Health and Care Bill

Baroness Tyler of Enfield Excerpts

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

[Baroness Tyler of Enfield (LD)]

I rise to speak to Amendments 51, 98, 141, 151 and 162 in my name and, briefly, the other amendment to which my name is attached. I shall make one opening remark. This group is all about children and young people. I know that all noble Lords feel very strongly about this issue. Children and young people make up 30% of the population but are not mentioned anywhere in the Bill.

Amendment 51 would require integrated care boards to share relevant information and data with key partners in the children’s system and to collect multiagency data from those partners. As the Bill stands, there are a number of crucial areas in which adults are, rightly, set to benefit from improvements to integrated working in ways that children are not. One of the most concerning ways in which it feels to me as though children have been an afterthought in the Bill is in the sharing of data and information.

Barriers to sharing information have been identified over many years as a key barrier to better joint working, commissioning and delivery of services but, due to the invisibility of children in existing data-sharing legislation, the children’s system faces even greater barriers to sharing information than that for adults. However, the measures to improve the sharing of information and data in Part 2 apply only to the adult system. Frankly, I find that inexplicable.

Alongside the noble Lords, Lord Bichard and Lord Hunt, to whom I am very grateful for adding their names to my Amendment 51, I heard numerous accounts of the huge challenges that the NHS and local authorities face in collecting, sharing and interpreting data as part of the recent Public Services Select Committee inquiry into child vulnerability. We heard this time and again. I quote just one sentence from the report:

“poor data-sharing between Government departments and local agencies endangered vulnerable children and their families by undermining safeguarding arrangements and preventing referrals for early help.”

As we heard from the noble Baroness, Lady Masham, following the heartbreaking murders of Arthur Labinjo-Hughes, Star Hobson and other vulnerable children in this country, it is essential that arrangements for data sharing between the health system and local authorities for babies, children and young people are urgently improved. As I have said, Part 2 focuses on data sharing between health and adult social care but does not extend this to the children’s system. It is not just that children are not specifically included in the wording of the Bill; they have been explicitly excluded.

As the noble Baroness, Lady Meacher, said, colleagues in the sector, including the National Children’s Bureau—to which I am very grateful for its help and support on these amendments—have engaged in discussion with officials on this issue. I was pleased to hear that this engagement is going well and is set to continue, but I hope to secure today the Minister’s agreement to look again at this issue, which is in the best interests of vulnerable children in this country.

Amendment 98 would add the discharge of duty as a safeguarding partner to the general duties of ICBs in Clause 20. It would require new regulations that specify how ICBs should perform the statutory child safeguarding duty when it is transferred to them from CCGs, which are obviously abolished as a result of the Bill. Although the statutory guidance Working Together to Safeguard Children already sets out the responsibilities of a safeguarding partner, the recent tragic events that I have just referred to show that a more robust legislative approach is needed to ensure that children are properly protected by a really effective multiagency safeguarding system.

It was heartbreaking, and I know that all noble Lords in the Chamber were shocked when they heard the details of the tragic death of Arthur Labinjo-Hughes, a six year-old boy who suffered prolonged abuse and was murdered by the very people who were supposed to keep him safe. I recently met the NSPCC, which highlighted government data showing 536 incidents involving the death or serious harm of a child due to abuse or neglect in 2020-21.

Sadly, young Arthur’s case is only one of far too many, but health practitioners such as GPs, nurses, midwives and health visitors are in a prime position to recognise and report safeguarding concerns; during medical examinations they might identify signs of physical or sexual abuse. Missed medical appointments can also indicate neglect. As the strategic safeguarding leader, the ICB will be responsible for ensuring that health practitioners are fully supported to work with other agencies on safeguarding and promoting the welfare of children. Alan Wood’s review from 2021, which has been discussed in the Chamber on a number of occasions, makes clear recommendations on strengthening the existing safeguarding arrangements, which came into effect in 2019, including by ensuring effective leadership, data sharing and scrutiny. The Bill offers a golden opportunity to act on these amendments to bolster local health partners’ role as a lead safeguarding partner and to embed effective joint practices that really do keep children safe.

Amendment 141 would require NHS England to assess how well an integrated care board has met the needs of children and young people in its area. In order to make a judgment about this, the amendment would require NHS England to publish an accountability framework for setting out national priorities for children and young people. Among other things, ICBs will have a crucial role in commissioning primary and community healthcare services directly for children and young people. They will play a key role in jointly commissioning services for disabled children and those with special educational needs, and in contributing to education, health and care plans, and they will be crucial in commissioning the joined-up services in the first 1,000 days of life, which the Government, to their credit, are investing in.

However, as we all know, there is unwarranted variation, with the support that children and young people receive in the health service often based on where they live rather than on their level of need. This amendment would create much needed accountability for integrated care boards and provide an overarching framework for children’s health that ICBs can work within, importantly without being prescriptive in any way about how local systems fulfil their duties.

Turning to Amendment 151, Clause 21 requires every integrated care partnership to develop an integrated care strategy. The amendment would require ICPs to consider specifically the needs of babies, children and young people when developing this strategy. I think the Minister knows my concern and that of other noble Lords—the noble Baroness, Lady Meacher, referred to it—that if we do not refer explicitly to children in the Bill, they will not be given priority equal to the adult population’s when it comes to implementation. Sadly, experience shows that when legislation does not explicitly require health systems to consider children, they are often overlooked in subsequent implementation.

