Levelling-up and Regeneration Bill

Debate between Lord Crisp and Lord Hunt of Kings Heath

Report stage
Monday 4th September 2023 Lords Chamber

[Lord Crisp (CB)]

My Lords, I will speak to the three amendments about healthy homes in my name in this group: Amendments 191A, 191B and 286. I support other amendments in this group; in particular, Amendment 198, which, like these amendments, links health and housing, and much of what I will say is also very relevant to that amendment.

I am very grateful to the noble Lords, Lord Young of Cookham, Lord Blunkett and Lord Stunell, for adding their names, and more generally to noble Lords across your Lordships’ House who have supported these amendments. I am also very grateful to the TCPA, which has supported me with these amendments; there is also a considerable campaign of support for them outside which it has created, including among builders, developers and insurers, all of whom recognise that action is needed.

I am also very grateful to the noble Baroness, Lady Scott of Bybrook, and the noble Earl, Lord Howe, with whom we have had two meetings, but sadly without any progress being made. I wait to hear what may be said later.

In describing these amendments, I will also explain why they are very different from the Government’s existing and planned policy. I make a point of this because the Government have consistently stated that these amendments are not necessary as they are already covered by existing or planned policy. However, these differences start with the recognition of the vital link between housing and health and well-being. They are intimately connected issues. Noble Lords will be very well aware of these connections and the problems—for example, of damp, cold, mould, air pollution, safety and more—when poor housing has caused deaths, illnesses and accidents. We need think only of the poor child in Rochdale who died from mould or the child in London who died from air pollution in their homes.

It is also important to remember to mention the mental health issues caused by poor, insecure, overcrowded housing and living in homes and neighbourhoods that are vulnerable to crime. I know that noble Lords debating the amendment of my noble friend Lady Willis will have much more to say about this, and particularly inequalities. It is the poorest people in the poorest neighbourhoods who are worst affected, and that is a very fitting topic for a levelling-up Bill.

Noble Lords will also be aware of the great strides earlier Governments made in understanding the relationship between health and housing and tackling them together, from Victorian times onwards—slum clearances over the ages, but also the great campaign of “Homes for Heroes” after the First World War. People recognised those important links, yet today, there is virtually nothing about health in planning and, if there is, it is about healthcare. The links between health, well-being and planning are simply not addressed. That is why Amendment 191A states:

“The Secretary of State must promote a comprehensive regulatory framework for planning and the built environment designed to secure … the physical, mental and social health and well-being of the people of England, and ... healthy homes and neighbourhoods”.


This does three very important things. It places health and well-being firmly at the heart of planning for the built environment; stresses the links between an individual’s health and the neighbourhood in which they live; and provides a clear aim for the whole planning and regulatory system. All three are important.

I recognise that this is a substantial strategic change in the approach to planning and regulation which, if adopted, will have a positive impact on the quality of housing and neighbourhoods, should reduce the likelihood of new slums being created and truly help to level up. It will also have a positive financial benefit by reducing the massive cost of poor housing to, for example, the NHS. I will not labour this point, but it is in the many billions of pounds. The respected Building Research Establishment estimates that it is £135 billion over 30 years. Of course, there is all the human cost of poor housing and huge cost to other sectors of the economy. In summary, there is a real choice here between carrying on as before and making a determined effort to create good housing for the citizens of this country that is fit for the future.

I turn for a moment to standards and quality. I imagine that all noble Lords are well aware of the poor standard of some recent developments, mainly but not exclusively those created through permitted development rights. We can see that existing arrangements have not stopped that, and new policies will lack the teeth to make it happen. Amendment 191A refers to the Secretary of State being responsible for creating

“a system of standards that promotes and”,

importantly, “secures healthy homes”. The system of standards covers 11 areas, which are linked concerns about individuals and the community. They bring health and environment and health and security issues together. Importantly, in Amendment 191B, it is the Secretary of State who is held to account by Parliament for delivery, by the mechanisms in the amendments.

We are not writing the policy; we are making sure it is delivered everywhere. We set out those principles to be followed which need to be enshrined in law; we have deliberately left the Secretary of State with space to define the standards, which will obviously change over time, and the methods they use to deliver them. We are not trying to rewrite government policy here; we are trying to enact legislation.

