Mental Health Bill [HL]

Lord Crisp Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

[Lord Crisp (CB)]

My Lords, I will speak to Amendment 148, which is in my name and that of my noble friend Lady Hollins. I also support all the amendments in this group. Indeed, on the ones introduced by the noble Earl, Lord Howe, I very much support the stories that we have heard and which he spoke about at Second Reading. I also note the points made by the noble Baroness, Lady Tyler, about non-drug therapies, which relate very much to what I will talk about.

I will make one general point: a generational change in the whole field of mental health is happening globally, with a shift towards more social interventions and preventions. This wider context needs to be recognised a bit more in the Bill. Amendment 148, which is about withdrawal from dependency-building drugs, is part of that context. I also agree very much with the point that the noble Baroness, Lady Tyler, just made that drugs are needed, and with the powerful points raised by the noble Baroness, Lady Fox, in the last day in Committee on the real pressures and problems that people within the NHS and beyond face in working with some of the people they end up having to work with, and on the conditions that they are working in. This emphasis on social interventions, therefore, is not at the expense of other aspects of mental health.

Some of these interventions do harm. I will come on to the point about withdrawing from drugs. On reducing prescribing and supporting withdrawal, I do not understand why this Government, through the Bill or otherwise, are not making changes that could help to reduce costs and improve services, which would take pressure off all services and, indeed, improve people’s economic position by enabling them to be fit to work.

Mental Health Bill [HL]

Lord Crisp Excerpts

Committee stage
Tuesday 14th January 2025 Lords Chamber

[Lord Scriven (LD)]

My Lords, I will speak to Amendments 22, 24, 25, 26, 29, 30 and 31 in my name in this group. I support Amendment 28, which was just spoken to very ably by the noble Baroness, Lady Browning, and Amendments 36 and 37, in the name of the noble Baroness, Lady Hollins. I want to put on record my condolences to her at what must be a very sad and difficult time.

Quite a number of amendments that I have put down in this group, particularly Amendment 22, are about prevention. It is about getting upstream and trying to use the dynamic support registers—the risk registers—in a better way, and, by so doing, having the correct information that is available to a place, rather than just to an organisation, such as the NHS or the ICB, within that place.

Amendment 22 would ensure that local authorities have an active role in assisting ICBs in identifying people for inclusion in the risk registers. NHS England’s policy and guidance on dynamic support registers states:

“Early identification of people at risk of admission to a mental health hospital and their access to person-centred planning and support are essential for the prevention of avoidable admissions”.


Many people with risk factors will first come into contact with a local authority, particularly people with learning disabilities and autism. It is important that the local authority has a clear responsibility to assist ICBs in identifying people for inclusion on the register, to ensure that people get the right support at the right time. I hope that the Minister will take this amendment in the spirit that it is given. This is an important issue which is not strong enough in the Bill and which really needs to be taken account of.

There have been difficulties for some people getting enrolled on the DSR, and this is particularly true for autistic people without a learning disability. Additionally, NHS England data shows that 52% of autistic people and people with a learning disability detained in a mental health hospital are not on a risk register prior to admission. Therefore, there is a gap, and the Bill gives us a chance to help plug it. Hopefully, placing this duty on local authorities will facilitate greater uptake and enrolment on the register for all, therefore helping to reduce admissions, improving support in the community and being a good preventive measure.

Coupled with this, Amendments 36 and 37 in the name of the noble Baroness, Lady Hollins, would help with that prevention role by making sure that proper provision was available. Taken together, Amendments 22, 36 and 37 would be a really good group of steps forward to help with preventive measures to make sure that all people who can be identified who come into contact with a local authority but are not known to the ICB go on the register, and that provision is made.

Amendments 24 and 29 would change the current language in the Bill. After listening to debate on previous amendments, I will not labour the point because I have a good idea what the Minister might say, but again I think the provision needs to be strengthened so that ICBs and local authorities have a duty to consider the risk register when exercising commissioning and marketing functions.

In Amendments 25 and 30 there is the same approach by strengthening the words in the Bill to ensure that ICBs and local authorities have a duty to ensure that the needs of autistic people and people with a learning disability are met in the community wherever possible. The current language in the Bill states only that ICBs and local authorities must “seek to ensure” that the needs of autistic people and people with a learning disability are met. This wording is vague and does not compel a strong enough duty to meet the needs of people in the community. Again, the amendments in the name of the noble Baroness, Lady Hollins, would strengthen my amendments even further.

These amendments are important. I hope that the Minister has listened very carefully, will make efforts to implement some of these steps and reports back on Report.

[Lord Crisp (CB)]

My Lords, I will speak to my noble friend Lady Hollins’s Amendments 36 and 37. I add myself to the comments by the noble Baroness, Lady Watkins, about the remarkable commitment that my noble friend is showing at this awful time and express my personal condolences. What I am going to say is based on comments that she has passed to me. I should perhaps say at the beginning that I too am an honorary fellow of the Royal College of Psychiatrists—“(unqualified)”, as others have made that disclaimer.

The purpose of these amendments is very clear. Amendment 36 states that ICBs

“must ensure the availability of integrated comprehensive, accessible, and responsive community services for autistic people and people with learning disabilities … to reduce hospital admissions … and … reliance on restrictive interventions”.

As the previous two noble Lords said, it is very much about prevention and creating appropriate services.

