Long Covid

Baroness Neuberger Excerpts

Thursday 17th November 2022 Lords Chamber

[Baroness Neuberger (CB)]

My Lords, I declare my interests as chair of University College London Hospitals NHS Foundation Trust, chair of Whittington Health NHS Trust and a member of the North Central London Integrated Care Board, as well as other interests stated on the register. I am most grateful to the noble Baroness, Lady Thornton, a wonderful fellow non-executive director at Whittington Health, for securing this debate. I too am very grateful to the Library, which has been hugely helpful, and I am enormously grateful to all other speakers, because most have said most of what I was going to say.

I have a very specific point. At UCLH, we a run a well-known and much-admired long Covid service, which is led by the remarkable Melissa Heightman, who is also a national specialty adviser for NHS England and the co-chief investigator for the STIMULATE-ICP study, the largest long Covid trial to date. We know that the service is desperately needed; we have heard that all around the House. Those who run this particular service are working night and day; it does not have the resources to do what is needed, to the extent that those who run it are begging for bits of resource from elsewhere, mostly for people. So short is the service of staff that they recently asked UCLH Charity to fund an extra consultant for two years, which it has agreed to. I am well aware, as we all are, that today is the day of the Autumn Statement and that times are tough, but it is really serious when an NHS trust with a £1 billion turnover has to ask its charity to support an on-the-ground service led by the national lead, even for a limited period of time—particularly for a service designed to help other NHS staff across London.

Worse still, as other noble Lords have said, some 10% to 14% of reported cases are NHS staff. Although we all know that, it is not generally known among the population—but it is not really surprising, given the higher exposure to the virus that they all had. What a difference getting them well and back to work would make to the cash-strapped NHS and to the challenge over staff numbers. We have real trouble in recruiting and, as others have said, we have people leaving the service.

[Lord Bethell (Con)]

Can I personally endorse what the noble Baroness just said, in particular her testimony on Melissa Heightman and the team at UCLH? I had extensive dealings with them as a Minister, and their work is absolutely first class. I am heartbroken to hear that they are having to reach to charity for financial support.

[Baroness Neuberger (CB)]

I am extremely grateful to the noble Lord, and I shall make sure that Melissa knows about that.

Meanwhile, we have all the figures that everybody has cited, and the ONS has reported that long Covid has adversely affected the day-to-day activities of 1.6 million people—that is absolutely huge, and other noble Lords have mentioned that fact. The NHS has tried to help with that ongoing issue but, unfortunately, not enough. I want to go through that, because I think that it is relevant.

In October 2020, NHS England announced a five-point plan to support long Covid patients; it commissioned NICE to develop new guidance and established designated long Covid clinics to provide

“joined up care for physical and mental health”.

It also created the NHS long Covid task force to guide the NHS’s national approach on long Covid, and it funded NIHR research on long Covid better to understand the condition. In July 2021, NHS England published its long Covid plan for 2021-22, which included investing £70 million to expand long Covid services and £30 million in the rollout of an enhanced service for general practice, to support patients in primary care. But when NHS England published its updated plan in July this year, the previously enhanced service funding was not continued, so primary care no longer receives any ring-fenced funding for this condition—yet, as we know, it affects nearly 2 million people.

The problem is both insufficient resources to do all the work that is needed and insufficient forward planning to enable those services that do exist to build up capacity, engage in research, recruit, train, educate, and care for patients, including, importantly, the large number of NHS staff who appear to have been affected. We have a major health problem here that is likely to run for many years. Treatment is uneven across the country and research, which will need a lot of funding, is in its early days. This is an additional burden on an already very stretched NHS, both with patients with long Covid and with the large numbers of staff who have it.

What we really need is a properly NHSE-commissioned service to be put in place now, with secure funding for the next several years, even in these cash-strapped times. It feels like a hand-to-mouth, temporarily funded arrangement, so it is really hard to build a resilient service for the longer term. Can the Minister assure this House that such long-term commissioning will now be put in place, given the recent evidence of the numbers of people away from work with long Covid, the huge proportion of NHS staff affected, making other NHS backlog issues worse, the general impact on the UK economy, which others have mentioned, and of course the sheer suffering that long Covid is causing?

Health and Care Bill

Baroness Neuberger Excerpts

Lords Hansard - Part 1 & Report stage
Monday 7th March 2022 Lords Chamber

[Baroness Cumberlege (Con)]

My Lords, I thank the noble Baronesses, Lady Brinton and Lady Finlay, for supporting Amendment 184ZA, which I have tabled. I think the noble Baroness, Lady Neuberger, is going to speak—yes, she is—and I look forward to that. I very much hope that other noble Lords will want to support this amendment, too. They would be in very good company with the royal colleges and the remarkable past editor of the British Medical Journal, Professor Fiona Godlee, who has done a lot on this subject. We have also had contact with a host of doctors and some very rewarding conversations with them. Many feel it would actually be to their benefit to make this all transparent and accessible to the public.

I pay tribute to Simon Whale and Professor Sir Cyril Chantler, who have done sterling work on this amendment. I know that Sir Cyril is known to many in this House because he has so many qualities: of leadership, clinical management and research, and in lots of other fields. This is my one opportunity to pay tribute to him through the Bill.

I also thank my noble friend the Minister and his officials. They have given their precious time, working very hard with me and my colleagues throughout the Bill’s passage. I mention particularly the government amendments concerning the declaration of industry payments to doctors and others that my noble friend introduced in Committee, and which I thoroughly welcomed.

