Health and Care Bill

Lord Kakkar Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[Lord Davies of Brixton (Lab)]

My Lords, I want to direct a few remarks to the issue of research, in broad support of the speeches made so far. The amendments in this group, taken individually, are generally to be welcomed, not least because they highlight the issues involved. However, taken as a whole, they suggest that there is a need for a more coherent approach, based on the common principles that apply across the whole range of providers and the whole spectrum of health and social care.

The point of principle is that there is a demonstrable association between the provision of high-quality care and participation in high-quality research. Put simply, patient outcomes in services that actively take part in research are better. This does not mean just future improvements in care, diagnosis and so on; the actual care provided alongside the research benefits from involvement in that research. It is reasonable to assume that the same is true of care services; I direct my remarks at healthcare, but I am sure these principles apply equally to those involved in the provision of social care.

Given the principle that research is so important, it is worth making a few additional points. First, research must be an essential element in a system of healthcare, involving both the bodies that deliver healthcare and service users. Hence ICBs need to have a research strategy and not just promote research but take practical steps to facilitate it. In this context, the importance of national research objectives should be emphasised. The involvement of these bodies in research should be more than just one more administrative hoop they have to jump through. It should be part and parcel of their core function, delivering better mental and physical healthcare. They also need to commit to training clinical staff in how they can participate to best effect in research, or at least in the importance of research to clinical care.

Secondly, there is a need to consider a duty on private providers of NHS services to participate in research. Of course, private providers have a duty to support and contribute to the training as well. It is easy for private providers to ignore the need for research, and this reduces the opportunities for those for whom they care.

Thirdly, on Amendment 96, I suggest that we need to go beyond the idea that clinical trials need to be considered by ICBs and other relevant agencies. We could go further and require ICBs to use their best endeavours to encourage and accept reasonable requests to support clinical trials and offer opportunities for patients to take part.

Fourthly, as we have touched on in previous debates in this Committee, it must be emphasised that, when addressing the issue of research, there is a need to refer explicitly to mental as well as physical health.

Finally, all of us should bear in mind the importance of service users being involved in research and of ICBs and other agencies keeping this in mind throughout the process of providing care. This includes the involvement of service users in developing the priorities of research in its design and in overseeing its carrying out. This is vital for making sure that the outcomes can be easily embedded in clinical and care services. It is worth emphasising this in the context of mental health, where most advances in patient involvement have taken place.

[Lord Kakkar (CB)]

My Lords, I thank the noble Baroness, Lady McIntosh of Pickering, and the noble Lord, Lord Sharkey, for the thoughtful way in which they introduced the amendments in this group to which I have added my name. In so doing, I remind noble Lords of three interests: I am chair of the Office for Strategic Coordination of Health Research, chair of the board of trustees of UK Biobank and chair of King’s Health Partners.

As we have heard in this debate, research is not only fundamental to securing the best outcomes for patients being treated in our hospitals and throughout our healthcare system; it is critically important for the sustainability of the healthcare system itself. Numerous reports and strategies have been published over the last 10 years, to the great credit of Her Majesty’s Government, in terms of putting innovation and research at the heart of repeated NHS strategies. It is therefore only right that your Lordships’ House pays particular attention to how securing the opportunity for that research and promoting the opportunities that will flow from it are reflected in the Bill. There is no question but that Her Majesty’s Government are deeply committed to this area, but, as the Bill is currently drafted, there is some anxiety that the provisions and clauses do not provide sufficient emphasis or obligation for the new NHS organisations, the integrated care systems and the integrated care boards—and, indeed, the continuing obligation for NHS trusts—to be actively involved in research.

Now why is this important? At the very least, we know that we need to continue to innovate, be it therapeutic innovation or innovation through devices—or, indeed, innovation of new working practices, pathways of care and delivery—if we are to continue the important advances in outcomes that we have been able to achieve in recent years and decades. As we have heard, research is at the very heart of our ability to improve the experience and clinical outcomes of our patients. Research is also fundamental in improving our ability to prevent disease. We have an obligation in this Bill to promote healthcare services and well-being and to avail ourselves of the substantial opportunities that exist with regard to a more focused prevention agenda. Much of that agenda must inevitably be driven by prospective research, to be conducted across broad and diverse populations on our fellow citizens.

There is the question of sustainability—the fundamental sustainability of the NHS. Here we recognise that, without research and the adoption of innovation resulting from that research, the demographic changes and increasing demands that attend the delivery of healthcare in our country will make the NHS unsustainable in future. Therefore, there is a very deep obligation, beyond what we can do for patients in terms of clinical outcomes, to put at the heart of NHS thinking and strategy, as well as delivery, the delivery of a substantial research agenda. We know that that that research agenda is secured centrally through the substantial commitment of public funds to the National Institute for Health Research, UKRI and Research Councils, which provide funding for research—and, indeed, for other contributions from government departments, including the third sector contribution and the substantial contribution for research provided by the pharma and biotech industries, and associated research opportunities.

All that needs to be directed towards NHS institutions that are ready to receive that substantial commitment to research and conduct in particular those clinical research opportunities which, regrettably, have been subject to variable performance over many years in the NHS. It is for that reason that this Bill must take the opportunity to address that variability in research participation and performance. If we do not achieve that, we are not going to utilise the full potential of the NHS to be able to deliver the benefits that have been so rightly predicted. Most of all, without ensuring a broad research culture across all NHS institutions and organisations, we are going to lose the direct consequences of such a research culture and infrastructure in terms of the fact that patients in research-active institutions have better clinical outcomes.