I note that the Explanatory Notes to the Bill say that Clause 4

“is designed to help ensure that ICBs can monitor individuals at risk of detention and put in place the necessary preventative measures to help keep people out of hospitals”.

Putting it simply, this amendment takes that rather weak wording in the explanation and toughens it up. The issue here is not about good intentions and ensuring that it is possible for something to happen. I am sure that all noble Lords share the intention and the hope that these things will be in place, but this is about making sure that something happens. It is about implementation and seeing that a change happens.

This is vital because it is clear that there are major problems in service coverage right now. For example, only a quarter of integrated care systems are meeting their target of having only 30 people per million admitted. Of course, that number would ideally be much lower than it is, but only a quarter of these systems are even meeting that. Amendment 36 spells out what these services should include. I will not read them out in detail but noble Lords can see that they cover all the relevant areas that one would expect: evidence-based treatments, crisis prevention and intervention services, non-restrictive walk-in services, and the provision of “suitable housing”.

I will comment on two of those items in a moment. All of them are important but what I think the noble Baroness, Lady Hollins, had in mind was not just discussing these items but seeing her amendment as an opportunity to discuss which services are the right ones—the ones that should be there—and which areas ICBs and local authorities should address. The key point at this stage is not so much about the detail but the need for some clear legislative requirements on what services must be provided. Good intentions are simply not good enough; implementation is what is needed.

I will mention two of those items that relate to points made earlier by other noble Lords in our debates on this group and others. One is the reference to “non-drug-based interventions” and “social prescribing”; their importance in community services applies in all kinds of ways. The second is the point about housing, which, as has been discussed, is vital. Ten years ago, I did a review for the Royal College of Psychiatrists on discharges from acute adult hospitals. A third of the people in those hospitals were there because they did not have adequate accommodation anywhere else. That third included people who had nowhere to be discharged to, in terms of adequate housing. It is a really serious issue. I make those points because both of these issues go beyond this amendment: in some ways, they are not about healthcare as much as they are about enabling people to have a decent life and creating the conditions for people to be healthy and live in the best way possible.

Amendment 37 is about issuing guidance on standards and monitoring and reviewing progress. Again, without that, we cannot be sure that this legislation will make a difference to the people who matter.

I will make three final points. I recognise that there are perverse issues of finance here because, of course, the NHS pays when people are in hospital and the local authority pays for the services in the community. Of course, that reminds us all of the need to get the social care policy right and the importance, wherever the boundaries fall between public bodies, of using public money wisely across organisations.

In that context, I stress that what the noble Baroness, Lady Hollins, has set out in this amendment is not an unachievable wish list. Even in today’s circumstances, some people are making real progress. Mencap pointed me towards the Black Country’s emergency response team, which noble Lords may know about and which meets many of these criteria for services. In 2022-23, it supported 51 people who were presumably being paid for by the local authority and who might otherwise have been admitted for the equivalent cost of a single assessment and treatment bed, presumably paid for by the NHS. Preventive and good-quality services so often make good financial sense, as well as being better for the people concerned. I do not know whether the Minister is familiar with that project but I would certainly encourage her to have a look at it if she has not already done so.

The second point I want to make is that, although I have not actually checked the reference, I believe that the Minister said something at Second Reading about delaying the implementation of some parts of this Bill until the services are in place. I would be grateful if she could say what was meant by that, but also why it is necessary when people can make progress quite quickly.

The Black Country example—and I suspect that there are others—shows that people are making progress and that, in many ways, it is better to have a stretching target that people are moving towards rather than saying, “If you don’t have the services, we won’t implement the legislation”. We need to keep moving forward and show faith both in what this Bill is designed to achieve and in the Government’s agenda on prevention and on moving towards the community. No doubt the digital transformation is also extremely relevant here.

Anti-depressants: Cost, Risks and Ramifications

Lord Crisp Excerpts

Wednesday 11th December 2024 Lords Chamber

[Baroness Merron (Lab)]

I am not specifically aware, but I will be glad to look into this.

[Lord Crisp (CB)]

My Lords, I want to raise the issue of dependency on anti-depressants. As the Minister will know, a lot of people have great difficulty coming off these anti-depressants. It is striking that for those using drugs illegally or with substance abuse, there are many services, but there are no services in the NHS for those seeking to withdraw from anti-depressants. This is a major problem. With that in mind, I ask two questions. First, will the Government consider the delivery of a helpline, which has been called for in a number of reviews, so that people can have some access to help? Secondly, will they support an NHS project designed to introduce withdrawal services within the NHS?

[Baroness Merron (Lab)]

The noble Lord makes an important point about the effects of withdrawal from any medication. I am not sure that this is an exact answer but there is the 111 helpline, which has been expanded to refer to mental health services, so people can ring and ask those questions. However, I take his point about withdrawal. We may wish to consider this as we go towards the 10-year plan.

Mental Health Bill [HL]

Lord Crisp Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Lord Crisp (CB)]

My Lords, I too welcome the Bill. It is overdue and times have changed. People’s views and sentiments, and our knowledge, have changed over those years. I welcome the principles that seek to rebalance the way we handle these issues.

All this is in the context of a Bill that is about the safety of service users as well as public safety. I want to come back to the former but, very briefly, on public safety, I note that the bar for detention will be higher—there must be evidence that

“serious harm may be caused to the health or safety of the patient or of another person”.

