Health and Care Bill

Baroness Tyler of Enfield Excerpts

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

[Lord Stevens of Birmingham (CB)]

My Lords, continuing the outbreak of consensus, a large number of mental health stakeholders welcome the fact that the Government have accepted these amendments, which draw heavily on amendments a number of noble Lords brought forward in Committee. I think I said at that point that they would represent a spine-stiffener for the Government in their commitment to ensure that mental health sees a growing share of the growing NHS budget and an accountability booster for the NHS. I think they do that.

However, before the Minister concludes on this item, will he say whether, when setting the mandate for NHS England for the financial year ahead—the mandate that will therefore be laid at some point within the next 30 days—the Government might set the mental health waiting time standards, the very welcome consultation on which concluded last week, in a way that other amendments in this group would look to advance? None of that should detract from the fact that these amendments have wide support outside this place and will make a real difference to mental health in the years to come.

[Baroness Tyler of Enfield (LD)]

My Lords, I rise to speak to Amendment 184, tabled in my name. I shall first respond briefly to the government amendment introduced as a result of the discussions in Committee, which set the context for my amendment. I welcome the government amendment requiring the Secretary of State to publish his expectations about increases in the amount and proportion of mental health spending by NHS England and ICBs. I also welcome amendments requiring NHS England and ICBs to include information about spending relating to mental health in their annual reports.

However, it is stating the obvious to point out that their ability to do so is ultimately reliant on the Government—that includes the Treasury—prioritising sustained growth and investment in mental health. This is critical to avoid a widening care deficit in mental health and inequity between physical and mental health care standards. When I say “a care deficit” I want to explain briefly that the healthcare system is still operating in the context of a mental healthcare deficit, where not all those who need help and treatment will seek it or be able to access it and it is estimated that 1.7 million people are waiting to access mental health services.

That is the context of my Amendment 148. It is designed to build on the welcome government amendments and to provide what I call the critical third pillar of reform, which is service access standards. I welcome the measures that the Government have already taken in relation to access standards as part of the NHS long-term plan, but I believe we need to go a bit further and give them more teeth. Waiting time standards can play a critical role in making progress towards our shared ambition of achieving parity of esteem, particularly in service response times. Standards are a driver to secure the resources needed for services to be able to meet demand in an effective and timely way.

Key to the successful implementation of the service access standards will be two things: first, the funding to develop services in a way that means they can meet these standards without leading to unintended consequences, such as transfer of delays from accessing the system to further down the care pathway; and secondly, a clear expectation that these standards must be matched with a sufficient workforce so that the standards are delivering better care and not shifting problems further down the line.

Having these service access and waiting time standards underpinned by legislation would be a very effective lever for improvement by helping to identify where additional resources are needed. I have looked very carefully at the two points in the response published last week to the consultation on NHS access standards. I think the key points were clear: new targets cannot be introduced without additional funding to support them; respondents were generally strongly supportive of new targets in mental health; quality as well as speed of response is important; and expanding the range of the targets to include preventive and early intervention services would be beneficial.

I took heart from the news release that accompanied the publication of that response. I saw that the Minister for Mental Health, Gillian Keegan MP, said:

“Improving access to mental health services is a top priority. These new standards would help patients get support faster—including having a face-to-face assessment within one hour of being referred from A&E. I know there is more to do and that’s why we’re transforming mental health services in England with an extra £2.3 billion a year and will soon be launching a national conversation to inform a new long term Mental Health Strategy later this year”.


That is all very welcome. With such an endorsement from the Minister in the other place, I hope that the Minister will feel able to support my amendment, which provides that critical third pillar of funding, workforce and waiting time standards to ensure that all those aspirations become a reality.

--- Later in debate ---

I hope noble Lords will agree that, given the amount of comprehensive work already under way and the reports my right honourable friend the Secretary of State has committed to publish, a report such as the one outlined in the amendment is unnecessary. So I beg to move the amendment in my name and hope that the noble Baroness will consider not pressing hers.

[Baroness Tyler of Enfield (LD)]

My Lords, I thank the Minister for that very detailed and comprehensive response to my amendment. While in an ideal world I would like to see an amendment or measure in the Bill on waiting time standards to complement the other work, I accept that there is an awful lot going on that the Government are committed to. I think we will need to monitor very carefully how effective that is, but I will not press my amendment when the time comes.

