Health and Care Bill

Baroness Merron Excerpts

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

Moved by

[Baroness Merron]

2: Clause 1, page 1, line 5, at end insert—
“(1A) The Board of NHS England must be made up of—(a) a Chair appointed by the Secretary of State;(b) five other members so appointed of whom—(i) one must be appointed to represent Directors of Public Health;(ii) one must be appointed to represent the Local Government Association;(iii) one must be appointed to represent the interest of patients;(iv) one must be appointed to represent the staff employed in the NHS; (v) one must be appointed to represent the integrated care partnerships;(c) one further member appointed by the Secretary of State after being recommended by the Health Committee of the House of Commons as a person with appropriate knowledge and experience;(d) executive members as set out in Schedule 1 to the Health and Social Care Act 2012.(1B) In making the appointments in subsection (1A)(a) and (b) the Secretary of State must have due regard to—(a) the need to ensure diversity and equality of opportunity; and(b) the need to ensure that no person who could be perceived to have a conflict of interest by virtue of their current or recent employment or investment holding in any organisation with any role in the delivery of services to the NHS may be considered for appointment.”Member’s explanatory statement
This amendment requires changes to the membership and composition of the Board of NHS England to reflect its new role under the Bill.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley, for their support.

This amendment seeks to define the composition of the board of NHS England to better align it to the new requirements set out elsewhere in the Bill. There must not be any doubt as to why board members have been appointed. In other words, their appointment must be made on their ability to contribute and add strength to the board, rather than—perhaps—because of those whom they already know. Key factors in the appointment of board members need to be an independent assessment of their value and meeting a fit and proper test of freedom from conflict of interests—things that I hope we would all agree on in your Lordships’ House.

Beyond that, we must also look at what the new NHS England board will be required to do. Other parts of this Bill deal with the powers and duties of this new version of NHS England, originally the NHS Commissioning Board. This is the clearest demonstration of the reversal of the 2012 Act, as the new NHS England bears no resemblance to its original predecessor—and that is a good start. The new NHS England will of course be an amalgamation of the old NHS England, Monitor and the NHS Trust Development Authority. It will commission some specialist services. It will be the regulator of a market that no longer exists. It will performance manage both commissioning for integrated care boards and provision of services by trusts and foundation trusts.

This is indeed a wide range of responsibilities, and how it sits with roles within the department unfortunately remains as vague as ever, with the ability of Ministers to micromanage depending on other parts of this Bill. However, the most crucial policy change is that the new NHS England will sit at the top of a system based on the integrated care boards being the major commissioners of services. The Explanatory Notes and the government pronouncements about these new integration bodies strongly assert their role as driving the reintegration of the NHS, repairing the worst of the fragmentation caused by the 2012 Act and dealing with aspects of previous legislation which had a somewhat market-centric view of our NHS.

This purpose drives what we now need from the new board members of NHS England. Those new board members must chime with this new philosophy of partnership and collaboration rather than markets and competition. In the new world, the NHS will still be bound, as it always has been, by its core principles: comprehensive, universal, free, and funded from general taxation. Board members need a demonstrable record of commitment to these principles. They should also have a commitment to the new values, which favour a stronger role for patients and the public to have influence, a view of the NHS as contributing to reducing inequalities and improving well-being, not simply being a sickness service, and greater alignment of NHS services provided through local government. The current make-up of the board is a chair and five other non-executives, all appointed by the Secretary of State and then the appropriate executive directors. Given the huge importance of the NHS, it is appropriate of course that the chair and at least some of the non-executives are appointed by the Secretary of State. This amendment deals only with the remaining non-exec members.

--- Later in debate ---

Amendment 3 (to Amendment 2) withdrawn.

[Baroness Merron (Lab)]

My Lords, the noble Earl, Lord Howe, hoped that his comments would be helpful and I reassure him that he is always helpful in the comments that he offers. Today, of course, is no exception.

As my noble friend Lord Howarth said, this has been a very interesting debate and it has certainly stimulated many angles of consideration. At a minimum, that has been extremely useful because what binds us all together in this debate, whether or not we agree with the amendment, is the wish to see the new NHS England perform to the highest order in terms of not only confidence but effectiveness. I know that we all want to move in the same direction.

Clearly, we have heard differences of opinion. I am grateful to the noble Baroness, Lady Walmsley, for speaking further to the point about representation. I say to my noble friend Lord Howarth that I did not interpret her as having reservations; her concerns were more about clarification, and I share them. The intent of the amendment was not that people should be consulting back and be a straightforward linear representative, but that they should represent and come from the area which we were discussing. The noble Lord, Lord Patel, made a particularly strong case for the importance of influence in public health; that was echoed by my noble friend Lord Brooke. We are all keen, I am sure, to see the ability to promote good health and well-being such that the NHS, as I said in my opening remarks, should not be focused entirely on dealing with ill health, important though that obviously is.

It is important that we get the right people in place to build the right team. It is crucial that they work together. I am sure that many noble Lords who are non-executives on boards know that a successful board is one that invites challenge, dissent and the widest range of voices. I certainly hope the new NHS England board will do this.

As the right reverend Prelate the Bishop of London so clearly put it, it is too easy for patients’ voices to be forgotten—this must not be the case. I know the noble Earl, Lord Howe, will do his best to ensure that those voices are well heard. Certainly, we in this House will continue to pursue that.

The areas outlined in the amendment from which we had hoped to seek representation remain as important as ever after this debate. I am sure that the noble Earl, Lord Howe, and the Minister will reflect on them in the context of the debate. I thank the noble Lord, Lord Mawson, and the noble Baroness, Lady Harding, for providing challenge, as is quite right and proper. I look forward to the new board of NHS England doing the job we all want it to do. In view of our debate, I beg leave to withdraw my amendment.

Amendment 2 withdrawn.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I feel that today’s debate on this important group of amendments should carry much weight because, at its core, this is about treating people as whole people and seeing them as physical, mental and social beings. Our welfare on each of those fronts is absolutely key to the others. It is not possible simply to treat one without regard to the others, and it is crucial that we enhance people’s well-being across our whole complexity as human beings.

I am glad to speak to this group of amendments because, as we have heard across all sides of the Committee throughout today’s debate, the reality is that, despite the best efforts encapsulated in the mandate, and many times in policy, we find that competing priorities, an avalanche of guidance and instructions, and events—the pandemic has been referred to several times, of course—mean that mental health services can be, and indeed have been, relatively left behind. As the Centre for Mental Health reports:

“Mental health problems account for 28% of the burden of disease but only 13% of NHS spending.”


In the debate today we have also asked ourselves: where is the accountability? For example, we know that in many clinical commissioning groups the actual spend on mental health was below what it was supposed to be, yet there have been no consequences. We need to address not just the finances but the mechanisms around it and the impact on individuals.

The founding National Health Service Act 1946 rightly spoke of a comprehensive health service that secured the improvement of both physical and mental health, and subsequent Acts, quite rightly, have confirmed this. In operational terms, the Government require NHS England to work for parity of esteem for mental and physical health through this NHS mandate, but we know, and have heard again today, that this requirement falls down when we go to a local level.

One way or another, we will all be familiar with a whole range of stories of people who have not been able to access treatment in a timely manner or who find that they are pushed around a system with very little effect and discharged from care before it is appropriate, with consequences that are all too clear to see. It is difficult to overestimate just how challenging this is, not just for the individuals but for local commissioners, because they face competing pressures in trying to deal with this.