The question is: what counts as evidence? Where is the place for the judgment of experienced clinicians? Is that evidence? Is the testimony of relatives? What is the definition of “serious harm?” I understand the need for transparency, but this is a very difficult area that will obviously need much more discussion at later stages of the Bill.

I also welcome the separation out of the care for people with learning disabilities and autistic people, the attention to the needs of people in the criminal justice system and, of course, the importance of tackling racial disparities.

We have had a lot of impressive briefings for this Bill. I will quote one of them, from Blooming Change. That was the one about children who had experience of the system. There were lots of issues about patient safety and quality of care. They talked about being injured during restraint, just being drugged and restrained and being scared all the time. There is a dreadful sentence there, which I will read out:

“Hospital makes you worse … going into hospital with one problem and then leaving with trauma, new behaviours, new diagnoses, assaults, PTSD – it’s awful”.


I noted the earlier comments by the noble Earl, Lord Howe, about the very large number—I think it was 52,000—of uses of restrictive interventions in the last year, and the comments of the noble Baroness, Lady Watkins, about this, and about the importance of children not being in adult wards. It seems to me that this is a great example of what we just heard from the noble Lord, Lord Alderdice, about admission making the situation worse. The idea was to put people into a ward, but, actually, it led to a deterioration of their condition.

If I think about the Mental Health Act, I understand why the review that a lot of this was based on was focused, but actually we cannot think about the Mental Health Act in a vacuum. Let me pick up two or three examples of that. The first one is that the very same Sir Simon Wessely asked me 10 years ago to look at the capacity of acute adult wards across England. I did so, and with a group we were in contact with every service in England and with consultants who were leading the admission and discharge of patients. One of the interesting findings of that was that something over 20% on average of discharges were delayed because of housing. Indeed, of all those units in England, only two had any links with the housing authorities. This seems to me to be a very fundamental point: if you are stuck in hospital, you may well lose your accommodation, which will lead to other problems. That is just one example of many wider social issues that need to be taken into account, even though we are focusing on something as narrow as the terms of the Mental Health Act.

There is also the impact on A&E, which the noble Baroness, Lady Barker, and the noble Earl, Lord Howe, referred to very early on about just shifting the problem if we are not careful: shifting it from one place to actually landing up in A&E, where there may not be liaison, psychiatry or anything else that will help with the problem.

A number of noble Lords deplored the lack of a wider Bill in which this would nest, but it is very clear that this needs to be implemented in the context alongside other changes that are already under way. There are some profound questions here about care and treatment. We have been very privileged to have heard from a lot of people who know a great deal about this, including a number of very distinguished senior commissioners who could give us insight, as well as parents who can give us remarkable insight and profound comments.

If you look at some of the statistics, healthy life expectancy for all of us has improved massively over the last 40 years, but the gap between life expectancy for those with severe mental illnesses and life expectancy for the rest of us has doubled since the 1980s and is now 20 years behind. If we also look at some other evidence, the NHS independent Mental Health Taskforce argues that outcomes from severe mental health problems have worsened in recent years, and others have argued that they flatlined for about 40 years and, in some cases, have deteriorated.

Various noble Lords have talked about the importance of the change in the model that we are talking about here, with much more focus on the community, much more focus on prevention and much more focus on thinking of this end to end, rather than just as isolated incidents involving isolated patients who do not have relationships with the rest of the world in that sort of model. It really seems to be fundamental that we get hold of those issues; even if they are not in this Bill, they need to be linked to an understanding that those changes may well come with the forthcoming 10-year plan and the implementation of this.

I want to touch on a wider point about the overmedicalisation of common problems. Here is another statistic: in the year to April, 8.7 million people received antidepression tablets—and that is just England, without counting anywhere else. The major problem in that area, apart from the overprescribing itself, is helping people to get off those drugs in due course, which is another example of where some of our current practices have been doing harm. We need a new emphasis on some of the social interventions that many noble Lords have mentioned and a new emphasis on patient safety.

Lastly, this is only legislation. It needs to be accompanied by a real implementation plan for the management of change because it cannot be treated in isolation. These other moves and other leaders are making change happen elsewhere. I very much welcome the Bill and look forward to the discussions about some of these important issues in Committee and beyond.

NHS Continuing Healthcare

Lord Crisp Excerpts

Monday 2nd September 2024 Lords Chamber

Asked by

[Lord Crisp]

To ask His Majesty’s Government what assessment they have made of the effectiveness of NHS Continuing Healthcare in supporting people with long-term complex health needs living in their own homes or in community facilities.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

NHS continuing healthcare fulfils a unique function within the health and social care system, providing support for people with the highest levels of need by fully funding their health and social care. To monitor its effectiveness, the department works closely with NHS England, the wider sector, such as the Parliamentary and Health Service Ombudsman, and voluntary organisations which represent people with lived experience. This includes assurance work and projects to promote consistency in implementing this care.

[Lord Crisp (CB)]

My Lords, I thank the Minister for her very positive response. As she says, NHS continuing healthcare is vital. However, there are problems. Some of those are about finance, but I want to ask her specifically about the criteria for eligibility both nationally and locally, which are obscure and difficult. First, at the national level, can the Minister define precisely the level of nursing or other health services that a local authority can legally provide and which therefore do not have to be provided by the NHS? Secondly, almost 85% of applications other than fast track are refused, yet people have been encouraged to apply by health and care workers locally. Does the Minister agree that more needs to be done to ensure there is a clear understanding of who may or may not be eligible, rather than wasting so much of patients’, relatives’ and professionals’ time on unsuccessful applications?