Children and young people have distinct development needs. They use a distinct health and care system staffed by a distinct workforce with its own training, and they are covered by distinct legislation. Simply hoping that integrated care systems will take full account of that of their own accord will just not cut it. A more robust legislative approach is needed. Like the noble Baroness, Lady Meacher, I was also pleased to hear that the Minister in the other place recognised the importance of focusing on children and families in the new ICS structures and made a commitment that the Government would develop bespoke guidance for integrated care systems on meeting the needs of babies, children and young people. That is why I support Amendment 177 in the name of the noble Baroness, Lady Meacher, and to which my name is attached, to put this guidance on a statutory footing.

Amendment 162, on Clause 26, would require the Care Quality Commission to work jointly with Ofsted to plan and conduct reviews into the provision of health and children’s social care in integrated care board areas.

Again, I refer back to my experience as a member of the Lords Public Services Select Committee. I can confirm, as the noble Lord, Lord Hunt, will be able to, that the committee investigated the role played by the relevant regulators and inspectorates. Indeed, we took evidence from the senior leaders of the relevant inspectorates and regulators, specifically Ofsted and the CQC. Our conclusion was that, despite the very best intentions, these inspectorates do not work together closely enough or have a truly integrated approach. It is telling that our report revealed that the CQC itself called on the Bill

“to give it the ‘ability to look at [the] care of children across all settings’ as part of its regulation of Integrated Care Systems”.

I believe that the Bill should give the Care Quality Commission and Ofsted powers jointly to hold integrated care systems, service providers and local decision-makers accountable for the long-term outcomes for children’s health, including health inequalities.

I very much support Amendment 177 in the name of the noble Baroness, Lady Meacher. It has been explained and it very much goes with the grain of my other amendments.

I also strongly support Amendment 142 in the name of my noble friend Lady Walmsley, which would provide an opportunity for the Government to ensure that children and young people are prioritised on ICBs while maintaining local flexibility, which is important. An impact assessment would allow for good practice to be shared quickly and for both Houses to exercise effective scrutiny over the implementation of this legislation.

On Amendment 87 in the name of the noble Baroness, Lady Finlay, the idea of the appointment of a strategic clinical lead for children and young people’s health is an excellent proposal, but I will leave the noble Baroness to express that.

In conclusion, the Government have a very important agenda for children. There are a lot of things that they are trying to do. I strongly support most of them but I really feel that we must have an effective legislative framework to allow that agenda to be taken forward successfully.

[Baroness Finlay of Llandaff (CB)]

My Lords, this group of amendments is particularly important because it concerns the next generation, addressing children and young people’s health and social care needs. As has been said, I have tabled Amendment 87. I have also put my name to Amendments 141, 151 and 162, introduced so comprehensively by the noble Baroness, Lady Tyler. I also support the other amendments in this group.

These amendments address how the needs of children and young people aged nought to 25 will be met by the relevant healthcare and social care provision within the area of each integrated care board. A bonus from recognising this in the Bill would be the encompassing of young people with learning difficulties and autism, whom we discussed last week.

I was struck by a figure raised during the debate in the other place. According to Young Minds, 77%—more than three-quarters—of sustainability and transformation partnerships failed to consider children’s needs sufficiently. Only one of the 42 ICSs in existence listed a strategic lead for children and young people. Given the range of agencies and pathways, someone must have responsibility for the integration of services at the local level and for listening to the needs of young people.

More than 12.6 million children aged 18 and under live in England, yet the Bill reads as if it is written by adults for adults. Let us not forget that an estimated 800,000 children in England are child carers and more than 250,000 of them are likely to be providing high levels of care for their relative.

Alarmingly, the UK is fifth from bottom among 27 European countries for infant mortality, and one in six children has a diagnosable mental health condition. The number of children in looked-after care is rising and we have heard terrible stories of children whose lives have been lost through abuse and illness.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

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

[Lord Patel (CB)]

My Lord, I rise very briefly to support Amendment 37 in the name of the noble Baroness, Lady Thornton, to which I have added my name. She and the noble Baroness, Lady Meacher, have identified in detail why this is a key amendment that identifies the core representation that is required for ICB boards to function satisfactorily and develop strategies for population health in their area, and I strongly support it.

[Baroness Tyler of Enfield (LD)]

My Lords, I shall speak very briefly to Amendment 38 in the name of the noble Lord, Lord Bradley. I have huge sympathy with the intention behind this amendment. Everything that we have talked about so far on mental health has pointed to the fact that unless there is a strong mental health voice on ICBs, the whole issue of mental health funding and the priority it has will not get as strong a voice as it should. I recognise that some argue that we should not overspecify the membership of new bodies but should allow each integrated care system the flexibility to develop based on its own set of local relationships, and I do not overlook that point. However, my natural sympathy is that it is only too possible for mental health concerns to be ignored when decisions are made about resource allocation and prioritisation without a strong mental health voice around the table.

However, I think I may have a way through this. We need to look back to the discussions we had on Tuesday about the overriding importance of mental health being explicitly mentioned in the triple aims. If such an aim were in place, I think we would be hard pushed to form an ICS or an ICB without mental health representation and we might be able to argue that it is not necessary, in those circumstances, to have it in the Bill. However, if that aim is not explicit, then the argument put forward by the noble Lord, Lord Bradley, is very strong indeed.

