Health and Care Bill

Baroness Pitkeathley Excerpts

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

[Baroness Finlay of Llandaff (CB)]

My Lords, I added my name to Amendments 133, 139 and 161, which were so ably introduced by the noble Baroness, Lady Greengross, and others. I also have Amendments 143 and 144 in my name. All the amendments aim to tackle the accountability gap: the inconsistency of provision of continuing healthcare across different parts of England.

The noble Baroness, Lady Greengross, alluded to some diseases, but this goes much wider. There are people with spinal injuries and long-term multiple sclerosis and there are people who have had strokes. They all need ongoing long-term healthcare at a high level—way above the level that can be provided by social care.

The problem is that the accountability gap exists and there is inconsistency in the quality of provision, with eligibility criteria being interpreted differently in different areas. Amendments 143 and 144 aim to strengthen the powers of NHS England in the Bill to give direction to integrated care boards, with the particular aim of closing this accountability gap. Within the existing system, NHS England is responsible for holding clinical commissioning groups accountable for their discharge of continuing healthcare and functions.

In the reformed system proposed by the Bill, NHS England will hold these boards accountable in a similar way, but I question whether it has adequate authority both in the current system and the proposed system and whether the levers available to it to act meaningfully are adequate. While the intention prior to the Lansley reforms was to give NHS England powers to intervene to create meaningful change in practice, the powers were restricted to high-level interventions where there was a failure of governance at the highest level, rather than interventions where a CCG was failing to implement good practice or to adhere to national policy.

The 2018 report by the Public Accounts Committee in the other place supported these concerns and stated:

“NHS England is not adequately carrying out its responsibility to ensure CCGs are complying with the legal requirement to provide continuing healthcare to those that are eligible.”


There are limited accountability mechanisms and there is inadequate data collection at present. These amendments seek clarification and would drive long-overdue improvements in the quality and, importantly, the consistency of the way that continuing healthcare decisions are made and the process is administered, with the aim of improving outcomes and reducing the strain of applying for continuing healthcare for people who live with complex health needs and for their loved ones, in particular their family and carers.

[Baroness Pitkeathley (Lab)]

My Lords, I very much support the noble Baroness, Lady Greengross, in her amendments. We should be clear that continuing health needs are ignored by assessors because of the issue of who will pay. I have experienced this twice with neighbours and friends. It was clear to me that both patients had complex needs, mentioned by the noble Baroness, Lady Finlay, and had undeniable continuing care needs, so I was puzzled as to why the families were working out how to fund places for their relatives. They had never been told of the possibility of continuing NHS funding. I suggested that they quote the legislation back to the assessors and of course when they did so they found that funding would be provided—and some years later it is still being provided. Without this chance encounter with me, and asking the right questions, those families would have been denied the funding that is their right.

[Baroness Barker (LD)]

My Lords, as ever, it is a great pleasure to row in behind my former boss at Age Concern—the inspirational leader of Age Concern for so many years—to return to an issue that Age Concern and its successor body Age UK have for decades raised with successive Governments during successive NHS reorganisations.

It is important, at the outset of this debate, that we understand the true importance of NHS continuing care. On one level, an individual level, it is about enabling people who have long-term conditions to live dignified lives in the community. At a strategic level, in terms of healthcare planning, it is about keeping people out of acute hospitals, which is the most expensive form of care.

The reason why it is right, again, that we seek to put these amendments on to the face of the Bill is that, at an organisational level within the NHS, there has never been a full accountability path for NHS continuing care. That means that, when it comes to individual decision-making on the part of members of staff in relation to individual patients, the decisions fall down. We have not just wide variation between different organisations but wide variation between particular practitioners, who sometimes resort to using non-standard checklists to make decisions, with inconsistent decision-making.

As a result of that, it is hardly surprising, but a real condemnation of a long-term failure of the NHS, that there is a need for an organisation such as Beacon to exist. It is a social enterprise set up by the main charities that gives information to older people and their carers. It should not have to exist. The fact that it does, and that it is a profitable social enterprise business, is testimony to the extent to which older people and their relatives are being badly let down on this.

I hope that in raising this yet again we have shone a light on a part of the NHS system that goes to the heart of what this Bill is supposed to be about. If we do not make this an express responsibility of the NHS in the Bill, yet again it is just not going to happen.

Health and Care Bill

Baroness Pitkeathley Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, it is clear from the number of noble Lords wishing to speak in this debate that this group of amendments is extremely important. I want to speak particularly in favour of the amendments from the noble Baroness, Lady Hollins, about integration, which she put before us so eloquently.