[Baroness Merron (Lab)]

I do understand the concerns raised by the noble Lord and agree that we need to take a close look at all these areas. I have already raised that with officials and with Minister Kinnock, who is the responsible Minister in this area. On the second question, there is indeed a relatively low conversion rate, and I understand that the decision was originally made to ensure that everyone who might be eligible is actually assessed. The assessment acts as a gateway to other NHS-funded care but, having looked at it, this could perhaps be made somewhat clearer. On the first question, the noble Lord will understand that I cannot give a definitive answer, and he will be aware that legislation does not limit the number of hours or the cost of nursing care that a local authority may provide. However, the Care Act 2014 sets out that local authorities can provide nursing care only in very limited circumstances—for example, where it is a minor part of overall care, such as basic wound care.

NHS: Long-term Sustainability

Lord Crisp Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Crisp (CB)]

My Lords, I congratulate my noble friend on his excellent speech introducing this debate. I am very much looking forward to the maiden speech of the noble Baroness, Lady Ramsey of Wall Heath, bringing her great expertise to bear on this issue. I declare an interest, I suppose, as former chief executive of the NHS in England and Permanent Secretary at the Department of Health between 2000 and 2006, when I had the privilege to work with three noble Lords who are taking part in this debate: the noble Lord, Lord Reid of Cardowan, as Secretary of State, and then successively the noble Lords, Lord Hunt of Kings Heath and Lord Warner, in your Lordships’ House.

I want to make three points about the major reforms that are required, and a fourth point on implementation. I shall state them briefly at the beginning, in case I run out of time. The three reforms follow very much from what the noble Lord, Lord Scriven, just said: that we are using a 20th-century model of service delivery for 21st-century issues, and that must change. The second point is that the Government need to create a cross-sector health and care strategy and plans, of which the NHS is part. Thirdly, this needs to be underpinned by changes to professional education—that is fundamental, but it has not yet been mentioned and I want to say something about it. Finally, implementation needs to be based around a shared vision that motivates and involves people, and efforts to build consensus and momentum.

I say in passing that I very much enjoyed the speech of the noble Baroness, Lady Blackwood. It was fantastically important. I also know that the noble Lord, Lord Bethell, and others will be talking about the links between health and prosperity. A healthy workforce and a prosperous country are fundamental.

The first major reform is the need to change the model, with much more focus on primary and community care, support for carers and social care, and action by many people. It cannot be just the same model or a question of more GPs and nurses. Around the country now, we see community health workers doing outreach, the great programme of Growing Health Together in Surrey, and people creating the future. We need to build on those examples of what a new model of primary and community-based care will be.

I turn to the second major reform. I have spoken many times in the House about the African saying, “Health is made at home; hospitals are for repairs”. I have also been pressing the case for quality standards to include healthy homes. The NHS is dealing with many problems that it has not caused, and those need to be addressed at source. There needs to be a government cross-sector health strategy and plan, of which NHS and social care is a part. I suggest that that plan needs to focus on the aim of creating a healthy and health-creating society—and indeed a prosperous society while we are at it. The focus should be not just on dealing with the problems—by tackling such things as air pollution—but on creating the conditions for people to be healthy. Think of Sure Start, for example, which I know many noble Lords will be aware of. Such a plan would create the conditions for people to be healthy. That is why we should be looking at health as being about healthcare and the prevention of disease but also the promotion of the causes of health and creating the conditions.

The third major reform underpinning all this is a need to transform professional education. I am happy to be associated with a radical group of young professionals who are starting to drive this agenda, recognising that they will need different skills for the sort of model I am talking about, as well as retaining the basic science.

The final point is implementation. My experience as chief executive is that I was lucky to arrive at a point when two things had happened. First, the Government of the day brought people together to create a plan; they built energy and hope, and there is not much energy and hope around today. That hope and energy created good will that carried us forward two or three years. That good will lasted a really long time and allowed us to make radical changes, including bringing in the private sector and other things. It is very much harder today, obviously. As was already mentioned by the noble Lord, Lord Hunt, by the end of 2005 waiting lists were below 1 million, with a six-month maximum wait, and there was more improvement to come from then on. It is very much harder today. The NHS is in worse condition, although there is still good care being provided, as the noble Lord, Lord Patel, emphasised. But the Government must do something—whether it is a new Government coming in or this Government continuing—to bring people together around this problem and create a solution that people will buy into.

We must also deal with the presenting problem. We cannot just deal with the long-term. A new Government coming in will have to look at the waiting lists and how to handle that, but they must then pivot to health. Twenty years ago, I believed that we must talk about the issues people were presenting with, such as waiting lists and A&E, and then pivot to a focus on health. We never quite pivoted to health. It is time now to change from talking about healthcare to talking about health, which embraces healthcare but also prevention and the creation of health.

Dementia Palliative Care Teams

Lord Crisp Excerpts

Thursday 15th June 2023 Lords Chamber

Asked by

[Lord Crisp]

To ask His Majesty’s Government what plans they have to expand the use of dementia palliative care teams in England in accordance with the model introduced in Derbyshire.

[Lord Crisp (CB)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare a personal interest, as I have a relative who is cared for by the Derbyshire palliative care team which is as described in the Question.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

The Derbyshire model is recognised as an example of best practice. The Derbyshire palliative care service toolkit has been widely shared by NHS England, which encourages regions to adopt good practice. Resources from the toolkit have also been published on the FutureNHS platform. It is a superb example of how better integration of the excellent services already available, not always requiring more funding, can have a positive impact on communities.