Turning to the amendment before us, I am delighted to say that together we have fashioned a form of words which reaches, I hope, common ground. Together with my team, we have constantly amended many amendments in discussing with officials what they thought was particularly important and what we thought was important. I think we have reached a happy place. My noble friend the Minister and his officials deserve praise and thanks for their tireless efforts and, unreservedly, I give those to them now.

In Committee, we debated an amendment on establishing a register of doctors’ interests. My noble friend made the point that this information should be collected locally by those who employ doctors, rather than nationally by the GMC. I understand what the noble Baroness, Lady Finlay, said about it making sense to have the GMC involved, but in the end we agreed that this information should be collected locally. The problem is that these declarations are often out of date or incomplete, and in some cases the information is not collected at all, so it is very difficult for patients and the public to find out where that information is—and now they will have to go to the employer of the doctor. Sometimes it is hard for them even to find out if it exists, so I understand the logic that has just been proposed by the noble Baroness, Lady Finlay, that the GMC should be the body that collects this information. However, we have had very strong pushback on this. So, in the end, we have agreed with my noble friend that this information should be collected locally and made available to patients and the public.

Amendment 184ZBB simply puts into law what should be happening already. It would require any organisation that employs, contracts with or commissions a medical practitioner to provide medical services, or provides practice rights—we put that in because we wanted to cover the private sector as well—to obtain from that doctor a declaration of his or her financial and nonpecuniary interests. This, as I have said, can be done locally and it will be done through the annual appraisal that trusts have to carry out with employees. I think the missing piece in this puzzle is the doctors’ regulator. This amendment requires the GMC to take reasonable steps to assure itself that doctors are providing this information locally: that is very important. Following discussions with the Minister’s officials, the amendment now also requires the CQC to assure itself that employers are collecting the information and publishing it. We think this is sensible and I am pleased that we are all agreed.

I hope this puts all of us—my noble friend, the GMC and those of us who have tabled this amendment and support it—on the same page. However, I would be very concerned if none of this was laid down in legislation. These requirements and responsibilities are clearly spelled out in law at present, and we see from the research that this leads to very patchy compliance. This is not acceptable to any of us. So, finally, this amendment is simple and clear and is aligned with the position of the Government and the GMC. It requires employers and doctors merely to do what they should already be doing, but are not in all cases. It places a light but important duty on the GMC and the CQC to assure themselves that doctors and employers are indeed doing what they should. This is in the interests of doctors. Indeed, Professor Carl Heneghan, in oral evidence to our review First Do No Harm, stated:

“I think it’s important that if I’m treating you, you know who’s paying me.”


We owe it to patients and the wider public to improve transparency and to ensure that nothing undermines trust in our medical professionals. I hope my noble friend the Minister will agree that this amendment does achieve this in a way that he can support and that it fulfils all our aims.

[Baroness Neuberger (CB)]

My Lords, I support the noble Baroness, Lady Cumberlege, in what she has just said, as well as my noble friend Lady Finlay and the noble Baroness, Lady Brinton. I pay tribute to the noble Baroness, Lady Cumberlege, for the extraordinary work she did on First Do No Harm, which led—gradually—to this amendment. I too pay tribute to Cyril Chantler, who I first knew when serving on the General Medical Council with him. I declare an interest as chair of University College London Hospitals NHS Foundation Trust and of Whittington Health NHS Trust. I am, as I just said, a former member of the General Medical Council, and I am somewhat surprised, I must say, that it has said yet again, including this afternoon by email, that it does not really support this.

Health and Care Bill

Baroness Neuberger Excerpts

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

[Lord Stevens of Birmingham (CB)]

My Lords, I will be brief. In response to the noble Lord, Lord Lansley, in fairness, there is logic to the broad direction being set out by the Government here. As the financial health of foundation trusts improves, their ability to seek self-generated capital investment will, in all likelihood, be much higher, looking over the next four or five years, than it has been during the more constrained financial circumstances of prior years. So it is not unreasonable to have a set of measures in the Bill that would enable Ministers to ensure that the NHS sticks with the capital expenditure, voted for by Parliament, for the NHS in any given year; nor is it unreasonable on the part of the Government to seek to ensure that there is a mechanism by which that capital can be allocated fairly across the country according to need, rather than purely according to an individual institution’s ability to finance it.

All that being said, rather than this being a fundamental matter of principle in the way that our last two discussions have been, these amendments have a lot to commend them. They are entirely pragmatic and put the right safeguards around what should be only an emergency power. As the noble Lord, Lord Crisp, laid out, that was the basis on which a consensus was achieved back in 2019. It provides good incentives at trust level for sound financial management and, frankly, it provides a bit of a pressure release or a safety valve against an overly artificially constrained capital settlement in certain years or parts of the country.

I very much hope that, in the constructive spirit with which I think these amendments are being advanced, this is something that the Government might consider favourably.

[Baroness Neuberger (CB)]

My Lords, I declare an interest as chair of University College London foundation trust. I want to echo everything that has been said. I do not really understand why what was a carefully negotiated agreement seems to have been reneged on. I think it would be great to have some kind of explanation from the Minister as to why that should be the case.

I rather agree with the noble Lord, Lord Lansley, that some of those freedoms for foundation trusts are essential, and that fettering foundation trusts too much will not do much good. I really want to agree with everybody and not waste any more time, but please can we have an explanation?