Amendment 2 agreed.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

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

[Baroness Tyler of Enfield (LD)]

My Lords, I support Amendments 297A and 297D. I will be brief, because we have already had a very lengthy and wide-ranging debate. The amendment in the name of the noble Baroness, Lady Hodgson, is important, and she has set out the case for a named GP very well. As people become older, they tend to develop a more complicated and interrelated set of healthcare needs, and a GP who has that overview and can liaise with the family is extremely important.

I will add two quick points that have not come up in the debate so far. First, it might sound like a statement of the blindingly obvious, but for this very desirable amendment to happen, there need to be enough GPs in the system. Frankly, I am concerned that, despite commitments from the Government to increase the number of GPs by 6,000 by 2025, there is no current plan for how this will be achieved. The number of qualified full-time equivalent GPs is smaller today than it was in 2015.

Secondly, in relation to health inequalities, it is matter of real concern that GP practices serving more deprived populations receive less funding and often serve much larger numbers of patients than GPs in more affluent areas. I looked at the figures, which I will not repeat, and there are huge disparities in the size of the lists that they serve. I feel that passing an amendment of this sort on continuity of care would most likely benefit patients in the most deprived areas. With this debate, and if this amendment were accepted, I hope that there would be more pressure on the system to relieve that very unhelpful trend.

Amendment 297D is an extremely important amendment, and I am very grateful to the noble Lord, Lord Hunt, for raising it. I do not want to repeat what he said, save to say that I would see this review as a first step towards strengthening the rights of care home residents and their relatives to visit, to keep in touch and to spot the signs of abuse. We all understand how hard the pandemic has been. Most care homes have done their level best, despite a lack of access to PPE and testing in the early days. None the less, many of the visiting restrictions that have been imposed have far too often been blanket restrictions, rather than restrictions that took individual cases and individual needs into account.

We had the repeat Statement from the Minister last week on vaccinations, and we were told that there is now no limit on the number of visitors allowed in care homes. I can tell noble Lords that I have not been able to visit my mother inside her care home since before Christmas, because there have been continuous outbreaks of Covid. Often it affects only two people, but that is enough to shut the care home down. This is why there needs to be a more proportionate and individually judged approach to these things.

Finally, if we had a review of this sort and could strengthen rights, I would hope that we could also strengthen the human rights of care home residents, including self-funded residents who currently have no recourse to the Human Rights Act, which is fundamentally unfair.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I attached my name to Amendment 290 in the name of the noble Baroness, Lady Greengross, but I support all these amendments. The comments made by the noble Baroness, Lady Watkins, on Amendment 291 were particularly important as an improvement, but it is still crucial that this is all looked at holistically.

I will confine my remarks to Amendment 290, which is about social prescribing for dementia, focusing in particular on music and the arts. We have discussed social prescribing extensively and I will not go back over that ground. However, I will note how much the Alzheimer’s Society website stresses the importance of music and the arts for the quality of life and care of Alzheimer’s patients, and dementia patients more broadly.

I want to join up a couple of dots. The amendment talks about ensuring that health professionals are aware of the benefits, but I would like to word it much more strongly to ensure that this is regarded as an essential part of care, not a luxury add-on extra—“If we can find the money we’ll do this nice thing”—which all too often is how it is regarded. On that point, I link back to my Amendments 237 to 239, which were debated in a previous Committee session, on ownership of care homes and the flow of funds into care homes, and the fact that 16% to 20% of money in the average care bed is going into financial instruments. If we took two-thirds of that money and put it into more traditional medical, social-type care, and put in some more money for carers to be paid a little better, we would still have some money left for this kind of social prescribing. If we look at that in this context, we see how we join all this up. We really need to stress that social prescribing is an essential part of care, not some luxury add-on extra.

In one more effort to join up the dots, I will make the point that often in your Lordships’ House different people work on different areas and things are not joined up. We have some noble Lords, particularly on the Cross Benches, who do a lot of work in the creative industries, which, financially, are suffering enormously through the Covid pandemic. There is something to be done here in joining up with government-funded projects that help people in the creative sector do some training and get some skills, to enable them to take their skills, knowledge, enthusiasm and energy into social care—thereby spreading economic prosperity and improving people’s quality of life. Let us try to join these things up a bit more and not look at them in silos.