[Lord Crisp (CB)]

My Lords, I am grateful to the Minister for that very positive reply, with which I absolutely concur from my own experience. It is good to have the chance to say something positive about people working in the NHS at a time when it is under such great pressure.

As all noble Lords know, dementia is a dreadful and deeply distressing disease, or set of diseases. One in three of us will experience it and almost all of us will be affected, as family or as carers. It is a very complicated process that people have to go through. One of the issues I want to ask the Minister about is co-ordination of care and the help that is available to people. People looking after people with dementia need help with medication, with incontinence, with devices and aids, with falls, with hospital clinics and with a whole range of different issues, coming from primary care, social services and hospital care. The dementia palliative care team in Derbyshire provide the co-ordination. What needs to happen in cases where there is no such team? How can that care be co-ordinated or does it all land on the principal carers and the spouses and partners of the people concerned?

My second question is—

[Noble Lords]

Oh!

[Lord Crisp (CB)]

Sorry. I note the Minister’s point about the excellence of this particular team and the intention to spread the idea. How far do the Government think it will spread and be adopted in other parts of the country over the coming two or three years?

[Lord Markham (Con)]

I thank the noble Lord. I have an auntie with dementia in care in Derbyshire. The noble Lord is correct that it is a perfect example of a wraparound service that takes in all the facilities that people need. The intention is that we want to spread that everywhere. It is the responsibility of each ICB to set the right commissions in their local area, but we are spreading knowledge of the dementia model as far as we can. A big example is that we promoted it at the recent national clinical excellence celebration day in the Midlands.

NHS: Performance and Innovation

Lord Crisp Excerpts

Thursday 15th June 2023 Lords Chamber

[Lord Crisp (CB)]

My Lords, I congratulate the noble Lord, Lord Scriven, on his excellent speech. It was good to hear him take on the big questions in terms of what this is all about, what it is for and where we are going. He reminded me of my friend, who said this to me the other day: “Did you know that primary care is based on a 1948 business model? What else in our society is still operating on such a model?” The noble Lord also reminded me of something that is very close to my heart, having spent the past 17 years working on health in African countries: how much we can learn from people who do not have our resources, our baggage of history and our vested interests. He made a strong point about the importance of investing in primary care and community care to move the whole system on.

I want to reflect on the people side of innovation and improvement, as well as on some of the innovations of recent years; there have been some massive innovations in recent years. I also want to talk about some of the barriers to this sort of innovation. Let me start with a few reflections on the past. The last time the NHS was in serious trouble was at the end of the last century; I became chief executive and Permanent Secretary at the Department of Health at the beginning of this century. In that period, a number of big changes were introduced. Some of them were service changes. We tried to get waiting lists down—does this sound familiar?—and worked on best practice in ophthalmology and orthopaedics, separating elective and emergency orthopaedics. It all sounds quite familiar in terms of the sorts of things that were being done but, importantly, these things were changing the way in which people went about doing their jobs. It was not about some wonderful, whizz-bang technology coming in from outside, although technology helps; let us be clear on that. Good knees and hips—the joints themselves—were important as part of this, but it was about people.

Interestingly, we also introduced a number of policy changes. One was about offering patients a choice: if they had waited more than six months, they could go to another hospital. We also introduced competition, with South African units coming in to do some work on elective surgery. I would be happy to show the Minister the graphs I am holding, but the really interesting point is that you barely had to have a South African doing three eye operations before there was a change in the behaviour of the people in the NHS. Very few people exercised that choice and the competition was pretty marginal, but, frankly, the system changed quite dramatically. It was all about people’s behaviour.

That theme—people’s behaviour and clinical leadership—is very big. Let me turn to one of the most radical things that happened in those years: the introduction of nurse and non-medical prescribing in 2003. It was deeply controversial. The medical establishment was broadly against it, but it was the palliative care physicians who came and lobbied me about it because, frankly, they did not want to be woken up in the middle of the night. They knew that their nurses were quite able to change the dose of opiates. This measure was controversial when it was brought in in 2003, but I suspect that new medical students and doctors do not even know that nurses have not been prescribing for ever. It simply is not controversial now, yet many countries around the world, including most of our neighbours, do not allow anyone apart from doctors to prescribe. This was a big strategic change, and it came from clinicians.

Another change that has come from clinicians—this time, much more recently—is social prescribing. Again, it is something on which the UK is very much leading the way around the world. There are big and fantastic changes coming through from the people within the system and linked to it. It is really important that we acknowledge this. Some real, current examples of this include the virtual wards that are springing up all over the place. Again, these are examples of people inventing new ways of handling the system; things are very much helped by technology there.

What I want to touch on goes back to my point about learning from Africa. In the borough of Westminster, in 2021, community health workers modelled on the Brazilian model—not the African model—were introduced. Community health workers are local people who know their community and visit every house in their area once a month. They talk to people about health, they listen to them about health and they explore their health issues, after about six months’ training. It turned out that within six months there was a big increase in the uptake of immunisations, a big increase in screening and health checks and a reduction in unscheduled GP appointments. It was concluded that they were very effective at identifying unmet need, co-ordinating care—a very big issue—bridging health and social care and so on. From having four community health workers the borough of Westminster now has 30, and the programme is expanding at Bridgwater, Calderdale and Cornwall.