[The Lord Bishop of London]

My Lords, I rose on the first day of this Committee to speak to the membership of NHS boards. I rise today for a similar reason: I think it is very difficult to stipulate the membership of boards, just as the noble Baroness has said. However, as I said with NHS boards, I say with ICB boards that I think the voice of the patient is central. Along with my role as the Government’s Chief Nursing Officer, I was director of patient experience while I was in the Department of Health. As a nurse at that time, I believed I had a patient focus. However, I learned that my default was always as a professional and that the patient needs a voice and empowerment. While I recognise the clinical voice and would always want it on the NHS board and the ICB board, it does not replace the voice of the patient and the carer.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

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

[Baroness Tyler of Enfield (LD)]

My Lords, my name is attached to six amendments in this extremely important group. I should like first to turn to Amendment 14 in the name of the noble Baroness, Lady Thornton, to which my name is attached. Other noble Lords have expressed support for amending the triple aim to explicitly include health inequalities, and I add my voice to that call. The examples given by the noble Lord, Lord Patel, and others about the real-life causes and impacts of health inequalities show just how important it is that we strengthen the Bill.

I would like briefly to highlight the specific impact of mental health inequalities, which are pervasive and deeply embedded. As the noble Lord, Lord Crisp, said in our debate on Tuesday, mental illness itself causes inequality. People with severe mental illness live, on average, between 15 and 20 years less than the general population. Black people are more than four times as likely as white people to be detained under the Mental Health Act. There are higher rates of suicide in the LGBT community, yet many in that community do not, or feel that they cannot, seek healthcare because of fear of discrimination. People with a learning disability often suffer with significantly worse physical and mental health than the general population.

The Centre for Mental Health Research has shown that it is often groups of people with the poorest mental health who have the greatest difficulty accessing healthcare that meets their needs and produces good outcomes for them. Unless an ICB is focused on which groups of people have the poorest health in the first place and understands why that is the case, it will, frankly, struggle to reduce the inequalities flowing from that.

Amendment 14 would amend the triple aim duties specifically for NHS England. Amendments 94, 185 and 186 in the name of the noble Lord, Lord Patel, to which I have attached my name, would replicate that explicit inclusion in the triple aim for integrated care boards, NHS trusts and NHS foundation trusts.

As the noble Lord, Lord Young, has said on health inequalities, regarding them as implied in the first element of the triple aim—to consider the impact of decisions on the health and well-being of the population—does not, in my view, get us any further than where we are today. Given the statistics that I have outlined and the fact, as we have heard, that the pandemic has made things a lot worse, we clearly need to go further.

I turn now to Amendment 65, regarding the role of local health systems. It seeks to strengthen the health inequality duty placed on integrated care boards by giving them a requirement to

“implement systems to identify and monitor inequalities in physical and mental health between different groups of people within the population”

of their area. As things stand, the provisions in the Bill will ensure that NHS organisations are required to address inequalities in a similar way to how CCGs currently do it. But we need to see more ambition. The provisions would be strengthened and not merely transferred. The current requirement to “have regard to” is not enough. Local health systems have a central role to play in addressing health inequalities. They are ideally positioned to understand the challenges in their areas and, to use the jargon—for which I apologise —co-produce local solutions with communities. The development of integrated care systems gives us a new opportunity for local areas to take population health and place-based approaches, so that the vulnerable groups who have been referred to do not fall through gaps.

There is a lot about health inequalities that we do not know; we suspect, but we just do not have the data. Amendment 65 proposes that the Bill includes clearer and more direct requirements for integrated care boards to focus efforts on identifying and monitoring those inequalities. Currently, the quantity and quality of data collected is inadequate for it to be fully disaggregated against the different protected characteristics and provide a real insight into the inequalities that exist. That is why I have attached my name to Amendment 61 in the name of my noble friend Lady Walmsley, which I strongly support.

Robust information and data are prerequisites for any action. Improved data collection—both on health services and on wider inequalities in the area—will lead to a far better assessment of what needs to be done, particularly in areas such as public mental health and the local NHS workforce. I will quote one statistic about GPs. A GP working in a practice serving the most deprived patients will, on average, be responsible for the care of almost 10% more patients than a GP serving a more affluent area. This simply cannot be right.

I will end by quoting from work we have already heard about—the work of Professor Sir Michael Marmot. It needs no introduction. He has demonstrated that efforts to address health inequalities will benefit society as a whole. The NHS Long Term Plan states:

“While we cannot treat our way out of inequalities, the NHS can ensure that action to drive down health inequalities is central to everything we do.”


I urge the Government to ensure that the Bill does just that.

[Lord Desai (Non-Afl)]

My Lords, as an NHS patient but not an expert, I will say one small thing about inequalities. Given the way in which the NHS is structured, with no money paid up front and with excess demand and inadequate supplies because of budget shortages, it is forced to allocate treatment by queuing—and queuing, obviously, means that people have to wait.

There is a fallacy that somehow the poor have more time than the rich. In my experience it would improve matters immensely if, when appointments are given, there was less delay in the patient seeing the person whom they are supposed to see. I know that, right now, there are standard regulations that cover these matters, so that people end up waiting three hours. I have done that. But my time is not as valuable as that of someone poorer. You do not measure the value of your time by your income. So it would improve matters if the allocation of services were made using communication devices. This would waste less of patients’ time and help them better access services.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

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

[Baroness Jones of Moulsecoomb (GP)]

My Lords, I rise as a member of the general public who can barely tell the difference between paracetamol and ibuprofen but does know, after all my years observing people, that people in good mental health often exhibit much better physical health as well, because they have more resilience, they are more aware of their physical health and they take measures to make themselves healthier. Parity of esteem is a beautiful concept because it does not sound competitive and the more we spend on mental health, the less we might have to spend on physical health. Therefore, it is a no-brainer. I am astonished that the Government did not put it in the Bill when it is such a well-known concept. I very much hope that the Minister will—[Interruption.] That was a Tory intervention and now there is a Labour intervention.

