Health and Care Bill
Baroness Walmsley ExcerptsThursday 13th January 2022
(2 years, 7 months ago)
Lords ChamberRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: HL Bill 71-II(b) Amendments for Committee (Supplementary to the Second Marshalled List) - (13 Jan 2022)
Baroness Walmsley (LD)
I support these amendments and in particular the words of my noble friend Lady Northover. I too am a member of Peers for the Planet and, as a biologist, I have been devoted to trying to address climate change ever since I knew anything at all about it. I particularly support the noble Baroness, Lady Hayman, in her determination to mainstream the issue. It is not the responsibility of just Defra but every department of government and every single individual in this country.
From my work on the Science and Technology Committee, I was aware of the health service’s 5% contribution to our emissions, but also of what the NHS has already done and pledged to do under the leadership of the noble Lord, Lord Stevens. I confess I was a little surprised when I saw these amendments; I thought, given all that, “Why does the noble Lord think more needs to be done?” The noble Lord, Lord Stevens, knows more than I or any of us do about the health service, so if he thinks more needs to be done, I am with him. We absolutely should support these amendments.
I would like to ask the Minister one particular question. The NHS has a very large portfolio of property and the Prime Minister has promised 40 new hospitals in a certain period of time. Leaving aside the fact that some of the buildings promised are not hospitals and are not new, if we are building new buildings, I would like to be assured that all of them will be zero-carbon. That can be done and there is no excuse not to do it.
Baroness Wheeler (Lab)
My Lords, I congratulate the four noble Lords who have produced this excellent suite of amendments across the Bill to ensure that ICBs procuring or commissioning goods and services on behalf of the NHS are firmly focused on their responsibility for NHS England’s commitment to reaching net zero by 2040. It has been an excellent and informed debate, and one with much enthusiasm to reassure the noble Baroness, Lady Hayman.
We fully support the amendments and have little to add from these Benches following the expert contributions of those proposing the amendments and the other noble Lords who have spoken. I am sorry my noble friend Lady Young, who put her name to the amendments, cannot be here. She was a key member of our team during the recent passage of the Environment Bill, and her expertise and wisdom always guides and reflects our approach. The House is clearly interested in this vital matter, as we saw this week in an important Oral Question on the Prime Minister’s promise for a new, overarching net-zero test for new policies. Assuming the Government fully support the key commitment from NHS England, I hope that, in his response, the Minister will accept the need for the amendments and will not argue that the proposed new clause is unnecessary as NHS England already has a commitment that will percolate down to ICBs.
As we have heard, the power of public sector procurement is a massive issue and there is no bigger part of the public sector than the NHS. The NHS has such an important impact on other environment issues, such as waste, pollution and resource consumption, especially for plastics, paper and water. We should ensure we are on the front foot in using that impact to deliver the net-zero commitment.
The NHS has made a start, but there is much more to do. These amendments would reinforce the importance of action in these areas for the new bodies and processes that the Bill creates. The NHS is a big player and, as noble Lords have stressed, it can play a big role in tackling all of these climate change and environmental challenges. Procurement is a strong lever that the NHS can utilise in key markets, particularly in those areas where it is the sole purchaser. The noble Lord, Lord Stevens, was very eloquent on this issue and I look forward to the Minister’s response in the light of his contribution.
Like other speakers today, my noble friend Lady Young wanted to stress that action so far is only the beginning. In the light of the importance of climate change and other environmental challenges, we strongly support such a duty being in place for all the public and private bodies with significant impacts when future legislation comes through Parliament. We did that when inserting a sustainable development duty into the remit of every possible public body from the late 1990s onwards, but this time it has to be not only enacted but managed, delivered, tracked and reported.
As the Minister, the noble Lord, Lord Callanan, told the House this week, every sector of government needs to do its bit, and we need to hold them to that. These amendments are vital, since every public body will have to take further action this decade if we are to restrain temperature rises to two degrees—far less, 1.5 degrees.
Finally, I too thank Peers for the Planet both for its work and, especially for me, its excellent briefing. As noble Lords have stressed, the NHS has committed to net zero and aims to be the world’s first net-zero national health service. It is responsible for around 5% of the UK’s carbon emissions. That is why the NHS’s role and contribution to net-zero targets should be fully integrated into the Bill. I look forward to the Minister’s response and his detailing of how the NHS is to achieve its ambitions. I hope that he will acknowledge that its commitment must be in the Bill. These amendments present a vital opportunity to enshrine in law a commitment that I think most, if not all, would want to see delivered.
Baroness Walmsley (LD)
My Lords, I support Amendment 17 from the noble Baroness, Lady Morgan. There are of course different waiting-list lengths in the different Administrations, but I take the point made by the noble Baroness, Lady Finlay, about fair funding. She makes a very good point about Wales.
I too have had experiences like those of the daughter of the noble Baroness, Lady Fraser, over my Covid vaccination status, because I live in Wales and the NHS app in Wales did not seem to speak to the other one. But, as the noble Baroness, Lady Bennett, said, that is something that needs sorting out at a different level.
As I said, I live very near the border in Wales, so I am acutely aware from personal experience that the nature, quality and resources of healthcare in England affect the people of the devolved Administrations. I accept what the noble Lord, Lord Lansley, said: it is not just about people near the border—Anglesey is not at all near the border—but in day-to-day working it affects people near the border very frequently.
These are of course devolved matters, but in their practical, day-to-day operation the borders are what people call “leaky”—in other words, people travel both ways for work, school, shopping, leisure and indeed health services. So, particularly in the border areas, it makes a lot of sense to do what the noble Baroness, Lady Finlay, said happens all the time: for GPs to be able to refer patients for a particular service to or from the devolved nations. That is why anything that affects the provision and quality of services in England also affects Welsh and Scottish people in particular. I suspect it is slightly less the case for people in Northern Ireland, although waiting lists there are particularly concerning.
So this is particularly important in relation to the location of specialist hubs, because the border areas of both Wales and Scotland are very rural and the distances and transport difficulties to their own hospitals can be long and difficult—even more so if the patients have to cross the border. We need to ensure that anything done in the Bill makes cross-referral able to continue as easily as it does at the moment.
What discussions have taken place with the devolved Administrations about the Bill? Are there any aspects of it that are still waiting for the agreement of the Governments of Wales, Scotland or Northern Ireland?
Baroness Thornton (Lab)
My Lords, I am very grateful to the noble Baroness, Lady Walmsley, because she has helped me to clarify my thinking about this group of amendments. Basically, they have good intentions and they make good points about the things that need to happen, but I am not absolutely certain they need to be in the Bill. I am also particularly grateful to the noble Baroness, Lady Finlay, for her very well-informed contribution about what actually goes on. There are of course problems in relationships between the devolved nations and NHS England, some of which are down to not being very well organised, some of which are down to arrogance on the part of the bigger ones, and some of which are down to the funding not actually being available—and some of them might be politically motivated too.
Amendment 17 opens some new thinking on the subject of integration, and accepts that devolution has given us different systems for care in Wales, Northern Ireland and Scotland, but seeks to ensure that what is done in one part of the UK—that is, England—does not adversely impact on other parts. The intention to bring collaboration between the nations is, of course, commendable.
I note that Amendment 205 places some requirements such that
“Welsh Ministers, Scottish Ministers and a Northern Ireland department must make regulations providing that the choices available to patients in England by virtue of regulations under section 6E(1A) or (1B) of the National Health Service Act 2006 (inserted by section 69 of this Act) are available to patients for whom they have responsibility.”
Again, we can understand the need for consistency, but I am unclear about how that will play out against the devolved nature of healthcare—so I think the case will have to be made out for that and, indeed, why that would be included in the legislation.
In a similar fashion, Amendment 301 looks to establish interoperability around the use of data across the whole UK. Again, that is a wholly worthwhile intention, and one that I would hope that the various authorities could collectively work on and agree. Once more, what the role is for primary legislation to address this point is not entirely clear, and I welcome the discussion. I look forward to hearing what the Minister has to say.
Baroness Walmsley (LD)
My Lords, like the noble Baroness, Lady Thornton, I shall start with those who I think should not be on the board before I turn to those who I think should. To a great extent I support the noble Baroness’s Amendment 29, but with a small caveat that, if she wished to press it, might require a bit of redrafting. I will explain.