As has been emphasised, this group of amendments is about not just getting on the road to financial parity, important though that is, but changing the culture and the whole means of monitoring and implementation, so that disparities can be addressed—indeed, if possible, so that difficulties can be headed off at the pass. It is a well-worn phrase, but it sometimes seems that mental health is a Cinderella service—the one that can be cut first, to the benefit of the more visible services. Some of the recent statistics show that one in four mental health beds has been cut in the last decade, while just last year 37% of children referred by a professional to mental health services were turned away. That is a shocking statistic that we need to move away from.

I thank noble Lords for promoting these amendments and for their contributions illustrating what they mean and the reason we need them today. The noble Lords, Lord Stevens and Lord Patel, made timely points about the impact of the pandemic. If this is not a moment for focusing more on mental health, I do not know what is. The challenge we have and the difficulty presented by the pandemic is that while there is a focus on cutting waits for operations—and we know that is important—this could be a reason for mental health services to get somewhat lost, when in fact the pandemic reminds us of the importance of mental health and the need for the NHS to meet the needs that there now are.

The amendment by the noble Lord, Lord Stevens, encourages and directs the actions necessary for transparency on expenditure. I recall that they were referred to in the debate as legislative levers, and that is indeed what they can be. For me, they encourage not just accountability and transparency but actual action and change—the change we need to see.

The noble Baroness, Lady Hollins, referred to parity of esteem having to be applied locally, not just at a higher level. That is the only way we will see a difference in mental health services and improve the mental health of people in this country.

The noble Lord, Lord Crisp, made reference to the fact that legislation is trying to catch up with where we are as a society, and the noble Lord, Lord Warner, referring back to the meeting he attended, said that the public are well ahead of the game. I believe that is true. Indeed, as the noble Baroness, Lady Watkins, said, we have to prepare for tomorrow. It is not satisfactory that we stay stuck in today, or indeed in the past.

In my view, these amendments move us on. They bring mental health services into real parity with physical health services, but they also connect mental and physical together. I hope they will find favour from the Minister.

[Lord Kamall (Con)]

I begin by thanking all your Lordships for the wide-ranging debate. I want to say how much more I learn, listening to the contributions in each of these debates, before I stand up to speak. I thank all noble Lords for their contributions. As the noble Baroness, Lady Merron, says, this debate carries some weight for our understanding that social, mental and physical well-being are equally important. We should not seek to suggest that one takes precedence over another. I also thank the noble Lord, Lord Stevens, for kicking off this debate with his encouraging and not critical amendments; I take them in that spirit.

Following on from that, and before I go to some of the specific amendments, I will just reflect on some of the contributions made thus far. I first thank the noble Lord, Lord Howarth, for raising social prescribing. I know we have discussed this a number of times since I became the Minister, with particular contributions from the noble Baroness, Lady Greengross, on the importance of art and music in helping to unlock the mind and touch the soul.

As has been made clear, social prescribing is a key component of the NHS’s universal personalised care, and I know that, crucially, this can work well for those who are socially isolated or whose well-being is impacted by non-medical issues. The NHS has mechanisms to ensure that social prescribing is embedded across England: for example, the primary care network directed at enhanced services specification outlines that all PCNs must provide access to a social prescribing service.

I also thank the noble Lord, Lord Patel, for raising the importance of the mental health of children and for making sure that we do not forget, even within mental health, that many sections of our society can quite easily be forgotten.

I agree with the right reverend Prelate the Bishop of London: we have come a long way. I remember as a child in the 1970s going to visit my uncle who was a psychiatric nurse at Claybury Hospital and looking at the patients, with the innocence of a child, and thinking, “These people don’t look ill to me.” We have come far since then. I remember the Rampton hospital scandal in the late 1970s, where the patients were treated appallingly, almost not as humans, and with a lack of dignity. The fact that today we are discussing the parity of mental with physical health shows how far we have come as a society.

We also spoke about loneliness and isolation. The noble Baroness, Lady Watkins, and I have had conversations about loneliness and some of the civil society projects that, for example, bring together lonely older people with children from broken homes so that both can benefit and learn from each other. I remember a story that I have mentioned in the past: in one of the projects I visited, a rather old man said, “I lost my wife five years ago and I had almost given up on life. The fact that I am now working with children from broken families and am almost being a mentor to them gives me a purpose to live—a reason to get up in the morning. I have no longer given up on life.” There are so many of these civil society projects, and no matter how we legislate, sometimes those local projects get to the nub of the problem in their local communities.

I have to pay attention when not only two former NHS chief executive officers but the former Chief Nursing Officer speak in the debate. The noble Lord, Lord Crisp, talked about the focus on outcomes, not inputs and how it is important to make sure that we are not gaming the system, mentioning mental illness and mental health but not doing anything effective about it.

Autism was mentioned by the noble Lord, Lord Warner, a former Health Minister. We are fully committed to improving access to and provision of health and care services for autistic people and people with a learning disability. I know that we have had at least one debate on the treatment of patients with autism and sometimes the terrible conditions they experience. That just shows how important this is.

I am trying to say that in many ways that the Government are absolutely committed to supporting everyone’s mental health and well-being and to ensuring that the right support is in place for all who need it. I therefore welcome the amendments which look to ensure parity of esteem across physical and mental health. I assure noble Lords that we support the sentiments behind these amendments and take mental health seriously.

Indeed, one of the considerations in weighing up the many arguments for further measures in response to Covid—from those who were asking for lockdown, for example—is that we also had to recognise that there was a mental health impact to lockdown. As a Government, we had to look not only at the societal and economic impacts but the mental health impacts within health considerations.

On the amendments, I will first address those tabled by the noble Baroness, Lady Hollins—I add my voice to those of the many noble Lords who have paid tribute to her work over many years in promoting this issue and ensuring that we take it seriously. I also pay tribute to the noble Baroness, Lady Walmsley, for making sure that we are informed about this. These amendments would explicitly reference both mental and physical health and illness in certain provisions of the Bill. I understand that the intention is to ensure that due attention is given to both “mental and physical health” and “mental and physical illness”. Indeed, you cannot separate mental and physical illness, as the noble Baroness, Lady Jones, said. We have moved way beyond “Pull yourself together, man” or a stiff upper lip attitude. We see how mental health plays a role, for example, in terrorism, with those who are recruited to be terrorists, or in those with eating disorders, or the number of people in prison who suffer from mental health issues. It is important that we fully recognise that.

Public Health: Night-time Working

Baroness Merron Excerpts

Thursday 6th January 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, night working can place a strain on people’s health through increased incidents of depression, diabetes and cardiovascular disease. Can the Minister tell the House what work the Government are doing with unions and employers to reduce this link between night working and ill health, and what account they are taking of the TUC report which calls for greater attention to the pressure of night working on home life and relationships?

[Lord Kamall (Con)]

A number of noble Lords have made the very important point that there is clearly an impact on individuals of working at night, including fatigue, wider pressures and disruption to family life. The sleep review has looked at this and reported just before Christmas, after consulting a wide range of stakeholders. The Office for Health Improvement and Disparities will publish its report in the summer of 2022, I hope.

Medical Schools: Training Places

Baroness Merron Excerpts

Monday 13th December 2021 Lords Chamber

[Lord Kamall (Con)]

There has rightly been much discussion of workforce planning for the NHS and adult social care, and the Bill will build on this. Clause 35 will bring greater clarity and accountability in this area, requiring the Secretary of State and the NHS to produce a workforce plan.