I understand that this is a huge challenge, but it is just smart, quite honestly. It offers us a chance to make a real positive change—a societal change for people. I also very much support Amendment 5 tabled by the noble Lord, Lord Stevens, and all the subsequent changes through the Bill, and Amendment 138, tabled by the noble Baroness, Lady McIntosh of Pickering, which my noble friend Lady Bennett has also signed. I look forward to subsequent discussion with the Minister on this issue.

[Baroness Tyler of Enfield (LD)]

My Lords, I rise to speak to the rather large list of amendments in this group—15 at the last count—to which my name is attached. I declare my interests as laid out in the register, particularly my new registered interest as a non-executive director of the Royal Free London NHS Foundation Trust.

Before turning to specific amendments, I have a couple of general points which apply across the board. The first concerns the scale of demand. Despite welcome investment and greater focus in recent years on mental health, there are now an estimated 1.6 million people waiting to access mental health services and so on a waiting list, and prevalence data suggests that some 8 million people with emerging mental health issues would benefit from services if they were able to meet the thresholds to access them.

Frankly, there are still too many instances of mental health services not being prioritised, such as the lack of investment in the mental health estate, which has a real impact on the trust’s ability to ensure both a safe and, particularly, a therapeutic environment. Also, the Prime Minister’s announcement on investment in new hospitals almost entirely overlooked the needs of mental health trusts.

The second general point is that the need to replicate the parity of esteem duty in the 2012 Bill throughout this Bill is more important than ever at a time when there is growing unmet need across multiple areas of health and care. Local health systems therefore face difficult choices around the allocation of resources. The full mental health impact of the pandemic is still emerging but mental health trust leaders report extraordinary pressures; in particular, a high proportion of children and young people not previously known to services are coming forward for treatment, often more unwell and with more complex problems.

The various amendments in the names of the noble Baroness, Lady Hollins, and my noble friend Lady Walmsley to which I have attached my name, and which I strongly support, recognise the important role that NHS England, ICBs, NHS trusts and foundation trusts will each have in advancing parity of esteem between mental and physical health. It will be important that amendments to the Bill that explicitly require the prioritisation of both physical and mental health are made at each level of the system. Simply put, trusts’ ability to prioritise both physical and mental health is crucially dependent on the extent to which integrated care boards and NHS England do the same. Ultimately, of course, each level in the system’s ability to meet this requirement is reliant on the Government prioritising both physical and mental health.

I will turn briefly to various sets of amendments. As I have said, a lot of these amendments are about explicitly including mental health on the face of the Bill, at each level and relating specifically to the NHS triple aim. I want to explain why that is important. As I said, Section 1 of the Health and Social Care Act 2012 enshrined in law a duty for the Secretary of State to secure parity of esteem between mental and physical health services. While the new Bill does not remove the duty from the Secretary of State, it fails to replicate it in the triple aim, and this sends out an unhelpful message. I fully accept that culture change needs far more than legislation but legislation can and does send an important signal, which is why we need parity of esteem strengthened throughout the Bill.

We know that the burden of mental illness in the UK far outstrips spend and that referrals to mental health services were at a peak during the pandemic. Thus, I strongly support the amendments tabled by the noble Baroness, Lady Hollins, and my noble friend Lady Walmsley which explicitly reference mental health in parts of the Bill setting out how the triple aim applies to trusts, foundation trusts, integrated care boards, NHS England and the licensing of healthcare providers. This would ensure that the whole of the NHS is aware of its duties around parity of esteem.

I turn briefly now to what is happening at the local level. A recent survey by the Royal College of Psychiatrists found that almost two-thirds of responding psychiatrists considered that their local area had been ineffective in working towards parity of esteem, and fewer than one in 10 said that their local area was effectively promoting parity. That is why each ICB should be required to promote parity; it should be included in their forward plans and they should be required to report on it as part of their annual reports. This would help transparency and help to hold the system to account; that is why I have added my name to the amendments from the noble Baroness, Lady McIntosh, and strongly support a separate amendment from the noble Baroness, Lady Hollins, which calls for a duty on ICBs to promote and seek parity of esteem between physical and mental health and, critically, to annually report on their efforts to do so.

I come now to the Secretary of State’s responsibilities in all this. Having the parity of esteem in the 2012 Act has helped to secure welcome and important initiatives, such as the five-year forward view for mental health and the review of the Mental Health Act. Amendment 263 in the name of the noble Baroness, Lady McIntosh, to which my name is attached, builds on this duty and requires the Secretary of State to outline to Parliament how the resourcing of mental health services and prevention efforts have ultimately improved care for people with mental illness and those at risk of developing poor mental health. This will bring further and much needed parliamentary scrutiny to this issue, and help us understand how we can build on current efforts to improve care and, most importantly, improve outcomes.

I turn finally to Amendments 5, 12 and 136, in the name of the noble Lord, Lord Stevens, regarding the funding of mental health. Of course, financing is one of the most important indicators of parity of esteem—if it is real—and legal teeth to ensure clarity on it are absolutely critical. As I highlighted earlier, even with recent efforts, spending on mental health is not commensurate with the burden of mental illness in this country. Indeed, a King’s Fund analysis recently found that mental health outcomes accounted for 23% of the burden of ill health in the UK but received only 11% of spend for both prevention and treatment.

The Government’s recent spending review did not specifically allocate any additional funding for mental health services, despite over £44 billion being pumped into the NHS over the course of the spending review and services facing increased and sustained pressure. The mental health sector has made it clear that it will need to cut services from April 2022 if additional funding is not received. The noble Lord, Lord Stevens, is very well placed to know the right mechanisms and levers to pull to ensure improvements in how we fund mental health services, and how different parts of the system are held accountable for their efforts to do so.