Vaccination: Condition of Deployment

Baroness Tyler of Enfield Excerpts

Thursday 3rd February 2022 Lords Chamber

[Lord Kamall (Con)]

I thank my noble friend for his question and for his longer-term engagement with me on this issue. I assure him that we are keeping this under constant review. The evidence changes. We are aware that new variants will arise, as is natural with any virus. Given the replication factor, when the virus replicates, there will be some imperfect replications and so there will be variants. That is just part of the virus spreading. As my noble friend acknowledges, we cannot give an absolute guarantee that there will be no new variants, but we are keeping an eye on all the variants and their continued transmission, along with the tools that we are using to protect workers, staff and everyone, to make sure that we are continuing to protect people as best as possible.

[Baroness Tyler of Enfield (LD)]

My Lords, I was pleased to hear the Minister say just now that some care homes will choose to keep this as a condition of employment because of the reassurance that it gives to both the relatives and the residents. In this increasingly fractious debate on mandatory vaccinations, one voice entirely missing has been that of patients, social-care users and care home residents on what they want. Could the Minister tell me, first, what consideration in the decision to change the policy was given to the wishes of patients and residents? Secondly, will patient-voice groups or relatives’ groups be included in the consultation referred to by the Minister? Thirdly, what will be the position of patients who, due to their own vulnerabilities, actually do not want to be treated by staff who, despite being given every opportunity, have chosen not to get vaccinated?

[Lord Kamall (Con)]

I thank the noble Baroness for raising that point. It is really important to note that, when engaging in debates such as this, it is sometimes easy to forget patients, and we should not do that. The health service should be all about patients; it should be patient-centred. I understand the concerns. One of the reasons that we originally introduced VCOD, particularly for care homes and then more widely, was that patients were very concerned and relatives of patients were concerned about their loved ones—they were terrified, given the early outbreaks that we saw in care homes. On the particular consultation, I am afraid that I do not have the information with me, but I will commit to write to the noble Baroness.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to speak on this group of amendments, but I want to focus particularly on Amendment 219. There are around 6.5 million unpaid carers in the UK, a number which increased to 13.6 million, or about one-fifth of the population, during the height of the pandemic. Some 1.4 million people provide more than 50 hours of unpaid care per week. Unpaid carers are often relied on to provide this care, yet receive minimal or no formal support themselves. Instead, many report feeling isolated, undervalued and pressured by the challenges of stress and responsibility. Being a carer is emotional and physical labour.

A lot has been said about the Carers UK survey, which identified that 56% of unpaid carers were not involved in decisions about patients’ discharge, with seven out of 10 respondents not being asked whether they were able to cope with having the patient back home and six out of 10 receiving insufficient support to protect their own or the patient’s health and well-being. This lack of support reflects the absence of a unified and systematic approach to identifying and supporting unpaid carers. It demands urgent remediation, especially as we know that unpaid carers are twice as likely as non-carers to have ill health, and the majority have reported worsening mental and physical health during the pandemic.

I endorse Amendment 219 because it talks about carers who work with people who come into contact not just with hospital services but with NHS services. In my work as a community mental health nurse, in many instances I saw that people were not admitted to hospital for years—which was actually a very good outcome—but their carers’ needs were just as great in supporting them with long-term problems in their own homes. This amendment would create a duty in respect of any person receiving NHS care, whether that is in the community or in hospital. The NHS must identify unpaid carers, particularly young carers, and ensure that their health and well-being are properly considered. This is a vital public health duty.

[Baroness Tyler of Enfield (LD)]

My Lords, I strongly support this group of amendments. I particularly endorse Amendment 269 regarding young carers, which was spoken to so compellingly by the noble Lord, Lord Young.

I wish to speak primarily about Amendment 221, to which my name is attached. It is about protecting existing rights of carers. I know that the point has already been made, but it is worth repeating. Amendment 221 would retain existing rights being taken away by this Bill as it repeals the Community Care (Delayed Discharges etc.) Act 2003. I find that a pretty extraordinary position to be in.

I want briefly to focus on the impact of caring particularly on women and employment, without in any way wishing to diminish the very important role played by male carers within the family. It is just a fact that women are more likely than men to be carers. According to some research conducted by Carers UK with the Universities of Sheffield and Birmingham, women have a good chance of becoming carers 11 years before men. Women are also more likely to reduce their working hours in order to care, and they are more likely as a result to have lower incomes and end up under-pensioned in retirement.