[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.

Health and Care Bill

Baroness Neuberger Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 24th January 2022 Lords Chamber

[Baroness Whitaker (Lab)]

I add my support for Amendments 172 and 214, speaking as a vice-chair of the All-Party Parliamentary Group on Speech and Language Difficulties and a patron of the British Stammering Association. These amendments, which again have the support of the Royal College of Speech and Language Therapists, would do much to safeguard the position of that now rare commodity— speech and language therapists. As has been said by both noble Lords who tabled the amendment, they do not all work in the NHS.

The view of the Department of Health and Social Care is that speech and language therapists should be added to the shortage occupation list, because the profession is facing a range of pressures, including increasing demand in mental health in particular. The NHS long-term plan identified speech and language therapy as a profession in short supply. The need for those therapists must be taken account of in workforce planning.

Similarly, Amendment 214 provides an incentive to ensure that there are enough speech and language therapists to meet current and future demand, which is just not the case at present. I remind noble Lords that meeting communication needs, as well as ensuring the ability to swallow safely—both at risk from a wide range of conditions—are an essential component of well-being, and often safety itself. I hope that the Government will look favourably on these amendments.

[Baroness Neuberger (CB)]

My Lords, most of what needs to be said about this group of amendments, which I support, has been said, and said brilliantly well—it has been a wonderful debate. However, I would like to make one more key point. I chair University College London Hospitals Foundation NHS Trust and Whittington Health NHS Trust. In the last two years, during Covid, much of my time has been spent not in your Lordships’ House but walking around both of those institutions, saying thank you and listening to my exhausted staff.

One of the key reasons for putting the issue of reporting to Parliament on workforce planning into the Bill is that our staff—not just their organisations but the individuals themselves—want it to be there. They know what the issues are; they live with the shortages and they know that it has not been thought through. My noble friend Lord Stevens made that very clear: it has not been thought through. If they are not taking early retirement, as some are, they are living with the consequences. We could and should do so much better for them, and for the long term—and our staff know that. For their sake, if for no other, we must put this on the face of the Bill.

[Baroness Bennett of Manor Castle (GP)]

My Lords, this has been an extremely rich and vital debate on crucial amendments, albeit conducted in two parts. I will briefly offer the Green group’s support for all of these amendments. I aim not to repeat anything that has been said but to offer some uniquely Green perspectives on this set of amendments.

I will take them in two groups, starting with Amendments 170 and 173 in the names of the noble Baronesses, Lady Cumberlege and Lady Merron. These are particularly important because they very clearly and explicitly lay out the responsibility of the Secretary of State. When I tabled some amendments last week on the Secretary of State’s duty to provide, they met with something of a frosty reception in some quarters—but it is clear from all sides of your Lordships’ House that it has to be the responsibility of the Secretary of State to ensure that there is a plan for the workforce. I stress that that is coming from all sides of your Lordships’ House.

It is worth referring to the King’s Fund briefing, which I do not think anyone has mentioned yet. I will quote one sentence:

“The measures in the Bill to address chronic staff shortages remain weak.”


That is what a respected outside observer says. Your Lordships’ House is seeking to plug that gap. The noble Lord, Lord Lea, suggested that this was all terribly difficult, and that is undoubtedly true, but a lot of people have been thinking about this for a very long time. I was at a briefing for the Royal College of Physicians before the pandemic, in person, with no masks in sight. It was more than two years ago and they were talking about the need for workforce planning, saying, “We know how this should be”. Indeed, on the Royal College of Physicians’ website, more than four score organisations are listed as backing these amendments for workforce planning. So the support is very much there.

That focuses particularly on the medical side of things, but I will refer also to the Age UK briefing. We have had some very valuable contributions about care workers from the noble Baronesses, Lady Verma and Lady Hollins, but Age UK considers that we need to look at this much more broadly. It is calling for a robust accreditation scheme for care workers working in CQC-accredited facilities. We need a different system.

I think it was the noble Baroness, Lady Hollins, who talked about how this is a low-pay sector, but we also need to talk about this differently and recognise that it is also a high-skill sector. I think of some of the care workers whom I have met: care workers who cared for doubly incontinent, aggressive, advanced Alzheimer’s patients, and who had done so for decades. Anyone who claims that these are not people with amazing levels of skill really is denying an obvious fact. We need to acknowledge the skills of care workers and to make sure that they are appropriately remunerated.

I want to pick up another, perhaps specifically Green Party, point that no one else has picked up on. I noted that the chief executive of NHS England was recently forced into a new deal with private hospitals, which she said did not provide good value for money. The deal provides more care in private hospitals to help recovery from the Covid pandemic; it sees the Government going against NHS England and deliberately pushing up the role of the market in healthcare. For those who deny that this is happening, I am afraid this is very clear evidence of it.

I turn to a report of the Centre for Health and the Public Interest, which notes that the great majority of private hospitals rely entirely on NHS staff contributing outside their NHS hours on a self-employed basis. We are talking here about doctors and associated health professionals such as anaesthetists and other clinicians. The NHS paid for their training, pays for their pensions and covers their insurance, yet we talk about private hospitals “helping the NHS”. Listening to this debate, I think that perhaps as part of the amendments on Report, we need to think in the context of workforce planning about the financial contribution to be made by the private sector to the cost of training to adequately recompense the NHS for what the private sector gets out of it to make profits.