Additional provider medical services are very useful in many areas to fill gaps in primary care capacity. They may provide additional services from which other NHS primary care services have opted out, such as out-of-hours services or enhanced services beyond the capacity of local NHS GPs to deliver. In some areas they have taken over primary care services where NHS GP practices have become too small to be viable or all the partners have retired.
Some APMS services are commercial businesses with a responsibility to their shareholders to make a profit, and I do not think these should be on the board. However, some APMS contracts go to NHS entities, and I would not want to exclude those. Of course, we must remember that for many years GP practices have also been small businesses, sort of, operating within the umbrella and ethos of the NHS. They too need to clear their costs or they will close down.
That is all well and good. However, if the Government are serious that they want to exclude private sector interests from ICBs, they must surely agree to include in that ban non-NHS entities that hold APMS contracts. A failure to accept the amendment of the noble Baroness, Lady Thornton, must surely make us a little suspicious about the Government’s claim that their amendment inserted in another place would successfully exclude private interests from the board.
Amendment 29 would extend the range of those involved in commercial enterprises from being members of the board of an ICS beyond those that we have just discussed in relation to the noble Baroness’s Amendment 28. Amendment 29 would specifically exclude NHS GP practices and voluntary or not-for-profit organisations from the ban. There are many types of organisations that would be included in the ban, although they could be heard on the board of the integrated care partnerships. Those include: pharmaceutical companies; providers of medical devices, equipment or premises; people who own care homes; and many other essential services without which our NHS could not survive. However, their importance should not entitle them to influence the constitution, strategy or commissioning principles of the board of the ICS. They are important providers that will be appropriately involved in planning at other levels, but they should not be able to steer fundamental decisions without the suspicion that they might have a commercial interest in such decisions. Indeed, the ban proposed in the amendment would protect such companies from such a suspicion, so perhaps it would be welcomed by them.
Turning to those who should be on the board, I will not repeat what the noble Baroness, Lady Hollins, said in introducing her amendments, because she has done it extremely well, particularly emphasising the impact of integrated services on people with learning difficulties and people with autism and how they could benefit from better integrated services if we got it right. So, I support her amendments.
I turn to Amendment 37, to which I have added my name to those of the noble Baroness, Lady Thornton, and the noble Lord, Lord Patel, for the following reasons. According to the Explanatory Notes, each ICB and its partner local authorities will be required to establish an integrated care partnership, bringing together health, social care and public health. The constitution of the ICB as it stands in the Bill specifies that the board must include only a minimum of three types of people who the Government clearly believe are essential to the effective operation of the board. They are someone from NHS health trusts or foundation trusts, someone from primary care, and someone from one of the local authorities in the area. If it is okay to prescribe these members, would it not also be wise to prescribe a few other key people with appropriate knowledge in order to achieve the ICB’s objectives of bringing together health, social care and public health? This amendment therefore suggests five other nominees—not 15, bearing in mind the Government’s wish to keep the ICB to a manageable size. But given the powers of the board, I would think it essential to have people nominated from mental health, public health, social care, health trade unions, patients and carers to bring their knowledge to strategic decisions.
If the board is to comply with the ambition of parity of esteem for physical and mental health—which we talked about two days ago—it will be important to have someone with the knowledge of how mental health services are working, as my noble friend Lady Tyler emphasised. Public health is a very particular discipline, the importance of which has been amply shown during the pandemic, which also has a vital role to play if we are to improve the health of local people and level up inequalities. Social care provision should never be separate from or subsidiary to health, as it is intrinsic to the functioning of health services in every area, so it is inconceivable that any ICB should ever be without someone from that sector.
The NHS is a people business, which is why those who deliver the services and the patients who are on the receiving end should have a voice at the top. Similarly, those thousands of unpaid carers, without whom vulnerable people would use up more of the NHS’s scarce resources than they currently do, should be represented at the very top of these new organisations. Their contribution to the efficient use of the board’s financial resources is crucial.
If the objective is to encourage more integration and collaboration, how could it be right not to have these additional five or six groups of people helping to make the strategic decisions? If that is not the case, as has been said by other noble Lords, the board could be dominated by the large acute hospitals and primary care, and the integration objective of the Government, which I endorse, would fail. I look forward to the Minister’s reply.
Lord Kamall (Con)
My Lords, this has been an excellent and wide-ranging debate, and I really am grateful to all noble Lords who tabled amendments today.
With your Lordships’ leave, I turn first to Amendment 18 in the name of the noble Baroness, Lady Thornton. This amendment would mean that the relevant ICB and ICP would need to be consulted before NHS England is able to provide support and assistance to bodies other than NHS bodies. The NHS has, under successive Governments of all political colours—indeed, since its foundation in 1948—commissioned care from various sectors to help it be more responsive to patients’ needs, and particularly to help deliver the commitments set out in the NHS constitution.
The vast majority of NHS care has been—and will rightly continue to be—provided by taxpayer-funded public sector organisations. But experience before and during the pandemic has demonstrated how important it is for NHS England to have the power, as the Trust Development Authority currently does, to provide support and assistance to any providers of services on behalf of the NHS. This will ensure that independent providers can, if necessary, be commissioned to provide important additional capacity where needed.
Baroness Walmsley (LD)
I apologise for interrupting the Minister, but I want to ask him a question going back to Amendment 28 and the APMS contracts. If we were to bring forward an amendment that made it very clear that we had no objection to NHS entities or not-for-profit organisations with APMS contracts being on the ICB, would he take a more friendly approach? It would just eliminate those that take profit out of the NHS.
Lord Kamall (Con)
I thank the noble Baroness for that suggestion and for trying to narrow the gap that there clearly is. If an amendment were put forward, we would look at it very carefully and consider the unintended consequences from the way it is drafted. We will consider it but, as I am sure the noble Baroness appreciates, I can make no promises at this stage.
I turn to the point made by my noble friend Lord Hunt of Wirral about how provider input in the work of an ICB will be reconciled with assessing both the suitability and performance of providers. As my noble friend correctly noted, each ICB must make arrangements on managing the conflict of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore, each appointee to the ICB is expected to act in the interests of the ICB. They are not delegates of their organisations, but are there to contribute their experience and expertise for the effective running of the ICB—a point made most eloquently by the noble Lord, Lord Mawson, my noble friend Lady Harding and the right reverend Prelate the Bishop of London. It is important that this is about expertise, not the trust or organisation that they are taken from, or their skills and knowledge, as the noble Lord, Lord Mawson, said.
We are also keen to allow ICBs to develop their own governance arrangements, which best take their local circumstances into account. We want to give them the flexibility to learn and develop as their best practice evolves, so that other ICBs could learn from that best practice where there are concerns.
To support ICBs, NHS England is working with them to issue guidance and to develop and make clear our expectations of ICB leaders—expectations that have been reflected in the discussions and fantastic contributions from many noble Lords. For these reasons, I regret that the Government cannot accept these amendments at this stage. However, I hope I have given noble Lords such reassurance that they feel able to withdraw their amendments.
Turning to the membership of integrated care boards, I will begin with Amendments 27, 37, 38, 39, 40 and 41. I am grateful to all noble Lords who have brought forward these amendments today. I understand the interest from all sides in this membership. Schedule 2 sets out the minimum membership of the integrated care board; it will need to include members nominated by NHS trusts and NHS foundation trusts, by persons who provide primary medical services and by local authorities of areas that coincide with or include the whole or any part of the ICB’s area.
I take the point of the noble Lord, Lord Bradley, about mental health. I am sure he recalls the debate on Tuesday, when noble Lords felt very strongly about this. I have offered to meet many noble Lords from across the Committee who indicated that they want to see this parity with mental health, which they do not believe is implicit at the moment, even if we believe that “health” refers to physical and mental health. Indeed, it refers to spiritual health in many ways. But we understand that we have to close that gap and I will make sure that the noble Lord, Lord Bradley, is invited to those meetings.
It is important for us that we are not overprescriptive, which is especially true of any membership requirement. Any extension beyond the proposed statutory minimum will risk undermining local flexibility to design a board, as my noble friends Lord Mawson and Lady Harding and others have said, in the most suitable way for each area’s unique needs, drawing on the best expertise, but not where they are from. It may also make the boards less nimble and less able to make important decisions rapidly if we overprescribe.