Two things about this are worth noting. This came about because of a British doctor, who is now at Imperial, who was working as a GP in Brazil. He brought this back with him to this country and spent years developing the ideas about how it would work. It would not surprise me at all if in 15 years’ time the front line of a lot of primary care was community health workers and then nurses and then doctors—a really radical change of the sort that the noble Lord, Lord Scriven, was talking about. So, there are big changes happening.

Outside the health service, too, there are non-health actors, such as the City Mental Health Alliance with the big companies in the City of London—all about nature and gardening, which I am sure noble Lords know all about. There is the Daily Mile in schools where teachers and pupils run a mile every day. There are 15,000 schools in the UK and many more globally doing that. So there is an awful lot of innovation and creativity, and these are all about passionate people making change.

It is true that the system needs external challenge from time to time; it must not get too cosy. But it is important for any Government to back their people. It is not always easy. Politicians, I know, of all parties are in a hurry and trying to push people into making change, but these innovations have basically come from within the system, from people who understand the detail. Understanding the detail is really important here, because it is easy to have big ideas about how things may happen. Too often, politicians will be talking about reform, when really they should be talking about evolution and taking people with them. Reform is something that tends to be done by you to other people. I think it is really important to get behind our health leaders and health people in all places, including the Derbyshire dementia team in Chesterfield, which I was talking about in Oral Questions.

Particularly at a time when people are exhausted—people have talked about a global epidemic of exhaustion in health systems—and demoralised, and there is a lack of vision around the world about what health services are, which the noble Lord, Lord Scriven, raised, there are some important things about the attitude towards where we seek innovation. None of that should detract from the extraordinary technological and scientific advances: targeted drugs; improvements in breast cancer treatment; the phenomenal changes in children’s cancer over the years; the enormous development, in my time, of catheter labs; how heart conditions are being dealt with differently; robot surgery; and so many more extraordinary things that we are able to do already compared with 15 or 20 years ago. We need both parts. We need technological innovation as well as human.

Let me now turn to the barriers to innovation on the people side. First, I will kick off with one of the issues: the financial rules, the constraints landing on our clinicians. I received a tweet—which I will not attempt to read on my phone in case it goes off wrongly—from a GP two days ago. He is somebody I know who does a lot of innovative work. He says that for four years he has been a clinical director of an ICN, and he thought that would be where he could make change happen, but he found it was about governance—a point the noble Lord, Lord Scriven, talked about—and that the financial rules meant that they kept returning to the GP contract, with all its constraints. The stuff they wanted to do was more community-oriented, inventive and innovative, about actually helping people with their health—to take a point from the noble Lord, Lord Addington—as well as with the immediate problem that they may have come into the GP surgery with, but the financial systems were getting in the way. I think that is a really big problem across the entire NHS.

The second problem that I want to talk about is that I get lots of people talking to me about the NHS, even though I left it 17 years ago, and the biggest complaint I hear is about the lack of joined-up behaviour. I mean joined up not between departments but between primary care and secondary care, or between the guy dealing with your knee and the guy dealing with your head or whatever—that whole issue of communication. Technology can help with that, no doubt at all, but we still have examples where people are using different record systems—the GP is using a different record system from the dementia care team, to go back to that particular story—and governance often militates against people working together effectively.

The final issue is the attitudes, behaviours and, underlying those, professional education—how people have been brought up within the system. The noble Lord, Lord Scriven, is quite right that we should be thinking 20 years ahead about what the jobs are going to look like. That means we need to change professional education profoundly. I know a lot of people are thinking about it, but I do not know that people are doing it.

We from the All-Party Parliamentary Group on Public Health recently published a report on this with a great title, not necessarily the best thing about it: Probable Futures and Radical Possibilities. We were saying, “Having looked around the world, this is what the future looks like and this is some of the radical change”. It picked up, and I am going to pick up, four points. The first is on technology:

“Science, technology and data will determine much of the framing and the language of health, shape how health workers think about health problems and possible solutions and how they act”.


It is going to be fantastically important and a much bigger bit of all professional education for the future.

The second point, which we heard a lot from young doctors in particular, was about the things not on the medical education agenda. There was no preparation around social prescribing. There is a great Beyond Pills campaign being developed by younger doctors and the College of Medicine. They are much more interested in a biological-psychological-social model than a purely medical model. Big changes are needed, and these are young people making these arguments.

The third point is on a set of skills. These are the so-called soft skills because they are difficult; they are the ones about teamwork, influencing people, relationships, participation and improvement science. It is worth remembering that in healthcare, as everywhere else, relationships trump systems. That is how you get around the systems and make them work. It is about learning about those soft skills.

The final point was that an awful lot of young people within the system—and this is around the world, not just the UK—feel trapped looking at a future of AI, technology, protocols and tougher management regimes, wondering what it will mean to be a professional in the future, feeling that they are just going to be turned into technologists, technicians, rather than the professionals of an older generation that many of us would recognise. They argue that there needs to be a much greater emphasis on relationships creating health; health workers as agents of change; facilitating change in patients, organisations and society; and being curators of knowledge.

So I would ask the Minister, in conclusion, whether he accepts that there needs to be more attention given to the financial rules guiding people’s behaviour in practice, particularly around primary care, but, secondly, to have a thorough look not just at numbers of healthcare workers but at the professional education that shapes them over so many years.

