses and leaks wasting water at an unacceptable level. So, we can expect the companies to accept some of the cost of fluoridation themselves, without passing it on to the customer.

Can the Minister also say what is the plan for regular measurement of the fluoride content of water, and at what point in the delivery journey will it occur? What will this cost, and where will the cost fall? Will the Government allow companies to pass this cost on to the consumer too, although they can clearly afford to absorb it? The reason I ask is that water companies share water all the time and there is a possibility that, without frequent monitoring, the fluoride content delivered to customers could turn out to be either too high or too low to be effective.

The second category of question concerns what other proposals for reducing the incidence of tooth decay have been considered by the Government, as mentioned by my noble friend Lord Storey. I have dealt with the availability of NHS dentistry, but it is excess sugar and acids in the diet that cause tooth decay. Sadly, poor diet is a major problem, particularly among poorer children, for whom the most common reason to be admitted to hospital is the need for complex extraction of rotten teeth. Fluoride can, of course, can be administered in other ways: either applied by the dentist or by regular use of fluoride-containing toothpaste—fortunately, most toothpastes contain fluoride. However, many children eat too much sugar, drink too many acidic fizzy drinks and do not brush their teeth regularly.

As my noble friend said, there used to be a school dentistry service to check for problems, and dental nurses used to visit nurseries and primary schools to teach good dental hygiene. I have myself sat in on such a session and it was excellent, but I do not believe it happens any longer. Have the Government costed a return to these schemes? As for diet, we will be dealing with that in a later group of amendments. So, while accepting the potential benefits of what is proposed, I ask the Minister to assure the House of the cost-effectiveness of the measures, explain the impact on family budgets and tell the House what other measures are being considered to achieve the same ends, which we all want to see: better and more equal dental health.

[Baroness Merron (Lab)]

My Lords, I welcome the amendments in this group, which focus on the need for universal access to dentistry and the introduction of fluoride into water. As my noble friend Lord Hunt said, they are about treatment and prevention, which are equally important when it comes to considering how we tackle tooth decay and oral health. I am grateful to my noble friend, the noble Baronesses, Lady Northover and Lady Walmsley, and the noble Lord, Lord Young, for their support for these amendments.

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[Baroness Walmsley (LD)]

My Lords, I declare an interest as a member of the All-Party Parliamentary Group on cancer and a great supporter of John Baron’s campaign on outcomes. Of course, as noble Lords across the Committee have said, the key to getting better outcomes is early diagnosis, rigorous audit, and proper dissemination across the country of what we know works. I certainly support what the noble Lord, Lord Moylan, is trying to do.

I do not oppose the government amendments outlined by the Minister, despite the rather unusual fact that they were only agreed with the Opposition Front Benches at the last minute—that is, this morning. I thank him for clarifying that; although cancer outcomes were the principal focus of Clause 4, they are not the only objective that should relate to cancer patients. The department has consulted with cancer charities, which, of course, represent many thousands of patients, to ensure that the new legislation meets their needs. Can the Minister say when the effects of Clause 4 will be reviewed and any action, if necessary, taken? Although generally approved by the sector, Macmillan is still concerned about how a focus on survival will affect those who, sadly, have terminal cancer and do not expect to survive. What they need is palliative care and measures to make the quality of their last few months of life as good as possible. Could this issue be a key part of any future evaluation of cancer care?

[Baroness Merron (Lab)]

My Lords, we are very pleased to support the government amendments that we have heard outlined. Crucially, they focus on cancer outcomes. As the noble Baroness, Lady Morgan, underlined, that includes survival, quality of life, experience of treatment, end-of-life care as well as diagnosis—in other words, the whole experience in treating somebody as a whole person on a journey that they may have to face. I congratulate the Minister on bringing the amendments forward. I also thank the noble Lord, Lord Moylan, supported by the noble Lords, Lord Aberdare and Lord Vaizey, and others, for highlighting the fact that pancreatic cancer has such an aggressive nature, and yet the symptoms are so silent and often misunderstood that it presents a particular challenge in the context of the care that we are speaking of today.