To move away from those two broad areas—the important impact on patients and the important opportunity to provide the broader research agenda with the innovation that flows from it—there is a third imperative: our capacity to attract and retain staff. As with any facet of manpower planning, it is vital to provide the opportunity for NHS staff members and healthcare professionals to be research-active. It provides a substantial incentive and encouragement and allows for career development, ensuring that we retain colleagues for longer and are able to develop them to make different contributions—all vitally important. If we take this as a whole, it is appropriate that Her Majesty’s Government give some very careful thought to the purpose of these different amendments and how what is being said in your Lordships’ House today might be included in the Bill in such a way to strengthen these research obligations and ensure that NHS organisations deliver on the health agenda.

--- Later in debate ---

[Baroness Harding of Winscombe (Con)]

My Lords, I add my voice in support of Amendment 170, so ably and brilliantly introduced by the noble Baroness, Lady Brinton, my noble friend Lady Cumberlege and the noble Lord, Lord Stevens.

At Second Reading, I spoke of my personal experience along the timeline set out by the noble Lord, Lord Stevens, as the person charged with developing the 2019 people plan with said absence of numbers. I do not wish to go into more detail on the history; I would rather spend the brief time I have available talking a bit more about why I think this amendment is needed and attempting to pre-empt some of the potential objections which I suspect will come from my noble friend the Minister.

A number of people have alluded to it, but we should be under no illusions that this is the most important debate we will have on health and social care. All our fantastic, lofty ambitions for our health and care system are for naught if we do not have the people to deliver them—and we should be under no illusions that we do not have them today.

I add my voice to those of the noble Baroness, Lady Hollins, and my noble friend Lady Verma: there is undoubtedly an important point about ensuring that healthcare assistants, nurses and managers in social care are paid appropriately. We also need to face the fact that we do not have enough people working in health and care in every single role in the system.

This is not a UK-only problem. As the noble Baroness, Lady Brinton, and the noble Lord, Lord Patel, said, this is a global issue. We cannot rely on people from outside the UK alone to solve our problem; we have to solve some of this ourselves. We undoubtedly need more people, but I would argue that we also need to work differently; we need both more and different. We need to address the way we work in health and social care, which is at the heart of this Bill. We need to embrace new professions and do the forward planning to make that possible, whether that is recognising sonographers as a registered profession; pushing forward on physician associates, where we are some 10 years behind other countries in the world; or developing an approach to credentialling which enables our clinicians to have more flexible careers, as science and technology change through the course of their lives. All of these ways to work differently from the way we operate today are as important as having more people. Neither more nor different is possible unless we start by being honest about the size of the problem, which is why Amendment 170 is so important.

I believe there are two substantial disincentives for this amendment being accepted. A number of your Lordships have alluded to the first one: anyone running a large people-based organisation is always tempted to focus on the urgent today and not invest in training and development for the future. It is just too tempting for the NHS, as well as the Secretary of State and undoubtedly the Treasury, to want to retain the flexibility to focus on the short term and raid the training budget for the future. Any one of us who has run any organisation knows that that is a human temptation. This does not make them bad people and it is not party political; it is just the reality of running a large organisation. That is why legislating to force transparency is so important.

The second major disincentive relates to a view that I suspect has been held in the Treasury for the best part of 20 years and which is counter to most economics. It is a belief that the way to control workforce costs in the NHS is to constrain the supply. I am not a brilliant economist, but most economics is the other way round: the way to reduce the cost is to increase supply. I have no doubt that it is quite a strongly held view in Her Majesty’s Treasury that the way we control workforce costs in the NHS is by constraining the supply. The reality is that that market mechanism is completely failing.

You have to look only at the costs the NHS is paying for locum, agency and bank staff. A recent Getting It Right First Time report, published last autumn, stated that 27% of workforce costs in emergency departments are for locum, bank or agency staff, which tells you that they are not properly staffed. If you are a young junior doctor in your third year in your career and you work as a locum for one week, you will earn £5,800, but if you work for the NHS for one week, you will earn £3,300. We should not be surprised that junior doctors with large student debts want to work as locums, yet we also know that that materially reduces their fulfilment and the quality of the care they deliver. The economic incentives are not working, despite the deeply held view that if we constrain the supply the NHS will somehow magically transform itself.

That is why we need to put this in the Bill. We do need more people, but we also need to drive incentives for transformation, and we will do that only if we face into the challenge. Those working in higher education can plan only if we give them a signal, and transformation teams can challenge the way we work only if we are honest about the need for that transformation.

One final reason I really urge my noble friend the Minister to accept this amendment is that our wonderful people, who have worked so hard in health and care over the last two years, need hope—and we can send them the strongest signal of hope that we really hear them, that we really understand the people challenges that they face, by putting this in the Bill.

[Lord Kakkar (CB)]

My Lords, I support Amendment 173 in the name of the noble Baroness, Lady Merron, to which I have added my name, and I broadly support the amendments in this group.