It is important to remind the Committee—I apologise if noble Lords do not appreciate the repetition—that we set a floor and not a ceiling. The ICB can appoint board members if it wishes. Local areas can, by agreement, go beyond the legislative minimum requirements. They will want to ensure they appoint individuals with the experience and expertise to address the needs and fulfil the functions. Areas are already doing this. For example, in south-east London the ICB is proposing to include three provider members—acute, community and mental health—and six place members, one for each borough. This approach is exactly how we want ICBs to use the flexibility available to them.
If, in time, some of the concerns expressed today by noble Lords become clear—such as issues being skated over, ignored or elbowed out by others with louder voices—we may need to add further requirements that relate to ICB membership, and there are regulation-making powers in place in Schedule 2 to allow the Secretary of State to do so. Furthermore, NHS England has the power to issue statutory guidance to ICBs. It could, for example, use this to recommend that each ICB should consider appointing a learning disability and autism senior responsible officer, as I know the noble Baroness, Lady Hollins, has asked for and has spoken about most eloquently many times, most recently in a debate a few weeks ago.
Taken together, our approach reflects our view and, I reiterate, the view of the NHS that we should not attempt to overlegislate for the composition of ICBs and instead let them evolve as effective local entities to reflect local need. Let us get the right balance between the top-down and bottom-up approach, and make sure that they are relevant to their local areas. I am afraid that these amendments are seen to take a different approach, by adding more people to the minimum requirements for the ICB, making them larger but not necessarily better. They also add additional complexity by introducing a significant number of members who are responsible for activity outside the NHS. We think these would be better represented on the integrated care partnerships, which have a broader remit. I come back to the point that it is about expertise, not which trust.
I will consider the comments made by noble Lords very carefully if some of the concerns have not been met, and will have future conversations, between this stage and the next, if they feel that we have not addressed their concerns completely. I regret that the Government cannot accept these amendments. I hope that I have given your Lordships some, if not complete, reassurance and that noble Lords will feel able at this stage to withdraw and not press their amendments.
Health and Care Bill
Baroness Walmsley ExcerptsThursday 13th January 2022
(2 years, 7 months ago)
Lords ChamberRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: HL Bill 71-II(b) Amendments for Committee (Supplementary to the Second Marshalled List) - (13 Jan 2022)
Baroness Walmsley (LD)
My Lords, I shall speak more briefly than I had intended, because this has been a very long debate, absolutely full of expertise, about a suite of amendments all of which have considerable merit. I know that both Ministers on the Front Bench have been listening very carefully and have noted the consensus across the Committee that this Bill will not succeed unless it addresses very clearly the disgraceful health inequalities in this country at the moment.
Health inequality affects quality of life, life expectancy and, in particular, healthy life expectancy, which has now stalled across certain demographic groups. As we have heard, it has been analysed brilliantly by Professor Sir Michael Marmot. It affects the well-being of the patient and their family. The really sad thing is that much of it is preventable. These things are particularly rife in the poorer parts of the country, because that is where the social determinants of health such as housing, referred to by my noble friend Lord Shipley and others, have most effect. We have heard a number of statistics about health inequalities, but I shall give your Lordships just one. People living in the most deprived areas of the UK spend almost a third of their lives in poor health, compared to only about a sixth of those living in the least deprived areas. That says it all.
Unfortunately, inequalities were not at the forefront of the Government’s response to the pandemic. They suspended equality impact assessments for legislation, resisted publication of evidence of the impact of the virus on BAME individuals—as pointed out to them eloquently by the noble Baroness, Lady Lawrence—and failed to provide adequate isolation support for those on low incomes, forcing them to go to work. The Covid pandemic has therefore seen the biggest shift in life expectancy in the UK since World War 2: a fall of 1.2 years in males and 0.9 years in females. It is therefore essential to heed Sir Michael Marmot’s words and “build back fairer” and not just “better”.
The noble Baroness, Lady Greengross, kindly mentioned the report of the Science and Technology Committee on healthy ageing. I was a member of that committee under the capable chairmanship of the noble Lord, Lord Patel. It became very clear from our witnesses that unhealthy ageing happens years before the person is old and depends enormously on their demographic and their lifestyle. For their sake and for the sake of the future of the NHS, for which no Government will ever be able to provide enough funding unless something is done on prevention, we must do something to level up the health outcomes of the nation. This Bill is a very good place to start all over again on that agenda.
I have added my name to Amendment 11, so ably introduced by the noble Baroness, Lady Thornton, whom I must congratulate on the way she analysed these issues at the beginning of this debate. I thank her for that. Also crucial is Amendment 14, so ably promoted by the noble Lord, Lord Patel, and my noble friend Lady Tyler. Amendment 11 is an attempt to ensure that NHS England produces guidance about the collection, analysis, reporting and publication of the data which makes transparent the performance of various NHS bodies on health inequalities. Without collecting that, we cannot judge the performance of those organisations. If it is not done consistently, we cannot assess an organisation’s performance in comparison to other similar bodies. That is why such guidance must come from the top. I know that the Government want each ICS to do its own thing in a way which it considers most appropriate for its area. However, for the important objective of levelling up health outcomes across the population, judgment of performance can be made only if the data is comparable between one ICS and another or one trust and another, so we cannot leave it to them to collect the data in any way they like.
Of course, there are big issues about the resources available for the collection and analysis of data, but such information is essential if improvements are to be made. Therefore, a duty to “have regard” to guidance published by NHSE would put pressure on the organisations to so arrange their finances as to ensure adequate resources for this, and, of course, it would be cost-effective.
I also have Amendments 61 and 63 in this group. They would insert “assess and” into new Section 14Z35 inserted by Clause 20, which covers the duty of an integrated care board to reduce inequalities in access to health services across its population and in the health outcomes achieved. Although it is well known that, in general, the lower the demographic the greater the health inequalities, this is by no means uniform, even across a single local authority, let alone across a large ICS area. Indeed, even within a single local government ward, which may be fairly affluent in general, there are often pockets of deprivation. Every local councillor knows where they are. In order to devise policies and deploy services geographically in a way that improves access and outcomes for those deprived communities, the ICS needs to drill down and do the detailed work to identify where they are and what factors are damaging health. It may be poor or overcrowded housing. It may be lack of access to shops selling healthy food. It may be lack of access to leisure and sports facilities in which to take exercise. It may be poorly performing schools or overstretched primary care services. It may simply be poverty, preventing people heating their homes adequately or buying nutritious food. In rural areas, it may be lack of access to pretty well everything, as the right reverend Prelate reminded us. Whatever it is, you cannot fix it until you know what and where it is.
That is one of the reasons why we reject the new power of the Secretary of State to meddle in the reconfiguration of health services locally, but that is a debate for another time. In cases such as this, an overview will not do, and local knowledge is key. That is why we believe it is essential to mandate an ICB to do the detailed research on which to base its commissioning decisions, so that it can fulfil the duty to reduce health inequality put on it by this Bill—once it has been amended by a lot of these amendments.
Baroness Walmsley (LD)
My Lords, I thank the Minister for his very able response, but I have to say that I am very disappointed by it. He appears to be sticking to his brief and resisting all of our amendments. I suppose this is not surprising because his brief was written before this very powerful debate. Now that he has heard the debate, I hope he will go back to the department, discuss with his colleagues, and reflect on the need to put something in the Bill to ensure that the new world of integrated care systems really addresses health inequalities.
Health and Care Bill
Baroness Walmsley ExcerptsTuesday 11th January 2022
(2 years, 7 months ago)
Lords ChamberRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: HL Bill 71-II Second marshalled list for Committee - (11 Jan 2022)
Baroness Walmsley (LD)
My Lords, I support the demand of the noble Baroness, Lady Thornton, for an impact assessment and look forward to having the many hours it will take to read and thoroughly digest. As she said, this is a Bill of 244 pages with 155 substantive provisions and 156 delegated powers, over half of which allow no parliamentary scrutiny. Although the general thrust of it, in relation to easing the transition to more integrated and collaborative working, is welcomed and indeed demanded by the sector, that same sector is now very hesitant about its introduction at this time. As I prepared this speech, there were 122,000 absences in the NHS due to Covid and 200 members of the Armed Forces were being drafted in to help; 24 hospital trusts had declared a crisis situation, 20% of beds are occupied by Covid patients in 16 hospital trusts, and discharge targets are not being met.
So, despite the many preparations for this structural change to the NHS, many in the sector have welcomed the short delay in implementation that is being proposed. The Government have said that they want the Bill to be permissive, but the question is, permissive to whom? It is a skeleton Bill that gives a wide range of powers to the new ICSs to commission services in the way they think fit, but it also gives the Government unprecedented powers to use regulations, guidance and even published documents to specify what should be done in future. It gives the Secretary of State considerable new powers.