A focus on outcomes that covers matters other than treatment will be particularly crucial following the backlogs that the pandemic has inevitably led to, with delays in people seeking check-ups and treatment. Macmillan has let us know that more than 31,000 people in England are still waiting for their first cancer treatment, and it has also said of the Bill that for those living with cancer

“not a lot will look different.”

It is therefore crucial that the Minister assures noble Lords that stakeholders are supportive of the changes outlined in this group.

On the point about survival rates lagging behind those of other countries, that is not because the National Health Service is worse than other healthcare systems at treating cancer once it is detected but because it may not be as good at catching cancers in the crucial early stages. In other words, late diagnosis lies behind our comparatively poor survival rates. A key advantage of focusing on outcome measures is that it will give healthcare professionals much greater freedom and flexibility to design their own solutions, which could include running wider screening programmes and better awareness campaigns, and establishing greater diagnostic capabilities at primary care. A further advantage of this new focus is that it will better align NHS priorities with patient needs, which, after all, are core to our discussions on the Bill today.

I have a final and gentle word for the Minister to back up the introductory comment of the noble Baroness, Lady Walmsley. It is of course usual to consult the Opposition and others in advance to ensure that amendments are acceptable and do what is required—in other words, to strengthen the case. I know that this did not happen until very late in this case, and I am sure the Minister will not wish to repeat that practice. In summary, however, we very much welcome these amendments.

[Lord Kamall (Con)]

I thank the Opposition Front Benches for being so gracious given the fact that we notified them late and did not use the correct procedure. I apologise for that once again and I know that the Bill team also apologises for it. We are all on a steep learning curve, as I am sure all noble Lords acknowledge. I thank both noble Baronesses. I hope the lesson has been learned, and we will not have an excuse next time.

I will address Amendment 294 before I come to our amendments. I thank my noble friend Lord Moylan for tabling it. To reassure him, the pancreatic cancer audit is included in the national cancer audit collaborating centre tender, which is currently live. Some reporting timelines are included in the specification for this audit, developed in partnership with NHS England and NHS Improvement, but I am told that during a live tender the document is commercially sensitive and cannot be shared beyond the commissioning team, as this could risk jeopardising the procurement process. The future contract is anticipated to start in autumn of this year. However, it is not possible to confirm the timelines for a new national audit topic for pancreatic cancer until the procurement completes and the contractual deliverables are signed. Unfortunately, therefore, this cannot be aligned with the passing of the Act.

My noble friend will be aware that NICE clinical guideline NG85 recommends that pancreatic enzyme replacement therapy, or PERT, should be offered to patients with inoperable pancreatic cancer and that consideration should be given to offering PERT before and after tumour removal. NICE acknowledges that this is a priority area for improving the quality of health and social care and has included PERT in its quality standard on pancreatic cancer.

We have taken and will continue to take steps to support Pancreatic Cancer UK’s campaign to encourage greater uptake of PERT by doctors treating pancreatic cancer patients, in line with NICE guidance. We are in the process of commissioning a PC audit and, while the scope of this is not confirmed, we will certainly include this in the scoping of the topic. As I said, NICE acknowledges this as a priority area and, while its guidelines are not mandatory for healthcare professionals, the NHS is expected to take them fully into account in ensuring that services meet the needs of patients.

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[Lord Warner (CB)]

My Lords, I will speak briefly in support of Amendment 289. It is worth remembering that the NHS used to have convalescent beds—I went to one as a boy, recovering from peritonitis. These have disappeared over time. When in the 1980s and 1990s nursing homes were set up in increasing numbers across this country, we found that they ended up on the means-tested side of the boundary between health and adult social care. In a way, the NHS lost out because these resources were on another side of the boundary, which was defended with jesuitical force to make sure that people did not drift into the NHS who might get care that was not means tested but free. We have ended up shooting ourselves quite badly in the foot by allowing these services to drift out of the NHS and into the adult social care system.