Many noble Lords have identified the question of workforce as the most important single issue that the Bill has to address. Without effective workforce planning, the NHS, as we have heard—and, indeed, the care system—is in peril. Previously, our country and the National Health Service have depended on overseas doctors and nurses to come and fill large numbers. That has been the principal basis of workforce planning for many years—indeed, decades. But that is no longer a viable option. The World Health Organization has estimated that, globally, there will be a shortage of some 18 million healthcare professionals by 2030. That will be a particularly difficult challenge across the globe, and it means that we can no longer depend on importing healthcare professionals to meet our ever-increasing needs. This is well recognised by all who are responsible for the delivery of healthcare and, indeed, by Her Majesty’s Government.

The question is: how can we dependably plan for the future? Unfortunately, it has to be accepted—indeed, it has been accepted in this debate—that planning to date has failed miserably. That is not a malicious failure, but it is a reality, and one that we can no longer tolerate. That is why amendments in this group that deal with the requirement for independent planning and reporting on a regular basis to provide the basis for determination and projecting future health and care workforce needs, are appropriate—indeed, essential.

My noble friend Lord Warner raised a separate issue about a group of amendments that will come later in the Committee’s consideration, which propose the establishment of an independent office for health and care sustainability. This is a recommendation of your Lordships’ ad hoc Committee on the Long-term Sustainability of the NHS and adult social care, chaired by my noble friend Lord Patel. It is this emphasis on ensuring that there is independent, long-term planning and projection that can provide the fundamental and accurate foundations for workforce planning. We need a broader assessment of what the demand for healthcare will be, and that demand is complex and driven by not only demographic change but changes in the way that we practise, changes in expectations, adoption of technology and changes in working practices. That all needs to be brought together to provide the foundations for planning. Without this emphasis and this obligation secured in the Bill, the NHS and adult social care in our country will not be sustainable.

I very much urge the Minister, in considering this group of amendments, to help your Lordships understand why it would be wrong to secure this emphasis in the Bill. If Her Majesty’s Government are unable to secure this emphasis in the Bill, how can they reassure noble Lords that the failures in planning that have dogged NHS performance with regard to workforce over so many years will not be repeated in the future?

[Baroness Finlay of Llandaff (CB)]

My Lords, to state the obvious, without a workforce plan we cannot have a workforce. Amendment 170 certainly seems to get to the heart of the issue, which was so well introduced by the noble Baroness, Lady Cumberlege, and my noble friend Lord Stevens.

Health and Care Bill

Lord Kakkar Excerpts

Lords Hansard - Part 3 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Fraser of Craigmaddie (Con)]

My Lords, I support both these amendments, and I refer to my interests as laid out in the register as a trustee of the Neurological Alliance of Scotland and chair of the Scottish Government’s National Advisory Committee for Neurological Conditions.

There is evidence, as we have heard, that people provided with early palliative care and support in all settings, as is laid out by Amendment 52, achieve better outcomes and, as the right reverend Prelate the Bishop of Carlisle said, that it prevents unwarranted hospital admission. I would commend the Minister to look at the model in Scotland, where the Scottish Partnership for Palliative Care brings together health and social care professionals from hospitals, social care services, primary care, hospices and other charities to find ways of improving people’s experiences of declining health, death, dying and bereavement.

Perhaps what differentiates palliative care from just good care is the awareness that a person’s mortality has started to influence clinical and more personal decision-making. However, I beg to disagree with the noble Baroness, Lady Finlay. This is not about the fact that we are all going to die; it is about life. It is about the care of someone who is alive—someone who still has hours, days, months or years remaining in their life. It is about optimising well-being in those circumstances.

A major problem for people who need and would benefit from specialist palliative care is that they are often referred very late to such services or not referred at all, because such services are erroneously perceived by many other professionals, and the public, as relevant only at the end of life. Unfortunately, access to specialist palliative care is therefore not available to people dying with neurological conditions. Although there has been some progress, most people dying with terminal or progressive neurological conditions die under the care of generalist health and social care teams, in hospitals, care homes or at home. The recent research by Marie Curie, quoted by many noble Lords this evening, points out the patchy access to palliative care, and people with neurological conditions are overrepresented in not being able to access it.

There is a very high level of unmet need. As the noble Lord, Lord Patel, mentioned, we should be angry that end-of-life care is not available—and for over half of people with neurological conditions, I am angry. For those who are receiving support from generalist teams, we know that hospital beds and suitable care packages are extremely scarce, especially as the health and care system seeks to cope with the Covid pandemic and its impact. As a result, we have a problem, and people are facing the end of their life without the support they require.

In a caring society, palliative care should be embedded into this Health and Care Bill. It should be a core service, available to all those who need it. I urge the Minister to support these amendments.

[Lord Kakkar (CB)]

My Lords, I intervene briefly to support the amendment moved by my noble friend Lady Finlay. In so doing, I would like to put a question to the Minister. In the context of contemporary, 21st-century delivery of healthcare, how can it be justified that palliative care is not considered part of the continuum and has to be funded in a different way? How can it be that those specialists delivering palliative care are unable to integrate it into the broader considerations of delivery of healthcare in their institutions and systems? It seems completely counterintuitive that that continues to be the position in our country. If Her Majesty’s Government were minded not to support these amendments, it would be helpful to understand how they justify that position and justify differentiating palliative care from other services that are rightly fully funded by the state.