Health Promotion Bill [HL]

Lord Crisp Excerpts

2nd reading
Friday 2nd December 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I welcome this Bill and congratulate the noble Lord on promoting it. I very much support the focus on health promotion, physical activity and cross-government action. After all, the department is called the Department of Health and Social Care and not the department of health services and social care, and the noble Lord is the Minister for Health and not just health services.

Like the noble Lord, Lord Lansley, I will also be widening the debate slightly. I am particularly pleased that the Bill widens the debate on health. Too often, we talk just about health services and healthcare, and sometimes prevention, but we almost never talk about the third important area of creating health, of which health promotion is a part. All three are important and essential.

All of us understand what we mean by healthcare but it is important to distinguish prevention, which is about the causes of disease, pathogenesis and pathology, and about activities focusing on, for example, heart disease, stroke, cancer and tackling air pollution, and health creation, which is about the causes of health, salutogenesis, but not the causes of disease. I describe this as creating the conditions for people to be healthy and helping them to be so. Those causes include, for example, opportunities for social interaction; healthy working environments and development; being in touch with nature; having a meaning in life; relationships of all sorts; being well-fed and well-housed; the agency to act and decide, as opposed to alienation and anomie; and self-respect. We want healthcare, the vital services of the NHS, and the approach to prevention that this Government are moving on, but we also want the positives of actively creating health.

I have often quoted in your Lordships’ House the saying from a great Ugandan doctor:

“Health is made at home, hospitals are for repairs”.

Indeed, I know that the former Minister, the noble Lord, Lord Kamall, has quoted this back to me on occasion. It is a very valuable point. It is why I talk about a health-creating society and why I am promoting the Healthy Homes Bill. The first time I raised this in your Lordships’ House was in a Cross-Bench debate on 26 November 2015, when I moved that this House takes note of the case for building a health-creating society, where all sectors contribute to creating a healthy and resilient population. There were many powerful speeches from all sides of the House. I believe we need this even more than ever, and that we are not going to make progress on health unless and until we recognise that creating health is as important as disease prevention and healthcare. Obviously, there are links and overlaps, but let us recognise these very important distinctions.

It is also worth noting that health creation operates at four levels: the health of each of us as an individual is intimately connected to the health of the local community in which we live, to the health of wider society and to the health of the planet. I will think about this while turning specifically to the Bill and its focus on health promotion and sport. Health promotion as usually described is generally about the individual, lifestyles, activity and diet. It is also about the important point that the noble Lord, Lord Addington, made about walking, rather than physical activity in general, which has been recognised since the Greeks as being vital to health. As the noble Lord pointed out, what he is proposing is also about sociability and bringing people together, creating purpose and creativity. I am pleased to see that he has included nature in the Bill. It is also about self-respect, being successful and achievement. All these factors are for the individual as well as for communities: bringing people together, sharing and community facilities. It is also about opportunities in a wider sense, and sport has long been a driver for social mobility. As he has drafted the Bill, it is also about the planet, nature and the environment.

I commend the noble Lord for the Bill, with its focus on health promotion, sport and wider physical activity, and for promoting a national plan for sport. This is not the whole story—of course it is not; he does not present it as if it were—but it is a very important part of a health-creating society. As he said very eloquently in his speech, the public get this; this is a win-win because people will understand why the Government, in creating a health-creating society, are promoting sport in this way.

I ask the Minister whether the Government will recognise that they need to think about three distinct elements of health—health services, prevention and health creation; each distinct but linked to the others—and whether they will promote health creation. Finally, I say to the Minister that many people and groups around the country are actively involved in creating health. Would he be willing to meet representatives of the Health Creation Alliance, which brings many of these groups together?

Health and Care Bill

Lord Crisp Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

Moved by

[Lord Crisp]

At end insert “, and do propose Amendment 88B in lieu—

88B: Insert the following new Clause—
“Smokefree 2030 consultations
(1) The Secretary of State must, no later than the relevant date, consult on—
(a) any recommendations of the independent review into tobacco control announced by the Secretary of State on 4 February 2022 which in the opinion of the Secretary of State require consultation before implementation, and
(b) any other options for tobacco control considered appropriate by the Secretary of State.
(2) The Secretary of State and the Treasury must, no later than the relevant date, consult on one or more statutory schemes to regulate the price of tobacco products which fund delivery of— (a) the Government’s Smokefree 2030 ambition, (b) a reduction of inequalities related to health, and (c) improvements in public health.
(3) In subsections (1) and (2) the relevant date is the earlier of—
(a) the last day of the period of 6 months beginning with the day on which this Act is passed;
(b) the last day of the period of 3 months beginning with the day on which the report of the independent review referred to in subsection (1) is published; (c) 31 December 2022.
(4) The Secretary of State must lay reports before Parliament on the consultations carried out under subsections (1) and (2) and a Minister of the Crown must, within 12 weeks of completion of the consultation, arrange to make a statement to each House of Parliament setting out in detail any steps which will be taken to implement the findings of the reports, and the proposed timescales for doing so.””

[Lord Crisp (CB)]

My Lords, this amendment replaces the “polluter pays” tobacco levy Amendment 85 and consequential Amendments 86 to 88, which were passed by this House on Report by 213 votes to 154.

I very much thank the Minister for the time that he and other noble Lords and colleagues in the Bill team and Treasury have taken to explore with us opportunities for reaching an agreement. We are disappointed that we have not yet been able to achieve a compromise. I also thank other Lords very much for their support for this Motion, which has come from all sides of the House.