These three amendments, which build on the mental health investment standard—something I very much welcomed at the time—at a local level for ICBs, adding an additional legislative lever and helping to increase overall transparency on how local areas fund mental health services, are extremely important. Finally, at national level, I strongly support the need for greater transparency for both the Government’s intentions on mental health spending and NHS England’s response to, and meeting of, these intentions.

While we often hear encouraging and warm words of support on mental health from the Government—and they are welcome—these amendments would make clear where those words have been put into action. As the old saying goes, what gets measured gets done.

[Lord Patel (CB)]

My Lords, I will speak to the amendments in the name of my noble friend Lady Hollins. I have put my name to several of her amendments and I will speak to them all but, before I do so, I pay a very special tribute to her. For decades now, she has fought hard to improve the care of people with mental health and learning disabilities. Any progress that has been made has been to her credit, and any progress that we may help to make will not be ours but hers. We should try to help her.

On 8 February 2012, this House voted to put into legislation that mental health should be given parity of esteem with physical health. It was the only amendment of the 2012 Act that was carried, by a very narrow margin, as the then coalition Government had a big enough majority in both Houses. I remember apologising to the noble Earl, Lord Howe, who was the Minister taking the Bill through the House, for moving the amendment—I do not know why. He looked pretty confident, as he should have been because I was not confident; but I had moved the amendment on behalf of my noble friend Lady Hollins because it was her amendment. It just so happened that she was not able to be here; she was advising the Vatican at the time. Despite that, and to give credit to initiatives by NHS England and other NHS bodies, progress has been made—but it has been slow.

I declare an interest. I hold an honorary fellowship of the Royal College of Psychiatrists, which I am very proud of. In my time as a high-risk obstetrician, unfortunately, I had to look after women who suffered from severe puerperal depression and I can testify to how serious a mental condition it is.

Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) (No. 2) Regulations 2021

Baroness Tyler of Enfield Excerpts

Tuesday 14th December 2021 Lords Chamber

[Lord Cormack (Con)]

My Lords, I would not doubt for half a second that my noble friend was entirely sincere. I also believe that she made some extremely powerful points which apply right across the legislative pattern, and which apply equally to both Houses. I hate to say this of a Conservative Government, but they behave as if they treat Parliament with contempt. Whether one is talking about Christmas tree Bills, Henry VIII clauses or the lack of impact assessments—a point made so very powerfully by my noble friend—the Government are found wanting. If we were marking in Greek letters the performance of the Government, I would, as an old schoolmaster, give them “gamma double-minus.”

It really is sad that we have a Government who are treating Parliament in this manner. I sincerely hope that, when he comes to reply, my noble friend the Minister will give a firm undertaking to draw the attention of his parliamentary masters in government to this debate and to the speech of the noble Baroness, Lady Noakes, in particular. They should read, mark, learn and inwardly digest it—to quote the collect for the second Sunday in Advent.

When it comes to the substance, I always deplore anything that smacks of retrospective legislation, because that again is treating Parliament with studied contempt. I know how difficult it has been during these last 18 months or more. We all know that—and we all know that mistakes have been made, sometimes with the very best of intentions. But it is deeply disturbing that there has not been a recognition that retrospective legislation is the very antithesis of democratic parliamentary government.

I have suggested many times, including very recently, that there should be a continuing committee of both Houses looking at Covid legislation and being able to pronounce on it quickly. I made this point only recently to my noble friend. He completely, I am afraid, misunderstood it and told me quite inaccurately that this was a matter for the Lord Speaker—but anybody who knows what the Lord Speaker is able to do and not able to do knows that that is fundamentally wrong.

I know that he is new to Parliament and is serving his apprenticeship with great distinction—we all appreciate that—but it is important that the powers that be realise that in an unprecedented situation unprecedented measures are sometimes needed. They have shown that by issuing diktats; they have not shown it by creating a vehicle for continuous parliamentary monitoring—and they should.

On the subject of compulsory vaccination, my noble friend Lord Bethell knows very well that I have been on about this almost from the very beginning, urging that care home workers should receive compulsory vaccination, and I believe that it is entirely logical to extend that to those who work, because people who come into close proximity to patients at their most fragile and their most vulnerable should not themselves be a potential risk to those patients. We know that in some care homes during the early months—I appreciate that it is much better now—you could find that 30%, 40% or even 50% of care home workers, looking after the most fragile and physically feeble of people, themselves not vaccinated.

How do you solve this? It is, of course, a combination of persuasion and cajoling, but at the end there has to be a point where you say that we cannot allow this to continue indefinitely. Therefore, I think on that point the Government are right and I am grateful for it.

However, we are a Parliament and therefore I come back, as I began, to the admirable speech from my noble friend Lady Noakes. She pointed out—as many others have over the past two or three years, particularly the noble and learned Lord, Lord Judge, who I think must go to bed with an image of Henry VIII by his bedside—how cavalier has been the treatment of both Houses of Parliament by the Government. We are approaching a new year. Let it be a resolution of the Prime Minister and all his Ministers that they are accountable to Parliament; they are not the masters of Parliament.

[Baroness Tyler of Enfield (LD)]

My Lords, I wish to make some comments about the actual substance of this statutory instrument, although I will start by saying that I have a lot of sympathy with what has already been said about the lack of proper parliamentary scrutiny and indeed the lack of an impact assessment, which is extremely regrettable.

As I have said in your Lordships’ House before, I am very sympathetic to the overall principle that both front-line health and care workers should be vaccinated. However, as I have always said, it must be handled in the right way, particularly given the absolutely acute pressures that both health and social care are under and will be over the winter months. It is absolutely critical that the right amount of help and support is made available to health and care workers who are genuinely vaccine hesitant—and that means things such as one-to-one conversations during work time in which they can express what their concerns are and, I hope, get additional information.