[Baroness Merron (Lab)]

My Lords, with the intensification of the Covid booster programme, more doctors will, of course, be diverted from their usual roles, making it even harder for people to get an appointment at their local surgery, and record waiting lists will continue to increase. What revisions will the Minister make to existing plans for numbers of training places to meet the need for more trained staff, including doctors, nurses, lab technicians and auxiliaries? How will the Minister respond to the report from the Royal College of Surgeons that 13,000 planned operations have been cancelled in the last two months alone?

[Lord Kamall (Con)]

The focus and priority for the next three weeks is on omicron and making sure that people get their boosters as quickly as possible. It is not only doctors who are involved: nurses, pharmacists and, incredibly, a number of civil servants are now taking part in that programme. For the next three weeks, the focus is on getting more jabs into arms.

Health and Care Bill

Baroness Merron Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am glad to speak in this Second Reading debate on a Bill that has generated much anticipation and interest; the Minister’s comments today have also created much anticipation and interest. I am grateful to the many parliamentary colleagues, organisations, charities and representative bodies that have given their time to give their invaluable views and expertise to many of us in your Lordships’ House. I also thank the Minister and his team for making themselves available, and for the extensive work that they have already undertaken and will continue to undertake. I look forward to the maiden speech of the noble Lord, Lord Stevens of Birmingham; I wonder how he decided to choose this particular Second Reading in which to make it.

However, I am sorry to say that this is the wrong Bill at the wrong time, as it fails to deal with the real and immediate issues in the health and care system: scandalous social care provision; no workforce planning; no strategy for integration between health and social care; weak and underfunded public health services; and inadequate levels of funding. Regrettably, the Bill does nothing to resolve the democratic deficit around accountability in the NHS, and fails to put patients, their carers and the workforce at the heart of building back a better NHS. It is not about improving well-being or addressing the social determinants of poor health. Nothing in this Bill will make much difference to the long waits for people in pain and distress, or those who experience delays in waiting for an ambulance. As for it being the wrong time, we know that the pandemic is far from over. We still await proposals for social care integration, and the most vital issue—responding to the workforce crisis in the NHS and social care—is not even at the planning stage.

Let us remind ourselves that this Bill began as a legislative response to desperate pleas from the NHS to reverse some of the provisions in the Health and Social Care Act 2012, which made it impossible to develop the NHS Long Term Plan. There were demands to end compulsory competitive tendering for health care services and allow much greater co-operation and joint working between various bodies. Also, it was clear that the informal organisational arrangements that the NHS had developed in the sustainability and transformation partnerships needed to be put on to a statutory basis. These have become the proposed 42 integrated care partnerships.

So, a Bill that was expected in 2017 is now with us in 2021 with the addition of extensive new powers for the Secretary of State, which give rise to deep concern. These extend to direct involvement in service reconfigurations, which could be as purely operational as moving a clinic a few yards down the road. They refer to the transfer and delegation of various functions in relation to arm’s-length bodies, the regulation of healthcare and associated professions, and reporting on workforce needs. After Committee in the other place, out of the blue, the Government added a highly contentious new clause concerning the social care costs cap, which will doubtlessly stimulate many hours of debate in your Lordships’ House.

We acknowledge the proposals around information standards and information sharing; setting up, at long last, the Health Services Safety Investigations Body; the introduction of Care Quality Commission powers to investigate adult social care; the reference to medical examiners; food advertising to combat obesity; fluoridation; and the banning of virginity testing.

From these Benches, we broadly support those parts of the Bill that remove the worst of the 2012 Act, but will look to add key safeguards to ensure proper governance and accountability and prevent new arrangements being open to abuse around contracting, particularly with the private sector. However, as I mentioned earlier, we do not support most of the proposed new powers for the Secretary of State in the absence of a proper case being made for them. Of course, the Delegated Powers and Regulatory Reform Committee has reported on these issues; we will be looking very closely at its report.

It is a matter for regret, as I have said, that the Government did not bring forward legislation in 2017 to solve these problems with a far simpler Bill. Having missed the opportunity to act decisively at the right time, we now have to rush through a far more complicated Bill at a more complex time.

Part 1 mostly sets out yet another NHS reorganisation of commissioning on the back of many previous attempts to do likewise. Commissioning will still be conducted on many levels and be difficult to understand and manage. What the public will make of all this is unknown—but then, perhaps nobody actually asked them.

We know that, in Committee in the other place, the Government made a virtue of the flexibility of the Bill. This extends to changes to procurement and pricing, although no details are available. There is a similar lack of detail about what will happen at place, or indeed how “place” is to be defined, or how the two headed integrated care systems will function and how the money will flow.

The Part 1 new powers of the Secretary of State that are spread through the Bill were not what the NHS asked for. Ironically, one relative success from 2012 was the separation of NHS operational accountability from Ministers; the reasons for reversing this are hard to fathom. As any former Minister, including myself, will understand, it is mystifying as to why Ministers should seek such powers.

We will seek to include amendments that will strengthen the governance of integrated care systems by requiring stronger public, patient, carer and staff involvement as a right. We will seek to ensure that the best people are elected or appointed into key roles with due regard to diversity, fairness and transparency. We will seek to prevent the potentially undue influence of private sector organisations in commissioning, and ensure that contracts are awarded with a proper and transparent process that is as good as the Public Contracts Regulations that will be disapplied. Moreover, the Part 1 clause about discharging patients before they have had their social care needs assessed needs fundamental safeguards to ensure that we do not hear once again of an elderly person being returned in the early hours to a cold and empty home. This has to stop.

Let me turn to what is perhaps the most challenging clause, the one relating to workplace planning. If there is one thing about which there is universal agreement, it is the inadequacy of this clause. Having the right workforce across the health and social care sector is the issue of the day, and the response thus far is wanting. We need to see a more resolute approach that properly plans ahead across the NHS, social care and public health. This is not just about doctors and nurses but about the entire team, including cleaners, care assistants, lab technicians and catering staff. Last but not least, there is the last-minute new clause on the rules for calculating the cap on care costs, which will be robustly scrutinised and opposed by these Benches and by many others.

Of particular interest to me as a former Health Minister are a range of other welcome provisions dealing with virginity testing, fluoridation and hospital food, to name but three of the public health measures on which I used to work. However, it is disappointing to see a dearth of proposals on dealing with the increasing and unacceptable level of health inequalities that have been exacerbated by the pandemic and well highlighted by Professor Marmot over many years.

As was experienced in the other place, we know that there will be many more proposals for new clauses to cover other matters. This is surely a Christmas tree Bill, and decorations will surely abound. We will be glad to support the three new clauses proposed in the other place dealing with duties on reducing inequality, attention to waiting times and restricting the use of the term “nurse”.

Before I conclude, I wish to come back to the important matter of patient safety and the health services safety investigations body. We strongly supported the original Bill and were very disappointed when it suddenly fell off the Government’s radar. Despite efforts from across the House, Ministers were unable to explain where it had gone and why it was not being vigorously pursued in the light of the urgent imperative to embed the “lessons learned” culture into the NHS.

The aim of this body is of course to improve the quality of locally conducted investigations and to reduce the incidence of future harm to patients. The benefits cannot be quantified, but the expectation and the hope are that they will far outweigh the costs incurred by the investigations, avoid costs associated with correcting or compensating for harmful incidents, and encourage health improvement. I hope this will be a major contribution to patient safety.

In conclusion, I regret to say that, however this Bill is presented, it is in effect yet another NHS reorganisation. In the last 30 years, we have seen around 20 reorganisations of the NHS, and the British Medical Journal has observed that

“Past reorganisations have delivered little benefit.”


