Homecare Medicines Services (Public Services Committee Report)

Baroness Morris of Yardley Excerpts

Thursday 2nd May 2024 Lords Chamber

Moved by

[Baroness Morris of Yardley]

That this House takes note of the Report from the Public Services Committee Homecare medicines services: an opportunity lost (4th Report, Session 2022–23, HL Paper 269).

[Baroness Morris of Yardley (Lab)]

My Lords, I am very pleased to introduce this debate on homecare medicines on behalf of the Public Services Committee. In opening, I thank all the witnesses who appeared before our committee for their time, expertise and co-operation with us. I thank the team who served us so well: Sam Kenny, Tom Burke, Claire Coast-Smith and Lara Orija. I personally thank all the committee members, who worked hard on this report and, I think, are pleased with it and determined to see it through.

I know that committee members will understand when I thank the noble Lord, Lord Blencathra, because without him, we would never have looked at this issue at all. I was aware of homecare medicines, I knew what an important service it is, but I had no idea of the challenges it was facing or how ineptly people were dealing with those challenges. We are grateful to him for that, but the problem that emerged was that we were not the only ones who did not know about the challenges: it seems that nobody running the service knew about the extent of the challenges either.

This is an important issue: it is a picture of how the NHS should be. It is a forward-looking service. It offers patients the opportunity to have medicines and treatments in their own home, to have choice and flexibility around their lives. It saves money for the NHS and patients, and it is something that needs to work, because it could be a vision of the future. It has increased in recent years. There are 500,000 prescriptions now, 2.8 million deliveries a year and, over the last 15 years, on average, a 10% increase in those using the service each year.

However, if you read our report, or you look at the evidence, there is one overriding conclusion that you are left with, and that is the difference of opinion between the different witnesses who appeared before us. What was frightening, almost scary, was that that difference was split into two clear groups: the clinicians and those who use the service, who talked about the many problems; and those who manage, run and regulate it, who did not seem to see any problems at all. How that lack of observation and communication has arisen must be something that the department sorts out before it can move forward.

Having said that, I feel it is a strange report. Of all the reports I have been involved with during my time in both Houses, I do not think I have ever seen an issue that I am more confident can be solved. We are not asking for more money; it is not politically contentious; it is not backward-looking, it is forward-looking; we just need somebody to grab hold of it, make the difference and make it work. This is not something that is an aspiration or something that has a 10-year forward look; this is something that can be done now. We can get it right and make life better for patients and for the NHS. In essence, homecare medicines is a market, and the hospital trusts, each trust individually, are the purchasers holding the money. They contract with two elements. One is the drug companies, the pharmaceutical companies; and the second is the homecare providers which deliver medicines and appliances to people’s homes.

What is perhaps unusual, but never mind, is that the contracts themselves are between a chief pharmaceutical officer in each trust and a large pharmaceutical company. Some 80% of the trusts have no contractual arrangements at all between themselves and the service provider, they just have a service level agreement. But that is not unusual; they are not the only part of the public sector that puts out a tender, monitors its performance, makes adjustments and gets on with it. However, if you look at what we know about the effective delivery of public services or private services, some elements have to be in place. You need information about what is going on. You need to agree performance indicators. You need to know how an organisation is performing against them. You need to know who is holding them accountable and you need to know who to go for when things go wrong. Not one of those things is in place in homecare medicine, and it is a service that is relatively small compared with many of the big public services that we run.

First, there is data, but—believe it or not—none of it is in the public domain; nor is it available to clinicians when they are advising patients on what to do. The National Homecare Medicines Committee, one of those which manage the service, collects 27 key performance indicators and passes them to the NHS, but they are never published or made available to anyone. Then there is a completely different set of KPIs between the pharmaceutical companies and the homecare companies which deliver the medicines on their behalf. There is no standard template across the country; every single one of those contracts can take a different shape. They are not published, the trusts and clinicians do not know what is in them, and they never know whether they have been achieved.

If that was not a big enough mess, on top of all of that—believe it or not—all the data is self-reported. That is not only a recipe for a service that does not work well but it means that no comparisons are possible when the NHS trust is spending money to place its contract. It has no information against which to judge either the performance of its present contractor or anyone else. Almost more important than that is that no information is therefore collected about how seriously patients suffer from service failure. No one in the NHS or anywhere else collects information about the impact on patients served by this poorly run service.