[Baroness Walmsley (LD)]

My Lords, I feel honoured to be a fellow Member of this House with the noble Baroness, Lady Finlay, because of her professional and political work in raising this issue before your Lordships.

I want to use a word that has not been used yet in this debate, and that word is “fear”. The noble Baroness, Lady Fraser, nearly used it when she said that people are scared. Anybody who has read the reports that say that only 50% of people who need palliative care receive it will feel fear: “Is it going to be painful?”, “Am I going to be able to bear it?” and, on the part of the carer and family members, “Is it going to be terrible for my loved one?”, “Am I going to be able to help them?”, “Am I going to be able to cope?” The physical pain is part of it, but, as the noble Baroness, Lady Hollins, said, the fear and the psychological distress make things a great deal worse. At a time when it is in our power to give people a good death, we are not doing it; that is a disgrace.

Health and Care Bill

Lord Kakkar Excerpts

Lords Hansard - Part 1 & Committee stage
Thursday 13th January 2022 Lords Chamber

[Lord Shipley (LD)]

My Lords, now that we are in Committee, I remind the House of my interest as a vice-president of the Local Government Association. I rise to speak to Amendments 152, 156 and 157, to which I am a signatory. I will not repeat all the excellent points made by the noble Lord, Lord Young of Cookham, and others, but I hope the Government will accept that what is being proposed is central to the success of this Bill, and that is because the NHS does not exist in a vacuum.

We know that prevention and early treatment of people’s ill-health will help them, reduce demand for hospital beds and lead to a more efficient use of public resources. We know well enough that poor housing contributes to poor health. These amendments to Clause 21 present an opportunity for the Government to demonstrate their commitment to truly tackling health inequalities and, in particular, to ending rough sleeping, by the end of this Parliament in 2024. As the noble Lord, Lord Young, and others have clearly laid out, the beneficial impact on a range of groups experiencing social exclusion and poor health outcomes would be significant. That means that there must be integrated approaches between housing, health and social care at the point when integrated care partnerships create their healthcare strategies.

Research shows that an average local authority might have around 1,400 people a year experiencing multiple disadvantage, including support needs around mental and physical health, homelessness and contact with the criminal justice system. Around 58,000 people a year experience the most severe disadvantage. It is therefore essential that local integrated care partnerships consider all the ways in which health intersects with housing.

I was concerned to read recently that in July last year 77% of women leaving our largest women’s prison became homeless. Homelessness inevitably leads to poor health. As Professor Dame Carol Black’s recent review of drugs highlighted, unless housing and housing support needs are addressed, the health service will fail to improve people’s health consistently, regardless of how effective the commissioned health services may be.

We know this approach works. The Government’s welcome effort to vaccinate people who were homeless went alongside a push for not only GP registration but provision of emergency accommodation. This acknowledged the need to bring together support into housing alongside access to basic health services. Indeed, we have seen the Government revisit this approach just before Christmas, with the Protect and Vaccinate scheme. Since the Government have recognised the need for this integrated approach, I cannot see why they would object to these amendments that would help continue it.

Amendments 152, 156, 157 and others seek to make our NHS systems more effective in the delivery of services to the most excluded and marginalised in our society. As it stands, people are forced to attempt to navigate a siloed and fragmented health service that does not adequately address their complex health needs. For example, one patient with alcohol and other addictions, supported by Changing Lives, could not access mental health services until after his alcohol addiction was addressed. However, with the right support from Changing Lives’ inclusion health approach, this patient is now managing abstinence from alcohol and engaging with mental health support. Crucially, his experiences highlight the challenges in addressing substance misuse in isolation, without making support available to address mental ill-health at the same time.

The Government may argue that it will be sufficient to address these concerns in guidance, but I hope they do not. I acknowledge that guidance would be beneficial in ensuring that approaches to inclusion health populations are considered within integrated care systems. However, without legislation, tackling inclusion health would become nice to do rather than something that must be done.

A recent example of this is Covid-19 vaccine uptake among people who were homeless. We know that where inclusion health services existed, there was a concerted effort to ensure good vaccine uptake, but without these specialist services we simply do not know how effective vaccination programmes have been. The only data available from July 2021 show vaccination rates to be substantially lower among people who were homeless compared to the general population.

I am aware that commissioning strategies and services for inclusion health populations is already on the agenda of some integrated care systems, but we need all integrated care systems to play their part. Guidance will not be effective enough to ensure the provision of specialist support everywhere, not just in some places.

In conclusion, the level of complexity of the marginalised and excluded experience can be met only by embedding inclusion health throughout the health and care system at the highest levels. Legislation is the most secure way to achieve this. Otherwise, there will continue to be a postcode lottery in access to the right healthcare services for these groups, resulting in that “disease of disparity” the Secretary of State wants to address.

[Lord Kakkar (CB)]

My Lords, I first join other noble Lords in thanking the noble Baroness, Lady Thornton, for the thoughtful way in which she introduced this group of amendments. I support Amendment 14, in the noble Baroness’s name, and Amendments 65, 94, 186 and 195 in the name of my noble friend Lord Patel. This is a vital group of amendments, as your Lordships have already heard, because it is focused on inequalities. Clearly, no society, Government or Parliament can tolerate the inequalities that we see in both clinical outcomes and access to healthcare that have remained despite our remarkable healthcare system and the NHS. It is for that reason that it is absolutely right that, in the opportunity afforded by this Bill, inequalities are properly addressed.