So the questions for the Minister are many. Why will this Bill be any different? How will the 85-year-old with multiple needs get better care based on them perhaps being treated as a whole person as a result of this restructuring? How will waiting times for elective surgery for cancer and mental health support be improved by this reorganisation? How will health inequalities, which have widened, and life expectancy advances, which have stalled, be corrected by this Bill? A real test for this Bill is: will it makes things better and, if so, for whom?

This Bill can do some good, but its timing is unfortunate at best and an opportunity missed at worst. The question remains as to whether this is the right Bill or the right time. However, if the Bill is to be implemented from 1 April, it has to be the best that we can collectively craft. We look forward to making a positive contribution to making it so.

Cigarette Stick Health Warnings Bill [HL]

Baroness Merron Excerpts

2nd reading
Friday 3rd December 2021 Lords Chamber

[Baroness Merron (Lab)]

My Lords, it is a pleasure to speak in this Second Reading debate on a Bill on which varying views have been expressed. I fear that the noble Lords, Lord Moylan and Lord Naseby, will be somewhat disappointed in me, but it is a risk I am prepared to take because I congratulate the noble Lord, Lord Young, on bringing the Bill forward today. He rightly commands much respect across the House and is a doughty and informed campaigner on this issue.

I am pleased to say that this measure, which was proposed in the other place as an amendment to the Health and Care Bill, has the support of these Benches. It is important to remember why we are talking about it today. We are not talking about it as a measure for a measure’s sake, but as a major contribution to the improvement of people’s health, the reduction of inequalities and people living longer and healthier lives. That is the reason we are discussing it today.

We welcome the Government’s ambition to be smoke-free by 2030, and I hope the Minister will be able to welcome the measures outlined in the Bill. If we look at the 2019 prevention Green Paper, the Government committed to making smoking obsolete, but regrettably there is still no sign of the proposed and promised bold action that they agreed was essential to achieve that extremely challenging shift. There have been great strides in reducing smoking rates and improving people’s health and life expectancy over the past 20 years, but we must acknowledge that a continuing decline in smoking rates is not guaranteed and needs further work. As we have heard, evidence shows that we must constantly renew and refresh our tobacco control strategy to avoid stagnation in smoking rates and a widening of the already significant inequalities in rates between those who are richer and those who are poorer. With only nine years left to end smoking, Cancer Research UK analysis shows that the 2030 target will be missed by seven years and that it will be doubled for the most disadvantaged. I hope that is of concern to this House.

I am pleased to observe that tackling smoking is not a party-political issue. Governments of all stripes have implemented a comprehensive approach to tobacco control, starting at the beginning of this century with banning smoking in public places and in cars carrying children, then the point-of-sale display ban, which I saw through as Minister of Public Health at the time, through to standardised tobacco packaging. They have all helped to drive down smoking rates and have discouraged people, particularly the young, from starting smoking in the first place.

Nowhere is this consensus more evident than in the cross-party support for the Government’s smoke-free 2030 ambition, which if delivered would represent one of the most transformative public health statements and achievements in modern history. It is supported by more than three-quarters of the public, with majority support from voters of all political parties. This suggests a mandate to demand bolder action from the Government to end smoking by 2030.

Ending smoking will improve the quality of people’s health and save millions of lives in decades to come. It will also help to dramatically reduce health inequalities and lift thousands of households out of poverty, making it absolutely central to the levelling-up agenda. Tobacco is the leading cause of health inequalities in our society and is responsible for half the 10-year difference in life expectancy between the richest and the poorest. For every smoker who dies, another 30 are suffering from serious smoking-related diseases that affect not just the smoker but all those around them. This burden is dis- proportionately concentrated in our poorest communities; the Covid pandemic has really laid this bare for all to see. Consequently, people in these communities would accrue the greatest benefit from policies to deter people from smoking and make it easier to quit. Ending smoking for all would lift 500,000 households out of poverty. That includes 740,000 working-age adults, 180,000 pensioners and 330,000 children concentrated in the north and Midlands.

Ending smoking in these communities would not just benefit the health and well-being of individuals but inject into local economies money previously and literally going up in smoke. This would show just how serious the Government are when they talk about levelling up, but disappointingly they have thus far opted not to support the amendments proposed to the Health and Care Bill to get us on track to meet the smoke-free 2030 ambition. This includes the measure we are discussing today. These amendments form a key part of the comprehensive package of messages and measures needed to drive down overall smoking rates while also tackling the disproportionately high rates of smoking among poorer and more vulnerable groups.

To their credit, Ministers in the other place expressed support for the principle behind the amendments, but said they needed more time to consider the proposals. My point to the Minister today is that it has been more than two years since the Government announced the 2030 ambition. With that in mind, when will action be under way to deliver this important commitment?

Ministers have also stated that the Health and Care Bill is not the right place for measures to tackle smoking, which will instead be announced and introduced in the forthcoming tobacco control plan. However, this plan has already been delayed twice and seems unlikely to be published this year as proposed, meaning that we might not see concrete action to deliver the smoke-free 2030 ambition until 2023. When can we expect to see the plan?

We cannot afford to wait this long. The Government have the opportunity to adopt this Bill or accept the tobacco amendments to the Health and Care Bill. We have an opportunity now to move this agenda forward and start building back the nation’s health as we emerge from the worst of the pandemic. I urge the Government not to waste this chance. The Bill would play a contributory and important role in helping us reach the smoke-free 2030 ambition. I hope the Government feel able to support it.

Coronavirus Act 2020 (Early Expiry) (No. 2) Regulations 2021

Baroness Merron Excerpts

Tuesday 30th November 2021 Grand Committee

[Baroness Brinton (LD) [V]]

My Lords, this is beginning to have the feeling of “Star Trek”, which is certainly not my intention. Thank you, Deputy Chairman. I declare my interest as a vice-president of the Local Government Association.

From these Benches, we will not oppose the expiry of these 12 provisions, although we have some comments on them. It was really good to hear the Minister outline the “hands, face, space” guidance, readopted in the past couple of days. Will there be a public communications campaign to reinforce it because, sadly, I suspect that not many people will have heard it in Grand Committee today in Parliament, let alone in the outside world?

Yesterday, in the Statement repeat, we debated masks and self-isolation; we will do so again tomorrow when we look at the SIs. On vaccination, it was good to hear the Prime Minister and the Secretary of State refer to the clinically extremely vulnerable in this afternoon’s press conference. I promise the Minister that I will not repeat all the questions I asked him yesterday, but not one of them has yet been answered. Delivering either the fourth, or a booster, jab for 3.7 million clinically extremely vulnerable people will not work effectively without clearer information systems on exactly who the CEV are and which jab they should get; there is still a lot of uncertainty there. I thank the Minister for his offer of a meeting during yesterday’s Statement. With today’s announcement, vaccination is becoming urgent; I look forward to hearing from him shortly about when it can happen.

From these Benches, we want to make a brief comment on the assessments for local authority care and support. I note that the Explanatory Memorandum says that only

“eight local authorities used these powers between April 2020 and June 2020. No local authorities in England have used them after 29 June 2020.”

That is good to hear, but it is evident that assessments are still happening very slowly. It is one of the problems that hospital trusts across the country are facing, with people in beds awaiting an assessment. Some of that is much more about workforce availability, both in the NHS and in the local authority system, than about the arrangements to reduce these assessments.

Reference has already been made to local authorities having virtual meetings. Members from these Benches and others objected when the Secretary of State decided that all local authority meetings had to cease being virtual in January this year. It has meant that a number of councillors have been unable to attend their council meetings through no fault of their own. If the Lords can have a handful of people contributing virtually, and with cases going up and certain areas having problems, is it possible to return to virtual meetings and leave the matter as a choice for the local authority concerned?