Lord Howarth of Newport (Lab) [V]
My Lords, I fully support the objectives of my noble friend Lady Merron and her co-signatories to Amendment 2. However, as indicated in Amendment 3, in my name, I believe that it would be appropriate to add to the board’s membership a person representing a very important element of providers, who are always at risk of being overlooked when the NHS is, as is so often the case, under intense pressure.
There is a growing body of research evidence demonstrating that non-clinical approaches can be highly beneficial to health and well-being. Engagement of the creative imagination and with the arts, culture and nature has profound health-giving benefits, as well as leading to improved well-being. Other non-clinical approaches, such as engagement with sport or volunteering, are likewise beneficial. Moreover, they offer significant benefits in easing pressures on general practitioners and the wider healthcare system. Before the pandemic, it was estimated that one in five GP appointments was for non-medical reasons. A survey by the Royal College of General Practitioners in 2018 found that 59% of family doctors thought social prescribing could reduce their workload.
Non-clinical approaches can help us move away from the present state of affairs, in which we are under-doctored and over-medicated, and they will bring significant cost savings. The World Health Organization’s scoping review reported that evaluation of Arts on Prescription suggested an average return on investment of £2.30 for every £1 spent, through reductions in unnecessary prescribing and reductions in the use of health services, including emergency hospital admissions.
The potential benefits of such approaches have been recognised by the Department of Health, in the establishment of the National Academy for Social Prescribing and in the preventive strategy set out in the NHS Long Term Plan, which envisaged that:
“Within five years over 2.5 million more people will benefit from ‘social prescribing’, a personal health budget, and new support for managing their own health in partnership with patients’ groups and the voluntary sector.”
But that was under a different Secretary of State and before Covid and the huge growth in the backlog that is now absorbing so much of the energy and thinking time of the NHS.
These benefits are experienced not just by the individual; they are societal. A society in which fewer people are lonely and gloomy and more people are energised and filled with a sense of achievement, new self-esteem and optimism, and in which through shared activities they build social capital, is on the way to being what the noble Lord, Lord Crisp, and colleagues have characterised as a healthy and health-giving society.
We all acknowledge that to create such a society we must address the social determinants of health, as argued so compellingly by Professor Sir Michael Marmot. To do so requires not only the integration of the range of health and social care services but an integration of policy across Whitehall and between Whitehall and local, regional and devolved government, in full partnership. Place-based strategies for health are crucial. Integrated care boards, integrated care partnerships and the NHS as a whole must draw on a full range of resources and strengths.
If government fails to act across the board in addressing the societal issues that generate so much ill health and fails to develop a fully-fledged preventive strategy, we will continue to see the NHS beleaguered, insufficiently funded and struggling to cope, with endemic ill health on an enormous scale. We need to make the whole of government an integrated care system. The Department of Health cannot solve the problems of health on its own.
Meanwhile, we must give the best help we can to the board of NHS England by furnishing it with a broad membership along the lines proposed in these amendments, ensuring that, at the highest strategic level, representative voices of a wide range of contributors are heard, including those of the non-clinical providers who have such an important part to play. I beg to move.
Baroness Walmsley (LD)
My Lords, I have added my name to the amendment from the noble Baroness, Lady Merron, which I fully support.
Schedule 1 gives a dazzling array of consequential amendments to a vast list of other legislation, which must have taken some poor civil servant weeks to compile, but it does not tell us who will be the extremely important and influential additional people on the board—those who will steer the good ship NHS England along its course. Like any other ship, it needs a captain, officers and crew with the knowledge, experience, expertise and attitudes to steer the ship in the right direction and to enable it to fulfil its functions efficiently and effectively—in whose interests? Those of the patients, of course.
It is also important that nobody on board—let us say, perhaps, the pilot who steers it into port—should have the power to steer the ship not in the direction it should go but in a direction chosen in that person’s own interests. That is why the noble Baroness, Lady Merron, and those of us who support her have attempted to specify some of the kinds of people who should be at the helm of this organisation in the new world of integrated care services—and those who should not.
They should include someone to represent public health, especially given the recent experience of the pandemic and the certainty of others in future. They should include local government, given its responsibility for the crucial areas of social care and the social determinants of health outside the health service. They should ensure diversity and include people who can ensure that patient and staff interests are taken into account when decisions are made—after all, without staff there would be no service. They should include someone who can keep an informed eye on the way the ICSs are progressing. They should not include anyone with a financial or employment interest in any organisation that delivers services to the NHS.
This Government have a very poor track record in ensuring that people with a financial interest do not benefit from government contracts. We have had far too many of those scandals relating to the provision of PPE, testing kits and other products and services during the pandemic. Some of those have only recently been revealed. We must avoid that happening as we set up this new body, for which we all have such great hopes. That is why I recommend this amendment to the Minister and look forward to his response.
Lord Mawson (CB)
My Lords, I was one of the people, along with Paul Brickell, who wrote for Hazel Blears the structure for the Olympic Park Legacy Company. I was involved in that project from day one—along with Lord Rogers, who, sadly, has recently died—and for 19 years. We thought a lot about this question because, in east London, we had to engage with six different boroughs around the 248-hectare Olympic Park. We knew that if we simply brought together representatives, many of whom did not have good working relationships or the necessary practical skills, to deliver that project, we would have another Olympic failure on our hands.
The structure that we wrote for Hazel Blears at that time suggested that we needed to bring the right people together for that project: for example, Keith Edelman, who had just successfully built the Arsenal stadium might be a rather important person to have on the board because he understood the detail about stadiums and how you run them—and we were about the build a half-a-billion-pound one. Or perhaps we would need someone like Nick Bitel, who had set up the London Marathon and knew something about sport and the politics of sport; I discovered a great deal about how complicated all that actually was. Or we might need on the board the most successful Labour mayors in that area—Sir Robin Wales of Newham and the mayor of Hackney.
I am very supportive of what the noble Baroness, Lady Harding, is saying. We built a team of the right people to ensure that we delivered a serious legacy on that 248 hectares in east London. I suggest that noble Lords go and have a look at what happened as a result. Empowering the chairman to choose the right team with the right skill set is absolutely crucial if we are to transform the NHS and make it fit for purpose in this century.
Baroness Walmsley (LD)
My Lords, I wonder if I may make a slight clarification; I hope that the noble Baroness, Lady Merron, will agree with me. It is not that we believe that the people who we specify should be representatives of the sectors from which they come. Rather, given the functions of NHS England, the three of us who have signed this amendment feel that those with background knowledge of the sectors that are absolutely key to the success of NHS England should be on the board. They would be there not as representatives behaving in a unitary way, as the noble Baroness, Lady Harding, said, but having the background knowledge and information that can be shared with the rest of the board to make decisions.
The Lord Bishop of London
My Lords, I declare my background as a former government Chief Nursing Officer and non-executive director of a number of healthcare trusts. I was not going to speak, but I have listened to noble Lords’ comments today and I come down with the noble Baroness, Lady Harding, in saying that we should not stipulate what skills are required of a board too tightly. What is in front of organisations changes over time, so the chair needs to be empowered to change. However, one caveat is that it would be wise to consider having somebody on the board with a background in patients. I speak from experience as a clinical professional: we can too easily forget the patient and to see things through their eyes. Far too often, we see things through the eyes of the clinician, which is not always in the best interest of patients.
Baroness Walmsley (LD)
My Lords, I am certainly with the noble Baroness, Lady Finlay, on the issue of outcomes. Like her, I am a member of the All-Party Group on Cancer, and I was right behind our former chairman John Baron’s attempt to get a clear focus on outcomes. I am delighted to see how successful that has been.
My Amendment 8 is very simple. It would prevent the Secretary of State tinkering too often with the mandate. As others have said, the mandate is the primary instrument through which the Secretary of State provides the Government’s direction to the NHS. He is right to do so, since the NHS uses the most enormous amount of our money and is of vital concern to every voter and taxpayer—those whom the Government represent.
However, the NHS is a little like the “QE2” in that it is absolutely enormous and takes quite a while to change direction. Indeed, a great many levers have to be pulled for it to do so. Chief executives, boards and professional staff need time to set new plans, targets and employment policies—to say nothing of moving the money around—to comply, as they must, with changes to these mandatory directions from on high. It is therefore highly undesirable for a Secretary of State to change the mandate too frequently. As the noble Baroness, Lady Thornton, said, even when it happens, adequate notice and reasons must be given.