More worrying is that, despite this country’s substantial investment in healthcare and the development of health systems over the past 70 years, these disparities in outcomes and access to healthcare described geographically and across different ethnicities and socioeconomic groups have continued to grow. That is despite all the success we have seen more broadly in delivering healthcare, addressing prevention and improving treatments.

It is also right to recognise that inequalities in outcomes and access to healthcare are best addressed at the local level. Through a focus on integration in not only the capacity of services but the capacity to integrate the development of policy and its execution across healthcare and through local government and the other elements of the state—education, employment, housing and so on—we will have the greatest opportunity to address social determinants of health. There has probably been no other health Bill presented to this Parliament since the creation of the NHS that provides the greatest opportunity to take that combined and collective approach.

It is therefore quite right that one turns attention to the triple aim. This is a laudable addition to the Bill, with an absolutely appropriate focus on promoting health and well-being, ensuring access to quality care for all citizens and ensuring the appropriate and effective utilisation of healthcare resources. Why not add to that triple aim a fourth clear objective to address issues of inequality? The triple aim does not mandate action, but it provides the context in which a framework should be developed locally, cognisant of the healthcare needs of the local population. An ideal framework would ensure that we drive collaboration and co-operation as required to focus activity and the allocation of resource and establish a local vision and determination to address health inequalities.

To fail to take this opportunity would be disappointing and, quite frankly, unacceptable. As we have heard in this excellent debate, if we fail to address these inequalities not only will they have a continuing and profound impact on health outcomes and access to healthcare for large numbers of our fellow citizens, but there are broader societal and economic consequences of continuing to accept inequalities in healthcare. I hope that, in answering this debate, the Minister will be able to confirm that Her Majesty’s Government are prepared to consider this issue and will put inequalities the heart of this Bill in the triple aim—becoming a quadruple aim—and will ensure that, at a local level, data collection and reporting become a primary focus of healthcare systems.

[Baroness Harding of Winscombe (Con)]

My Lords, I begin by declaring my interest as the recently departed chair of NHS Improvement. I support these amendments, especially those that seek to extend the triple aim, such as Amendments 14, 65 and 94, as the noble Lord, Lord Kakkar, just set out so eloquently. It seems there is no disagreement in the Committee about the importance of addressing health inequalities. Anyone who has lived through the past two years can see that plainly and clearly, as Covid has so cruelly highlighted the health inequalities in this country. The question is how we make sure this Bill genuinely tackles the issue that we all agree about so passionately. Why is it important, as just set out by the noble Lord, Lord Kakkar, to put the duty to address health inequalities in the Bill?

Health and Care Bill

Lord Kakkar Excerpts

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

[Baroness Walmsley (LD)]

My Lords, a duty to establish parity of esteem between physical and mental health was, of course, inserted into the Health and Social Care Act 2012 at the instigation of the noble Baroness, Lady Hollins—if I remember rightly, we on these Benches were right behind her. That is not reflected in this Bill, as she said, despite the fact that the importance of addressing mental health issues has been so amply demonstrated by the rise of these problems during the Covid pandemic. The shortage of services to address them is of great concern—services which were already under stress before the pandemic started because of underfunding over many years.

Although the insertion of parity of esteem into the 2012 Act was welcome and significant, no legislation is enough without the resources in cash and people to make it happen. They have not been forthcoming in the amounts needed to match the growing demand. Like the noble Baroness, Lady Hollins, and my noble friend Lady Tyler, I too have heard concerns in the sector that the share of resources that are currently available might be cut over the next three years under the Government’s plans.

The situation is not good. Waiting lists, particularly for children and young people, have been growing. I understand that the average waiting time for a young person for a first appointment is something like 13 weeks and 18 weeks to get to a referral for treatment. It is a bit of a postcode lottery, because some young people get there quite quickly and some wait a very long time. The noble Lord, Lord Warner, is absolutely right that it takes a great deal longer for those waiting for a diagnosis of autism.

According to research from the Resolution Foundation, in 2000, 24% of 18 to 24 year-olds had a common mental disorder. That was the lowest rate of any age group at that time. By 2018-19, that figure had grown to 30% and, astonishingly, by April 2020 it was up to 51%. So, as we set up the new integrated care system, it is essential that we restate the equivalence of mental and physical health. We know, as the noble Baroness, Lady Jones, so eloquently reminded us, that each affects the other, but it is not enough to assume that that is understood in this legislation. It must be clearly stated in both Clause 16 and Clause 20, where the noble Baroness, Lady Hollins, seeks to add it to the duty of the ICSs to secure improvement in the quality of services. We support her, of course.

Perhaps at this point I will mention my little amendments in this group. Amendments 48 and 49 are two of those little amendments that would insert the words “physical or mental” illness into Clause 16, which specifies a list of health provision that the ICB must make for its population. Other noble Lords would insert similar amendments into other places in the Bill. I support all of them.