I know very well from personal experience that care homes that, for example, have brought GPs in to have one-to-one conversations, taken the concerns that care workers have expressed seriously and tried to explain why it would be a good idea to have the vaccine, have had an awful lot of success, and I am concerned that there is not enough focus at the moment on that help and support. It was very regrettable—this point was raised by the Secondary Legislation Scrutiny Committee —that the draft Explanatory Memorandum made no reference to any lessons learned from the rollout of the earlier care home regulations, as well as being silent on what contingency plans the department had to cope with the expected staff losses when the regulations take effect. I know that those staffing issues will be particularly acute in London, where I live.

I recently had a helpful meeting with Healthwatch, which shared with me some very good research. It commissioned an organisation called Traverse to undertake in-depth conversations with a range of people, mainly of African, Bangladeshi, Caribbean and Pakistani ethnicity, to understand the reasons for their vaccine hesitancy and what can be done about it. Although the research was carried out with the groups I have specified, I suspect that the conclusions drawn in the report have more widespread application.

I found it interesting that the attitudes expressed were incredibly personal to the individual. One of the lessons learned is that you cannot lump all this together and say, “This is the issue for this group”; you have to think very carefully about individual concerns. There was most clearly, as we know, a lack of trust, which featured strongly in terms of the vaccine, and there was very strong distrust of those who had any possibility of standing to gain commercially from the rollout, which I thought was an important point. Probably most notable of all, people said that they trusted most of all front-line healthcare workers to talk about Covid and the vaccine and had less trust in very senior people in the NHS or Public Health England, who were perceived to have less tangible experience. That interesting document ends with very seven practical tips: ways to try to encourage health and social care workers to become less vaccine hesitant.

I end by asking the Minister whether he is aware of this document—if he is not, I am very happy to send it to him—but, more generally, what steps the Government and NHS England have taken to promulgate this sort of important and practical good practice and advice?

[Baroness McIntosh of Pickering (Con)]

My Lords, I echo the words of my noble friend the Minister in introducing the regulations before us in praising the heroic efforts of the whole health service: the volunteers, nurses, doctors and pharmacists—everyone involved. The vaccination programme is essential, but I hope that GPs and practitioners will have the vaccines in time to roll them out. My noble friend is aware of my work with the Dispensing Doctors’ Association.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, it is a privilege to follow the noble Baroness, Lady Campbell. I want to congratulate the noble Lord, Lord Stevens, on his quite outstanding maiden speech.

Overall, I welcome the shift away from competition to greater collaboration and integration in our complex health and social care sector that this Bill signals, but, like others, I am very concerned about the timing of this legislation. The health and social care systems currently face extreme challenges, workforce shortages and burnout, a resurgence of Covid with a new, more transmissible variant, a huge pandemic-induced backlog of treatment, winter pressures and social care in crisis. Now does not feel like the right time for a structural reorganisation which will inevitably divert scarce clinical and management attention from front-line delivery. So my first question to the Minister is: why now?

Secondly, the fundamental problem that the NHS is confronting is a lack of capacity and resilience, particularly the lack of spare capacity in the system, meaning that it is continuously running at an unsustainable “hot” level of bed occupancy. The UK has 2.7 hospital beds per 1,000 of population compared to an EU average of 5.2 and significantly fewer doctors and nurses per head of population. So my next question to the Minister is: what plans do the Government have urgently to increase capacity and deal with workforce shortages, and how does this Bill help? Like others, I strongly support the calls for Clause 35 to be amended so that the Secretary of State must publish independently verified assessments of current and future workforce numbers every two years.

I wish to focus briefly on three issues that I shall pursue in the Bill. First, the Bill reads as if it is written by adults for adults. Babies, children and young people make up 30% of the population. They have their own distinct workforce, a distinct legal framework and distinct services. More needs to be done to ensure that the benefits of integration apply equally to the children’s system, and this should be made explicit in the Bill.

It is vital that children are prioritised in the new integrated care systems and that a national accountability framework supports them to deliver improvements in health and social care outcomes for children. There must be a plan to set out clearly how existing duties, including leadership of local safeguarding arrangements, will be transferred from CCGs to integrated care boards without endangering the safety of children or impacting on the provision of services. Following the heartbreaking and horrific murder of Arthur Labinjo-Hughes, the Bill should be used as an opportunity to strengthen leadership within these safeguarding partnerships, to improve independent scrutiny of the arrangements, and to ensure that action is taken in response to the lessons learned.

Secondly, as highlighted in a recent report on child vulnerability by the Lords Public Services Committee, there needs to be improved data sharing to allow better joint working across health, education, and children’s social care. As the noble Lord, Lord Bichard, pointed out, data sharing in the Bill currently applies only to the adult system, for reasons I do not understand. The Bill must surely be amended to make it clear that the benefits of better information and data sharing apply equally to children and that agencies can and should share data where it is in the best interests of children to do so.

Mental illness represents up to 23% of the total burden of ill health in the UK but only 11% of NHS England’s budget. At present, there is no assurance in the Bill that mental health will be given equal precedence with physical health in integrated care systems or by NHS England. This is disappointing after the hard-fought and successful battle, which many noble Lords were involved in, to amend the 2012 Act to make it clear that the Secretary of State must prioritise mental health as much as physical health. While the new Bill does not remove this duty from the Secretary of State, it fails to replicate it in the new triple aim. Like the noble Baroness, Lady Morgan, I want mental health to be mentioned explicitly in the NHS’s triple aim and in relevant parts throughout the Bill to specify that NHS England, ICBs and ICPs are expected to pursue “parity” between mental and physical health in all their functions and to report publicly on their outcomes.