Secondly, there is no effective system of regulation. There are three regulators: the Care Quality Commission, the General Pharmaceutical Council and the Medicines and Healthcare products Regulatory Agency. They all inspect a different tiny part of the system; there is no one with overall responsibility. The problem is that this is not a high priority for any one of these regulators.

The Care Quality Commission does about three inspections a year. It does not collect complaints; there is no section in its books or charts for complaints received about homecare medicines. It has never chosen to do a thematic review and there is no evidence that we could find of a prosecution it has initiated. Whatever people who work at the CQC think about when they get up in the morning, it is not, “I wonder how homecare medicines is getting on”. When we asked those three regulators about the gaps in between the bits they inspect, they all said, “That’s fine, we don’t overlap—but there are no gaps in between”. That is not an effective system of regulation, and it helps nobody.

Thirdly, in a system such as that there would have to be infrastructure and support to go with it. Chief pharmaceutical officers in each NHS trust are busy people. They have a very demanding job, and the responsibility of sorting out the contracts with the big pharmaceutical organisations falls to those men and women. Everybody who came before has admitted that this requires specialist knowledge and that there is a huge amount of effort involved in managing the contracts and being aware of the impact on patients. The support and expertise that they would need to do that job is just not there.

Procurement hubs serving NHS trusts often have no homecare medicines specialists. Each provider has developed a different system, with no single NHS system for providers to interact with. On prescriptions, they have to re-read the evidence to make sure that somebody is not making it up. Some 6,000 paper prescriptions go into the system every day on more than 1,000 different templates—it is no wonder that nothing that comes out makes sense. It is beyond belief that in 2024, some of those prescriptions are still sent by post.

That is the environment in which we expect trusts and clinicians to make decisions about a key service, on which they are spending public money and on which clinicians need good-quality advice to advise their patients on the decisions they should take. They are not faced with any KPIs that they can monitor; they do not know how one provider performs against the other; they know that there is no effective regulatory system, that there is an inadequate infrastructure to support them, and that no one is holding the ring to keep it all together. At the end of the day, there is no one in overall charge for them to turn to for help and advice.

It is not surprising that this leads to a system that fails everyone it seeks to serve. First and foremost, it fails patients. There is no complaints system and nowhere for people to go if something goes wrong. The things that can go wrong go very wrong and are very serious: the medicines do not turn up; the wrong medicines turn up; the medicines turn up at the wrong time; the medicines turn up, but the person who was showing the patient how to inject them does not turn up; or the medicines are out of date. The catalogue of what happens in an NHS service that puts safety at the top of its priorities is frightening.

The impact for the patients is also serious: they miss medicines, become more ill and need to go back to hospital and have operations. Because no data is collected about how much harm is done, I cannot stand here with certainty and say that people lose their lives—no one can—but what we can say with certainty is that people do not recover as quickly, and they are given extra burdens to deal with because the system does not work as it should.

It also has an impact on each NHS trust. If you are not getting the service from the homecare provider—and if you have no one to complain to because the providers do not have good phone systems with somebody who picks up the phone at the end who knows you—you will go back to hospital. You will go back to the consultant who gave you the prescription or to A&E, and you will ask for help. That means that every hospital in this country, which have already paid taxpayers’ money at a time of reducing budgets to the provider to deliver the service, will have to pay again to remedy the defaults in the service.

If you talk to any of the groups representing clinicians or patients, they will tell you the horror stories of how much they have to do to mitigate the weaknesses in the system. Crohn’s & Colitis UK told us that 10% of specialist nurses spend one day a week on the consequences of an inadequately delivered homecare service. The British Society for Rheumatology told us of one clinic where a nurse spends a quarter of their time chasing after homecare services. In Leeds, people have set up their own infusion unit so they can teach the patients how to inject the drugs. They provide the drugs out of their budgets to start them off, because it takes eight weeks for the provider to get their act together.

The other losers are the NHS and the country, because it is money wasted. It is the case that the NHS, the department and Ministers do not know how much money is spent on homecare services. We had four different estimates, between £2.9 billion and £4.1 billion, and I am still sure that no one knows exactly what it is.

Yet I remain an optimist. All that can be solved; it is a tragedy, but it is solvable. Part of the anger or frustration is that it has not been grabbed hold of and solved already. We might get somewhere if we put a system in place that has comparable data, if we get the regulatory system sorted out, if we put in support for procurement, if we move more to electronic prescriptions and if we put a named person in overall control, who wakes up every morning knowing that their job is to make sure this works all right.