Amendment 76 would also insert parity of esteem into new Section 14Z38 in Clause 20, which refers to the duty to obtain appropriate advice. We put it there to emphasise the fact that mental health is a very specialised area, and often very good advice can be obtained from small community or not-for-profit social enterprises that deliver mental health services in the community where people work and live, often to very marginalised groups. Large organisations such as an ICS might very easily overlook such good advice about what is needed and where to put it. I support the amendment spoken to by my noble friend Lady Tyler that the triple aim must become a quadruple aim. Mental health needs to go right at the core of what we are trying to achieve.

There is an enormous and growing number of people in the country with poor mental health. The NHS cannot just treat its way out of the problem. There needs to be more focus on public mental health, much of which is addressed by the small community groups I just mentioned, the role of which we will deal with later with Amendment 148 and others. But without the specific acceptance of the parity of esteem duty in the Bill, there is a danger that the diagnosis, prevention and treatment of mental ill-health will continue to take a back seat. It must be in the statute.

[Lord Kakkar (CB)]

My Lords, I support the objectives of this group of very important amendments. In so doing, I remind noble Lords of my interests as chairman of the King’s Fund and of King’s Health Partners. I have seen this work directly in King’s Health Partners through a programme defined as Mind & Body, which proposes to promote pathways of care across the entirety of our health economy that look in equal measure at physical and mental health for all patients, irrespective of their principal clinical presentation. Initiatives such as that important programme could be brought to fruition only because of the emphasis in the 2012 Act regarding parity for physical and mental health. It demonstrates very clearly that legislative intervention can have a profound impact. I very much join in congratulating my noble friend Lady Hollins on her relentless commitment to these issues in your Lordships’ House over the past 10 years, which have had and will continue to have a profound impact.

It therefore seems counterintuitive for Her Majesty’s Government, in bringing forward this important legislation, to move away from the opportunity to emphasise the importance of this parity. Is it sensible to move away from this position? Why not use the opportunity afforded by this important legislation to emphasise once again the importance of parity between mental and physical health in every respect—not only funding but the organisation and supervision of services and the construction of organisations within the NHS—so that, step by step, we can achieve what every Member of your Lordships’ Committee who has spoken in this debate has emphasised?

Will the Minister, in replying to the debate, reassure your Lordships that not proceeding with these amendments does not undermine what has been achieved so far and that what is proposed in the Bill can without the amendments achieve the continued momentum and concentration of focus on this vital issue, to ensure that we continue not only to develop mental health services but to ensure that they can be integrated more broadly into physical health, and that physical health services can be developed to ensure that the mental health consequences of physical conditions can also be appropriately addressed? In taking this holistic approach, we will achieve the objectives of better well-being and health for all our fellow citizens—one of the most important aspects of the triple aim.

[Baroness Finlay of Llandaff (CB)]

My Lords, I should declare my interests as having worked with liaison psychiatry extensively in the cancer centre in Cardiff, and as chair of the National Mental Capacity Forum for England and Wales.

One group that has not been mentioned yet—I appreciate the noble Lord, Lord Warner, mentioning some—is those with impaired capacity and learning difficulties. We should not underestimate the importance of access to psychiatry for those people who develop mental health problems as a result of their physical health problems. To view the two as separate is a fallacy because they are completely integrated in many people. Many people present initially with a physical illness but develop mental health problems which, if ignored, become really major. The opposite also occurs, of course. Those people with learning difficulties and impaired capacity at different levels often have a raft of quite serious physical medical conditions that might be particularly difficult to diagnose because their mental health problems get in the way of their ability to express themselves.

If we are really to drive up the health of the nation at all, we would be completely misguided to ignore the importance of this group of amendments. Like others, I urge the Government to grasp this nettle, put this in the Bill and make sure we finally address this severe imbalance, which has left so many people never accessing the care they need. That applies both to mental health care and to those with mental health difficulties who then fail to access the physical healthcare support they need because they just cannot express their needs properly.

Medical Schools: Training Places

Lord Kakkar Excerpts

Monday 13th December 2021 Lords Chamber

[Lord Kamall (Con)]

When training doctors from abroad, we follow international guidelines and World Health Organization ethical guidelines. For example, when I recently had a meeting with the Kenyan ministry to talk about the UK-Kenya health partnership, the point was made to me that they were training far more people than they had places for in their own country. They thought that their talent was a valuable export, while at the same time, remittances went back to their country.

[Lord Kakkar (CB)]

My Lords, I draw attention to my registered interests. Does the Minister accept that long-term workforce planning requires an effective apparatus that is able to understand the changing population demographic, changes in the nature of the delivery of healthcare and how technology and innovation might impact that? Do Her Majesty’s Government have a view about establishing such an apparatus as part of the current Health and Care Bill before your Lordships’ House?

[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.

Covid-19 Update

Lord Kakkar Excerpts

Wednesday 8th December 2021 Lords Chamber

[Lord Kamall (Con)]

I thank my noble friend for making those two important points. As we know from what happened previously, as a consequence of lockdown, many people were unable to have operations or even diagnoses. In fact, much of the waiting list—80%—is for diagnosis. It is too early to tell what the impact will be, but I will find out and write to her. It is quite clear that there will be a negative economic impact. I do not think one has to be the former head of research for an economic think tank to say that, but it depends on how long this lasts and what economic activity continues in the meantime. I will look at that.