Shortly after the 2010 election, I facilitated a proposal from a few large nursing home groups to take recovering patients from hospital to free up acute hospital beds. This was rejected by the Treasury which thought it would lead to large numbers of people who were being means-tested getting free NHS care. In fact, they were two separate groups and the NHS was punishing itself by keeping people in beds in the NHS at high cost. We know that about 25% of the people who are in acute hospital beds should not be there—they need not be there clinically—but they are holding on to those beds because there is nowhere else for them to go within the NHS system. We have ended up unnecessarily blocking beds and spending a lot more money because we cannot put in place a service that the NHS badly needs. I suggest to the Minister that we revisit this issue in the interests of the NHS and its patients.

[Baroness Merron (Lab)]

My Lords, I thank noble Lords for the debate this evening and for the amendments put forward, which have focused on what I would call a complete continuum of care and support where people need it most; my thanks also to the noble Baroness, Lady Finlay, for leading the debate. What we hear tonight is the need to drive up standards and availability in what can be accessed for reablement and rehabilitation.

As the noble Lord, Lord Warner, reminds me, I fear that, over time, we have perhaps lost a broader range of provision, and the word “convalescence” has somewhat left our vocabulary. The amendment tabled by the noble Baroness, Lady Greengross, to ensure that accommodation is available to people who are in rehabilitation—people who no longer need to be in a hospital ward but cannot return to their own home—is creative and practical. I hope that the Minister will look at exploring that idea.

NHS: Nurse Recruitment

Baroness Merron Excerpts

Thursday 27th January 2022 Lords Chamber

[Lord Kamall (Con)]

I am afraid I disagree with the noble Lord, because we are on track to reach our 50,000 target, particularly because we are not just using one route in. We are using a number of different routes; people can retrain from other courses, and we have apprenticeships. We are looking at completely different, innovative pathways into nursing.

[Baroness Merron (Lab)]

My Lords, the Government’s own impact assessment suggests that mandatory vaccination against Covid could lead to the loss of some 73,000 NHS staff in England. When designing their policies, did the Government take into account how many nurses might be among this number? Will the Minister take the opportunity of the Health and Care Bill to bring forward a long-term workforce plan to address the shortages of nurses and other staff?

[Lord Kamall (Con)]

I congratulate the noble Baroness on bringing up an issue for the Health and Care Bill. In terms of VCOD—vaccination as a condition of deployment—most NHS staff are vaccinated, and those who are reluctant to be vaccinated are being offered one-to-one conversations with management to see whether they can be persuaded to take the vaccine or be redeployed elsewhere.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Lord Bethell (Con)]

My Lords, I will briefly say that I am extremely optimistic about family hubs. They answer the challenge to solve the complexity around integration incredibly well. My noble friend Lord Farmer made the point that one cannot think of a better example of what integration looks like than family hubs. The noble Baroness, Lady Tyler, talked clearly and persuasively about the journey they have been on.

My noble friend has made the case for these amendments. Other noble Lords have made the case for updating the legislative framework. I ask the Minister to look carefully at what can be done to bring these laws up to date so that family hubs can thrive, as I believe they will.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Farmer, for introducing this important debate and to other noble Lords who have supported the amendments before us and spoken about how we can improve the support that families will receive through this Bill. As the Family Hubs Network rightly observes,

“prevention is simply listed in the Bill as one of several commissioning requirements of ICBs with no broad mention of children’s health”.

This group of amendments gives us the opportunity to sharpen this.

As we have heard, the issues that families face, in whatever form or shape, do not exist in isolation. In addition to the impact of financial, housing, social and other pressures, the physical and mental health of a child or young person affects the physical and mental health of not just their parents, but their wider family, and vice versa. It makes common sense to facilitate a healthcare system that is designed and resourced to actively take a holistic approach to the many issues that face children and those who care for them.

I cannot help but feel that the points raised today are not new. We have the experience of Sure Start to show us how effective properly integrated family services can be. As the Institute for Fiscal Studies confirmed:

“By bringing together a wide range of early years services for children under 5, Sure Start centres dramatically improved children’s health even through their teenage years.”


Early investment is crucial.