As we have heard, hospital discharge can be a pivotal moment for people providing care, particularly women. This amendment would ensure that assumptions are not made about carers’ ability to care, even when they may be working at the same time, that a solution is discussed and, ideally, agreed between families and services, and that carers are provided with the support they need to enable them to care safely and well. For those carers who are juggling work and care, which I can relate to personally, it is essential that their health and well-being are supported. This also has a positive benefit for employers. During the pandemic, the Carers UK research already referred to found an increase of around 2.8 million in the number of people who were juggling work and care, the majority of whom were women. Prior to the pandemic, some 600 carers a day were giving up work to care. During the pandemic, as the noble Baroness, Lady Pitkeathley, reminded us, carers have become the backbone of the care system, protecting the NHS and social care in many cases from collapse.

The Carers UK research also found that 72% of carers providing substantial care and working were worried about continuing to juggle care and work, and 77% of carers said that they felt tired all the time at work because of their caring responsibilities. During the pandemic, 23% of working-age carers providing substantial care had given up work, lost their jobs, lowered working hours or lost income if they were self-employed.

As the NHS works to reduce the backlog of care, hospital discharges will become ever more critical, as will support for carers. The two go hand in hand, and we must not fail those who have so selflessly shouldered such a heavy load.

[Baroness Altmann (Con)]

My Lords, I shall speak to all the amendments in this group, but I have added my name to Amendment 217 in the name of the noble Baroness, Lady Wheeler. There are two separate but related issues in this group of amendments, and it might be helpful for a moment to focus on them. The first is the needs of patients who are facing discharge from hospital. The second is the needs of unpaid carers in situations where patients are sent home from hospital. That second issue is covered particularly by Amendments 219, 221, 225 and 269. I support all of them, and commend the work and the words of the noble Baroness, Lady Pitkeathley, and the passionate speech from my noble friend Lord Young.

I wholeheartedly share the concerns about the repeal of the provisions in the Care Act 2014. The issue of patients needing to be discharged from hospital sometimes seems to be spoken of as if we are discussing objects rather than people.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

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

Finally, it is with humility that I propose amending the Children Act 1989. Internationally, it is highly respected and much copied. However, the intention of my amendments is to fulfil its key principles: the emphasis on prevention, on keeping children with their families wherever possible and on ensuring that help is available for parents who struggle to nurture their children or provide a safe and stable environment in which they can thrive. I commend these amendments to the Committee.

[Baroness Tyler of Enfield (LD)]

My Lords, I lend my voice to this important group of amendments. I will explain very briefly why family hubs are so important to many of the big themes that we have been discussing in the Bill so far: prevention, early help and integration in particular.

Family hubs have a very important role to play in improving early intervention services and helping with integration and data sharing, as we discussed earlier, among public services and the voluntary sector. Importantly, as the noble Lord, Lord Farmer, explained, the range of services available in family hubs often includes important services such as children’s health services, which are better delivered in a community setting and integrated with other family health services, rather than delivered in a hospital or somewhere that has a much greater focus on acute care.

The Public Services Committee, on which I served until very recently, produced what I thought was a very important report on vulnerable children recently. It put a national rollout of family hubs at the very core of a national strategy for child vulnerability, proposing that the most deprived communities be prioritised in the early stages of any such expansion. In our report, we set out what fundamental characteristics we thought should be at the heart of every family hub, including employing full-time family co-ordinators, offering addiction and domestic violence services, providing support for parents with poor mental health and organising parenting classes. I say that, because I hope that it illustrates the point I made about integration between health services and broader family support services.

I had the privilege as a committee member—I think the noble Lord, Lord Hunt, was with me—to visit Westminster family hub. I sat down and talked to a young mother with two young children who had a lot of very difficult issues that they were dealing with. The mother explained how the help and support she was getting through the family hub, both with her health issues and those of her children, as well as a wider range of issues, were helping her to keep her head above water. I was so impressed with that family hub and the help and support it was giving, and the way it was integrating statutory services and the voluntary sector.

I will make two other brief but important points. First, family hubs will be working with children from birth to 19. I see that as important, because families face challenges at any time, not just when children are very young, and focusing solely on early years and not helping families with older children does not have the same sort of holistic approach. So it is extremely helpful if, during early years, families build up these trusted relationships with people they meet in family support hubs of the type I have described, rather than sever that relationship when the child reaches the age of five. Parents can continue to contact a familiar team and access that trusted source of information and advice.