[Lord Kakkar (CB)]

My Lords, the Minister rightly made the point that two variants will shortly be circulating in high volume—the delta and omicron variants. Is he content that there is sufficient genomic sequencing capacity to distinguish between the two and, therefore, understand the epidemiology and the natural history of the two competing virus strains, at a basic level?

[Lord Kamall (Con)]

I attended a meeting this afternoon with leading epidemiologists, showing the data and separating the omicron variant, the delta variant and the original coronavirus. They have the data, and one of the reasons we have made this announcement is because we are able to distinguish between them. We are constantly reviewing the data for the original coronavirus and the variants but, if the noble Lord has any more scientific or medical questions, he should let me know or attend the briefing with Jenny Harries on Friday.

Health and Care Bill

Lord Kakkar Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I thank the Minister for the thoughtful way in which he introduced this Bill and draw attention to my own register of interests, in particular the fact that I am chairman of the King’s Fund, King’s Health Partners and the Office for Strategic Coordination of Health Research.

I welcome much of what is proposed in this Bill, because it has a specific purpose— to drive integration. It has long been desired across the National Health Service that greater emphasis be placed on integrated care, including integration between primary and secondary care, between physical and mental healthcare, and between health and social care.

Clause 5 also sets some guiding principles for all NHS organisations, with the triple aim of ensuring better health and well-being, improved quality of services delivered and the most effective and efficient use of resources, applied by the state for the provision of health services. However, it fails in setting a guiding light and principle for the NHS to address the important issue of inequalities, which we have seen exacerbated during the Covid pandemic. Might Her Majesty’s Government consider amendments that address this issue in Committee and ensure that there is a fourth guiding principle for all NHS organisations with a duty to address health inequalities and inequalities in outcomes?

We have heard about other important provisions in this Bill, many of which will be addressed by noble Lords today. Although there is consensus that much has to be achieved, a number of the provisions and the failure to address other issues are somewhat controversial. I hope Her Majesty’s Government will give sufficient time in Committee to ensure that these issues can be properly addressed and that there can be absolute confidence, finally, once this Bill passes through your Lordships’ House.

I will emphasise just three additional areas in the time remaining to me. The first is research. We all recognise that a research environment and culture is critical to the sustainable delivery of health and care in our country—research not only in terms of development of new therapies or devices but into new models of care and how best we can deploy the workforce to achieve effective and efficient delivery of healthcare. Clause 20 makes provision for integrated care boards to have a duty to promote research, but that does not appear to go far enough to ensure that the commissioning environment secures a proper ecosystem for research, driving not only the provision of facilities but a culture in the development of a workforce able to engage in research, which is the lifeblood of the future of the NHS.

There is also considerable concern about Clauses 25 and 142 regarding the change in the regulatory environment. It seems counterintuitive to provide a new system-wide regulatory obligation for the CQC, as mentioned by the Minister in his opening remarks, yet retain the very specific provision for the CQC to regulate individual institutions. Regulation drives culture and behaviour in the NHS, and those two objectives might be in tension with each other, driving unintended consequences and undermining the capacity to achieve true integration.

Finally, there is the question of the workforce. This is critical. Your Lordships’ committee on the long-term sustainability of health and care, chaired by my noble friend Lord Patel, identified this as the key issue critical to the sustainability of the NHS and the care system in our country. The provisions proposed in the Bill are welcome, but they do not go far enough. Your Lordships’ committee suggested the creation of an office for the sustainability of health and care, which would have responsibility to look at demand over an extended period—some 20 years—and, from that, understand what workforce decisions and planning measures should be taken to ensure a sustainable workforce, in terms of not only numbers but its capacity to deliver over time. Those measures are addressed in Clause 35. I hope we will be to explore some of these issues in Committee.

NHS: Elective and Cancer Care Backlog

Lord Kakkar Excerpts

Tuesday 7th December 2021 Lords Chamber

[Lord Kamall (Con)]

Even before the pandemic there was a growing number of referrals across elective and cancer care. This had been driven by a number of different factors, including people’s awareness of cancer, the symptoms associated with it and media campaigns. In addition, one of successes of having an ageing population is that people face a number of different issues. For example, over half of cancers are diagnosed in patients over 65. We know that we have to tackle this issue. That is why we have published the long-term plan with a £33.9 billion budget.

[Lord Kakkar (CB)]

My Lords, I draw attention to my registered interests. Is the Minister content that the NHS has a workforce strategy sufficiently robust to ensure that the extra funds provided can be effectively deployed?

[Lord Kamall (Con)]

In June 2019 the NHS published a people plan that would improve the NHS workforce, including a dedication to recruit more nurses. We continue to work hard to deliver that commitment. Latest workforce figures show that there are 5,100 more doctors and more than 9,700 more nurses.

Ageing: Science, Technology and Healthy Living (Science and Technology Committee Report)

Lord Kakkar Excerpts

Wednesday 20th October 2021 Grand Committee

[Lord Kakkar (CB)]

My Lords, I join other noble Lords in congratulating my noble friend Lord Patel on the remarkable, thoughtful and insightful way in which he chaired your Lordships’ Science and Technology Committee on this inquiry, on the preparation of the attendant report, and, of course, on the way he introduced this debate. In so doing, I declare my own interests, in particular those as chairman of the King’s Fund, of UK Biobank and of the Office for Strategic Coordination of Health Research.