I hope the Minister will be keen to embed change in this Bill to replicate the success that we saw through Sure Start. The first step towards doing this is to make sure that integrated care partnerships are properly required to consider how family help services can be thoroughly integrated into our health and care system, so that family members—no matter what form those families take—are seen as both individuals and groups who have an effect on each other.

[Lord Kamall (Con)]

I thank my noble friend Lord Farmer and all noble Lords who spoke about their experiences. The creation of integrated care boards represents a huge opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people.

Before I go into the specific amendments, I make it quite clear, as my noble friend said, that the Government set out in their manifesto a commitment to championing family hubs. We want to see them across the country, but at the same time we must give democratically elected councils the choice to shape how services are delivered, bearing in mind some of the points made by the noble Lords, Lord Mawson and Lord Warner, whom I thank for their experience on this.

The Government agree that it is vital to ensure that ICPs work closely with a range of organisations and services to consider the whole needs of a family when providing health and care support. In preparing the integrated care strategy, the integrated care partnership must involve local Healthwatch and the people who live or work in the area. We are working with NHS England and NHS Improvement on bespoke draft guidance, which will set out the measures that ICBs and ICPs should take to ensure they deliver for babies, children and young people. This will cover services that my noble friend considers part of family help.

In addition, the independent review of children’s social care is still considering its definition of “family help”, and the definition published in The Case for Change may well be further refined as a result of ongoing consultation. It would be inappropriate to define the term in legislation at this stage, pre-empting the full findings of the review and the Government’s response to it. Also, it is important that there should be a degree of local determination as to what should be included in the strategies of ICBs and ICPs. In order for them to deliver for their local populations, a permissive approach is critical.

On Amendment 167, we agree that family hubs are a wonderful innovation in service organisation and delivery for families. The great thing about them is how they emerged organically from local councils over the last decade. I pay tribute to my noble friend for the key role he has played in advocating family hubs and bringing this innovation to the heart of government. The Government strongly support and champion the move but we are clear that they have to be effective and successful—they need to be able to adapt to local needs and circumstances. They also need to be able to operate affordably, making use of a diverse range of local and central funding streams.

In both these regards, local democratically elected councils should hold the ultimate decision-making power over whether to adopt a family hub model and how it should function. As such, I regret that we cannot support the amendment, which would place too much prescription on the decisions and actions of local authorities and risk imposing significant new financial burdens. For this reason, I ask my noble friend to consider withdrawing his amendment.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 3 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I have added my name to the amendments in this group, so ably introduced by the noble Lord, Lord Crisp. The noble Lord, Lord Lansley, asked: what is the problem to which Clause 54 is the solution? But I want to know why the Government think that Clause 54 is the solution to the real problem. The real problem is that, over recent years, the funding focus has been on revenue to support the greater demands made on the health service, and, apart from occasional injections of extra capital funding, capital budgets have been inadequate. In the meantime, hospital trusts of both types—foundation and NHS—have found it impossible to keep up with the need for repair and maintenance to buildings and plant and, crucially, to invest in modern technologies that would enable them to deliver more effective care.

An NHS Confederation survey prior to the spending review in October last year found that 81% of leaders said an insufficient capital settlement could impact their ability to meet estate and service safety requirements, and 69% of leaders said a poor capital settlement threatens their ability to fully embed digital transformation in their care and even hampers their efforts to maintain staff levels or keep appropriate records of patients who need elective care. Many of our hospitals and clinics are located in very old buildings and some certainly show it, but capital funding has not kept up with demand for years, and this new Secretary of State power in Clause 54 will not solve the wider problem. St Mary’s Hospital in Paddington will need £1 billion to repair the hospital or services could be shut in six to nine years. Many buildings on the site date back to the hospital’s founding in 1845. One part of the hospital can no longer be used, as the building will no longer support the weight of modern hospital beds.