Health and Care Bill

Baroness Neuberger Excerpts

Lords Hansard - Part 1 & Committee stage
Thursday 13th January 2022 Lords Chamber

[Lord Bethell (Con)]

My Lords, I came face to face with the nation’s health inequalities every morning in the departmental Covid response group, the COBRA meetings and the COBRA gold, when we went through the hospitalisation details and ICU data and heard stories from the front line of how people who had comorbidities particularly associated with obesity were filling up our hospitals as the virus spread through the country in wave after wave. That health inequality hit this country hard in very real terms. It cost a lot of lives, caused a lot of misery and cost our health system an enormous amount of money. It cost this country and its economy a huge amount of money and it is time that we came to terms with that challenge and solved the problem.

As a number of noble Lords have pointed out, the NHS must step up to its responsibilities in this area. There are complex reasons for these inequalities; some are environmental, some are behavioural and some are to do with access. But the NHS and whole healthcare system must realise that it needs to be involved in all aspects of those, and prioritise and be funded accordingly. The Bill already does an enormous amount to change the healthcare system’s priorities. Putting population at the heart of the ICSs is one really good example of that.

To anticipate some of his remarks, I know that the Minister will point to the Office for Health Improvement and Disparities. As the noble Lord pointed out, however, it has a tiny budget and cannot take responsibility for the nation’s health. Our councils are stony broke, as I found in my experience of dealing with them over the last two years. There is no one else to do this; this is not someone else’s problem. This is to do with the British healthcare system, and it needs to stand up to that responsibility. Zero progress has been made in the round over the last few years and we have gone backwards in the last two years in a big way. We need to make this a massive priority.

This is a fantastic Bill; I am really supportive of it. It came from the healthcare system originally. In this one area, however, there is a graphic lacuna that needs to be addressed. The noble Lord, Lord Kakkar, put it so well in his inimitable way. The prioritisation of inequality must be put in the Bill and it needs to be heard throughout the healthcare system that this is the new, central priority that needs to be added to everyone’s job description.

If, for some reason, we do not do that there will be huge consequences. The healthcare system is unsustainable in its current form. We cannot continue to have a large part of the population carrying grievous comorbidities or disease and afflictions which are undiagnosed or not properly mended turning up in our hospitals at a very late stage and costing a fortune to mend. These health inequalities, whether they relate to disease, injury or behavioural issues such as obesity, are costing us a fortune. Only by putting tackling inequality on the face of the Bill can we really give it the priority it deserves.

I also say to the Minister that there is a sense of political jeopardy about this as well. We went into the last election committed to levelling up on health. We have gone backwards in the last two years through no fault of the Government, but if the Government do not step up to their responsibilities in this area, and if the NHS and the healthcare system do not change their priorities, the voters will judge us extremely harshly. For that reason, I urge the Minister to listen to this debate and look very carefully at ways of amending the Bill.

[Baroness Neuberger (CB)]

My Lords, I want to pay tribute, as other noble Lords have, to the noble Baroness, Lady Thornton, for her very thoughtful introduction. It is remarkable and absolutely wonderful to see consensus breaking out across the Committee. I will speak specifically to Amendments 152, 156 and 157 in the name of the noble Lord, Lord Young of Cookham, whose words on the need to make this really serious by stating it on the face of the Bill I echo.

I am a former chief executive of the King’s Fund and am currently chair of University College London Hospitals and Whittington Health. These issues are very dear to my heart and the hearts of those institutions. I also want to say thank you to Crisis for its briefing and add to the words of the noble Lord, Lord Young of Cookham, in praise of Pathway, which has done the most extraordinary work in this area over very many years.

I want to talk particularly about the NHS-funded Find & Treat service, which was set up 13 years ago and is run by UCLH, which I chair. This service was set up in response to a TB outbreak in London and aimed to provide care for people experiencing homelessness and people facing other forms of social exclusion. The service did exactly what it says on the tin: it went out and found people—and still does—who were at risk of contracting TB, wherever they were sleeping, and offered them diagnosis and treatment. Back in 2011, a study concluded that this service had been not only effective in helping to treat people with TB who were experiencing homelessness but cost effective in doing so, both in terms of costs saved to the health service and improved quality and length of life for the people receiving care. Fast-forward a decade and the evolution of this service meant it could be similarly mobilised at the beginning of the Covid pandemic. It provided urgent and necessary care to people who continue to experience the poorest health outcomes.

The King’s Fund published a report in 2020 on delivering health and care for people sleeping rough. It supported the need for inclusion health services to be provided much more broadly than at present. Importantly, it also concluded that local leadership is absolutely vital in crafting that approach and said that local leaders should model effective partnership working across a range of different organisations.

Embedding inclusion health—I cannot say I really like the term, but everybody knows what it means—at the level of integrated care partnerships will help ensure that our healthcare system can no longer ignore, forget or overlook people who are all too often considered “hard to treat”, despite proven interventions showing the opposite. It will ensure that integrated care partnerships and systems take that vital first step towards closing the gap of the most significant health inequalities in our society by having to recognise and consider people facing extreme social exclusion and poor health outcomes in their local areas.