Since Committee, the Government have proposed the extension of permitted development rights to embrace sites in countryside areas, farms, national parks and hotels. This makes these amendments even more necessary. We need the health and well-being focus, the coherence and the standards as a counterbalance: a free-for-all will not help the public or the economy. As the APPG on homelessness said even before that extension was proposed, PDR can provide extra needed housing, but it needs to be done well, which is why that cross-party group supports these amendments.

Let me touch on costs. I imagine that some noble Lords will be thinking, “Doesn’t this cost a great deal of money?” I am not talking about the difference between lower-cost and higher-cost houses, I am talking about the difference between lower-cost housing and housing that is simply not fit for purpose. The analogy I use is the MOT. The MOT dictates whether or not a car is fit to be on our roads. If we have such a test for our cars, we also need to ensure that our housing is fit to be on our streets.

I have so far talked about the extraordinary opportunity cost of not addressing these issues. If we do not address them, we are condemning a lot of people to poor housing. But let us look at it from the other side for a moment: from the point of view of opportunity, and homes for heroes, if you like. Who have these homes been built for? There is opportunity here if people have a secure home, a secure base from which to operate, space for children to do their homework, where they are not spending all their time worrying about repairs and everything else. This is about life chances. It is not just about housing affecting health and well-being; it affects people’s life chances in the long term.

These are powerful arguments, and I wait to hear how the Government are going to respond. However, I should say at this point that I expect to take this to a vote, because I want His Majesty’s Government to think again and engage with the arguments about health, well-being and standards. They have not done so thus far, but it is very important that they do. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I shall speak to Amendment 198 in my name and those of the noble Baroness, Lady Willis of Summertown, the noble Lord, Lord Foster of Bath, and the right reverend Prelate the Bishop of London.

The noble Baroness, Lady Willis, very much regrets that she is unable to be present, for unavoidable reasons, and has therefore asked me to speak to her amendment. In essence, it would ensure that the planning system is contributing to the levelling-up agenda by designing the places people need to thrive and contributing to a general health and well-being objective. Let me say here that I entirely endorse what the noble Lord, Lord Crisp, with his great experience, said. This amendment is entirely consistent with and complementary to his, and I am glad that he will press his to a Division.

I should say that my interest in this came from the particular issue of health inequality, but it is active travel on which I will focus. Subsection (4) of Amendment 198, to which local planning authorities or, as the case may be, the Secretary of State would have to have regard, emphasises some of the points the noble Lord, Lord Crisp, is making:

“ensuring that key destinations such as essential shops, schools, parks and open spaces, health facilities and public transport services are in safe and convenient proximity on foot to homes … facilitating access to these key destinations and creating opportunities for everyone to be physically active by improving existing, and creating new, walking and cycling routes and networks … increasing access to high-quality green infrastructure … ensuring a supply of housing which is affordable … and meets”

health, accessibility and well-being needs. That is entirely consistent with what both the Government and the Opposition would think of when they talk of health and well-being.

Health and Care Bill

Debate between Lord Crisp and Lord Hunt of Kings Heath

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I shall speak to Amendment 112 and 17 others that are in my name. I am very grateful to the three noble Lords who have added their names to these amendments. These are terribly straightforward; it is the same point in a number of different contexts. As we put it in the explanatory statement, the amendments

“would require Integrated Care Boards to work with the four primary care services … when preparing and revising their five year plans, in the same way they are required to work with NHS trusts and NHS foundation trusts.”

It is a very simple, straightforward point and a matter of proportion. It is appropriate to give a similar level of influence and respect to primary care as we give to acute services.

I will mention that there are some practical difficulties —obviously, there are many more primary care services than NHS trusts—and come back to that at the end. If it is not obvious enough that we should do this, I want to pull out three points about why this is so important; I expect that others will mention other points. I am talking here about GP surgeries, as opposed to the other three services, although I totally endorse everything that my noble friend Lord Low just said about ophthalmology services.

First, if it is true, as Members across this Committee have argued for however many sessions it has been, that a large part of the future is community-based, then alongside public-health figures and their clinical work, it is primary care—nurses and others, not just doctors—who will be the essential guides and specialists to help all those place-based, arts, non-clinical and inequalities-busting activities that we have talked about for a considerable part of this debate. They have that key role.