I note that the Explanatory Memorandum says:

“This instrument does not relate to withdrawal from the European Union/trigger the statement requirements under the European Union (Withdrawal) Act 2018.”


However, it is only fair to point out that Section 25 gives early expiration to the power to require information relating to food supply chains to avoid serious disruption. In principle, we do not have a problem with that as a provision during the pandemic, but I say to the Minister: that statement may be true in treaty and UK legislation terms but, as we face this Christmas, there are increasing concerns about disruption to food supply chains, for three reasons.

One is a direct consequence of Brexit. European providers of food and many other products have significantly reduced or stopped exporting to the UK because of the complex, slow and, for both exporter and importer, expensive costs now that we are outside the European Union. Since Brexit, the reduction in the number of EU abattoir workers—as they leave the UK—has meant, this week and for the past month, thousands of pigs and other livestock being culled but not brought into the food chain. Worse, the increase in avian flu cases and the restrictions placed on all poultry farms mean that there are concerns about the supply of birds for the Christmas dinner table. Thirdly, there is a delay in foods and other goods coming in from around the world as a result of the pandemic. This is what one might describe as a perfect storm. Is the Minister confident that, given all these factors as well as trying to manage omicron in its early stages, it is appropriate to expire this particular provision?

We accept the expiry of emergency volunteering leave and compensation for emergency volunteers, although I do want to comment on the problems with the Bring Back Staff scheme, especially for doctors and some nurses. It was absolutely fine in principle, until it hit human resources in trusts. I know of two doctors who had recently retired and were kept hanging around for five months. One was a doctor teaching trainee doctors; however, she was unable to be used because the system just made it impossible for her. If there is any cause to reintroduce this particular provision, will the Minister ensure that we do not gold-plate the complex HR arrangements, making it impossible for staff, former staff or those who might come back on a temporary basis to do so?

We do not believe that the extension of time limits for retention of fingerprints and DNA should remain. We objected to that a year ago, when it was brought in.

Finally, I wrote to the Minister earlier today with real concerns about the problems that some returning international travellers are facing, following the new regulations that came into force at 4 am today, arising from concern over omicron. This is a logistical problem with the change from lateral flow to PCR tests and the passenger locator form. As of this morning, it was still possible to put only the details of your lateral flow test on to the passenger locator form, not the arrangements for the PCR test. One cruise company has 700 people coming into a UK port tomorrow and, despite talking to officials, it cannot get a sense of how the passengers will be able to get off if their details are not on the passenger locator form. I hope another method has been found, otherwise this may be a bit of a problem.

It is right that the Government made the provisions we face today, even if we do not agree with all of them. But I say to the Minister that, as with other statutory instruments, holding on to some of these provisions for a little longer, even if unused, might be useful in case the pandemic takes us down a course that not one of us wants, as the Government and other public services might need to call on them at short notice.

[Baroness Merron (Lab)]

My Lords, I thank the Minister for his most helpful introduction to these regulations, which we will not be opposing. As he acknowledged, when the original Act came into force, we were in extraordinary times and they required unprecedented legislation. However, as time moves on and experience and circumstances change, it is right that we seek to remove powers that are no longer needed. The move to do so today is welcome because, in those circumstances, such provisions should not remain in statute.

Examples of those include Section 56 and Schedule 26 powers relating to magistrates’ courts; Part 1 of Schedule 16, which provides for the temporary closure of education and childcare settings, and was not used; and Section 78 powers around local authority meetings, which need to go because the provisions are simply out of date. On this, I add my voice to a point I made previously in Grand Committee: as the Minister has heard from noble Lords today, surely how a local authority meeting is conducted must be the responsibility of the local authority itself. In the case of these regulations, I accept that the provision is out of date, but perhaps the Minister will apply his consideration to that more general point. The provision of powers to detain infectious people was particularly controversial and it is right that it is removed, having been used only 10 times, the last being October last year.

I will raise a few points with the Minister and I first emphasise the need for clarity of communication from the Government. With that in mind, I refer to the comments of Dr Jenny Harries, the head of the UK Health Security Agency, which she made on BBC Radio 4’s “Today” programme. She said:

“If we all decrease our social contacts a little bit, actually that helps to keep the variant at bay”.


However, a spokesperson for Prime Minister Boris Johnson said that he does not share her view. I understand that the Government have sought to reassure the public that they have no plans to tell people to limit their social contacts with others, which is in direct contrast to the view of this leading medical expert. I would be extremely grateful if the Minister could clear this up for us today.

--- Later in debate ---

[Baroness Merron (Lab)]

That was an invitation I could not refuse to assist the Minister.

[Lord Kamall (Con)]

Thank you. I appreciate it.

[Baroness Merron (Lab)]

Before we go off the issue of face masks, I appreciate the explanation about restaurants, but my question was about large gatherings—for example, cinemas, theatres and conferences, to name but a few. The explanation about restaurants does not apply there. I hope the Minister will take this back as it is simply a question of where is the logic regarding the venue. It seems to make no difference; it is about the fact of there being a number of people.

The real point I would re-put to the Minister, which links with that, is my question about the comments of Dr Jenny Harries on Radio 4. She said that we should decrease our social contacts, whereas the spokesperson for the Prime Minister says that we will not be doing that. I am very concerned about mixed messaging, as I am sure the Minister is—I know he is from what he has said. It would be extremely helpful to put on the record where we are on whether decreasing social contact makes a difference.

[Lord Kamall (Con)]

I apologise if I was not clearer before. I thank the noble Baroness for taking advantage of the opportunity to ask that question and finding the urge to do so irresistible. On theatres and cinemas, one of the things that was put to us was that in a restaurant, you are constantly taking a mask on and off, whereas in a cinema or theatre you are not really eating that much. Okay, you might well go to buy your ice cream—I do not know whether they still sell ice cream and jelly babies in theatres, or whatever it used to be; this will look very odd in Hansard when someone reads it—but you are not constantly doing and you are more or less constantly wearing your mask. However, I will take that back. It is a fair point, and one thing that I do when I am being briefed is to challenge because I know that noble Lords will rightly challenge me on this issue.

In response to the comments by Jenny Harries, I hope I have been clear that we take advice from a range of advisers and there is not yet consensus, but we have been relying not just on making mask mandatory when necessary as a precaution, but at the same time on people’s individual behaviour and them acting responsibly. It is about getting that balance right. We listen to Dr Jenny Harries, but she is one of a number of experts whom we listen to. We weigh up the different views; it is as simple as that. As we have been clear, there is no one trigger for any of these measures. We always consider a range of measures, including capacity in the NHS, the trends et cetera. I have listed them in previous debates. It is not one person whom we listen to. We listen to a range of experts.

Food (Promotion and Placement) (England) Regulations 2021

Baroness Merron Excerpts

Tuesday 23rd November 2021 Grand Committee

[Baroness Brinton (LD) [V]]

My Lords, I declare an interest as a vice-president of the Local Government Association. I thank the Minister for his introduction to these regulations. The comments of the noble Lord, Lord Brooke of Alverthorpe, as chair of the APPG on obesity, were particularly helpful.

These regulations sit behind recently revealed alarming figures showing that nearly a quarter of children are overweight or obese when they start primary school. That figure has risen to a third by the time they leave at 11. The Government are right to be concerned about the overconsumption of food and drink high in calories, sugar and fat, which leads to obesity and associated obesity illnesses. I will come on to the regulations shortly, but from these Benches we want to make two other comments.