We all know that there will be considerable discussion during the course of this Bill on the need not to be overly prescriptive and burdensome to ICSs and ICPs by way of legal duties. But ICSs and ICPs know all too well the realities of failing to support people with complex and overlapping needs. I know that the chair of my own North Central London ICS, Mike Cooke, is sympathetic to the spirit of these amendments and believes it is important that extra steps are taken to meet the health needs of the most excluded, such as street homeless people. The chief executive of UCLH, David Probert, and the chief executive of Whittington Health, Siobhan Harrington, concur in thinking that if we extend the aspiration to reach out to excluded groups to something that all ICSs, ICPs and systems must focus on, it would be hugely beneficial for planning and joining up systems to avoid inappropriate or unnecessary admissions and poor care planning. Plenty of people want to do this within our health system.

I support Amendments 152, 156 and 157 and look forward to working with the Government and colleagues across the House and within the NHS to ensure their success in achieving a critical and long-needed systemic change to our health and care system. Addressing the needs of the most excluded has to be on the face of the Bill.

[Lord Crisp (CB)]

My Lords, I will make three very practical points about the impact of some of these amendments. First, on tobacco, we have heard from at least two noble Lords that half the difference in life expectancy between the rich and the poor in society is due to tobacco. It seems a no-brainer that work on this has to be continued. I also make the point that it took something like 50 years after the evidence was first available for the control of tobacco to be put into legislation, despite the efforts of the noble Lord, Lord Young of Cookham. It is not a quick win; we need to persevere, keep the pressure on and keep this very firmly in NHS plans at all levels.

Secondly, I want to pick up on the vital point that housing needs to be much more integrated with health and care. Let me take us back in history to 1919 and the first Ministry of Health, which had responsibilities covering health, housing and planning for many years, understanding the very important links there. Covid has shown that a house and home is an absolute foundation for health and well-being in all kinds of ways. I will not labour that point at this stage in proceedings, but will pick up another that has not come up, which is how important housing is to the provision of NHS services.

Seven years ago, the Royal College of Psychiatrists asked me to look at the reasons for the pressure on admissions to mental health acute wards. I did so; I think it expected me to say that those wards needed more beds, but I came out saying that we needed more housing. I found that something like one-third of the patients in mental health acute wards in adult hospitals either had been admitted because there was nowhere else for them to go or were staying there because there was nowhere for them to live to be discharged to. Housing was the biggest issue. Of the 25 NHS trusts around the country, only about three had specific, strong links with their local housing associations. There is a really big pressure for integration there.

Thirdly and finally, I come to Amendments 152 and 157 about the so-called inclusion health services. I agree with my noble friend on the nomenclature and that the naming is rather awkward, but these are extraordinary vital. We have heard examples of services that work; the issue here is how we can make sure that those services are spread and used elsewhere. I remind the House that, when we talk about inequalities, we all, including me, talk in fairly general terms. If you have a quantum of money and invest it in the health of the well-educated middle classes, you will get a small gain. If you invested that same quantum of money in the needs of this group, you would have a massive gain. That should inspire us to keep the pressure on the Government to make sure that we put tackling inequalities absolutely at the heart of the Bill.

Health and Care Bill

Baroness Neuberger Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Neuberger (CB)]

My Lords, I declare my interests as in the register, specifically as chair of University College London Hospitals NHS Foundation Trust and of Whittington Health NHS Trust, and as vice-chair of the UCL provider alliance. I am grateful to the King’s Fund and others for their briefings, and declare a further interest as a former chief executive of the King’s Fund. I add my congratulations to the noble Lord, Lord Stevens of Birmingham, on his superb maiden speech and share his concern that there is not a greater focus on mental health in this Bill, and indeed on the determinants of health and public health in general.

We have so little time to speak that I will simply support what many noble Lords have already said in asking for further assurances around workforce planning and education and training, given that we have an absolutely exhausted workforce and we face tough recruitment issues. If it is bad in health, it is completely dire in social care. I also echo what other noble Lords said about the Secretary of State’s new powers and the effect on the poorest of the way the £86,000 social care cap is designed.

I will focus on three specific things. The first is capital spending limits for NHS foundation trusts, because the present drafting differs significantly from what was set out in the NHS’s 2019 legislative proposals. I hope we can go back to those proposals, which were a sensible compromise between system and organisation. That is particularly important for specialised commissioning, given that ICBs are set up largely to be accountable to their local populations. In north-central London, only a third of our provider income and asset base relates to north-central London residents, so safe- guards are essential to ensure that ICBs have a statutory responsibility to maintain and develop specialised service assets, as well as those serving their populations.

The Bill appears to say that NHS England can pass many of its commissioning activities but not its responsibilities to the integrated care boards. Delegating complex commissioning arrangements for those specialised services where there is no evidence base for joining up pathways of local care will lead simply to a fragmented approach. Providers such as my own, UCLH, Great Ormond Street and others providing regional or national specialist services face the prospect of agreeing contracts with 42 ICBs rather than a single commissioner, adding significant bureaucracy and transaction costs. I wonder whether that can be sensible.

I am absolutely delighted that the membership of the ICBs will include, among others, representatives from local authorities. The guidance from NHS England states that it is expected that the local authority representative

“will often be the chief executive”.

This wording implies some flexibility, but there is a very strong case to be made for the local authority representative being one of the local council leaders, who are, after all, the elected representatives responsible for running local services, including children’s and adult services—precisely those services where we need improved integration with health, as many noble Lords have said. I hope the Minister can give us an assurance that each ICB will have the freedom and flexibility to reach this decision locally.

Lastly, most of us will warmly welcome the Health Service Safety Investigations Body. The Bill makes provision for creating a safe space within investigations to enable clinicians and others to provide information without the fear that that will be disclosed or used for disciplinary purposes. That is understandable, but the clause as drafted seems to cut across the unique constitutional role of the Parliamentary and Health Service Ombudsman to investigate complaints about the NHS and other public services.