I say to the Minister that we have been very pleased with the support and response that we have had from his department; it has been helpful throughout. They have not spelled it out, but I think that both he and the Minister who is no longer in the department were surprised at the lack of awareness of this service and the state that it is in. That is why I am an optimist: I know that we await a further report in the summer.

However, there is a tendency in government to turn to the existing structure and people to create something that is better—which is what I have worried about most. There is a lack of trust between those who have been shouting for a long time that things are badly wrong and those who have not heard them and have not done anything about them. My request to the department and the Minister is not just to do all these things but, most of all, to consult those who have the best experience of what has gone wrong and the best ideas about what could be done to make it better.

I very much hope that our report helps not just the department and the NHS to get this better but all the clinicians and patients who have not been treated as well as they should and have not had the support that they should for many years. That is the goal, and I think that it is achievable. I promise that my committee is absolutely determined not to let this go, by whatever means we can. I have no doubt that we will be back at this again. I thank the Minister and the department for the support so far and offer our every help in their future work.

--- Later in debate ---

[Baroness Morris of Yardley (Lab)]

My Lords, I thank everyone who has contributed to a very good discussion built on a very good report. I do not want to keep us long because I do not think there is a lot else to say at this point.

We have been through a number of hurdles, and I absolutely understand where the Minister is coming from—10 days ago, he was not aware of the problems, but that is a description of us all, apart from the noble Lord, Lord Blencathra. The first hurdle to jump was to get people in key positions aware of the problem, and that has been achieved. Secondly, I think there is a joint determination to do something about it and a feeling that it cannot wait. Thirdly, there is some agreement on some of the things we can do, and a willingness to have an open discussion on how we might do some of the more problematic things. I am particularly grateful to the noble Lord, Lord Allan, for stretching my mind and knowledge on what might be possible in terms of digital technology—things I had not even thought of.

The other thing that has been important today, which I was very keen that we do, was to get a next step. These good ideas fall between discussions, and things happen and no one picks them up again. I am therefore absolutely confident that I can speak for the committee in accepting the invitation to attend a round table after the announcement is made. I think that, from our point of view, that is a very good next step, along with the announcement of the person in charge and the further letter expected from the Minister’s department in the summer. Therefore, that is our next step, and I am sure that there will be more steps after that.

I just want to say one thing, which is a note of caution —it was referred to, I think, by the noble Lord, Lord Willis. The Minister will have to make his own judgment, but I think the overriding impression in our committee was that it was really hard work to get those already managing the system to accept that there was a problem. It was really tough to get them to that stage, and I am not sure that they got there; they might have got there in their own minds, but they did not acknowledge that to us. Because of that, the committee has a concern as to how much they are going to push this forward, but, more than that, the clinicians and the patients have concerns as well. The Minister may want to reflect on that and do what he can in whatever decisions he takes.

My last sentence is this. All those things are good, but we have absolutely raised expectations of those who use the service, the clinicians and the trusts, and we cannot let them down because they do not deserve that. I finish by thanking everybody for their contributions, and I look forward to further discussions. I beg to move.

Motion agreed.

Emergency Healthcare (Public Services Committee Report)

Baroness Morris of Yardley Excerpts

Thursday 20th July 2023 Grand Committee

[Baroness Morris of Yardley (Lab)]

My Lords, I am also pleased to be able to contribute to this debate as a member of the committee. I pay tribute to my noble friend Lady Armstrong, who was the inaugural chair of the Public Services Committee and has led it through its first years. Indeed, this report was the last from the committee under her chairmanship. I overlapped with her only on this one report, but I could tell from the time I spent on the committee how much she had done to establish it as a very important committee in our House. I know that there have been a whole series of reports which will add to our debate and our consideration of some crucial issues facing society at the moment. On behalf of all committee members, I place on record our appreciation for the contribution she has made.

I am sorry that this debate is taking place seven months after the report was published. There was never going to be a queue at the door waiting to get in as the debate started, but I hope the appropriate authorities can take note of this.

Governments are always reluctant to use the word “crisis”, as lots of things flow from that. Our committee found that there was a crisis in emergency care, and we used that word. I think we produced sufficient evidence to say that there was a crisis.

Even if you do not take that point, it is interesting to look at the document published by the Government since then, the Delivery plan for recovering urgent and emergency care services, in which they describe what happened last winter and the state we are in. They said it was

“the most testing time in NHS history”,

that there were

“problems discharging patients to the most appropriate care settings”,

and that hospitals reached record occupancy levels. The document also says that patients were spending longer in accident and emergency departments and waited longer for ambulances, and that that has taken its

“toll on staff, who … work in an increasingly tough environment”.