In the 40-odd years that I have been working on these issues, I have never heard anyone say anything other than that collaboration would be a lot better than the current situation and that collaboration between health and social care is absolutely vital. Everyone always says that, and in recent years we even have had the hope that, when the Department of Health changed its name to the Department of Health and Social Care, we would begin to see more movements towards integration. Sadly, little progress has been made.

If one asks any patient about integration between health and social care, they think that it already exists. Most patients have absolutely no idea about different jurisdictions, how one sorts out a medical bath from a social bath or how different pots of funding ensure different points of view. That is, of course, until the patients start to find their way around the system in the way in which the noble Baroness, Lady Barker, brought so amusingly to mind. The lack of incentives to integration in the Bill are disappointing. I have not seen anything in it that will stop 15-minute visits by overworked and underpaid care staff or any ideas about integrating services and having much better integrated budgets—still less about data sharing. Those are all the things that we need if we are truly going to move to proper integration.

As the noble Baroness, Lady Barker, reminded us, at a time when waiting lists for the NHS are growing longer by the minute, should it not be a priority to ensure that no one stays in hospital longer than they have to by having discharge procedures that provide a seamless transition and making sure that the all-too-frequent readmission because of inadequate co-operation between the NHS and local authorities does not happen? We hear that care jobs are unfulfilled and that requests for care are turned down because of staff shortages. Local authorities struggle to recruit enough workers to meet increasing demands. No wonder that that is the case when one can earn more by filling shelves at Sainsbury’s.

A truly integrated service would mean that, the minute that someone is admitted to hospital, plans should be being made between health services, social care and the often-ignored but often significant voluntary services about what is going to happen on discharge. Sadly, the usual pattern is for a conflict to emerge, usually on a Friday afternoon, between a hospital ward desperate to empty beds and social care services inadequately prepared or even informed. What happens? The person goes home, the care services are not adequate and so the person is readmitted to hospital. I know someone in my local area in Herefordshire, an elderly lady who has been admitted 14 separate times since last July, and still care services to keep her adequately at home are not provided.

The Bill is a failed opportunity because we are seeing social care once again as the poor relation, the tail-end Charlie, that is considered after everything else is settled. Social care could be at the heart of a levelling-up agenda if we had a vision for its workforce and the impact that it has on the health of a community in the broadest sense. Care providers could be encouraged to diversify their businesses to reach out creatively into the community by providing tax incentives, for example, or reductions on business rates. If we want a high-skill, high-wage economy, what better place to start than social care, with its huge workforce badly paid but certainly not unskilled? Those skills could be developed by providing training, and retention could be dealt with by better career progression and recognition of qualifications. It is sad that we are not looking at practical ways in which to develop that integration in the Bill.

Fixing social care requires two things: money and better integration. We will come on to money later in the Bill. For the moment, I hope that the Government will give proper recognition of and acceptance to the amendment on integration in the name of the noble Baroness, Lady Hollins.

[Lord Warner (CB)]

My Lords, I will speak briefly in support of the amendments in the name of the noble Baroness, Lady Hollins. I had intended to put my name to them; I apologise to the noble Baroness for being so slow off the mark. I also strongly support the amendment in the name of the noble Lord, Lord Layard.

Both these amendments, in their different ways, go some way to righting what I consider to be two big wrongs inflicted on local government in the past, where responsibilities have been transferred to it but have not had their funding sustained into the future. The first was the closure of long-stay hospitals in the 1980s and 1990s. When I was a director of social services, I was the NHS’s favourite person when building provision and making available services for people coming out of long-stay hospitals. After a few years, I and my many colleagues became forgotten men and women because the money that was transferred was never maintained in real terms over a couple of decades.

Fast-forward to the 1990s and the setting up, with much enthusiasm, of the Roy Griffiths community care changes. These enabled the Government to get off the hook of an expanding social security budget. It was another repeat performance: the money was not maintained in real terms in the longer term. What we saw in both cases was local government having to pick up the tab without support from the Government—successive Governments, that is; I am not making a party-political point—to ensure that those services could be maintained for the people who became the responsibility of local government.

The amendments in the name of the noble Baroness, Lady Hollins, remind people that there is an obligation to make sure that both health and social care produce good outcomes for the people who are now primarily the responsibility of local government, which, as the noble Baroness, Lady Pitkeathley, gently reminded us, has been underfunded over a long time in terms of maintaining these services. The amendment in the name of the noble Lord, Lord Layard, is another righting of a wrong and we should all get behind it.

--- Later in debate ---

Amendments 57 and 58 not moved.

[The Deputy Chairman of Committees (Baroness Pitkeathley) (Lab)]

Before I call the next amendment, I remind your Lordships that the noble Lord, Lord Howarth of Newport, is taking part remotely.