The Bill prohibits the national ombudsman from accessing information held in the HSSIB safe space without seeking permission from the High Court. Schedule 14 appears to strip the ombudsman of long-held constitutional powers by being excluded from the safe space while the same exclusion does not apply to coroners. This would be the first restriction on the ombudsman’s powers since it was established back in 1967. It contravenes international standards set out in the Council of Europe’s Venice principles and the United Nations resolution on the role of the ombudsman, which was co-sponsored by the UK Government, and it will undermine public confidence in the administrative justice system, with patients feeling that they have less access to justice and public accountability when failed by NHS services—because we do not always get it right, as the noble Baroness, Lady Cumberlege, has made abundantly clear. I welcome the broad thrust of the Bill, but there is still much to clarify and change.

Health

Baroness Neuberger Excerpts

Thursday 26th November 2015 Lords Chamber

[Baroness Neuberger (LD)]

My Lords, it is a great pleasure to be able to follow the noble Lord, Lord Smith of Hindhead, and congratulate him on what he had to say. His maiden speech has given us a great deal of information about his role as chief executive of the Association of Conservative Clubs and chairman of the Committee of Registered Clubs Associations, but has also made us laugh. One of the things that we enjoy in this House among all the good fellowship that the noble Lord referred to is occasionally being allowed to laugh. What the noble Lord said to us was both moving and sensible, and he has illustrated in what he had to say the essential nature of human-to-human contact—not only virtual but in fact, in clubs and associations. I very much look forward, as I know we all do, to what he has to say in future debates. If the noble Lord is not an expert, he certainly had something of substance to say, which we all valued hugely.

I also pay tribute to the noble Lord, Lord Crisp, for introducing this debate. I will contribute a few thoughts about one of the wider issues that shapes the nature of the nation’s health and which many other noble Lords have referred to—the issue of loneliness and isolation. However, I want to start by talking about babies and young children and about the considerable body of evidence we now possess about the development of a child’s neural networks and the fact that it is absolutely essential for parents and caregivers to talk to children and hug them. This is not only about making them feel secure and loved but about allowing their brains to develop properly.

I raise this point to draw a comparison with newspaper reports a couple of days ago, which some of your Lordships may have seen, about a major piece of research conducted by scientists at the University of Chicago. The research demonstrated that people who live alone and are lonely have signs of highly strung so-called “fight or flight” responses in their nervous systems, as well as greater numbers of a type of white blood cell that boosts inflammation. People who had this in their bloodstream were also more likely to report that they felt lonely even a year after the original study was undertaken, suggesting that the emotions and the chemistry may feed off each other or be related in some way. The academics described the loneliness as chronic and suggested that the constant stress, and its biological effects, could “amplify or prolong” people’s sense of isolation, much as those who feel ill often tend, unconsciously, to avoid other people.

What can we possibly draw from this? As the right reverend Prelate said, it is that lonely people are more prone to disease; the noble Lord, Lord Crisp, said this too. It means that loneliness is dangerous, that lonely people die earlier and that there is a real physical effect—we have heard that from many speakers around the House. Just like babies, older people need human interaction and stimulus, and the lack of it may lead to physical ill health and early death. Just as babies need human interaction for their brains to develop and grow, so adults need human interaction to keep them healthy. But with older people, the science is in its infancy, even though the psychosocial observation is commonplace. We all need to be needed.

What can we do? Along with the great charities that do much to try to reduce the isolation of lonely people, such as the Silver Line, Contact the Elderly and many others, I believe that we need to encourage everyone to contribute something to society, even if they are housebound or isolated. Housebound people can be telephone volunteers: they can buddy other isolated people and can plan activities from home. But doing this is not a free good. The people concerned would need to be chivvied, encouraged, monitored, thanked and probably trained as well. The cost is in sorting out the systems and in getting sufficiently motivated volunteer organisers to keep it going. But it would undoubtedly be life-transforming and, arguably, if the statistics are right about the actual financial cost of loneliness, let alone its emotional and social costs, worth it.

If we were to invest in this kind of loneliness-avoiding work, which is largely low-tech and easy to manage, we would create a healthier society with fewer costs to the NHS. A small investment here could make a big difference and save the public purse millions, as well as alleviating distress, loneliness, ill health and isolation. It has to be worth a try in creating a healthier society. So I very much second my noble friend Lord Crisp’s call for an ad hoc committee on creating a healthy society, because I think there are practical ways in which we could do it.

Care Services: Older People

Baroness Neuberger Excerpts

Wednesday 22nd June 2011 Lords Chamber

Asked by

[Baroness Neuberger]

To ask Her Majesty’s Government, in the light of the Equality and Human Rights Commission’s interim report on the care of older people in their own homes, what plans they have to ensure appropriate care that respects dignity.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, dignity and respect are the cornerstones of good quality care. The Government have made the Care Quality Commission responsible for assuring quality of care. It is the responsibility of local authorities to specify and commission care and providers to deliver it. The Government’s planned reforms for health and social care, with an emphasis on better commissioning, should increase our ability to drive up standards in services and result in improvements in quality of care.