First, the Conservatives in government have consistently cut public health budgets to local authorities over the last six years. The King’s Fund says that, on a like-for-like basis, the 2019-20 budget is 15% less than that of 2013-14, including a more than 5% cut to obesity services. In addition, the reduction in school nurses as well as health visitors over the last decade has meant that some of the vital early face-to-face advice on nutrition to parents of young children has gone.

Worse, some of the excellent work done by chefs such as Jamie Oliver and by the campaign of Henry Dimbleby—both of whom over the years encouraged much healthier eating in schools—has been reduced if not lost. In fact, recent reports say that high-fat, high-carbohydrate foods such as the dreaded turkey twizzler are re-emerging on to school menus.

The second issue from these Benches is the decline in fitness of our primary school children. This has been a long-standing problem, but the sale of playing fields and focus in the curriculum on core subjects have all led to a reduction of time when children can exercise, take up sports and essentially get the habit early, which will also impact on their weight. This January, Sport England noted that children’s activity levels were down in 2019-20—pre pandemic—with only 44% of children and young people meeting the Chief Medical Officer’s guidelines on taking part in sport and physical activity for an average of 60 minutes a day. Now is the perfect time, as restrictions have been relaxed, to increase the time that young children can undertake sports and exercise. Can the Minister say what influence the Department of Health and Social Care has with the Secretary of State for Education in remedying this matter and what plans there are to fund more opportunities for young children to participate in sport and exercise?

Turning to the regulations, I note that this follows a decade of trying to encourage large supermarkets to reduce salt and sugar in their own direct products, as well as encouraging their suppliers to reformulate. However, not all of them have achieved enough, nor have they changed their attitudes towards promotions.

If the Grand Committee will permit me an anecdote, one of my adult children used to work as a buyer for a major supermarket, and its department had been asked to go back to suppliers to ask them to reduce sugar, salt and fat. My son was responsible for, among other things, dairy products. Most products and many suppliers were happy to work with the supermarket to achieve reductions, but both sides were completely stumped by one product: brandy butter. It has not just sugar and fat, but alcohol too. On this occasion, it was agreed there was very little they could achieve, other than to highlight its very red traffic light and recognise that it was a truly seasonal product that was not part of people’s everyday habits. But it is good they were thinking about it.

While the public health responsibility deal has improved matters a little bit, it is not nearly enough. One key area remains obvious. That is the influence of promotions targeted at children and their parents, both in store and on television. Other speakers have referred to multibuys, end-of-carousel promotions and queuing eye-catchers—far too often, junk food and sweets. While the public health responsibility deal has helped a bit in those larger supermarkets, it is certainly not enough, and it is good that healthier choices will be much more visible in shops and that buy one, get one free and three-for-two offers on high fat, sugar and salt products will be restricted.

On food scope, it was worrying to read in the past few days that a high level of juice in baby and toddler food, which has a very high fructose content, is not labelled as high sugar because the juice is natural and not added, processed sugar. Most parents of babies and small children believe that such products are not high in sugar. Surely, this needs to be added to the formulation list for HFSS products. Is the department looking at this?

It is right that environmental health food authorities should be responsible for enforcing this in localities, but I ask, as others have, whether there will be extra funding for environmental health to be able to carry this out. We need to remember that members of environmental health have many other responsibilities too, including the vital role during the pandemic of test and trace, working with local resilience forums. The Government cannot keep loading extra responsibilities on to beleaguered local authorities without funding them properly. Will there be funding for this for the enforcement bodies?

From these Benches, we regret that the food sector has not responded well enough to remove the need for this regulation, but we believe that the long-term health implications for our children are being damaged by current custom and practice. But this cannot be done without other actions too: funding more sport and exercise opportunities and funding enforcement are just two critical elements. The minimum of another five years to implementation, as outlined by the noble Lord, Lord Brooke of Alverthorpe, is too slow. Can the Minister please ensure that these changes are speeded up?

[Baroness Merron (Lab)]

My Lords, I appreciate the intent behind these regulations and thank the Minister for his introduction to them. I want to comment on the current situation and raise a number of questions following on from those that we have already heard, because I feel that it is the detail of the regulations that is wanting rather than what they are about.

To emphasise the points that have already been made in this debate and have been heard in your Lordships’ House on many occasions, the UK has among the highest childhood obesity rates in western Europe. One in four children is overweight or obese when starting primary school, and the number is one in three by the time a young person gets to secondary school. These children are obviously more likely to become obese adults—let us remind ourselves that, at present, one in four adults is obese—and therefore at greater risk of conditions such as diabetes, heart disease, fatty liver disease, cancers and mental ill-health. As we know, the situation is worse in poorer communities. Indeed, one in three adults in the most deprived areas is obese, compared with one in five in the least deprived—a clear inequality if ever we saw one. The discrepancy among children is even more alarming: more than twice as many children are obese in the most deprived communities as in the least, and that gap has nearly doubled under this Government.

There is no doubt that in-store promotions are incredibly effective in influencing what we buy. Research shows that we buy 20% more than we intended when faced by promotions. Cancer Research UK has shown that greater volumes of high fat, sugar and salt are likely to be purchased by those who are already overweight or living with obesity, so we see a correlation between promotions and obesity, and it is right that these regulations seek to tackle that. So, yes, it is right to take action to address this situation, not by limiting people’s freedom of choice but instead by supporting them to make healthier choices.

However, these regulations alone will not be enough, and it is this point that I want to emphasise to the Minister. We need a radical obesity strategy that goes much further, ensures that families are able to access healthy food and supported local leisure facilities, and ensures that poverty can be tackled. Without that, there will be no levelling up. All we will see is a continuing widening of the already considerable gap between those who have the means to manage their weight and those who do not.

--- Later in debate ---

[Lord Kamall (Con)]

Once again, I thank my noble friend for making that request. I always make it clear that it is important that we publish as much evidence as possible and let it be challenged; that is part of a healthy debate. If things do not work as intended, we should see what works and what does not. I am always very sensitive when someone says, “the evidence suggests”. We need to have that challenge but also make sure that we know what works. At the end of the day, we all want to see less obesity across our country, so surely it is important that we make sure that the evidence is there. Where something does not work, we will just have to try other ways.

On compliance, it is for local authorities to decide how best to enforce the requirements. Where an enforcement officer suspects that HFSS food or drinks may be inappropriately promoted, they should request further information to verify. If the product is in scope and has been promoted contrary to the law, an enforcement officer will consider what action should be taken.

[Baroness Merron (Lab)]

I thank the Minister; it is generous of him to give way. I would be very interested in how he sees the greater responsibility on local authorities. Picking up my question again, does he feel that local authorities are resourced suitably? Can they expect some recognition of this new and extremely important role, because the regulations require their co-operation too?

[Lord Kamall (Con)]

I thank the noble Baroness for that question. The Government are committed to ensuring that enforcement is proportionate and fair, and we intend to support local authorities and the judicial system on additional costs incurred as a result of enforcing the policy. Up front, I cannot say what those costs will be, but we want to understand what they will be to help enforcement.

I was asked whether we had watered down the policies for some products. We have excluded some products that are not among the highest sugar or calorie contributors to children’s diets or are not heavily promoted, but we will continue to keep the policy under review.

The noble Baroness, Lady Brinton, asked about weight management and other ways of tackling weight issues, including exercise. In March 2021, we announced an extra £100 million for healthy weight programmes to support children, adults and families in achieving and maintaining a healthy weight.