Amendment 59

Moved by

--- Later in debate ---

[Baroness Finlay of Llandaff (CB)]

My Lords, I strongly support this group of amendments. I would like to make sure that we realise that the medical humanities as a discipline have now been introduced in many medical schools. In my own, I was rather glad that AJ Cronin’s book The Citadel was introduced in general practice, particularly because, of course, he invented Dr Finlay, but there we are.

Quite seriously, we must not forget that loneliness kills. Loneliness is a true killer; it shortens lives. If people are not moving around well, they fall more and consume healthcare resources. Therefore, having green spaces and things such as sports for health, and so on is important. There is now also a body of evidence that the new intensive care units have used in the way that they are constructed, so that there is a view of outside spaces for those patients, rather than the total sensory deprivation that occurs to them in the very noisy and difficult environment of intensive care. Of course, music is used therapeutically during procedures and so on.

In the hospice world, lots of activities obviously go on in the day centres. As my noble friend Lady Greengross said, there is now good evidence for proper physiological mechanisms that explain why contact with these different disciplines—which were considered to be outside medicine—have a beneficial effect on healing, coping with pain and distress, resolving issues, reframing what is happening to you and so on.

I would like us not to forget that loneliness kills. Importantly, so many patients have said that they have a sense of personal worth when they are still able—however ill they are—to contribute to those around them and to a sense of community. These amendments go to the very heart of being human—that is, the inherent creativity within people that has been forgotten for decades in the provision of health and social care.

I can see that there are difficulties in bringing this into the Bill, but we should commend the noble Lord, Lord Howarth, for the sophisticated way in which he has worded some of these amendments. I hope that they can be built on as we go forward. This could save a huge amount of money for the NHS in the longer term. A huge number of side-effects of drugs could be avoided. People could be fitter. There would be fewer forms. There is a great amount of optimism behind these amendments.

[Baroness Pitkeathley (Lab)]

My Lords, what I want to say follows on very well from what the noble Baroness, Lady Finlay, said. I want to quote Sir Michael Marmot. He said:

“We need to adopt a health and social care system which prioritises not just the treatment of illness but how it can be prevented in the first place. The pandemic has made it crystal clear … why public health and … social determinants of health are so important. The health and social care agenda must be rebalanced towards prevention.”


This is essentially what the noble Lord, Lord Howarth, is saying. It is not just about the treatment of illness but about preventing it happening in the first place.

I commend my own general practice in north London. In despair at the quantity of antidepressants being prescribed with very little result, it took to organising community groups to do cooking, set up friendship groups and put people in contact with each other. It puts on bring and buy sales—all with people who, perhaps, in the past, might just have been prescribed antidepressants.

I want to say a word about the charitable aspect—the voluntary sector—to which the noble Lord, Lord Howarth, referred. Charities cannot operate unless their core costs are met. My own GP practice which did this wonderful work had to go to the local authority and to the lottery to seek some funding. We have to remember that, if we want voluntary organisations to participate in these wonderful preventive services, we need to ensure that they are properly funded.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I join pretty much everyone else in commending the noble Lord, Lord Howarth, for tabling these amendments. I have attached my name to Amendment 67, although it could have been to any of them.

It is worth making two broad points. In her wonderful contribution on the last group, the noble Baroness, Lady Cumberlege, used the really key phrase,

“the community provided the health”.

That is what this group of amendments is talking about.

A couple of groups back, the noble Baroness, Lady Thornton, talked about how, if the health system is working for people with learning disabilities, it is working for everybody. If we bring in the kind of institutions, frameworks and supports that we are talking about here—if we think about stopping people getting ill and caring for ill people—we will make our communities vastly better for everybody. This is an important point to make.

Like most noble Lords, I could come up with a list as long as your arm of wonderful places I have visited. I will not, but I will mention one, which brings together three elements of this: creativity, nature and culture. The Green Backyard in Peterborough is the most wonderful space. I defy anyone to walk into it and not smile. It has amazing, colourful, moving sculptures powered by water, with food growing—amazing salads filled with flowers. When I visited, I spoke to the carer of another visitor. This visitor had very profound disabilities—she was blind and non-verbal—but her carer said, “I’ve never seen anything like it. After the first time we came to visit, the next Monday, which she knew was the day we visited, she was all packed up, dressed and ready to go out.” This was obviously catering to someone’s needs absolutely brilliantly, but it nearly got bulldozed and turned into a block of flats a few years ago. Luckily, it was saved, but that is the situation we so often find ourselves in.