My final point to emphasise is the importance of family relationships and relationship support. One key thing about family hubs that is very important is the work they do to prioritise help with relationships—it might be couple relationships, parent-child relationships or even sibling relationships. By being able to deliver counselling and various other programmes to address some of the conflict and breakdown that often affects families in these difficult situations, they often help avoid the whole family reaching crisis point, particularly to the extent that parents have to access the courts to resolve disputes. For all these reasons, I very much support the amendments.

Health and Care Bill

Baroness Tyler of Enfield Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Scriven (LD)]

My Lords, I support Amendments 85 and 88 in the name of the noble Baroness, Lady Hollins.

We must be clear. The previous two speeches highlighted the elephant in the room: you cannot have integration on a sustainable basis unless you reform health and social care together. We have to be honest with ourselves that this Bill is predominantly about the reform of healthcare.

That was highlighted eloquently in the speech by the noble Lord, Lord Hunt, in response to my noble friend Lady Barker, about who should commission sexual health services. These have been lobbed to the side of the commissioning silo but it should be about how to break down this silo so that we have joint and sustainable commissioning around outcomes, rather than around which silo or which part of the health and social care framework should deal with it. It is the elephant in the room, but we are where we are so we must make this Bill better knowing that that is the real issue.

This is about three little words: social care services. It is clear to those who understand health and social care that the Bill has been written predominantly through the lens of healthcare. I do not blame anybody for that but clearly this is a healthcare commissioning reform Bill, with a little tinkering with the structure, and does not deal predominantly with those people who do not understand social care—unless they are asking for an NHS long-term care package, when the argument tends to be about not the care provided but the funding, including who is going to fund what part. That is when it affects people’s outcomes. Those three little words are really important, which is why the noble Baroness’s amendments are important. If they were accepted, the Bill would actually say that social care service and health outcomes are jointly important.

It is important that this is about integration. The noble Baronesses, Lady Pitkeathley and Lady Hollins, said that there is a significant difference between collaboration and integration. You can have two people collaborate but, if their silos send them in different directions, the outcomes will not be joint. The real issue is how we bring about integration. It will not solve all the problems but it will help to bring about the first stage of integration if you have a joint framework on outcomes for which both healthcare and social care are held accountable. That is why Amendment 88 is so important.

The Bill’s intention goes in the right direction but the three amendments in the name of the noble Baroness, Lady Hollins, will significantly help in that journey. They will not solve the problems fully but they are an important way to say to people who work in health and social care that they will be held responsible for the outcomes of individuals, whether their needs come under healthcare or social care. That is why I support these amendments.

[Baroness Tyler of Enfield (LD)]

My Lords, I support Amendment 101B in the name of the noble Lord, Lord Layard. Before I speak to it, I want to say how much I agree with the sentiment expressed by noble Lords on all Benches that true integration will be achieved only if the Bill is as much about social care as it is about health. It is such a fundamental point that I wanted to underline it.

I see Amendment 101B as an important continuation of our deliberations last week on parity of esteem because “parity of esteem” are simply meaningless words unless they are reflected in the provision of funding. First, like the noble Baroness, Lady Watkins, I acknowledge the welcome fact that NHS England has met its commitment to ensure that the increase in local funding for mental health is at least in line with the overall increase in the money available to CCGs through the mental health investment standard. It is also welcome that, from 2019-20 onwards, as part of the NHS long-term plan, that standard also includes a further commitment that local funding for mental health will grow by an additional percentage increment to reflect the additional mental health funding being made available to CCGs. I recognise all of that.

But—and it is a big but—the investment standard relates only to CCGs, and that total spending had already declined in 2019-20 compared with 2018-19 as a percentage of total NHSE revenue spend. Also, given the urgent need for healthcare, which, as other noble Lords have said, has been much exacerbated by the pandemic, this amendment would help strengthen the consideration of mental health services when large amounts of money are announced for Covid recovery—this is welcome—but it all falls outside the remit of the mental health investment standard.

We need to know how much of the money is currently going to preventive and community services—prevention is the overarching theme of this group of amendments—as opposed to acute services. We also need to know whether the spending increases we are seeing are simply because crisis services are so in demand; indeed, they are overwhelmed in some cases. We know from a recent survey by the Royal College of Psychiatrists that two-fifths of patients awaiting mental health treatment contact emergency or crisis services, with one in nine ending up in A&E. That is not a sustainable position.

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[Baroness Morris of Yardley (Lab)]

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

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

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

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

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

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

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

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

[Baroness Tyler of Enfield (LD)]

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

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

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.