Other amendments in this group deal with other aspects of the mandate, but I want to be fully assured that, given the difficult tasks we set our NHS, its outline instructions and targets are not unfairly changed too often. I feel justified in having this concern, because the evidence of clauses later in the Bill indicates to me a tendency by the Government to want to meddle where meddling is inappropriate and could have negative effects. I refer, of course, to the Secretary of State’s attempted power grab, which we will discuss later in Committee.
Can the Minister assure me that there is already some effective measure that would prevent the mandate being changed more than once in any financial year, which would make it very difficult for the NHS to comply?
Earl Howe (Con)
My Lords, I am glad to be able to respond to these amendments relating, in their several ways, to the NHS England mandate. I will cover each in turn.
I begin with my noble friend Lord Lansley’s Amendment 4. I confess that I am not in the least surprised that he, of all noble Lords, should have reminded us of the key importance of the NHS outcomes framework. Amendment 4 would require the Secretary of State to specify objectives that will help NHS England achieve improvements in the outcomes provided for in the NHS outcomes framework. As he and I remember clearly, the NHS outcomes framework is a set of indicators that provide for national-level accountability for the health outcomes that the NHS delivers. The first version was published in 2010 to inform the first mandate to what was then still known as the NHS Commissioning Board. In essence, it looks at long-term health trends across various domains, including quality of care and patient experience. It is a valuable resource and, as my noble friend knows, remains an important tool for measuring the NHS’s contribution to improving outcomes over the long term.
I quite agree with my noble friend that progress against outcomes is vital. That is why we have included Clause 3 in the Bill. One of the main advantages of a longer-term mandate is that it will allow us to take a longer-term view of progress against outcomes that can be measured meaningfully only across a number of years.
The noble Lord, Lord Patel, asked who will be responsible for improving outcomes. The answer is that NHS England and ICBs have duties in relation to improving the quality of services. I can assure him that we will hold them to account for doing so. Having said that, we are moving now to a system-wide approach. That entails the need to measure shared outcomes across health and the wider social care and public health system. Some of these outcomes are led by the NHS but many are system-wide, so the business of measuring patient and service-user outcomes will inevitably become more sophisticated.
We want to ensure that our system is flexible and able to adapt as those system approaches develop and mature. I hope my noble friend therefore appreciates why we would not want to enshrine the NHS outcomes framework in the mandate in statute, in a way that might limit or compromise our ability to explore broader system approaches as we go forward. However, I seek to reassure him that the NHS outcomes framework will continue to be a vital tool to look at long-term trends in health outcomes and the NHS’s role in supporting health outcomes. That basic role for the NHS outcomes framework will not change.
I fully understand the concern of the noble Baroness, Lady Thornton, in her Amendment 7 that the mandate should not be revised unnecessarily and without good reason. I completely agree with that sentiment; again, it lies behind our desire to look at the mandate over a longer timeframe than has hitherto been possible. My concern is that her amendment goes much further than, I suspect, she intended, because it would prevent the mandate being revised at all in anything other than an urgent or unforeseen situation. That would be unhelpful, because it would wholly prevent planned changes to reflect, for example, evolving strategic priorities, emerging evidence of need or even a planned general election.
The purpose of Clause 3 is to strengthen the role of the mandate by enabling the Government, where appropriate, to set a mandate that can endure, rather than having an annual use-by date. Looking back to our debates on the Health and Social Care Bill in 2011, the noble Baroness will remember that it was always the intention that the Government should set a multiyear mandate, and Parliament agreed. In practice, that intention has been hampered by the inevitability of an annual review of the mandate to a fixed deadline—a deadline that does not neatly align to a number of events and strategic processes, including the Budget, spending reviews and general elections. Clause 3 addresses this. I seek to reassure the noble Baroness that there is no intention to revise mandates unnecessarily at the drop of a hat, as it makes no sense to do so.
I am grateful to the noble Baroness, Lady Walmsley, for highlighting a similar set of issues to those raised by the noble Baroness, Lady Thornton. Her Amendment 8 would prevent the Government revising our mandate for NHS England more than once in the same financial year, for any reason. As I said to the noble Baroness, Lady Thornton, I completely understand her concern that the mandate should not be revised so frequently that NHS England is unable to plan for or deliver government priorities effectively. This is why I reassure her that this will not happen, except in the most exceptional of circumstances. I hope she accepts that reassurance, because it cannot be in the interests of any Government, or of patients and service users, to set a mandate that changes NHS priorities too frequently. I expect any such revisions to be very rare. As I have indicated, though, one can imagine that they may be necessary to respond to unforeseen events, to reflect the result of a general election or to signal future shifts in priorities at a point when the NHS is planning ahead. The Government need the necessary mechanism to deal with these and other similar eventualities.
The noble Baroness will see that Clause 3 already contains an explicit safeguard in respect of reasonableness: NHS England will not be obliged to revisit a business plan that it has already published, should the Government revise the mandate within a year of its issue. The Government will also have a continuing duty to consult NHS England before making any revision. I believe that, in combination, these two safeguards work together to fully answer the point that the noble Baroness made.
Baroness Harding of Winscombe (Con)
My Lords, I too support this group of amendments, both the parity of esteem words and the funding actions that make it up. I will briefly address the possible objections to it: first, it is not necessary because the Secretary of State already has a duty to maintain parity of esteem; secondly, as I think the noble Baroness, Lady Tyler, mentioned, this is culture change and legislation cannot drive that. In this case, actions speak louder than words. Being clear on the financial actions, as the amendments of the noble Lord, Lord Stevens, are, is a hugely important step on our culture journey.
Even though actions speak louder than words, the words matter too. They particularly matter when, as so many noble Lords have said so eloquently, mental health is so easily forgotten. It is all too easy to forget the hidden pain, anguish and need. I fear it is still far too easy to forget the hidden waiting lists. The words in this group of amendments are just as important as the actions, to make sure that we do not forget and build on the ground-breaking work that many, like the noble Baroness, Lady Hollins, have led for decades. We are on that journey, but we are definitely not there. I urge my noble friend to consider and accept these amendments.
Baroness Walmsley (LD)
My Lords, a duty to establish parity of esteem between physical and mental health was, of course, inserted into the Health and Social Care Act 2012 at the instigation of the noble Baroness, Lady Hollins—if I remember rightly, we on these Benches were right behind her. That is not reflected in this Bill, as she said, despite the fact that the importance of addressing mental health issues has been so amply demonstrated by the rise of these problems during the Covid pandemic. The shortage of services to address them is of great concern—services which were already under stress before the pandemic started because of underfunding over many years.
Although the insertion of parity of esteem into the 2012 Act was welcome and significant, no legislation is enough without the resources in cash and people to make it happen. They have not been forthcoming in the amounts needed to match the growing demand. Like the noble Baroness, Lady Hollins, and my noble friend Lady Tyler, I too have heard concerns in the sector that the share of resources that are currently available might be cut over the next three years under the Government’s plans.
The situation is not good. Waiting lists, particularly for children and young people, have been growing. I understand that the average waiting time for a young person for a first appointment is something like 13 weeks and 18 weeks to get to a referral for treatment. It is a bit of a postcode lottery, because some young people get there quite quickly and some wait a very long time. The noble Lord, Lord Warner, is absolutely right that it takes a great deal longer for those waiting for a diagnosis of autism.
According to research from the Resolution Foundation, in 2000, 24% of 18 to 24 year-olds had a common mental disorder. That was the lowest rate of any age group at that time. By 2018-19, that figure had grown to 30% and, astonishingly, by April 2020 it was up to 51%. So, as we set up the new integrated care system, it is essential that we restate the equivalence of mental and physical health. We know, as the noble Baroness, Lady Jones, so eloquently reminded us, that each affects the other, but it is not enough to assume that that is understood in this legislation. It must be clearly stated in both Clause 16 and Clause 20, where the noble Baroness, Lady Hollins, seeks to add it to the duty of the ICSs to secure improvement in the quality of services. We support her, of course.
Perhaps at this point I will mention my little amendments in this group. Amendments 48 and 49 are two of those little amendments that would insert the words “physical or mental” illness into Clause 16, which specifies a list of health provision that the ICB must make for its population. Other noble Lords would insert similar amendments into other places in the Bill. I support all of them.