The reasons for moving this amendment are very obvious. They are about the impact of smoking on health and about inequalities and levelling up. First, Members of your Lordships’ House understand very well that smoking is the leading avoidable risk factor in health and is responsible for years of ill health—chronic illnesses, years of misery, early death and, for the country, loss of talent and productivity to the nation as a whole. What noble Lords may not appreciate—I did only relatively recently—is that it is also a leading factor, perhaps the leading factor, in the differences in health outcomes between different sectors of the population. Some 50% of the difference in health outcomes between those in the highest socioeconomic group and those in the lowest socioeconomic group is due to smoking.

--- Later in debate ---

[Lord Kamall (Con)]

I thank all noble Lords who have taken part in this debate and the debates throughout the day. We managed to stick to the point and tried to be as brief as possible. I am afraid I will not be as brief as the noble Baroness, Lady Thornton, but I will try to be briefer than I usually am.

I should just make some acknowledgements, looking at the whole group. First, on learning disabilities and autism, I thank the noble Baroness, Lady Hollins, in her absence, for her constructive engagement with the Government.

On tobacco, I once again urge noble Lords to reject Amendments 85 to 88 and 88B. The independent review is not scheduled for publication until May, when we will of course consider our next steps. I understand that the noble Lord told us to get on with it, but we do not want to pre-empt the independent review. As it is in the process of being drafted, we really want to make sure that we have proper consultation and agreement, both across government and across the UK with the devolved Administrations.

I hope the noble Lord is in no doubt that we are also committed to the tobacco plan and the reduction of smoking. We just do not feel that this is the right amendment, but the noble Lord may feel otherwise. Any changes to tobacco legislation proposed by the Khan review, a plan supported by the Government, will be consulted on. We firmly want to make sure we reach our smoke-free 2030 ambition or get as close to it as feasibly possible.

There is a debate about the polluter pays principle. I am sure the noble Lord, Lord Crisp, will recognise the debate about Pigouvian taxes, taxing negative externalities and who is responsible. Who is the polluter? In the car industry we tax the driver, as they put more petrol in. Should it be the smoker or the industry? There is a debate about this, but I hope these issues will be considered by the Khan review.

I also thank the noble Lord, Lord Sharkey, for his constructive engagement on reciprocal healthcare. I am pleased that we were able to narrow the gap and get to the same place.

I turn now to the telemedicine abortion issue. The Government felt that we should have gone back to pre-pandemic measures, but it was right that there was a free vote. We saw the results of the votes in your Lordships’ House and the other place, and we accept them. The democratic will of both Houses is quite clear. At the same time, we also accept that there were some concerns, as my noble friend Lady Eaton rightly said, about underage women being forced to have abortions and safeguarding. My noble friend Lady Verma also made a point about issues in certain communities; we know that these things go on in certain communities and that there are close relationships.

After the reassurances I gave at the beginning, my noble friend Lady Eaton said she was reassured enough not to push her amendment to a vote. I hope that remains the case and that my noble friend has not been persuaded otherwise. It is important that we consult, treat this sensitively and get the appropriate guidance, but the decision has been made by both Houses and we have to make sure that it works and that we address some of the legitimate concerns that noble Lords have raised in this debate.

Given that, I ask this House to accept the Motions in my name.

[Lord Crisp (CB)]

My Lords, let me first say how much I respect the Ministers and appreciate the time they have given to me and other noble Lords to discuss the “polluter pays” amendment. I really appreciate it and found it very useful. I think it was the noble Baroness—I cannot remember the name.

[Noble Lords]

Eaton.

[Lord Crisp (CB)]

No, forgive me. It was the noble Baroness, Lady Cumberlege—my apologies for that very public senior moment—who earlier commended the Ministers on their patience and good humour, right to the end of this long Bill.

I think there is very little difference between us and that what I am arguing for is very much government policy, but there still is a difference. Let me also thank the other noble Lords who have spoken in this debate for their support. I was reflecting on this difference while the debate was happening and, at bottom, it is about making sure that something happens. It is not just about consultation, which we did not discuss. It is about the timetable too. It is about ensuring that we have a consultation to a timetable and that there is scope for action.

It is also about the reality. The noble Lord, Lord Young, spelled out for us that we have seen cuts in tobacco control over recent years and that there was a commitment given to considering “provider pays”—I think it was two or three years ago. We are all familiar with the fact that things can slip. At the moment, I suspect that we are going in the wrong direction on tobacco control and that it is slipping down the agenda.

I am left with two questions. First, where will the funding come from for the action that needs to be taken to intervene on tobacco control, which is something that we all want? I absolutely accept the noble Lord’s point on that. Secondly, will action actually be taken? I was very struck at our meeting with the Treasury, which the Minister kindly arranged, to find that the Treasury officials are rather opposed to any levy, despite the attractions and success of the pharmaceutical levy referred to by the noble Lord, Lord Stevens, in Committee.

While there is also enormous waiting list pressure, which we all know about and which I suspect has already been discussed many times during these debates, how will we find the money for something that is going to have a long-term impact, as opposed to dealing with the emergency right in front of us? Of course, we will all be aware that an election will be coming in due course. I suspect some things will rise up the agenda and some slip down it. You do not have to be a cynic to think that this could slip very easily. Therefore, for those reasons, I want to test the opinion of the House.