I also want to mention Amendment 90, in the name of the noble Lord, Lord Howarth. The noble Lord, Lord Best, has already said a great deal on this, so I will seek to add just a couple of small points—well, one small point and one quite big one. There is something called the lifetime homes standard, which I learned about when I visited Derwenthorpe in York with the Joseph Rowntree Foundation. The thing I remember about it, because it was so simple and obvious, was that the two-storey houses there had all been built with a space between the joists so that, if you needed to put a lift in up to the first floor, where the bedrooms were, it was a really simple and low-cost thing to do. It was a very simple piece of design. This will not be covered in the Health and Care Bill, but this relates to so many aspects of our society. You could say that housing is a health issue. In the first group this morning, we talked about social care and how many people cannot leave hospital and go home because their accommodation is unsuitable. We need to think all the way along the line across our society to make sure that does not happen.

Finally, I want to pick out one or two words in this amendment, which talks about housing and urban environments. I thought here of the New Ground co-housing development in north London, which is for women aged over 50. One aspect of it is looking at how people can support each other, be good neighbours and form a community that can provide support. This morning, I attended a King’s Fund briefing talking about social care and there was a great deal of talk about the need for digital innovation and technology. I tweeted, “What about social innovation?” We have to think about how we organise our societies and urban environments so that people can form those kinds of communities. If you visit any area of new housing being built around the country, there is typically precious little in it to encourage that kind of community development. The housing point is obvious, as is the environment point, but let us not lose the community and urban structure points from that amendment either.

Health and Care Bill

Baroness Pitkeathley Excerpts

Lords Hansard - Part 1 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I share the outrage of my noble friends and the noble Lord, Lord Scriven, about how this is proceeding. In a way, I can see how some of this has come about. Perhaps the Minister will say that the Government are building on what is happening on the ground. It is perfectly true that many organisations at a local level found their way around the disaster that was the 2012 Act. They set up systems so that they did not have to follow it and could collaborate and not compete. Many of those systems operate practically on the ground, but they do not operate in a proper legislative framework, as we have heard, and nowhere is that more important than the outrageous decision in some areas to preclude local authorities, as noble Lords have said.

For those of us who know our way around the system, it is easy to ignore the fact that most patients and users—after all, the Bill is supposed to be focused on their experience and what their outcomes will be—have no idea about the difference between local authorities and the local health producers. To them, it is all the council or the NHS, and they have no idea that the GP, the district nurse, the care provider and the local care home do not talk to one another or have any mechanism for coming together. That is the kind of mechanism that we are trying to establish. We must ignore the informal arrangements that may have taken place as a result of the 2012 Act, and establish the proper legislative framework in which all those who have the interests of patients and users at heart are properly represented.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I declare my position as a vice-president of the LGA and the NALC. I will speak particularly to Amendment 23 in the name of the noble Baroness, Lady Thornton, to which I have attached my name; it is unfortunate that we have not heard from her yet. It is about consultation with local authorities, which is what so much of our debate on this group thus far has already addressed. I particularly associate myself with the comments of the noble Lords, Lord Hunt and Lord Davies. A great rearrangement of the NHS has happened entirely under the radar, and it is deeply disturbing to those of us concerned about the risk of the Americanisation of our NHS and its takeover by private US healthcare for-profit companies.

I am slightly surprised that no one has yet mentioned the report in the Times this morning about the Health Secretary seeking to model NHS hospitals on academy schools, which has been seen as a large privatisation of our education system. Also, we found out only recently and entirely by accident that the Chancellor was giving days of his time to visit US healthcare companies in California. When you look at those facts, the runes seem very disturbing. To defend against the incidents that the noble Lord, Lord Davies, referred to, and the restructuring by stealth, we need local authority involvement. That is what Amendment 23 seeks to ensure, at least in part.

I also want to comment briefly on another amendment in the name of the noble Baroness, Lady Thornton, Amendment 44, which is about protecting the collective arrangements for pay and conditions for staff. We have to look at it in the context of the survey this week that showed one in four doctors saying that they were exhausted to the point of being impaired in their work. We have an exhausted, utterly worn-down workforce, and we have nurses who are not paid enough and end up going into food banks to feed their families.

It is obviously a matter of justice that we at least protect, and in fact improve, the pay and conditions of healthcare workers. But more than that, it is very much an issue of health as well, because workers who are overworked and underpaid are simply unable to deliver the quality of care that we would hope to provide.

I very much hope that this group of amendments will get some attention, because this has all happened under the radar. There has been no public discussion of this and that desperately needs to happen, so once again it seems to fall to your Lordships’ House to try to get this on the agenda.

Health and Care Bill

Baroness Pitkeathley Excerpts

Lords Hansard - Part 2 & Committee stage
Thursday 13th January 2022 Lords Chamber

I recognise the difficulty of outlining and detailing names in the Bill, but I would be interested to know from the Minister how the voice of patients and empowering them and giving them agency is threaded through this Bill.