On infant foods, we will shortly consult on proposals to improve the marketing and labelling of commercial food and drink products for infants and young children. I acknowledge many of the concerns expressed by the noble Baroness, Lady Brinton.

The noble Baroness, Lady Merron, asked why we are using secondary legislation. The different legislative approaches being pursued reflect the current legislative framework and implementation routes available to the Government. For the promotion restrictions, we used existing powers in the Food Safety Act 1990 to lay secondary legislation before Parliament in July 2021. The statutory instrument has been subject to the affirmative parliamentary procedure.

On how we look at issues of inequality, noble Lords made a very fair point. Perhaps I may be so bold as to suggest that one issue for people I talk to in many of the communities that we are supposed to be reaching out to is that, for far too long, the public health industry has been dominated by white middle-class people who feel they know better than immigrant and working-class communities. It is really important that we understand those communities. As someone who comes one of the communities that have been patronised, I recognise that we have to make sure that we work with them and do not just sit in a place like this and assume that we know better. It is important that we really understand them. What is really good about the Office for Health Improvement and Disparities is that “disparities” are on the label, on the tin, which means that we have to look at how we address them.

There were some questions about why smaller businesses are exempt. I hope that I have answered them.

On people not being able to afford to eat a healthy diet, anyone who has watched daytime TV will know that some of those programmes can show you how to cook a meal very quickly and much more cheaply than is the case with many of the convenience foods that you can buy. The problem is how we translate that from the TV and entertainment to people’s lives in reality. In many ways, it means understanding families, where the decisions are made and what they have access to in many of their communities. Anyone who has been to many of the immigrant communities, for example, will know that there are plenty of shops that sell and openly display fresh food, but how do we make sure that we translate that into healthy diets?

On their own, these regulations will not be enough. We also have to look at how we translate all this into understanding people’s lives right at the family and the community level. It is our goal to improve children’s health and to reduce obesity. The shopping environment plays a vital role in the way products are marketed to us—for example, the pumping out of the smell of fresh bread from bakeries. We know that marketing people are experts in understanding consumer behaviours, with factors such as the location of products at the end of aisles affecting what we buy. The Government are committed to getting the right balance between stopping bad practice and working constructively with industry. We also want to evaluate the evidence of the restrictions once the policy is implemented.

We believe that retailers can play a vital role in creating a healthier food environment that does not promote the overconsumption of less healthy products. The Government hope that these regulations will enable us to achieve a healthier food environment and make progress to halving childhood obesity by 2030, and allow us all to live longer lives in good health. I commend the regulations to the Committee.

Public Health England (Dissolution) (Consequential Amendments) Regulations 2021

Baroness Merron Excerpts

Tuesday 9th November 2021 Lords Chamber

Moved by

[Baroness Merron]

That this House regrets that the Public Health England (Dissolution) (Consequential Amendments) Regulations 2021 (SI 2021/974) have been introduced further to (1) the dissolution of Public Health England, and (2) the establishment of the UK Health Security Agency, via secondary legislation and without proper consultation or scrutiny.

Relevant document: 13th Report from the Secondary Legislation Scrutiny Committee

[Baroness Merron (Lab)]

My Lords, this regret Motion raises concerns about the lack of consultational scrutiny of the regulations introduced by secondary legislation associated with the dissolution of Public Health England and the establishment of the UK Health Security Agency. There is an important background to bringing this regret Motion before your Lordships’ House. The regulations are marked out by a lack of consultation and stakeholder engagement, the creation of a culture of blame for the shortcomings of government, confusion, and ongoing concerns about how the new arrangements will operate and be held to account.

In looking at how this came about, it is difficult to keep up with events, but, for the benefit of this debate, I will attempt to do so. In August 2020, during the parliamentary Recess, the then Secretary of State for Health and Social Care, Matt Hancock, announced in a press release that the Government were forming a new organisation, the National Institute for Health Protection, bringing together the existing health protection responsibilities discharged by Public Health England with the new capabilities of NHS Test and Trace, including the Joint Biosecurity Centre.

The press release advised that the new organisation was to be operational from 2021 and led by the noble Baroness, Lady Harding of Winscombe, who was appointed as the agency’s interim executive chair. This was followed by a Written Statement in March 2021, in which Matt Hancock announced the formal establishment of the UK Health Security Agency, which was previously the aforementioned National Institute for Health Protection, to take effect from 1 April 2021 and to be led by Jenny Harries, the Deputy Chief Medical Officer for England.

Later in the year, on 1 October 2021, the Government announced the launch of the UK Health Security Agency in a press release. On the same day, the Government also announced the launch of the Office for Health Improvement and Disparities, to be led by the incoming Deputy Chief Medical Officer for England. Confusion and obfuscation reigned throughout all of this, with the 2021 regulations—the subject of this regret Motion—being laid before both Houses of Parliament on 3 September 2021 and coming into force on 1 October 2021, as an instrument under the “made negative” procedure.

The House of Lords Secondary Legislation Scrutiny Committee noted in a report published on 16 September 2021that the regulations were “an instrument of interest”, due to the regulations making consequential changes to legislation that had referenced Public Health England. While Parliament was denied scrutiny and consultation was conspicuous by its absence, reaction to the dissolution of Public Health England was far from positive, with more than 70 health organisations, including the Academy of Medical Royal Colleges and the Faculty of Public Health, signing a joint letter.

The signatories were “deeply concerned” that the plans paid

“insufficient attention to the vital health improvement and wider functions of Public Health England”,

including necessary measures to target smoking, obesity and alcohol and to improve mental health. The signatories argued that it was a “false choice” to

“neglect vital health improvement measures”

to tackle Covid-19. I reflect that this is an observation repeatedly pursued in debates and Questions in your Lordships’ House.

Alexis Paton, chair of the Committee on Ethical Issues in Medicine at the Royal College of Physicians, argued that the decision to dissolve Public Health England was an attempt by the Government to save global face as a result of their response to the pandemic. Ms Paton stated that Public Health England had nearly 60 targeted programmes to improve health and well-being across the population, and that the loss of any of these services was too high a cost to pay. At the same time, the chair of the British Medical Association’s ruling council, Dr Nagpaul, queried the timing of this decision, questioning whether it was the right time for a major restructure, given the very immediate need to respond to the pandemic. Clearly, it was not the right time. The King’s Fund also stated that the Government’s decision to replace Public Health England with two new bodies would

“increase complexity locally and nationally”,

and indeed this is the case. There were also warnings that the restructuring of Public Health England would sap morale and focus and should have waited until the end of the pandemic.

I am grateful to the BMA for its views on this matter, including that the solution was not to reorganise in the middle of a pandemic but instead to restore funding and capacity, including increased support to local public health services. The BMA observes that previous reorganisations of public health services have not improved public health provision or the experience of the workforce, and that health inequalities have in fact worsened since the last reorganisations—even more so during the pandemic. Concerningly, the BMA also reports that morale is low, with widespread fatigue and burnout, while staff have also experienced inadequate consultation on the restructuring, despite the fact that they would have had so much to offer.

In a survey of public health doctors at the beginning of the year, over 60% said that they believed that the new form of organisation would actually worsen doctors’ ability to respond to public health challenges. Nearly two-thirds said that they were not confident that they would be able to contribute to the design of the new system, and almost three-quarters of respondents to a survey said that they had no confidence that the successor organisation to Public Health England would be sufficiently independent or able to speak truth to power. This is a serious charge sheet from those who work in the field and seek to improve the health of the nation by prevention rather than cure. I put it to the Minister that in the face of all this, it is hard to see how the new bodies could be independent or effective. They are not set up in statute and were created without parliamentary scrutiny or approval. I will be listening closely to the Minister’s response to the substance of this regret Motion. I beg to move.