Finally, on health inequalities, there is clearly scope for the Bill to be strengthened, as the noble Lord, Lord Patel, made clear. The pandemic has cruelly exposed and exacerbated health inequalities that have long existed in our society. I was going to set out various places where that could be done, but the noble Lord did it so comprehensively and clearly that I shall not repeat it.

If levelling up is to mean anything, the triple aim should be amended explicitly to reference health inequalities, thereby sending a clear signal to all parts of the new healthcare system that this is a priority at all levels.

Adult Social Care

Baroness Tyler of Enfield Excerpts

Thursday 2nd December 2021 Lords Chamber

[Lord Kamall (Con)]

I know that the noble Lord has been a champion in this area. We have been quite clear that, as we go forward, a number of issues have to be understood. For example, you cannot say that all unpaid carers are the same. They all have different needs: some can work and some cannot work; some can spend a couple of hours working and share their care duties with others; there are sole carers; some are elderly and some are younger. We want all the different partners to come together to discuss individual needs—including respite for carers, to rest and recharge—and to look at their financial situations. We have laid out that those who are not working may be eligible for other benefits on top of the care allowance that they get. We are exploring this. It is a process of discovery and we want to ensure that it works. We have therefore set out the vision and the three-year commitment.

[Baroness Tyler of Enfield (LD)]

My Lords, I would like to pursue the points that were raised a minute ago by the noble Baronesses, Lady Fox and Lady Watkins. Despite the welcome long-term aspirations in the White Paper, the reality is that the chronic workforce shortages in social care are getting worse, with uncompetitive pay being the main culprit. If Covid surges this winter because of the new variant, these workforce problems will be magnified, with potentially disastrous consequences. There are similar concerns with unpaid carers, as the noble Lord, Lord Dubs, has just said. With no new resources from the new levy coming on stream until October 2023, and all the fragilities that I have just described, what are the Government going to do to address the pay and retention issues now, over this winter?

[Lord Kamall (Con)]

The Government have been listening to the workforce and understand its pressures. We recognise that this is the vision, and that we need to look also at the short-term issues. We announced £162.5 million for the workforce recruitment retention fund, and the new Made with Care scheme to recruit social workers and to send a message that social work can be a rewarding career. We are talking to different bodies, including the Department for Education, about how we increase professionalisation. We have also increased the national living wage, meaning that many of the lowest-paid workers will be paid more. We are investing at least half a billion pounds in supporting the development and well-being of the social care workforce, including an investment in knowledge, skills, and well-being. We will work with partners to set the conditions for the professionalisation over a longer period. We cannot do this immediately; we want to consult the education sector and care and social care experts, to give recognition. That will be a precursor to making progress on pay.

Ambulance Response Times

Baroness Tyler of Enfield Excerpts

Wednesday 1st December 2021 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Lord for raising that point and making people aware of the challenges in Northern Ireland. As he will be aware, health is a devolved issue, but we are very much aware of the challenges in all four of the devolved Administrations. If he would write to me with extra information, I should be happy to pass it on.

[Baroness Tyler of Enfield (LD)]

My Lords, it is estimated that nationally, a quarter of patients in beds are clinically ready to leave hospital but cannot do so due to problems of discharge—particularly a lack of available care in the community. With fewer available beds, ambulances cannot discharge patients to a bed, leading to a lack of ambulances and paramedics available to deal with other emergencies. What plans do the Government have to deal urgently with the problem of discharge to help the NHS get through the winter?

[Lord Kamall (Con)]

All noble Lords have raised important points about the pressures on different parts of the system. In taking a systemic overall view, the Secretary of State is holding regular “pressure” meetings and looking at the key metrics in getting those pressures down. He is also looking at how we can tackle things systemically from within, including discharge issues. We are looking at how to improve on discharges to make sure that there is enough space, thereby continuing to ensure not only that elderly patients are back in their homes as quickly as possible, but that we reduce the length of time that others have to wait for ambulances.

Health Protection (Coronavirus, Wearing of Face Coverings) (England) Regulations 2021

Baroness Tyler of Enfield Excerpts

Wednesday 1st December 2021 Lords Chamber

[Baroness Altmann (Con)]

My Lords, on a personal level, I do not have a problem with wearing a mask. I understand that the Government are in a difficult position, because they are almost damned if they do and damned if they do not on issues of this nature. My concern is that we started off following the science but now seem to be anticipating what the science might show, in the absence of evidence that this omicron variant is any more deadly than previous variants. We seem to be ignoring the fact that, unlike when delta started, so much of the population is now vaccinated; they are therefore protected. The Government should be given enormous credit for the vaccination programme and the booster programme.

Looking at the evidence from the delta variant, as the virus progressed it became much more contagious, as all viruses tend to, but it was much less deadly. The people for whom it was particularly dangerous were those who were unvaccinated. Since we have given everybody who could have an opportunity to be vaccinated the chance to do so, and that some people have—for reasons that they know best—refused to accept the vaccine, it seems there are implications for the wider public in continuing to try to protect those people. I recognise that there are clinically vulnerable people who cannot be vaccinated, which is an issue in itself. But I am seriously concerned about wider society, particularly as the self-isolation rules will not run out until next March and have a psychologically damaging impact on society. They frighten the public and could cause, I believe, significantly higher numbers of deaths from loneliness, mental ill-health and illnesses such as cancer, which the public may be too frightened to see their doctor about, or for which GPs may now again say that they cannot see people face to face, and therefore miss the symptoms.