[Baroness Neuberger]

My Lords, I thank my noble friend the Minister for his reply. However, is he aware that a large proportion of the responses to the interim report from the Equality and Human Rights Commission have come from the care workers themselves who feel that in present circumstances they are simply unable to provide care that provides dignity to the older people in their care? Can he assure this House that in those reforms that are going forward, measures will be taken to make sure that local authorities must commission services that allow real dignity, which probably means rather longer passages of care for the people concerned?

[Earl Howe]

My noble friend makes some extremely important points and I agree with the thrust of them. As she said, these are interim findings. We all look forward to the finished report later in the year, which will no doubt contain deeper analysis than we have had access to so far. There can be no place for poor quality care in care services. We should all welcome an inquiry of this kind because it clearly will expose poor practice and will point the way towards some clear messages that we must bear in mind in the context of the Health and Social Care Bill. In that context, we are seeking to achieve much more joined-up commissioning so that we have health and social care working together towards quality outcomes.

Baroness Greengross: My Lords, does the Minister agree that a reprioritising of funding towards the care of people in their own homes is essential? Would he also agree that in training both commissioners and care workers a human rights approach is a very useful tool when caring for vulnerable older and disabled people in their own homes? I declare an interest as a commissioner on the Equality and Human Rights Commission.

Earl Howe: I certainly agree with the noble Baroness that being looked after in one’s own home is the preferred option for most elderly people. That is where we have to focus our attention and, over time, increasingly our resources to deliver good quality care in that context. She makes a very good point about training. Regarding the essential qualities of a good care worker, you cannot train anyone in a kind and compassionate attitude, which is probably the foremost requirement for anyone in that field. I take her point about human rights. My department is already speaking to the Equality and Human Rights Commission and has entered into a voluntary agreement with it to help us embed equality right across health and social care and to enable the commission and stakeholders to evaluate the progress we have made.

Baroness Wheeler: My Lords, I, too, welcome the work being undertaken by the EHRC on this vital issue. We know that there are substantial problems with commissioning and standards of care delivery. For example, many local agency contracts do not provide staff with travelling time between visits, which greatly adds to the pressures on them. Stories of older people even being catheterised to avoid the costs of an extra visit are not unheard of. However, as a carer, I stress that in my own locality, care agency arrangements work very well, to a high standard and as part of an integrated care package. How will the Minister ensure that future commissioning makes this experience the norm, bearing in mind that 81 per cent of publicly funded home care today is provided by the independent sector?

Earl Howe: The noble Baroness again makes some extremely good points. At the moment we have an architecture that, first, should ensure that basic standards of quality are maintained. We have that through the Care Quality Commission, whose job it is to register domiciliary care agencies and to ensure that they have systems in place to quality-assure themselves. That must be the starting point: agencies must make sure that they are delivering the service for which they have been commissioned. Secondly, it is also a matter of ensuring that we have visibility where problems arise and that service users are encouraged to believe that they can speak up for themselves, that whistleblowing is possible, and that anyone else who observes poor quality care should feel free to speak up and to know whom to tell when they see bad care happening.

Baroness Campbell of Surbiton: My Lords, over four-fifths of local authority-funded home care is delivered by the private and voluntary sectors. In light of this, will the Government use the opportunity of the current Health and Social Care Bill to clarify that private and voluntary sector agencies providing home care services on behalf of local authorities are performing public functions under the Human Rights Act?

Earl Howe: I am sure that the noble Baroness, with her experience, can tell me a lot of what I do not know about what is built into the contracts that local authorities take out with private, independent and voluntary sector organisations. I would be surprised if the human rights obligations she refers to are not built into those contracts. It is clear that everyone has a basic human right to be treated properly wherever type of care is being delivered. The key here is to ensure that service users are aware of their rights. As I said earlier, my department is extremely keen to embed equalities and human rights in everything that it is responsible for.

Baroness Jolly: My Lords, will the Minister tell the House what proportion of domiciliary care providers are owned by private equity companies?

Earl Howe: I am afraid that I do not have that figure in my brief. I am not sure whether my department will either but if I can find it out I will let her know, gladly.

Health: Stroke Treatment

Baroness Neuberger Excerpts

Wednesday 30th June 2010 Lords Chamber

[Baroness Neuberger]

My Lords, I congratulate my noble friend Lord Rodgers on securing this debate and the National Audit Office on its excellent report showing that much needed progress has been made in improving stroke care. It is a good-news story. I congratulate also the Stroke Association on its fantastic work, which has to a large extent pushed us all into taking this issue more seriously.

Having read the report in detail, however, I have to say that it is not wholly a good-news story. One section, “Stroke patients in care homes”, set alarm bells ringing when I read it. The report argues:

“There is no single source of information on the proportion of care home residents who have had a stroke. The evidence we collected for our 2005 report suggested that at least a quarter of residents have had a stroke, although local data collected for an audit of care homes in Somerset gave a figure of 45 per cent ... About 11 per cent of stroke patients are newly admitted to care or residential homes after their stroke … The Royal College of Physicians’ guidelines recommend that nursing and care home staff should be familiar with the common clinical features of stroke and should know how to manage them; and the Strategy states that Commissioners should consider providing training on stroke to care home staff. However, there is no requirement for care home staff to be trained in the communication, mobility and other needs of stroke patients, and our interviews and case study visits revealed a lack of recognition among some care home staff that a suspected stroke or TIA should be treated as a medical emergency”.