Amendment 76 would also insert parity of esteem into new Section 14Z38 in Clause 20, which refers to the duty to obtain appropriate advice. We put it there to emphasise the fact that mental health is a very specialised area, and often very good advice can be obtained from small community or not-for-profit social enterprises that deliver mental health services in the community where people work and live, often to very marginalised groups. Large organisations such as an ICS might very easily overlook such good advice about what is needed and where to put it. I support the amendment spoken to by my noble friend Lady Tyler that the triple aim must become a quadruple aim. Mental health needs to go right at the core of what we are trying to achieve.
There is an enormous and growing number of people in the country with poor mental health. The NHS cannot just treat its way out of the problem. There needs to be more focus on public mental health, much of which is addressed by the small community groups I just mentioned, the role of which we will deal with later with Amendment 148 and others. But without the specific acceptance of the parity of esteem duty in the Bill, there is a danger that the diagnosis, prevention and treatment of mental ill-health will continue to take a back seat. It must be in the statute.
Lord Kakkar (CB)
My Lords, I support the objectives of this group of very important amendments. In so doing, I remind noble Lords of my interests as chairman of the King’s Fund and of King’s Health Partners. I have seen this work directly in King’s Health Partners through a programme defined as Mind & Body, which proposes to promote pathways of care across the entirety of our health economy that look in equal measure at physical and mental health for all patients, irrespective of their principal clinical presentation. Initiatives such as that important programme could be brought to fruition only because of the emphasis in the 2012 Act regarding parity for physical and mental health. It demonstrates very clearly that legislative intervention can have a profound impact. I very much join in congratulating my noble friend Lady Hollins on her relentless commitment to these issues in your Lordships’ House over the past 10 years, which have had and will continue to have a profound impact.
It therefore seems counterintuitive for Her Majesty’s Government, in bringing forward this important legislation, to move away from the opportunity to emphasise the importance of this parity. Is it sensible to move away from this position? Why not use the opportunity afforded by this important legislation to emphasise once again the importance of parity between mental and physical health in every respect—not only funding but the organisation and supervision of services and the construction of organisations within the NHS—so that, step by step, we can achieve what every Member of your Lordships’ Committee who has spoken in this debate has emphasised?
Will the Minister, in replying to the debate, reassure your Lordships that not proceeding with these amendments does not undermine what has been achieved so far and that what is proposed in the Bill can without the amendments achieve the continued momentum and concentration of focus on this vital issue, to ensure that we continue not only to develop mental health services but to ensure that they can be integrated more broadly into physical health, and that physical health services can be developed to ensure that the mental health consequences of physical conditions can also be appropriately addressed? In taking this holistic approach, we will achieve the objectives of better well-being and health for all our fellow citizens—one of the most important aspects of the triple aim.
Health Protection (Coronavirus, Restrictions) (Self-Isolation) (England) (Amendment) (No. 6) Regulations 2021
Baroness Walmsley Excerpts(2 years, 8 months ago)
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Lord Cormack (Con)
If nobody else is going to get up, I will. My Lords, some of the things my noble friend said, I entirely agree with. There has been a very real degree of confusion. It is inexplicable to have a situation in which you are told not to go to your place of work, but do go to the office party. This confusion spreads like a cancer through a community—but we are here to debate something slightly different.
Yesterday in the other place, there was a massive majority in favour of the propositions before us. There is a very important constitutional issue here. This House is not the elected House. I believe fervently in it and have made that plain on innumerable occasions, and I believe that we have a real job to do, but when the elected House has given, by a massive majority, approval to certain orders dealing with the most important issue of the day, it would be ill advised for us to vote in a contrary direction.
While I admire my noble friend’s persistence—he certainly has not come new to this subject—I urge him, as the debate takes its course, to consider very carefully before he divides the House. There is clearly no doubt that there is a very real division in the Conservative Party, with the so-called libertarian wing. However, all these things have been oversimplified; the keynote of the debates has been hyperbole, which is not really very good for sensible parliamentary debating and democracy.
The fact that the Conservative Party is divided is common knowledge. I urge those who have not done so yet to read the main leader in today’s Times and a very penetrating article by our colleague, my noble friend Lord Finkelstein, also in the Times. I ask noble Lords please to read those articles and consider carefully what they say. We are at crisis point in this country when a large number, more than a hundred—99 voted and many abstained—of the governing party refuse to support the Government. That is a very serious matter.
However, an MP is an MP, no matter what constituency he or she sits for. Each Member of Parliament has a vote of equal value. Yesterday, as I said at the beginning, a massive majority of Members of the other place decided to support what the Government are proposing—a divided Government, yes, and the division in the Government is not caused, let us be honest, just by this subject. The appalling way in which the Owen Paterson affair was handled is indicative of a Government which have lost their grip.
My noble friend the former Chief Whip—he is an old friend—may be waving his hands at me; Chief Whips are important, but parliamentary democracy is even more important. I believe, as I said, that it would be ill advised for us to vote today against what the Government have proposed. We should not seek to contradict the other place but, with a degree of sadness perhaps, we should endorse it and certainly not divide the House.
Baroness Walmsley (LD)
My Lords, the Prime Minister has correctly pointed out that a “tidal wave” of the omicron Covid-19 virus is upon us. Yet the noble Lord, Lord Robathan, wants to do nothing. I do not agree with him. He wants to learn to live with the virus; most people do not want to have to learn to die with it.
There are three sets of regulations before us today. I will first deal with extending the mandatory wearing of face masks. We support it because face masks work. But who is monitoring or enforcing it? To give the Minister one example out of hundreds of thousands, on Monday one of my colleagues was travelling on an LNER train for two hours to come to your Lordships’ House—I must ask why we are here in person today—and only about 60% of the passengers were wearing masks and somebody behind her was coughing and spluttering for the whole two-hour journey. Nobody checked. This must be enforced.
The second set of regulations are on changing isolation rules for contacts of people testing positive. We support them but I have concerns about reported supply issues in self-administered lateral flow tests. People are just “strongly advised” to take tests for seven days after they have had contact. Will there be enough and will there be regular public information to remind people how important it is to take them? Will anyone check that they have done so?
Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) (No. 2) Regulations 2021
Baroness Walmsley Excerpts(2 years, 8 months ago)
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Baroness Walmsley (LD)
My Lords, before I follow up my noble friend Lady Tyler’s comments, I want to say how much I agree with the noble Lord, Lord Cormack. The way in which this has been done—I agree also with the noble Lord, Lord Hunt—is absolutely shocking; it is a contempt of Parliament. I was horrified when I read the report of the Secondary Legislation Scrutiny Committee about how bad it was and how late the sort of impact assessment—I call it a sort of impact assessment —has been produced.
Of course, we do not need an impact assessment to know what the problem at the heart of this is, apart from the compulsion element, which I understand: it is the fact that so many people are hesitant and mistrusting about having a vaccination. We also know from the work of Healthwatch, mentioned by my noble friend, that the most effective way of addressing the problems that people have with the vaccination is to have a one-to-one discussion with them so that they can say what their problems are and have them addressed. It needs to be done with a person whom they trust—somebody who they believe has some knowledge and understanding of the issues.
The difficulty with doing this at the moment is that all those people are very busy. We have the winter problems coming up; we have the omicron variant of Covid-19 increasing day by day and our NHS is on the edge of falling over. So I have a little suggestion for the Minister. There are plenty of doctors and nurses relatively recently retired who for one reason or another are reluctant to come back into the front line at the moment. However, they retain the respect of the health community. I understand from the executive summary that the total cost of replacing members of staff who are likely to leave because, whatever happens, they do not want to have a vaccine is £270 million. Could not some of that money be used to get those doctors and nurses with the knowledge and the trust of their recent fellows to have those conversations, without interrupting the staffing of hospitals, where it is bad enough at the moment, as we have lots of vacancies? We know that we cannot take all those people out to have those conversations, because it takes time and it has to be done with sensitivity and consideration. Could not some of that money be used to bring back some of those very experienced people to have those conversations and, hopefully, to reduce the number of those who absolutely will not be vaccinated and, sadly, will leave the profession?
I shall ask the Minister one more question. A few weeks ago, I asked him whether patients had the right to request that they should be treated by vaccinated staff only. Whatever the Government do, it will not all be done until April, which is months away. So there will be lots of patients treated between now and then by people who are not vaccinated. I asked the Minister whether patients had a right to request to be treated by vaccinated people only. He very kindly wrote to me, but I am afraid he was not able to give me a definitive answer. Now all the work has been done on this statutory instrument, I wonder whether things have become any clearer on that issue.