[Baroness Pitkeathley (Lab)]

My Lords, like the noble Baronesses who have spoken before me, I recognise the difficulty of being too specific about board membership, but I think that paragraph (h) in Amendment 37 in the name of my noble friend, to which the noble Lord, Lord Patel, has added his name, is wide enough to enable patients and carers to be represented. Indeed, given the Government’s commitment to the voice of patients and carers, I find it difficult to understand how they could not accept such an amendment. I know the Minister is extremely committed to that patient and carer voice.

I want to extend that a bit to making sure that we do not forget the vital contribution that charities and community organisations make to health and social care services through their well-documented ability to be innovative and flexible. Your Lordships know that in the course of the pandemic, they immediately operated better delivery mechanisms than the statutory sector was able to because they were able to be flexible. One million volunteers were recruited, and many people had experiences similar to mine, with people saying that it was only through the services of voluntary organisations and charities that they had any kind of support at all, particularly during the first few weeks of the pandemic.

When the Public Services Committee of your Lordships’ House did its inquiry into how public services had reacted to the pandemic, time and again we received examples of where charities were ignored by public service providers. Even if they were consulted at a later stage in planning, it was not to take account of their experience and skills but to assume they would co-operate in whatever role was doled out to them. That is not the way to make the best use of the untold amount of good will, experience and skill that exists in charities, especially in the areas of health and social care. This is a waste of scarce resources and must be recognised in the new structures as they are set out. There are many examples of where these partnerships work well, recognising the different skills on offer, and of where charities are treated as partners, but they must be involved in planning at the earliest stages and be supported financially if appropriate. They will always give a good return on resources.

The other area where charities make a significant contribution is in representing the patient and carer voice. Voluntary sector organisations are often the services that have most contact, especially with vulnerable people. Your Lordships will have endless examples of that. Much is made of how important the voice of the user, patient and carer is when planning or delivering the services. Co-production, co-design and the other buzzwords we hear all the time absolutely depend on being in touch with users and patients. Almost inevitably, the easiest way to access users and patients is through local or national charities which make users their focus, both in the planning of services and the governance of the organisation.

Proper involvement of users, patients and carers often throws up surprises, even pleasant ones, about money. If you really take the views of users and patients, you will often find that what they want from health and social care services is not what is being provided. They will often ask for less provision than we expect, so long as it actually meets their needs, not the needs estimated by the providers. This is a valuable fact when resources are short. It is one more important reason to forge partnerships with the voluntary sector when the memberships of ICBs and ICSs are being set up. Organisations in their areas should be considered as partners which have a great deal to contribute and will do so willingly and productively.

[Baroness Finlay of Llandaff (CB)]

I have two amendments in this group, so I will try to address them very briefly because of time. I am most grateful to the noble Baroness, Lady Thornton, for the way that she introduced this and would like to return very briefly to the issue of public/private potential conflict when public money is being spent, because there is an issue of probity around that. Having shared corporate accountability for the delivery, functions and duties of the ICS could be in conflict with the legal duties of company directors, as has already been pointed out, and therefore creates problems.

I know that the Government recognised this in the other place, but their amendment seems to fall short in two respects. It leaves to the appointed chair of the board the decision on whether a person with interests in private healthcare is incorporated into an ICB. The difficulty is that it provides a condition that their interests in private healthcare could undermine the independence of the health service, but it is very unclear how that will actually be measured. I can see that it would be a fantastic area for legal argument that a precedent had been set in one area that was being worked against by the chair of another ICB. I think this needs to be clarified, because they will be dispensing public money and there are examples already where different decisions have been taken. I will not go into those now because of time.

I turn briefly to the reasons behind the amendments I have put down and declare that I am president of the Chartered Society of Physiotherapy. I am most grateful to the noble Lord, Lord Bradley, for co-signing my amendments. There is a role in recognising that the allied healthcare professionals are the third-largest part of the workforce—the workforce is not just doctors and nurses—and are critical to the long-term plan for the NHS. They work across the health and social care boundary and out into the community. They are integral—physiotherapists in particular—to primary care, and speech and language therapists are essential for children and young people, particularly those with communication difficulties, and that of course includes those with autism and learning difficulties.

I also recognise, though, the problem that you cannot have everybody listed on a board and everybody wants their own so-called representation on it. It will be important that the terms of reference and the metrics by which the function of the board is measured and compared are very clearly laid out, to make sure that there is appropriate consultation at all times with those who are on the receiving end of healthcare, and that people such as allied healthcare professionals are appropriately involved in decisions for the patient groups on which they can have a major impact. Quite often they have a much more major impact than medicine or nursing will do in terms of a patient’s long-term quality of life, and rehabilitation in particular.

So I hope that the Government have listened to this debate and in particular will heed the important warning from the noble Baroness, Lady Thornton, in opening this debate and in the content of the amendments that she has tabled.