One should add to that what is in section 3.17 of the report:

“The best way of improving the value for money of stroke care is by preventing strokes from occurring. Reducing stroke incidence requires managing the risk factors common to all vascular disease … including high blood pressure and cholesterol, smoking, unhealthy diet and lack of exercise. In March 2009 the Department announced a unified approach to the prevention of vascular disease through the introduction of the NHS Health Checks where everyone aged between 40 and 74 will be risk-assessed and, where appropriate, given information, access to services and treatment. Full rollout of the programme is expected by 2012-13, subject to the next spending review”.

But why stop at 74, particularly if, as we suspect, retirement ages are to go up still further in years to come and people will choose, for both financial and lifestyle reasons, to carry on working and having a full and independent life? Is not stopping at 74 discriminatory?

Indeed, stroke services provide one of the clearest examples of discrimination against older people. Access to specialised stroke services is considerably worse for older people than for younger. A piece of work published by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians back in 2007 showed clear evidence of an age effect on the delivery of stroke care in England, Wales and Northern Ireland, with older patients being less likely to receive care in line with current clinical guidelines. Analysing data collected for the Royal College of Physicians’ stroke audit, it found that older patients were less likely than younger patients to be treated in a stroke unit, which is very serious given that we know that admission to, and care in, a stroke unit is the single most beneficial intervention that can be provided after stroke. Only 39 per cent of patients over 85 were treated in a stroke unit, compared with 48 per cent of those under 65. Older patients were also less likely to have a brain scan within 24 hours of stroke, with only 51 per cent of those aged over 85 having an early scan, compared with 71 per cent of those under 65.

The report’s authors also say that the failure to include sufficient numbers of old patients in trials—that is a much bigger problem than in stroke care alone—has led to an evidence gap in effective interventions for those patients. This is sometimes used as a justification for limiting treatment. For example, trials of thrombolysis for stroke have included few patients over 80 years of age and the drug is therefore not appropriately licensed in Europe for patients over 80. That obviously means that the number of older people who may benefit from such treatment is limited, which is really quite serious.

Ageism was identified also by discharge from hospital: individualised care planning goals for older patients were less likely to include reference to areas of higher-level functioning, such as leisure pursuits—older people might want some leisure—driving and return to work. Older patients were also less likely to have received dietary advice to reduce fat intake and to have discussed other risk factors such as smoking and alcohol consumption. The report’s authors recommend better education of healthcare professionals, development of research programmes that test interventions in sufficiently large numbers of older people to provide clear evidence for treatment, and continuing audit that can identify where ageism persists.

There is more. Research conducted at Mayday Hospital in Croydon and published in the Postgraduate Medical Journal, and a large piece in the Daily Mail on the subject, showed serious discrimination yet again. The study assessed the treatment given to 379 patients at a rapid access clinic for suspected stroke or mini-stroke between 2004 and 2006. Although all patients experienced substantial delays, younger patients were scanned more quickly and were five times more likely than over-75s to be given a brain scan to check for bleeds. Only one in 20 over-75s was given an MRI scan, compared with one in four of those under that age. The younger patients were also more likely to be given dietary and weight loss advice, despite all the evidence showing that both groups were likely to benefit from such information. Dr Karen Lee, who led the research, said:

“A change in the attitude of healthcare professionals is needed to root out ageism”.

The Department of Health said that it was,

“determined to ensure high quality care for all, regardless of age”.

The question that this raises is important. The NAO report shows some promising progress in stroke care, which is much needed after we were lagging behind much of the world. However, if persistent negative attitudes to older people are not rooted out in healthcare, we will see discrimination against older people who have strokes—and, let us face it, they are more likely to have strokes than younger people—continue for years to come.

The former older people’s tsar, Professor Ian Philp, published his second report, A New Ambition for Old Age, back in 2006. In it, he proposed new targets and protocols for emergency responses to crises caused by falls, delirium, stroke and transient ischaemic attacks. One example is that everyone having a stroke should be seen at a specialist neurovascular clinic within one week, while the current position is that about half to three-quarters are seen by two weeks. Other scholars have been writing in the BMJ, such as Jackie Morris, who called for appropriate environments for care of older people and said:

“Although intermediate care in the NHS is expanding, it is not yet keeping pace with the rapid and continuing closure of rehabilitation beds and offers only patchy input from specialists”.

Despite general improvement, there is a real issue about stroke care for older people. The Government now have a golden opportunity, for there are to be serious evaluations of effectiveness of care and stringent examinations of the budget. If, as it seems on the face of it, not providing better stroke care to older people is in fact costly, given that they will then need greater care from social and health services in the longer term and will fail to get back to independent life, is there not a cast-iron argument for sorting this out now? Does not that fit neatly with the commitments to end age discrimination in principle, because it is wrong, and particularly in health services where evidence of a certain amount of institutional ageism appears to be commonplace?

Back in 1999, Alison Tonks, then deputy editor of the BMJ, talked about partnerships with older people to enhance core teaching and about giving older service users the power to shape the curriculum of professionals. That seems an extraordinarily good idea. In some medical schools in the United States, young students, before they begin their course, spend a month with a family where there is someone with a long-term condition, often someone who has had a severe stroke. We could learn from that and teach our students differently about what it is like to live with a disabling condition and what inputs might have improved things early on.

Will my noble friend the Minister tell this House what he thinks can be done in the short term to improve stroke care for older people in this country and how he believes ageism within health services can be dealt with in the longer term? I very much hope that he will reassure me and this House that changing attitudes in health services towards older people—stroke would be a prime example for a pilot—is high on the Government’s list of goals to be achieved.