Annual statistics show that each year we do not invest enough and the problem only becomes bigger. We must keep reminding the Government of the consequences of this. It is worth noting that many areas of the country with the worst health outcomes have older estates, so upgrading these estates will lead to better outcomes for these populations. This is a health inequality issue. The problems are not confined to England. I could tell noble Lords some terrible stories about my local hospital in Wales, where health is devolved. It is easy to find examples of maintenance issues from hospitals, as these get a lot of coverage. The headline “Hospital roof crumbling” is always of interest to local media. However, there are also thousands of small community hubs and mental health trusts that desperately need new and updated facilities and equipment too, and they cannot shout as loudly. The backlog currently stands at £9.2 billion, with half of that, as we have heard, described as involving a high or significant risk to staff and patients.

The new powers for the Secretary of State proposed in Clause 54 would restrict the spending of any individual foundation trust in the same way as NHS trusts are currently limited. This may appear to be fair, and I do not oppose the principle of the Secretary of State having the power. However, it appears to me to be contrary to the principle of freedom of the foundation trusts as outlined by the Government when they were set up, and certainly contrary to the agreement made by NHS England and NHS Improvement with the sector through the September 2019 legislative proposal mentioned by the noble Baroness, Lady Neuberger, which was the result of detailed negotiations with NHS Providers on behalf of their foundation trust members. The reason given by the Government is that this is in order to avoid the overall health budget being exceeded. However, the power needs to be a very narrow reserve power, to be used when all else has failed, and that is what these amendments would ensure.

The Health and Social Care Committee in another place has made it clear that the powers should be used only as a last resort. It has to be remembered that, if a repair needs to be done on the basis of health and safety but is not done, it is the trust that will be blamed for any harm that comes to staff or patients, not the Secretary of State. They are accountable, and that is right, but it does not help them to keep people safe. The noble Lord, Lord Crisp, has tabled this group of amendments to narrow the scope of the power, to ensure in outline what must be done before it is used and, crucially, in my opinion, to require the agreement of Parliament. Currently, the proposal, like many others in the Bill, cuts Parliament out completely. Where the Government are proposing to wipe out an agreement with the sector which is only just over two years old, there must be compelling reasons, mitigating actions and parliamentary scrutiny.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Crisp, for introducing this group of amendments and setting out for your Lordships that what we need to see is a reasonable system of checks and balances which will serve financial flows and objectives and where, if tensions arise, they can be resolved quickly, fairly and transparently. Certainly, these amendments provide for this.

--- Later in debate ---

[Lord McCrea of Magherafelt and Cookstown (DUP)]

My Lords, there is a process that the noble and learned Lord, Lord Mackay, outlined tonight for how this issue could proceed. I believe we should bow to his legal and learned knowledge concerning this matter.

I think society should give everything financially and provide palliative care to those who are in need at the end of life. I trust and pray that this House will send a clear message that we will do everything to ensure people live with decency and honour rather than telling them that we will help them to die.

[Baroness Merron (Lab)]

My Lords, this debate has probably exposed more that is not resolved rather than what is resolved. Having listened very closely to the passionate, informed and often personal contributions from noble Lords this evening, I feel there was some inevitability that that is where this debate would lie.

I want to touch on the two amendments before us. I am grateful to the noble Baroness, Lady Meacher, for clarifying that Amendment 203 is a probing amendment. I am reminded of when we debated these issues in the previous group where your Lordships’ House had great regard for ensuring that a patient’s final wishes should be respected as a kindness. This allows respect and dignity but is also practical in respect of reducing unplanned hospital admissions and other interventions.

There may well be merit in further consideration of the sentiments in the noble Baroness’s amendment that patients should have the opportunity for meaningful conversation about what matters most to them at the end of their life. Of course, the noble Lord, Lord Carlile, is also right about ensuring protection for those who are more vulnerable, and I am sure that, in the course of further discussions, those considerations will be made.

With regard to Amendment 297 put forward by the noble Lord, Lord Forsyth, obviously your Lordships’ House has heard, as I have, the depth and range of concerns and opinions across this issue. Such an important legislative change as proposed in this amendment would need to be its own topic, in its own Bill. I do not feel that any steps towards such a monumental change should be added via an amendment to a Bill that concerns itself entirely with other matters, as does this Bill.

In conclusion, whatever the views of noble Lords on assisted dying and however strongly held those views are, I believe that your Lordships’ House should do justice to it but that this Bill does not provide that opportunity.