Secondly, I was dismayed by the way the Government criticised GPs recently. Primary care is under enormous pressure and I do not understand why the Government chose to do that. A large part of the problem is that there are simply not enough primary care specialists of all kinds, including GPs, and I do not think any progress has been made towards the promised 5,000 extra GPs. Primary care is under enormous pressure throughout the country and, while I greatly welcome the focus in the Bill and in government policy on waiting lists, I believe that it will be here in primary care that we will see the real battle for the future of the NHS. It is really important that we give those who are doing so much in our services the respect, influence and prominence that they deserve.

My third and perhaps, in some ways, biggest point is that primary care is changing very fast in all kinds of ways; it is an area where there is enormous innovation. As the Royal College of GPs itself says about the role of the GP, there is a place for one-off consultations—a place for the GP on the railway station, or wherever, where you can have a very quick consultation—but there is an even bigger place for the sort of continuing role based on the relationships between a GP and their patient that we are familiar with traditionally and which I thought the noble Baroness, Lady Cumberlege, described so well in describing her father as knowing his patients “inside and out”. That relationship, however, is not just with individual patients; it is a relationship with the community. Many GPs have taken that role, but more are taking on the role of a relationship with their community.

Some GPs are rewriting this role so that it is more of a public health role in some ways. There is Sir Sam Everington at Bromley by Bow, whom the noble Lord, Lord Mawson, mentioned in his great, eloquent speech on our last occasion in Committee, and others such as Dr Gillian Orrow, who is bringing together groups in the community and leading Growing Health Together in Horley. Others are taking on wider roles, such as Dr Laura Marshall-Andrews in Brighton. People are thinking about their role in a very different and important way and I apologise for giving three southern examples—they happen to be ones I know very well, but I know that this sort of innovation is going on around the country. More generally, of course, we can think about social prescribing and the way that that is changing primary care.

Here is the really big point: these doctors, nurses and others in primary care are acting as clinicians, of course, but they are also agents of change. They are the animateurs, the facilitators enabling local health-creating activity. For that reason, we need to have people like them fully engaged in the planning and all the mechanisms of the new NHS structures so that they can have the influence needed for the future.

I come back to the practical note I made at the beginning. Of course it will be difficult to engage primary care appropriately in every way and there might not be the same structure and arrangements in every part of the country, but it is really important that we get these primary care inputs into the five-year plans, their monitoring, planning and discussion so that they can really influence what will happen in the future. I understand that the Royal College of GPs is in discussion with the Department of Health. I urge the Minister to encourage his officials to find a way to make this obvious thing, which needs doing, work. It is vital that we do not disfranchise a key and currently quite largely demoralised sector or, as importantly, lose their valuable contribution.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have Amendments 117 and 218 in this group. I have also put my name to the series of amendments put forward by the noble Lord, Lord Crisp, but I start by endorsing what the noble Lord, Lord Low, had to say. I hope the Government will come back sympathetically in relation to that.

My Amendment 117 would ensure that primary care professions would have mandated roles within integrated care partnerships, with members appointed by each of the four practitioner committees: the local medical, dental, pharmaceutical and optical committees. Secondly —and this is very consistent with the amendments from the noble Lord, Lord Crisp—this would ensure that, in preparing their annual strategic forward plan, the integrated care board and its partner trusts and NHS foundation trusts would need to consult the relevant primary care local representative committees and publish an explanation of how they took account of those views when publishing their plan.

I have the same arguments as the noble Lord, Lord Crisp, and I will not repeat them because he put them so well. History has shown that, even when clinical commissioning groups were nominally under the control of GPs, they often found it very difficult to get the rest of the system to listen to their issues and concerns. I agree with the noble Lord that there is now so much pressure on primary care that there is a great risk that they will be ignored in the work of the ICBs in particular. That would be a great pity. It is not just GPs, but the other parts of the primary care world. The noble Lord, Lord Low, already referred to ophthalmologists and opticians, but there is also this conundrum about the ability of pharmacists to take some of the load off the system but there is also often the inability of the local NHS to talk to them and embrace them sufficiently.