Baroness Bennett of Manor Castle (GP)
My Lords, a great deal of concern about procedure has been expressed from all sides of your Lordships’ House. I have nothing to add on that, except to say that I share those concerns.
I have two specific questions for the Minister. The first builds on the comments of the right reverend Prelate the Bishop of St Albans, who talked about how we have to win the argument on vaccination and the concern about unintended consequences and potentially discriminatory outcomes. When I look at the impact assessment, it is focused entirely on the care and health sectors. For example, paragraph 126 refers to
“the possibility of negative behaviour change resulting from the policy. For example, a German experiment found that vaccination requirements increased anger among individuals with existing negative vaccination attitudes and led to a decrease in uptake”.
As far as I can see, there does not appear to be in this impact assessment any consideration of impacts outside the health and care sectors. If we are creating this process, it will have impacts right across society, not just in the health and care sectors. We are talking about systems thinking here: not just what making a decision in the health and care sectors means for the health and care sectors, but what it means across the whole of society. What are the negative impacts of people in general deciding not to get vaccinated because of this?
The second point I draw from a very useful briefing from the Homecare Association. I do not think anyone else has asked this question, and I feel I should ask it for the Homecare Association. It said that it is extremely concerned about the intention to legislate rather than persuade. It is asking about a contingency plan if, indeed, the results are towards the worst end of the impact assessment. What are the Government doing to plan for this situation, when we have already had 1.5 million hours of commissioned care not delivered between August and October because of lack of availability? If this gets much worse, what plans do the Government have to fill the gaps?
Breast Screening
Baroness Walmsley Excerpts(2 years, 8 months ago)
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Lord Kamall (Con)
The noble Baroness raises a very important point; we need to tackle inequalities not just in this area but across all healthcare. One of the things we have been looking at is research into why women in certain areas do not come forward. That is why we have invested in mobile breast screening units, so that we can take screening services closer to those people who are reluctant to come forward.
Baroness Walmsley (LD)
My Lords, we heard the Minister’s Answer about the money that has been pledged, but the elective delivery plan promised by the end of November has not been published. Can he say when it will be published and how it will help to find and treat the just under 10,000 fewer than usual women who would have been diagnosed with breast cancer between March 2020 and October 2021?
Lord Kamall (Con)
The plan will be published in due course. When we look at the backlog for the breast screening programme, we see that all 77 NHS breast screening providers are now operational and screening women. Some have caught up, and others are not predicted to recover by the end of March 2022. That is why NHS England and NHS Improvement have comprehensive plans, including spending and investment.
Health and Care Bill
Baroness Walmsley ExcerptsTuesday 7th December 2021
(2 years, 8 months ago)
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Baroness Walmsley (LD)
My Lords, being asked to make a winding-up speech is a mixed blessing. There may be nothing new to say, but at least one has more than five minutes in which to say it. Like the Minister and the noble Baroness, Lady Thornton, one has to listen to the vast majority of the debate. I am sure they will join me this evening in saying what an absolute pleasure it has been. We have heard passion, compassion and expertise, all peppered with a little bit of humour—and I am right with the noble Lord, Lord Rooker, especially on the medication. It has certainly emphasised why we need your Lordships’ House: to give detailed scrutiny to Bills coming from another place. In that respect, are we not very lucky to have been able to welcome the noble Lord, Lord Stevens of Birmingham, to our ranks? I welcome him and congratulate him on his maiden speech.
When I look at a Bill like this one, I ask myself whether it will deal with the most urgent issues in the sector. So I have a little list of the questions. Will this Bill fix the crisis in social care; reduce health inequalities; ensure parity of esteem between physical and mental health; reduce the backlog of treatments while improving patient safety; improve access to primary care and reduce the demand on A&E; enable those who need social care to get it and help unpaid carers; provide the right number of qualified staff in both the NHS and social care; enable the commissioning of multi-agency pathways; improve recruitment and retention of NHS and care staff to enable them to work within safe staffing levels; enable public health to carry out prevention activities and protect us all from future pandemics; enable research and innovation to be implemented as quickly as possible and ensure that patient data is shared only in the patient’s interest and with appropriate security? Unless the answer to these 12 questions is “yes”, the Bill should either be ditched or considerably amended. It is quite clear from this evening’s debate that your Lordships are determined to do the latter.
Like the noble Lord, Lord Warner, I start with the fundamental issue of why the Government want to push these measures through at a time when the NHS is stretched beyond endurance and social care is at breaking point. Thousands of hospital beds are occupied by Covid patients; others cannot be discharged because there is not enough social care. No wonder—some care homes have had to close because they did not have enough patients to make them pay during the pandemic; others have had to close sections of beds because they cannot get enough staff. The backlog for elective treatments is not going down well enough, and both health and care staff are exhausted. GPs and pharmacists are trying to do their usual job while at the same time stepping up the vaccine programme. A White Paper on social care was published less than a week ago and another is promised next year, and it is at this time that the Government have chosen to change the structure of the health and care system.
The Minister will no doubt say that many of these changes have been requested by the health and care sector to enable them to continue to work more closely together without legislative barriers. We know that many areas have been preparing for the change for some time. That is all true, and the direction of travel is most welcome. However, winter is upon us, and services are not showing the resilience we need in preparation for it while at the same time having to prepare for these imminent changes.
The Government are taking a very big risk by asking the system to make these changes now. Can the Minister please be clear about why he is so confident that it can be done next April without the NHS and care providers taking their eye off the very heavy ball they are already carrying? None one of us wants to see a “Titanic” disaster, but the iceberg is upon us.
I move to the obvious potential benefits of the new integrated care systems, if they are set up correctly and with everything thought through. The Bill has been described as broadly permissive, and this may allow services to be arranged to suit the particular conditions of each of the 42 areas and the sub-areas between them. However, there is a danger that funding will be sucked in, as usual, to the large hospital trusts in each area and social care and community services will be left behind. From these Benches, we are particularly concerned about this. How will that be avoided? How will all the relevant interests be appropriately represented? For example, certain aspects of health such as mental health, sexual and reproductive health, as mentioned by my noble friend Lady Barker, public health and prevention services such as anti-smoking, mentioned by my noble friend Lord Rennard, and weight loss pathways, as mentioned by the noble Baroness, Lady Jenkin, may not get the attention they need right at the heart, at the ICB level, where budget decisions are made. In Committee, we will of course probe how this can be achieved. However, if representation of these services is made at the right level, there is potential for improvement.
If major changes are to be made, there is one overriding issue that must be at the heart of all ICS management, and that is addressing the health inequalities in their area. Although some parts of the country suffer more than others, no ICS will be without a group of people and neighbourhoods where health outcomes are well below the average. How does the Minister expect the ICBs to deal with this? It is not only the right thing to do but also best for the economy. People are not productive if they are not well fed, a healthy weight, active and with good mental well-being. Indeed, if the NHS is to survive financially, we need to work on prevention of ill health and avoid an older population with multi-morbidities. How much more cost effective it will be to prevent this than to pay for its effects.
Inequality also exists in the ability to pay for care, and we will probe the effects of the Government’s recent cap proposals, as my noble friend Lady Pinnock explained. Reflecting what the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Kerr of Kinlochard, said, can the Minister say where the responsibility for family and friend carers will lie under the new regime? There are millions of unpaid carers in this country, some of them still children and some very elderly themselves. The recent White Paper says very little about them, but it is somewhere in this new system that the responsibility for their welfare will lie. Where is it?
My noble friend Lady Tyler, the noble Lord, Lord Farmer, and many other noble Lords have pointed out that, at the other end of the age scale, the Bill says nothing about children and there has been no child impact assessment. I will not repeat everything that they said, but can the Minister tell us whether we will get a child impact statement? Where will the responsibility for safeguarding children lie? If it is going to the ICBs, that is a very long way from the place-based committees where all the delivery of services are made, and the current system already leaks, so we must be very careful.