The committee could not match the description the Government themselves gave of the state of the ambulance service and emergency services at key points during last winter. So, whether you want to use the term “crisis” or not, our joint starting point is that things were intolerable last winter and have been intolerable for quite a while. We are not confident that they are going to be any better this winter. To some extent, the challenge for this debate and for the Government now is whether they can use those experiences and the evidence we gave in the report to make sure that things are not as bad next winter and that we can move on.

Lots of things have happened since our report was published, and I want to refer to some of them. It is very difficult, given the time of year and the way the public debate moves on, to know exactly what progress has been made since our report was published in January. I know that some of the figures on waiting times for ambulances have got better. I do not know if that is because of the time of year or because of action the Government have taken. However, I noted with some concern the National Audit Office’s report from June this year. When it looked at recent performance, it concluded that patient access to services for unplanned or urgent care has worsened; that there is too great a variation in service throughout the country; that the NHS has not met operational standards; and that performance has worsened in terms of delays in transferring patients from one service to another.

That is where I think we are. There is joint knowledge and a shared platform of debate that there was a crisis last time, and some of the statistics were very worrying. The one bit of evidence we have from a third party—the NAO report—does not indicate that things are getting any better. The effect this has had on the public, communities and their confidence is well known. It is no exaggeration to say that people lost their lives because this service was not performing at a higher level.

I want to take six points from our committee which struck me, on reflection, go through them and invite a response from the Minister. These are the six areas that stuck most in my mind, and I would like some reassurance that progress is being made on them. First is the immense complexity and connectedness of all the different parts of the system. We talk a lot about the health service and social care and how they do not work together. However, when you look at the emergency services, it is not just those two that have to work together: it is the police and the fire service, and the attitude of the public.

That leads to the second point: it is very difficult to work out who has the ability to effect change. People want to change things. They want to change their bit of the service, but they cannot change other bits. What became evident during the committee’s deliberations is that there is no one leader who can solve the difficulty. That is a problem, but the system itself does not allow people to make changes that have to be made if they are to improve their bit of the service. There has been a really good example of that since our committee’s report was published: the decision of the Metropolitan Police not to attend mental health cases.

I know why the police have done that, because in the committee you would hear somebody tell you that some police officers are spending the whole of their shift sitting in A&E with a person who has mental health problems, whom they have been called to assist. I can absolutely understand why they have said that that cannot happen any longer. I do not believe for one minute that the head of the Metropolitan Police has not tried to solve the problem as well, but I suspect that he has concluded that he cannot get other bits of the system to shift or make the changes in social care, the local authority or the health service—he has to act unilaterally to protect the service that he is absolutely accountable for and responsible for delivering. That is just one example, but that has happened in the last few months. We find so many cases of that, where people knew what they wanted to do to make their bit of the service better but were powerless, because changes needed to be made elsewhere, and the structure that could have brought everyone together to make the changes just does not seem to be there.

My third point, and the point that the noble Baroness, Lady Armstrong, made, was that people are risk averse, and there is very little approach to shared risk. I was pretty appalled to find that some schools, as a matter of policy, called an ambulance every time a child had a head knock, even if the parents were there and were prepared to take their child to accident and emergency. I do not want to belittle the difficulty of taking decisions like that if you are a headteacher or a teacher, but something is wrong there, if mum and dad say that they will take their child to accident and emergency, and the school says that no, the policy is that they have to call an ambulance for every child who bangs their head. We heard similar stories in care homes with patients who had fallen. The public are risk averse to making decisions which on reflection, might perhaps be more sensible.

We see that with 111 services as well. The statistics show that the 111 person is more likely to say to go to the accident and emergency than they are anything else, because there is a risk-averse attitude there. With some of the targets, the attitude to risk is problematic. For those responsible for making sure that ambulances do not wait in the car park at the entrance to the hospital, the best thing to do is to get the patient into the A&E waiting room, because they have then met the target—but it has not solved the problem for the patient, who is now in the waiting room. Others want to get them out the other end, because their target is to get the accident and emergency casualty waiting room down to as few people in it as possible. So they push the patients out to somewhere else, where they wait to go into care or back into the community, and they have met their target.

There are so many instances where people behave in a way that shows that they are not connected to other bits of the service, and they are risk averse. They want to solve their bit of the problem and make sure they can show that their service is performing better with regard to targets. No one actually says, “Let’s put our risks together—let’s put it all together and let’s have some sort of target, which means that I in my bit of the system act in a way that helps you as well as me”.