Your Lordships’ Science and Technology Committee identified the profound consequences of an ageing society and demographic in terms of the impacts economically and on the delivery of health services, but also of the broader societal impact. In considering the implications of ageing, we must be clear at the heart of all consideration and the development of any policy that it is the responsibility of society and government to ensure that we continue to deliver support and care for an ageing population compassionately.

We also have to ask ourselves the question, “What is going wrong at the moment?”, particularly in the delivery of health services. The committee was able to receive important evidence in this regard. We heard that the delivery of services is not joined up; we still provide healthcare services in a very disjointed fashion. In so doing, we have a focus on single diseases and single conditions, rather than providing a service for an ageing population where there is capacity to consider multiple comorbidities at the same time and provide interventions that ensure that each of those is addressed meaningfully and in an integrated fashion, so that individuals can maximise the opportunity for improved outcomes and avoid the many deleterious consequences of ill-co-ordinated multipharmacy and multiple ill-co-ordinated interventions.

Her Majesty’s Government will shortly bring to your Lordships’ House the Health and Care Bill. In that Bill there will be the opportunity to look at the way services are delivered. Is it Her Majesty’s Government’s intention that this Bill will provide the opportunity to deliver and address with a potential legislative change the important recommendations in this report that plead for the more co-ordinated and joined-up delivery of care services for an ageing population?

We also received evidence of the remarkable basic science research effort established over recent years in the creation of a new specialty of biogerontology—basic scientists studying the processes of ageing at a molecular and cellular level. That scientific output has identified hallmarks that can be associated clearly at a cellular level with the ageing process, such as telomere attrition, mitochondrial dysfunction and stem cell exhaustion. All this fundamental research provides the opportunity both for novel targets in the establishment of biomarkers that can be used to address, identify and diagnose the ageing process clinically at a much earlier level, and, most importantly, for novel therapeutic targets that will become future interventions and the opportunity for us to target the multifactorial manifestations of the ageing process.

We also heard that the next stages in the development pathway in clinical research in particular are dysfunctional. The current way we regulate clinical trials is to provide regulation to achieve a single treatment for a single disease, rather than undertaking clinical research for the ageing process, which, by definition, affects multiple end organs. We also heard that elderly populations and those with multiple comorbidities are frequently excluded from clinical trials, so much of the evidence generated for potential therapeutic intervention is generated in populations who are not elderly, and we extrapolate from those populations to a highly complicated ageing population. That is why the interventions we offer frequently fail to have the impact we might anticipate or to provide the advantages that so much technology and innovation in healthcare and research could provide. It is essential that the insights, innovations and interventions we will provide to deal with the ageing process and diseases associated with ageing are derived in and from those specific populations, rather than extrapolation.

Her Majesty’s Government have suggested that they will use the opportunity availed by leaving the European Union to look at the clinical trials regulation. Do they intend to look at the regulation to ensure that we can address this major fault in conducting clinical research to address the ageing process, so that we can not only achieve important benefits for those individuals and citizens who will benefit from the research output but have the opportunity to provide for our country to lead in the clinical development of interventions and innovations to address the ageing process?

Finally, we were also able to look at the question more broadly of how the health service can help us to address this important societal and national challenge. One of the important questions is how we are able to mobilise and use data collected within the National Health Service and in many large cohort studies that Her Majesty’s Government and research charities have supported over many years and decades, in terms of generating data to identify novel biomarkers, to establish approaches to appropriate imaging, and to apply emerging techniques of data science to these large cohorts and datasets to help us identify novel biomarkers and accelerate and improve the clinical trials process.

This is a very real challenge and once again Her Majesty’s Government have identified the opportunity to look at the general data protection regulation. Will that opportunity be used to provide for a review that allows us to access and address health data in a responsible and meaningful fashion, of course with appropriate social licence, to ensure that we can drive forward innovation in this important area? It is with data and it will be with innovation that we are able to make a major contribution to the issues identified in your Lordships’ Science and Technology Committee report.

Women’s Health Strategy

Lord Kakkar Excerpts

Tuesday 9th March 2021 Lords Chamber

[Lord Bethell (Con)]

I pay tribute to my noble friend for his campaigning on this important cause. It is not the specific focus of the health strategy but it will play a part in it, and I encourage my noble friend to submit the characteristically detailed evidence, for which he is so well known, to this important evidence-gathering process.

[Lord Kakkar (CB) [V]]

My Lords, I draw attention to my declared interests. In taking forward an initiative for clinical research as part of their G7 health agenda, how do Her Majesty’s Government propose to ensure alignment of the clinical research regulatory framework so that the approval of innovative devices and therapies is predicated on clinical trial and registry methodologies with appropriate representation of women, including those from ethnic minorities?

[Lord Bethell (Con)]

The noble Lord makes a really good point. I am not sure whether we have considered the gender aspect of the clinical trials work programme in our G7 agenda. It has been very much about pandemic-preparedness and ensuring that next time we are able to share clinical trial information. Of course, we pat ourselves on the back for our own vaccine clinical trials in the UK, which, I think, have met a new standard for gender representation. He makes a good point, however, about making that case in our G7 work programme, and I will take it back to the department for further consideration.