I hope the Minister will be sympathetic. If he says that he is not willing to tell ICBs that they must embrace representatives of the local committees then there is now a clear conflict. He is saying that it is up to the local ICBs to decide, but it has become abundantly clear that NHS England is giving out very heavy-handed guidance about who should be on ICBs. I would make this point to him: you cannot have it both ways. Either you leave it up to ICBs and withdraw this guidance, or Parliament has a role and a right to determine the governance arrangements. The action of NHS England in being so heavy-handed, such as saying that local councillors cannot serve on ICBs, means that the argument he put forward really does not stand up any more.

I move to my Amendment 218. On this one I must remind the House of my membership of the board of the GMC. The noble Lord, Lord Crisp, talked about the crisis in workforce issues generally, which I am not sure we are going to get on to today now. In relation to GPs, it is very apparent that not only do we have a chronic shortage but there is a grossly inadequate distribution of GPs throughout the country. Recent data, published by NHS England in November, shows that the primary care network covering an area in Gloucestershire described as 4PCC and comprising Cadbury Heath, Close Farm, Hanham and Kingswood had an average list of 1,138 patients per full-time equivalent GP. There are some others with similar figures. At the other end of the scale, Shore Medical primary care network in Dorset had an average list of 7,317 patients per full-time equivalent GP. York Priory Medical Group PCN had an average list of 7,154 patients per full-time GP and the Marsh Group PCN in Kent had an average list of 7,040 per full-time equivalent GP. These are huge disparities and there are many other areas that have average lists of under 1,600 and plenty with averages of more than 6,000.

The situation is really reminiscent of the situation before the start of the NHS. That is why in 1948 the Medical Practice Committee for England and Wales started work. It was charged with ensuring equitable distribution and, to a large extent, I believe it achieved its objectives. It was abolished in 2001 and I had better confess to the House that, I am afraid, I took through the legislation abolishing it. However, we were at the start of a massive expansion in the workforce at that time and felt that at that point the kind of bureaucratic way in which the MPC worked probably was no long fit for purpose.

We have a real problem here and confirmation of the dire situation was provided recently in research by the University of Cambridge’s department of primary care. A team including Dr Rebecca Fisher found that the significant GP workforce inequalities I have talked about are increasing and that workforce shortages disproportionately affect deprived areas. If you look at the situation in deprived areas, practices often have lower CQC scores, lower quality and outcome framework performances and lower patient satisfaction scores. Patients in those areas often have shorter GP consultations despite the fact that they have more complex health needs.

General practice is paid according to how many patients they have, with an adjustment made for the workload associated with those patients. Since 2004, the global sum allocation formula, known as the Carr-Hill formula, has been used to make that adjustment. However, Fisher argues that the consultation length is a flawed proxy for need and that the formula has long been widely acknowledged to be incapable of accurately weighing needs associated with socioeconomic deprivation. In 2020, after accounting for need, practices serving deprived areas received about 7% less funding per patient than those in non-deprived areas.

There is also the targeted enhanced recruitment scheme. This offers trainee GPs a one-off payment of £20,000 when joining a practice in an area that had long-standing difficulty in getting more doctors. However, this has not made a significant difference and clearly is not the answer to this enormous problem.

In the amendment—and I am very glad to have the support of the noble Lord, Lord Warner, and the noble Baroness—I have proposed the creation of

“the General Medical Practitioners Equitable Distribution Board”

as a first step. I envisage the board being invested with discretionary powers of negative direction, as was the MPC. It would consider applications from primary care networks, and they would be expected only from adequately doctored, or more than adequately doctored, PCNs. It would be a way of intervening in the market and making it more difficult to appoint GPs in those areas that are already very well supplied with doctors.

I accept that this is not the only approach, but it is an approach that has worked in the past. Frankly, I do not think that we can carry on without some major intervention to try to spread the load, because it is clear that all the odds are stacked against you if you are in an area of high deprivation where there are many more patients per GP. You get burnout among the professions and things become very difficult indeed. It looks as though financial incentives are not the answer. Clearly, we need to get more GPs into those areas to lessen the load, and then improve the quality and outcomes. I hope the Minister will be prepared to take this back and give it some consideration.