I hope that this mask-wearing SI will be lifted at the end of the three weeks. We need to trust the public. I agree that we need to help people understand the risks and that they need to consider them, but it is perfectly valid for people to decide that they do not consider the risks too large to stop them seeing friends and family. I have significant concerns about mandating and fining them for not doing things, when we do not have evidence to suggest those are as damaging to the public as we previously considered them to be.

[Baroness Tyler of Enfield (LD)]

My Lords, I would like to make a few comments about the mask-wearing regulations, which I strongly support while feeling that wearing masks should never have been abandoned in England. It is with great sadness that I have to tell the noble Lord, Lord Robathan, that at exactly this time last year I attended the funeral of a friend of mine, the exact same age as me, who died from Covid. I wonder what the families of the over 1,000 people dying from Covid each week would think if they were listening to our debate now.

The questions I would like to ask the Minister are primarily about compliance and enforcement. When I got on the Tube yesterday, it was clear to me that the message had not got across to quite a few people. I was concerned that there was no one standing at the Tube station to point out to people that it was now a legal requirement and that there were no notices making it clear that that was so, rather than a condition of passage. Those things are different. Can the Minister please explain the responsibilities for enforcement, particularly on public transport, as between, for example, Transport for London staff and the police or transport police?

It is going to be hard to get the messaging back on track after people have been told that they did not need to wear masks; now they are being told they need to again. There is a good reason for it but the bit I have not heard so far in the debate today is that mask-wearing is primarily about protecting other people. Yes, I believe scientific evidence says that it confers a degree of protection on the wearer but it is primarily about protecting others—and we do not know the medical vulnerabilities and risks of the people we sit next to, be it in this Chamber or on public transport. That is the main reason I feel mask-wearing should never have been abandoned.

I also want to ask the Minister about people who genuinely have medical exemptions. Clearly, there are people who do. Yesterday on the Tube, I was standing next to a lady who was wearing a green lanyard and a badge; personally, I found that very helpful. She was making it clear that she was exempt. To help with the compliance issue at the moment, what plans might the Government have to encourage people who are genuinely medically exempt to have badges, lanyards or exemption cards, or something like that? However, it was clear to me that a number of people not wearing masks on the Tube, yesterday and today, were certainly not genuinely exempt.

[Lord Cormack (Con)]

My Lords, I will intervene briefly. I do not like retrospective legislation, and even though these regulations have been introduced much more quickly than some previous ones, we should have brought them in a couple of days ago. Parliament should approve regulations before they are issued. I do not take exactly the same line as my noble friend Lady Altmann, although I generally find myself in great sympathy and agreement with her, because I think we are all tackling the unknown. Nobody knows just how severe this new variant is or how effective the vaccines—I am triple-jabbed—will be. We must bear that in mind.

I make a suggestion which I made a year or more ago, which I think has some merit. Your Lordships’ House and the other place have found our agenda dominated to a large degree by Covid and the various regulations that have been brought in to try to deal with it. I suggested then, and repeat now, that we must accept that we will be living with Covid for a very long time. I have accepted it by coming to your Lordships’ House in person almost throughout the whole pandemic, partly because I hate dealing with Zoom and Microsoft Teams, but also because I like the human contact here. I also believe that, if we are Members, we have a certain duty to be here.

It would help enormously if we could have a Joint Committee of both Houses sitting in almost continuous session, where we could discuss proposals, assess evidence and not disrupt the ordinary and important business of the House. There is a parallel, in a way, with how waiting lists have been added to in the National Health Service and people have been put under enormous strain because of Covid. We would be well advised to try to have continuous parliamentary supervision and monitoring of what the Government propose in the light of all developments. I put that suggestion forward once again.

I have another specific question which I would be grateful if my noble friend would answer. I was contacted a few days ago by someone living in south-west London who is unable to have a vaccine for medical reasons. There are such people. He went to inquire of his general practitioner about the medicine that is now being developed—I am terribly sorry; I am having a senior moment and its name escapes me as I stand before your Lordships. My noble friend referred to it and will know what I am talking about. The general practitioner in question had no knowledge of it, or of where my friend could get it.

I would like an assurance from my noble friend that there is a proper dissemination of information so that doctors who are approached by those who cannot have the vaccine for genuine medical reasons can be informed. I mean genuine medical reasons, as I was one of those, as the noble Baroness, Lady Thornton, knows, who called time and again for compulsory vaccination of those working in care homes. She is kindly nodding approval. I felt the same about those working in the National Health Service. Those who are in contact with the most vulnerable should be obliged to have protection.

Covid-19 Update

Baroness Tyler of Enfield Excerpts

Monday 29th November 2021 Lords Chamber

[Lord Kamall (Con)]

The noble Lord raises an important point. I will double-check the details as I do not wish to mislead him or the House. Given that this is a fast-moving situation, in which the data is very new, changing constantly and constantly being reviewed, it would be more appropriate if I double-check before I answer.

[Baroness Tyler of Enfield (LD)]

The new requirements are for all travellers arriving in the country to take a PCR test on or before day two and to self-isolate until they have received a negative test. However, on the government website today, it says that if someone has tested positive with a PCR, they should not be tested again using either a PCR or lateral flow test for 90 days, unless they have developed new symptoms. What are returning travellers who have tested positive in the last 90 days meant to do? Who is cross-checking the existing guidance against new regulations?

[Lord Kamall (Con)]

All I can do is thank the noble Baroness for her question. I will have to double-check; as she will imagine, I do not have all the answers at the moment. Throughout the day, as I was preparing for this, the advice was changing constantly, and things were being swapped in. Advisers from the Department of Health and Social Care were saying, “This is the latest advice”, but it was changing literally hourly. I will try to get the latest advice and share this with noble Lords.