The fourth point is that one thing that frustrated me, time after time, was that I sat and listened in the committee to the most wonderful pilots going on in different parts of the country. I thought, “Why have we got a problem? Why is anything wrong, because I have just heard the most wonderful example of what is happening?” Nobody knew why it did not happen elsewhere as well. Nobody knew who was evaluating it or who had the power to say that it should happen elsewhere, and that is a problem. So I say to the Government that, while I welcome some of the initiatives that they have announced in recent months—full service virtual wards, transfer of care hubs, and greater flexibility for clinicians—the key thing remains that they are all relatively confined things that are likely to bring about some success.

The key problem for me—and this is where I finish—is that, with the integrated care boards, who is going to make sure that someone can implement the plan that they have been charged with writing up? Could we do more so that the regulators actually make a judgment as to whether services are working together, as well as whether they are working for their own interests? Can the Minister perhaps reflect about whether he is absolutely confident that the people who need to make changes have the power to do so?

Health and Care Bill

Baroness Morris of Yardley Excerpts

Lords Hansard - Part 2 & Report stage
Wednesday 16th March 2022 Lords Chamber

Is it the Minister’s understanding that the Prime Minister will chair the Health Promotion Taskforce? If so—and this is the most important point for all of us on the committee, many of whom have been in sports policy for some 40 years—unless you have accountability to Parliament, you do not have the catalyst for change. With accountability comes the catalyst for change, and I simply ask the Minister to confirm that the Health Promotion Taskforce, covering the areas that the Select Committee has set out, will have teeth, not because it will be chaired by the Prime Minister but because it will be accountable to Parliament, so that Parliament can consider in detail the process, programmes, policy and direction in which we need to make significant advances to achieve improvements in wellbeing, health and sport, and the way that all three can work effectively together. I would like clarity on the commitment from the Minister, and I hope we will receive it this evening. I look forward to hearing from him, and I beg to move.

[Baroness Morris of Yardley (Lab)]

My Lords, I support the comments of the noble Lord, Lord Moynihan. I do not want to repeat points that have been made at this late hour, but I wish to emphasise that the arguments about the importance of sport and well-being do not need to be made again. Everybody from all parties, right across the House, understand their importance and the consequences of not getting them right. The good will has been there for years, but the ability to transform it into effective action has not, and lots of well-intentioned efforts in the past have come to naught. That is what is driving the committee that met under the chairmanship of the noble Lord, Lord Willis, and I agree with the questions that have been asked.

For me, it is a case of not relying on a cross-departmental committee to run this project. It has not worked in the past, and there is no reason to think that it would work in the future. Is there seniority? Is there someone with clout who can bang heads together? Is there someone for whom it is a very important part of their job, and who knows they will be held accountable? I agree with the noble Lord, Lord Moynihan, that the Health Promotion Taskforce does seem to offer hope. Clarity on that—letting us know about its leadership, and the presenting to Parliament of an annual report for discussion—would allay many of our concerns. I look forward to hearing the Minister’s response.

[Baroness Grey-Thompson (CB)]

My Lords, I draw your attention to my interests: I am chair of ukactive, and I have a number of interests in this area. I also sat on the Lords Select Committee.

I too am not going to rehearse the arguments we gave in Committee, but all the names added to this amendment have been involved in this space for many years. We have all been through various iterations of this, and we should be talking about physical literacy and physical activity, and slightly less about sport. That might be surprising considering my background, but as the noble Lord, Lord Moynihan, said, we have an obesity crisis and a generation of young people who are more likely to die before their parents, and there are a number of conditions that can be treated. Frankly, we have been tinkering at the edges of this for way too long. There have been programmes and lots of initiatives that have had some success, but if we are serious about the NHS and the health of the nation, we have to do things in a different way. I feel like I have been talking about this for about the last 30 years—the noble Lord has had a slightly longer time in sport than I have—but I will be interested to hear the Minister’s response in order to understand how we can genuinely make a change and stop going round in circles on this important issue.

Health and Care Bill

Baroness Morris of Yardley Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

In conclusion, I welcome the inclusion of housing in the Bill, as part of the integration of services to achieve health and well-being objectives. I support the amendments in the name of the noble Lord, Lord Howarth of Newport, in extending this to embrace the wider urban and green environment that impacts health and well-being. I also commend the noble Lord’s amendments that would give prominence in the Bill to the voluntary and community bodies of which, I maintain, those with housing objectives now represent an important part of the country’s social fabric. I support the amendments.