My noble friends Lord Shipley and Lady Pinnock have talked about local authorities, which have numerous responsibilities for social care and public health. This Bill should be creating a partnership of equals between the ICS and local government. In Committee we will probe how local authorities can influence the distribution of budget from the ICB. Many ICSs will cover several local authorities and some authorities will cross two ICSs. How will that work? Of course, it is at local level that all the services that we are talking about will be delivered, so we will also probe the relationship and lines of accountability between the place-based committees and the ICB. In his introduction, the Minister mentioned the phrase “bottom up”. The epitome of that in this new structure is the place-based committees and the voice of the patients they represent. How will their voices be heard at an appropriate level?
The Government are hoping that the new integrated care systems will be more financially efficient than under the old regime. This may be so, but it is vital that it is not at the expense of quality. We welcome the removal of the dominance of competition in procurement, with more emphasis on quality and collaboration, but we will be watching very carefully to ensure transparency in procurement. Contracts must go to companies and service providers who are chosen on their merits and not on who they know. The ICS board, however large or small it is, must be seen to be independent and not influenced by private interests, because it will have enormous power.
Talking of power brings me to the new powers of the Secretary of State. There may be justification for some of them for accountability’s sake, but these must be tempered by appropriate limits, consultation and transparency. However, there is more than a little tension between the Government’s stated objective of being broadly permissive towards the ICSs and giving more power to the Secretary of State, especially the power to intervene at an earlier stage in local service configuration, and even to propose a new local reconfiguration himself or herself. That is going too far and is against the spirit of the Bill.
If health and care organisations and providers are to work more closely together, a lot of patient data will be exchanged. The objective is to have a common system so that information can be quickly and accurately exchanged. We will scrutinise this part of the Bill to ensure that this is always in the patient’s interest with an appropriate level of need to know, privacy and accuracy. The mandatory health services safety investigations body appears in Part 4 of the Bill.
I well remember hearing a previous Secretary of State, Jeremy Hunt, at a King’s Fund lecture several years ago, describing how it would seek to find out what went wrong without apportioning blame, so that learning could occur across the system. It struck me then, as it does now, as a very worthy objective. He said it would be based on the Air Accident Investigations Branch, which has been very successful. For it to work in the interests of patients, it must be independent and have the trust of staff. The so-called safe space in which staff can explain what happened is a very important element of this, and I would be concerned about any attempt to encroach on it. We will look at that in detail at a later stage.
I end on the most important factor of all in the delivery of health and care services: the workforce. Over the past few years, the number of vacancies has been growing and is now chronic—not helped, particularly in the case of social care, by Brexit. Safe staffing levels have been breached, and that means that patients are in danger, so we will lay amendments to ensure the provision of sufficient staff with the right level of training to ensure safe staffing levels. Planning for the provision of enough qualified staff has not been good enough, and a review of workforce planning every five years will not do. Given how quickly things can change, that is not often enough.
We will support efforts to provide more accurate predictions of need and more frequent review of the plans to provide them. We are also concerned that the focus could be on NHS staff only and that care staff will be forgotten. Does the Minister agree that they, too, need skills and career paths to ensure high-quality care and encourage recruitment and retention? We look forward to the delivery of the £500 million for this promised in the White Paper and wonder whether the Minister can say how the training will be delivered in the new integrated service. It will be one of the most important duties of the new integrated care systems.
This must not be just another NHS reform Bill. It must be about improving the health and care of the whole nation. I look forward to the Minister’s replies to these important questions.
Health and Social Care
Baroness Walmsley Excerpts(2 years, 8 months ago)
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Lord Kamall (Con)
We have to recognise that if we look at the social care system, there are an awful lot of private providers. Quite often, when we look at private providers, it is private patients who subsidise their ability to provide places for state-funded patients. In our health system overall, there will always be a mixed economy, including state provision. Lots of our GPs, for example, are partnerships—they are not state-run, some of them are co-operatives, some are even for profit. When we look at the overall health system, there will be a general balance. I am not aware of the particular case, so I thank the noble Baroness for raising it, but one of the things we are committed to is making sure that we improve services, whether they are state-funded or private, as part of the overall system of healthcare that we have in this country. Clearly, where providers are not providing a service, there will be CQC and other assessments to see whether they are fit.
Baroness Walmsley (LD)
My Lords, Covid-19 is absolutely rife in our schools, both primary and secondary. Teachers are in the front line. There are whole classes and even whole year groups being sent home because the teachers are off sick and they cannot even get supply teachers. A lot of teachers are under 40. Why can they not get boosters? If vaccines really are the answer, during this winter period, that would help more children to be able to stay in school and avoid disrupting their education. Will the Minister tell us about that?
Secondly, I go back to what both noble Baronesses on the Front Bench raised. Where are the social care staff going to come from? When I looked at the paper that sat behind this Statement, I noticed that there was nothing in it about changing the salary level at which visas can be offered to social care workers coming from abroad. Why not? We are desperate for social care workers. Can the Minister tell me—and if he cannot, perhaps he will write to me—what proportion of vacant posts fall below the salary level required for a visa?
Lord Kamall (Con)
In terms of tackling the social care workforce, there are a couple of things: £162.5 million is going on a number of different schemes to make the social care sector an attractive place to work and we are looking, longer term, at professionalisation, so that people feel valued. At the same time, the minimum wage will help lift the pay of many people in social care work, but in the longer term we want to make sure that social care is not seen as the poor relation of other parts of the health service. We want to make sure that we have professionalisation and that it is all joined up. Some of these things will not be tackled in the short term, but we have a short-term programme called Made with Care, which is aimed at targeting and recruiting people to come and work in the social care sector. We realise that we have to do the long-term things, but also to promote short-term measures to tackle the issues we have at the moment. On specific statistics, as I am sure the noble Baroness can imagine, I do not have the details at hand but I commit to write to her.
Adult Social Care
Baroness Walmsley Excerpts(2 years, 8 months ago)
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Baroness Walmsley (LD)
I wish the Minister good luck with his nettle grasping—I think he is going to need it. He will know that the right housing is key to enabling people to remain safely and happily in their home, yet only £300 million, a very small amount, is being promised in the White Paper to integrate housing into health and care strategies. Take, as an example, the so-called extra care units, where people can live in a flat with appropriate on-site support; that will mean only about 3,000 such units across England. Can the Minister say over what period that money is being offered? Is it three years or a different period? How many units of supported housing can be provided for that amount of money?
Lord Kamall (Con)
I thank the noble Baroness for raising this issue. We want to ensure that people can live in their own home for longer. We have committed a sum of money and been quite clear that practical changes can be made, such as installing stairlifts, level-access showers, wet rooms, sensors, et cetera. New technology is constantly being developed to meet people’s needs in their own home. To this end, we have committed a further £573 million per year to the disabled facilities grant, from 2022-23 to 2024-25. We are also talking to local authorities and others, looking at whether we need to increase the subsidy amount per adaptation and reconsider funding allocation to better align with local needs, as well as funding a new service to enable minor repairs and changes to people’s homes. We need to know what needs to be done, and local authorities and others can come back to us on the adaptations that they need and the best way to achieve them. We must look at best practice to make sure that, as technology develops, people can stay in their own home for longer.
Ambulance Response Times
Baroness Walmsley Excerpts(2 years, 8 months ago)
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Lord Kamall (Con)
The noble Baroness makes a very important point: we should be looking at this in a systemic way. In fact, I did my PhD in a department of system science, where you look at problems in a holistic way—rather than analysing individual problems, you look at the whole system. We found odd unintended consequences. For example, a friend forgot his inhaler, could not get one from the chemist, could not get one from the A&E and, in the end, had to call out an ambulance. There are a number of times when ambulances are called out needlessly, and that is on top of the pressures we are already facing due to Covid. We are tackling the backlog, which, hopefully, will also reduce ambulance waiting times.
Baroness Walmsley (LD)
My Lords, is the Minister aware that every ambulance service in the country is currently on black alert? The problem goes both upstream, into the community, and downstream, into the hospitals and social care. What are the Government doing to decrease the number of older people being blue-lighted into A&E because they cannot get the social care services to keep them safe in their own homes?
Lord Kamall (Con)
The noble Baroness makes a very important point. We are all aware of the difficulties in different parts of the system. We have invested £450 million to upgrade A&E facilities in more than 120 separate NHS hospitals ahead of last winter, and this is being used to boost the physical capacity of A&E through expanded waiting areas, increasing the number of treatment cubicles, reducing overcrowding, et cetera. This is alongside an additional £1.8 million to place more hospital ambulance liaison officers at the most challenging acute trusts to help address the long delays, to reduce ambulance queueing and to get crews back on the road quickly.