Health and Care Bill

Baroness Pitkeathley Excerpts

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

The system that I am describing is one of our very best but they would openly admit that they are still in the early stages of that change, which is why it is so important that we put this in the legislation. I know that the Minister and the Secretary of State care deeply and passionately about addressing health inequalities; both have been very public about their commitment. I urge them to hear the spirit of the cross- party agreement in this Committee today and accept the amendments.

[Baroness Pitkeathley (Lab)]

My Lords, I support all the amendments in his group but particularly Amendment 68, in the name of the right reverend Prelate the Bishop of St Albans, about health inequalities faced by those living in rural areas. When you live in a rural area, it is often difficult physically to access a GP practice—if you do not have a car, try getting a bus in a rural area whose timetable coincides with the opening hours of your surgery—and to access health information if your internet is not up to scratch. There are many rural areas where connectivity still leaves a great deal to be desired. Pharmacies, too, can be difficult to access; although some run outreach services, they are by no means universal.

In rural areas, the important non-clinical services mentioned by my noble friend Lord Howarth are largely dependent on the voluntary sector. During the pandemic, when village halls, with their plethora of exercise, dance, art and social support services, were closed, many older people in rural areas were cut off completely, with disastrous effects on their mental health.

The problems of delivering social care in rural areas are also well known. When care workers are paid for home visits only for the time when they are in the home and not for travelling time—time that will of course be extended by the spread-out nature of those visits—it is no wonder that many private and voluntary agencies are handing back social care contracts to local authorities because they simply cannot deliver them.

Poverty, the underlying cause of inequality, is more widespread in rural areas than is often acknowledged. Escaping to the country is a nice idea, but unless you recognise the particular inequalities faced by country residents, it is not as you see it on the television. Moving as a couple approaching retirement is a different picture when one—usually the husband, both the gardener and the driver—dies, leaving an isolated widow in declining health. The cost of fuel is also more acute in rural areas, and you will find many older people who may own a nice-looking cottage having to choose between heating and eating, with consequential effects on their health and future dependency.

I very much hope that when the Minister replies, he will emphasise that when integrated care boards are considering the provision of services for the purposes of achieving equality of access for patients, they will consider those living in all parts of the board’s area.

[Lord Scriven (LD)]

My Lords, this is my first intervention on the Bill. I draw the Committee’s attention to my relevant interests in the register, namely as a vice-president of the Local Government Association and a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust.

I support this suite of amendments—particularly Amendments 11, 14, 65, 94, 186 and 195—which explicitly puts the issue of health inequalities in the Bill and makes it central to the aims of the NHS. It also deals with reporting and holding people to account for helping to reduce health inequalities.

The reason for my support is simple. I speak as a former NHS manager who, as a rookie many years ago, in the very early 1980s, was on the general management trainee scheme. For the first three months, our aim was just to go around. I remember asking the very naive question: “Who’s responsible for quality?” I expected the person who was showing me around to say, “Everyone”, but he said, “Follow me.” We went in his car for five miles outside the hospital to the health authority. We then went into a lift, down into the basement and through lots of corridors, and finally came to a door at the end of the corridor. The door was opened and in a dimly lit room was a middle-aged woman, surrounded by piles of paper. I said, “Who’s this?” I was told, “This is Gladys. Gladys is responsible for quality.” It was seen as someone else’s job.

That is why I have cringed a little when the Minister has said, in previous debates and Answers on health inequalities, that the Office for Health Improvement and Disparities is being established. That is well and good, but that office is not responsible for reducing health inequalities; everyone in the healthcare system and its partners must work together to reduce health inequalities. That is why it is really important that this is explicit. It is not just about health issues; it is about people’s income, work, environment, green space and transport. It should be explicit in the Bill as part of the triple aims—which will become four aims—and become part of monitoring. This issue must become central because something that I have learned about the health service is that unless the centre asks for it, and asks for it to be monitored, it just does not get done because it is not seen as important. That is why monitoring this at both local and national level will hold people to account so it does not become Gladys’s responsibility.

The Bill gives us a once-in-a-lifetime opportunity not just to put health inequalities centrally in the Bill but to make them explicit in the way that the NHS and its partners work. With a little extra legal push to the mill, so to speak, as well as the monitoring, the data and holding people to account, I believe that we can finally start to deal with these issues in a systematic way that shows improvement and will allow the NHS and its partners to know where to push a bit harder to get this done. That is why I support the amendments.

Health and Care Bill

Baroness Pitkeathley Excerpts

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

Furthermore, all candidates are required to declare actual or potential conflicts of interest during the recruitment process, which can then be explored by an advisory assessment panel. On appointment and subsequently, candidates publicly declare their interests in a register held by the public body. The Commissioner for Public Appointments regulates these appointments to ensure they are upholding the values of the governance code. I hope that is helpful and that I have reassured the noble Baroness, Lady Merron, sufficiently, at least at this stage of the proceedings, to enable her to withdraw her Amendment 2.