[Baroness Morris of Yardley (Lab)]

My Lords, I also wish to support the amendments that have been moved by the noble Lord, Lord Howarth, and supported by other speakers. I do not want to make a long speech, but I want to add weight to the argument by standing up and offering support. I will not repeat his arguments, but I want to pay tribute to the work that the noble Lord, Lord Howarth, has done in this regard. He chairs the All-Party Parliamentary Group which produced a report that was pivotal in taking this debate forward. The work that he has done with the National Centre for Creative Health has given us an army of evidence on its importance.

The amendments seem to fall into two groups. There are those around social prescribing for people with dementia as the noble Baroness, Lady Greengross, said, and the notion of health promotion by creating a better environment in which we live and preventing illness. That collection of amendments is an idea whose time has come. There is an amendment for later consideration to which I have added my name, for which the same arguments are being made for sport and recreation. I think of this as the whole area of health promotion, which is looking at non-clinical providers of healthcare. I think these amendments follow on very well from the last group of amendments that was debated.

The noble Lord, Lord Scriven, talked about the aims of this legislation as being about promoting well-being, and the noble Baroness, Lady Cumberlege, gave a very good example of how a community centre that had doctors in it has become a medical centre, and the message that they gave. Every single one of us here could make the arguments that we have heard so far, either from our own example—from our own health and well-being—or from something we have seen.

I wanted to mention two things. First, I declare an interest: I am director of the Royal Liverpool Philharmonic Orchestra, and the work that it does with Mersey Care NHS Foundation is magical. It sometimes goes unnoticed outside the region, but people with quite serious mental health needs are finding their well-being is promoted. They are enjoying themselves and feel more part of the community.

My second example is some work I did in Derbyshire with a charity of which I was patron, First Taste. The artwork it did in a care home meant that the prescription of drugs for sleeping and other things was reduced. All those arguments can be well made but my problem is this: I would have put money on no one standing up and arguing against these amendments. If you could stop 50 people out there and find three who will argue against these amendments, I would say “Well done”.

The danger for this area of policy is that no one is against it, but not enough is being done to get it to the top of the agenda. Sometimes, when no one is against it, you do not have the argument that promotes it up the national agenda. Everyone says “Great”, “We agree”, “It will be a great thing” and nothing happens. The stage of this area of policy is that everybody is doing a little bit. It is in the long-term plan. There are examples of good practice. We have the evidence that it works and the Government are investing some money, but it is never going to be an entitlement or a policy that has been enacted nationally unless something else happens.

In all public sector policies—it is the same in education—the biggest challenge is scaling up good practice. We now have lots of examples of good practice. What we need, and what is behind this amendment, is to scale it up so that it is not just a case of happening to live near an organisation or where somebody is making this happen. The amendments that we have, which are to the general duties of the integrated care boards, will be a step forward in trying to make this a national part of our well-being service. You are entitled to it; it is there and offered to you, no matter where you live.

That is the big task now. It is not making the case for social prescribing or non-clinical providers having a role to play in health promotion, but how we scale it up so that it goes higher up the agenda of people who are developing policy and deciding how resources should be spent in an area. Years ago, this would have been seen as a fringe interest and people might have thought the noble Lord, Lord Howarth, was eccentric in promoting such amendments. It is evidence-based now. It is what people know works and I think it is what people want. We just have to find a way of getting it up the agenda and making it happen. These amendments will go towards that end.

[Baroness Tyler of Enfield (LD)]

My Lords, I rise briefly to support this suite of amendments put forward by the noble Lord, Lord Howarth. I know how passionate he feels about this issue and how much work he has done in this area over many years. The noble Baroness, Lady Morris, has just taken the words right out of my mouth; I was going to start by saying that social prescribing is a phenomenon whose time has come. I think that is right. People understand that the approach of social prescribing is really opening up opportunities for people to improve health and well-being through non-clinical avenues. That is what this set of amendments is all about.

This is particularly relevant for people with long-term conditions and complex needs, particularly those with mental health conditions, suffering from dementia or experiencing loneliness. The one point I want to make, which I do not think has been talked about yet, goes right back to our opening debate today about how the ambitions of this Bill will be achieved only if there is true integration across health and social care. My big plea is: please do not forget social care when we are looking at this issue. When I say social care, I am thinking both about people who have domiciliary care in their own homes and people in care settings.