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

My Lords, I want to take the opportunity of this debate, arising from the dissolution of Public Health England, to pay tribute to PHE and its chief executive, Duncan Selbie. I also want to ask the Minister to tell us more about the Government’s intentions regarding public health, a matter that certainly deserves consultation, as my noble friend Lady Merron has insisted, and more than the perfunctory scrutiny—or non-scrutiny—normally given to a statutory instrument.

With other parliamentary colleagues—including a good number from your Lordships’ House—in the All-Party Parliamentary Group on Arts, Health and Wellbeing, I worked for some years with Mr Selbie and others in his team at PHE. At a time when the Department of Health, NHS England and clinical orthodoxy were far from recognising the significance of the well-being agenda, social prescribing and the potential of the arts to support health and well-being, PHE was positive and far-sighted. During the three-year period of the inquiry which led to the publication of the APPG’s report, Creative Health, in 2017, PHE worked constructively and thoughtfully with us.

The three key messages in Creative Health, underpinned by evidence, were that the arts can help keep us well, aid our recovery and support longer lives better lived; help to meet major challenges facing health and social care, including ageing, long-term conditions, loneliness and mental health; and help to save money in the health service and social care. Duncan was one of a number of distinguished people, including Professor Sir Michael Marmot, who publicly endorsed the findings of Creative Health. He said:

“This is an impressive collection of evidence and practice for culture and health”.


The publication of Creative Health was, I think it is fair to say, a turning point in the recognition by the health establishment of the importance of social prescribing and the engagement of individual creativity in promoting health and well-being.

In a speech at the King’s Fund in November 2018, the then Health Secretary, the right honourable Matt Hancock, explicitly acknowledging the significance of the Creative Health report, said that from now on prevention must be fundamental to NHS strategy and social prescribing must be fundamental to prevention. He stressed the value of the arts and culture in social prescribing, and the NHS Long Term Plan of 2019 reaffirmed the centrality of prevention. Mr Hancock established the National Academy for Social Prescribing later in 2019.

Much has happened since then. While I can well understand that the new Secretary of State is preoccupied with Covid-19, the clinical backlog that Covid has so much worsened and the pressures on the NHS workforce, I would ask the Minister to reaffirm that the Government’s commitment to their prevention strategy is not diminished and that they continue to recognise the importance of personalised health and of the arts and culture in contributing to health and well-being.

I hope the Minister will also pay tribute to Duncan Selbie and PHE. When it was announced that PHE was to be abolished, I was shocked. It was hard not to believe that PHE institutionally and Duncan Selbie personally were being scapegoated for the Government’s own failures in the early stages of the pandemic. Of course, I wish the successor institutions well and look forward to working with them through the APPG and the National Centre for Creative Health. It is a shame, however, that Mr Selbie was cast aside.

I am concerned that the “build back better” plan envisages shifting the NHS towards prevention only as a long-term priority. However, integrated care systems surely offer an early opportunity for the NHS to work better with local authorities and the voluntary and community sector, including arts providers, on prevention. Will the Office for Health Improvement and Disparities be working with other government departments responsible for education, housing and employment in addressing the social determinants of health?

I hope we can be reassured this evening that the Government recognise their error in having reduced the public health grant by no less than 24% per head over the last six years, with terribly damaging consequences, and that the restructuring that has now occurred is intended to provide more, rather than less, support for public health.

--- Later in debate ---

[Lord Kamall (Con)]

Maybe it is because I speak rather quickly, but in my remarks just now I talked about the difference between the negative and affirmative procedures, and the affirmative procedure needing parliamentary scrutiny—so I do agree.

[Baroness Merron (Lab)]

My Lords, this Motion has given an opportunity to put dissent and concern on the record, and we have heard that through voices from across the House. I am left thinking as a result of this debate that any reorganisation, particularly one such as the one we have discussed, would have greatly benefited from proper parliamentary scrutiny. I literally regret that this was not the case.

I am grateful to noble Lords for their thoughtful contributions and consideration. I echo the words of my noble friend Lord Howarth of Newport in giving thanks and appreciation of Public Health England and the entire team, led by the chief executive as was, Duncan Selbie.

Improvement of the health of the nation and the equal chance to live a long, happy and healthy life is paramount. As my noble friend Lord Stansgate said, sidelining Parliament is not the way in which to tackle this advance. Similarly, my noble friend Lord Hunt highlighted the fact that there had been a shift of blame from Ministers to officials—which again, as we have heard in this House, cannot be an acceptable way forward. I hope that the Minister heard his noble friend, the noble Lord, Lord Lansley, who called for an inquiry and for Ministers to think again about the best way in which to manage public health responsibilities. I am sure that the Minister will listen to those words as well the others that we have heard today.

While I appreciate that the Minister has been left somewhat holding the baby on this one, I have heard what he has said. Although I am disappointed in many of the conclusions that he has drawn, I beg leave to withdraw.

Motion withdrawn.

NHS: Fracture Liaison Services

Baroness Merron Excerpts

Monday 8th November 2021 Lords Chamber

[Baroness Merron (Lab)]

My Lords, there is no inevitability about osteoporosis and broken bones as the result of getting older, and yet osteoporosis affects 50% of all women, with those going through the menopause and after menopause experiencing it at a higher rate of incidence due to the reduction in oestrogen levels. Does the Minister acknowledge that two-thirds of women are not getting the treatment that they need, and that this was the case even before the pandemic? What steps are the Government taking to improve access by women to HRT and treatment for osteoporosis?

[Lord Kamall (Con)]

The noble Baroness raises an important point. A number of people are still waiting to be seen; NHS England is very much aware of the backlog and wants to address it. As a key part of the elective recovery plans, NHS England is working with a number of local integrated care systems to establish a greater number of clinics, as well as with community diagnostic centres, and is developing business cases. NHS England is also working with experts in the field of musculoskeletal health to improve patient pathways and to find new opportunities that, over time, will improve patient care and access.

Public Health Grant to Local Authorities

Baroness Merron Excerpts

Tuesday 2nd November 2021 Lords Chamber

[Lord Kamall (Con)]

I thank my noble friend for that very important question. We continually assess our preparedness plans for infectious disease outbreaks and pandemics to ensure that they remain as robust as possible. This assessment includes, as appropriate, incorporating lessons learned from exercises that test the readiness of our plans and from our experience in responding to pandemics, disease outbreaks and other types of incident in the UK. The UK Health Security Agency will be dedicated to ensuring that we are protected from all future threats, including pandemics.

[Baroness Merron (Lab)]

My Lords, areas of greater deprivation have disproportionately borne the brunt of cuts to the public health grant, despite many people in these areas having poorer health. In Blackpool, ranked as the most deprived upper-tier local authority in England, the per capita cut to the grant has been one of the largest, at £43 per person per year. Can the Minister explain to the House how and why these decisions are made, and will he ensure that fairness in funding is restored for those who need it most?

[Lord Kamall (Con)]

The noble Baroness raises a very important point about needing to tackle disparities across our nations. The ring-fenced grant that we provide to local authorities to spend on public health services comes with a condition that they consider the need to reduce health inequalities in their areas. Also, the grant’s distribution is heavily weighted towards areas facing the greatest population health challenges. Per capita grant funding for the most deprived decile of local authorities is nearly 2.5 times greater than that for the least deprived. In addition, noble Lords will be aware of the new Office for Health Improvement and Disparities. The pin-light focus of that office is on health disparities and how we tackle them.