[The Deputy Chairman of Committees (Baroness Pitkeathley) (Lab)]

My Lords, I remind the Committee that I must call the noble Lord, Lord Howarth, who is taking part remotely, to respond to the debate on Amendment 3.

[Lord Howarth of Newport (Lab) [V]]

My Lords, I very much appreciate the recognition by the noble Earl of the validity of the concerns put forward by the proponents of these two amendments, and his acknowledgment that the board of NHS England must contain balance and diversity. I also recognise the force of the points made by the noble Baroness, Lady Harding, and the noble Lord, Lord Mawson: it is essential that the chair should have power to ensure that the board is cohesive. I noted that the noble Baroness, Lady Walmsley, had reservations about the principle of representativeness which is stated in Amendment 2.

We have had a very useful debate. In light of the reflections put forward in the debate, particularly what the Minister, the noble Earl, Lord Howe, has said, I beg leave to withdraw my amendment.

Hospital Beds and Social Care

Baroness Pitkeathley Excerpts

Thursday 6th January 2022 Lords Chamber

[Lord Kamall (Con)]

All noble Lords will appreciate the work and dedication of all our social care workers, especially in these challenging times and with the extra pressure that omicron has brought. Throughout the pandemic, we have provided different types of funding. In December 2021, we announced an extra £300 million to support local authorities working with care providers to recruit and retain staff throughout the winter. This funding is in addition to the £162.5 million announced in October 2021. We recognise the issue, and it is about working with local authorities and others to make sure that this money gets into the system and achieves what it is intended to do.

[Baroness Pitkeathley (Lab)]

My Lords, following on from the question from the noble Lord, Lord Jones of Cheltenham, does the Minister agree that it will be important for the discharge team to also look at the reasons for admission, since many people would not have been in hospital at all—they would never have been admitted—if there had been adequate domiciliary care services? Will the task force focus on those issues as well as the issues for not discharging?

[Lord Kamall (Con)]

The noble Baroness makes an important point. The task force, working with all the various partners, is looking at the different pathways. Most patients can be discharged from hospital to their own home, but a number are held back because they should be discharged from hospital to their own homes but with a new additional or restarted package, which may take time. Patients might be discharged to residential care within the independent and community sector, but one issue is that a number of our care homes are owned privately and are not necessarily as joined up in the system. Patients may also have been discharged to a care home, but sometimes the family may not appreciate or approve of the first venue given and may push back and ask for another one. There are a number of issues that we are looking at; it is very complicated, which I am sure all noble Lords understand. We are trying to really push and get to the bottom of this. Another thing is to make sure that there is education across health and social care staff so that they really understand the needs of particular patients.

Health and Care Bill

Baroness Pitkeathley Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, it is a privilege to follow the noble Baroness, with her wealth of experience in this field, both personal and professional. I too welcome the noble Lord, Lord Stevens, and look forward to working with him again.

It has always been my role in your Lordships’ House to remind colleagues that, whatever reforms we make to health and social care, however many new acronyms we have, and however many new structures we set up, the bulk of health and social care in our society is provided not by paid professional services of any kind but by the so-called informal sector, the unpaid army of family, friends, neighbours and communities on whom we all rely.

Carers play an essential role in supporting the NHS and social care systems. Without their support, our systems would not have been able to cope with the increased demands they have seen during the pandemic. For many years, we have used the estimate of 6 million unpaid carers. During the pandemic, about 4.5 million people took on new caring responsibilities. Their total contribution is now estimated to be worth £193 billion every year—more than the cost of the NHS itself.

My test of any new legislation on health and social care is: how does it affect carers and will it help them be recognised for the vital role they play? The answer to that question is only partly positive. Carers welcome greater integration and collaboration between health and care services—the stated aims of this Bill—since their lives are made even harder when services are not joined up and data is not shared effectively and efficiently. I very much welcome the duty in Clause 6 to consult carers, and the duty on integrated care boards in Clause 20 to consult them around planning and commissioning.

There are some large omissions in the Bill which will have to be rectified if carers are not to suffer as a result of its introduction. For example, I suggest that a new duty should be placed on the NHS to have regard to carers and to promote their health and well-being. Carers are not systematically identified, supported and included throughout the NHS, although good practice does exist. In most social care systems, carers are legally recognised, but this does not apply to the NHS. For effective integration to be achieved across the system, there needs to be a statutory duty to have regard to carers and to promote their well-being. I remind your Lordships of the negative effects of caring on carers’ own health, with three-quarters of them reporting that their own physical and mental health is affected as a direct result of caring responsibilities.

Clause 80 is of great concern. This has been extensively debated in the other place. Incredibly, it actually removes rights from carers—rights which were hard fought for by me and many others during the passage of the Care Act 2014 and in other legislation. This Bill repeals the legislation that gave carers a fundamental right to an assessment and ensured that services were provided to make sure that hospital discharges are safe. There are endless horror stories about unplanned discharges with which I could regale your Lordships if time permitted. Some 68% of carers say that they were not asked whether they were willing and able to care at the point of discharge. Some 61% report that they were not given the right information and advice to help them care safely and well. Surely we must, at the very least, maintain carers’ rights, not reduce them—so this must be amended. I am sure that the Minister, with his understanding of carers’ needs, will be sympathetic.

I have two other areas of concern. The first is about the definition of “carer”. This is not defined in the Bill. Since the NHS is an all-age service, we assume that the definition that already exists under previous legislation will apply and that young and parent carers will therefore be included—but this must be defined and clearly stated in statutory guidance.

I also share the concern mentioned by many other noble Lords about the cap. Research by Carers UK found that 63% of carers were contributing financially in their role. For some, the contribution was relatively modest but, for others, it ran into hundreds of thousands of pounds. These proposals without the cap will leave many carers with low or modest assets very worried indeed.

I know that many of your Lordships recognise the contribution of unpaid carers. Indeed, many of us will be carers at this very moment, will have been carers in the recent past, or expect to be carers at some point in the future. I am confident therefore that we shall be able to amend this Bill to make it another important step in the hard-fought process of getting unpaid carers the recognition and support they so richly deserve.

Adult Social Care

Baroness Pitkeathley Excerpts

Thursday 2nd December 2021 Lords Chamber

[Lord Kamall (Con)]

The Government are in conversation with local authorities at the moment to look at the short-term issues. That is why we have announced increases in funding, particularly as part of the winter plan. The White Paper we are talking about today looks at the longer term, but we have also recognised the short-term issues, which is why we have announced these increases in spending.

[Baroness Pitkeathley (Lab)]

My Lords, we have been waiting for four years—sometimes I think I have been waiting 40 years—for a White Paper that contained a vision for social care that would, once and for all, rescue it from its Cinderella role in public services. I did not get that, but I am a glass-half-full person and am relieved by how many times unpaid carers are mentioned and how many warm words there are about identifying, recognising and involving carers. I thank the Government for that.

But family carers are at breaking point now. As my noble friend said, most have not had a single break since the start of the pandemic. They need immediate help, so will the Minister tell the House how the proposals in the White Paper will help stressed carers now? My second question is about integration between health and social care services, which is the only hope for real reform. It is frequently referred to in the White Paper, but there is no vision for how it will be delivered. We understand that another White Paper about integration is being prepared; I wonder why that is necessary when it could have been tackled in this one. Could the Minister update the House on progress and assure me that carers will be consulted as that paper on integration is written?

[Lord Kamall (Con)]

First, I pay tribute to the work that the noble Baroness has done for carers over many years. She has personally raised with me issues with carers, both paid and unpaid, as well. The White Paper clearly raises issues of professionalising, training and recognising carers to help make this a rewarding career for many. At the same time, it looks at unpaid carers and understands that, for a number of reasons, they are not all similar. Sometimes they are school-age children. We have looked at young carers and at elderly carers—for example my mother, who, in her 70s, looks after an 80 year-old sister who suffers from dementia. They have different needs.

We are first trying to look at how we can help make their task easier, for example through technology freeing up time. We are also looking at respite and how we can make sure they have breaks. We hope that those conversations will be had at the local level, between ICSs and health professionals having meetings directly with the individuals concerned to make sure that unpaid carers have the appropriate support.

NHS: Primary Care Surgeries

Baroness Pitkeathley Excerpts

Wednesday 24th November 2021 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for her speech. In answering, as this is for judicial review, I am sure she understands that I cannot comment on it. But I saw an interesting documentary over the weekend, so let me just read some words from it:

“Yes the NHS is a public service but how it spends its vast procurement budget, how it uses IT, how it fashions new processes and pathways for patients, plainly benefit from private sector experience.”


I admit I have plagiarised these words from Tony Blair, the last Labour Prime Minister to win an election.

[Baroness Pitkeathley (Lab)]

Is the Minister familiar with the research that shows that the longer the relationship between a patient and a GP, the less likely the patient is to need out-of-hours care or emergency hospital treatment, or to die, within 12 months? Are patients not right to be afraid that profit-making will interfere with those important relationships?

[Lord Kamall (Con)]

The standards of care that CCGs expect are clear in the contracts that they sign with GPs. However it is provided, patients should continue to expect the same standards of care.