Health and Care Bill
Lord Kamall ExcerptsThursday 20th January 2022
(2 years, 7 months ago)
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The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, this has been a fascinating debate, covering issues around prevention, as the noble Baroness, Lady Walmsley, said, and talking about what we mean by integration and how we make sure that it is more than just a word. I remind noble Lords that we have a forthcoming paper on integration as part of the overall package of the Bill, and a social care paper as well.
The noble Baroness, Lady Thornton, mentioned culture and attitude. I think it is very important to recognise that you can change structures and have legislation but you have to make sure that the culture and attitude are right across the system. I say to noble Lords that we fully sympathise with the intentions and I hope I can offer some reassurance.
In my departmental job as Minister for Technology, Innovation and Life Sciences, I feel very strongly that one way to drive integration is through better use of data across the system. Even before we look at integrating with social care, the NHS as it is at the moment is not sharing data well across the system. There are still a number of inefficiencies. I really believe in the digital transformation agenda and will give a quick example of that.
Just before Christmas, at a time when the NHS was under extreme pressure, I had my annual check-up in two parts. One part was an ECG at a local community centre; the second was supposed to be a telephone conversation with a consultant a week later. When the phone call came from the consultant, he started talking and I had to stop him. I said, “Have you seen my ECG results?” and he said, “No. What ECG? When was that?” I said, “This is all part of the same appointment. Can I now give you the date and time when I had it so you can look at the results?” “Don’t worry about that,” he said, “we’ll just have to make a new appointment”.
This was at a time when the NHS was under extreme pressure, as it is every winter. That shows the challenge. Even though we have been talking about the integration of health services since 1948, we still have these problems. That is why I believe so strongly in the digitisation and data-sharing challenge. It is not just because I am a geek and love technology; it really can make a difference, save money and lives and mean a more effective service all around.
I start by addressing Amendment 50 on fracture liaison services. Fracture liaison services and fragility fracture prevention are recognised by NHS England as critical to both healthy ageing and elective recovery. Within its high-impact restoration strategy, NHS England recommends that all systems optimise the secondary prevention of fragility fractures. NHS England is working closely with stakeholders to support the implementation of secondary fracture prevention services where they do not exist already and to support sustainability and quality improvement where services exist. Once again, this will rely on good data being shared across the system.
There are already duties in the Bill to require ICBs to commission such services. As fracture liaison services aim to identify people at risk and therefore prevent future fractures, their provision would already be covered in Clause 16 under new Section 3(1)(h), which places a duty on ICBs to commission such services or facilities for prevention, care and aftercare as the ICB considers appropriate. As I hope noble Lords will agree, it would be inappropriate to be overly specific in setting out the services to be commissioned as part of the new Section 3 that would be inserted by Clause 16, given the wide range of services the NHS needs to commission. However, I hope I can give assurances to noble Lords that NHS England will continue to monitor this and ensure that ICBs are commissioning effective fracture services. I hope we continue to drive this data being shared appropriately.
I turn to Amendment 51A. It makes sense that people should be able to receive emergency treatment wherever they are, as the noble Baroness, Lady Thornton, alluded to. We believe that is already the case. Once again, data would make a huge difference. If I am in Newcastle and fall off my bike and am taken to hospital, and if I have an existing condition, would it not be great if the clinicians when they triage me could know about it? I have asked my local GP practice to share my data on the app and it still has not done it. The mechanisms are there but the culture and attitudes are a huge challenge for whichever Government are in power.
The Bill confers a power on NHS England to publish rules that determine the people for whom each ICB is responsible. Those rules must make sure that everyone registered in the area, or everyone who may have need of services, is looked after. The Secretary of State may make regulations expanding that responsibility or creating exceptions where necessary. This was the case with existing CCGs and will continue under the ICBs. I hope I can reassure your Lordships that these regulations will be replaced to ensure continuity in this between CCGs and ICBs,
I now turn to the noble Lord, Lord Farmer, and his amendment. I also thank him for sharing his wisdom and his experience of family hubs. It is incredibly important. We agree with the spirit behind Amendment 57. We fully agree that, generally speaking, as the noble Baroness, Lady Walmsley, said, prevention is better than cure. One of the things that I have been reassured by in my early conversations in my role as a Minister for Health is the number of people in meetings who have said that they want to move towards a focus on prevention. That is not avoiding cure. We have to tackle cure, of course, but we can avoid a lot of that and save resources and time and promote better health and healthy living if we focus on prevention.
There are also duties in relation to the improvement of services for the prevention of illnesses as well as a duty to obtain appropriate advice, which expressly includes a requirement to seek advice from people with expertise in the prevention of illness. The NHS is already working hard to prevent ill health but, once again, we have to make sure that, in this prevention, people are all talking to each other, we are learning from best practice, and ICBs and trusts are learning from each other. As a number of noble Lords have made clear in their contributions in Committee, the issue is wider and social prescribing, for example, and other issues are really important.
Commissioners have also developed good practice, including funding alcohol care teams and tobacco treatment teams in hospitals, and expanding the diabetes prevention programme. This was re-emphasised in the NHS Long Term Plan, which contained commitments for the NHS to focus on major causes of ill health such as smoking, poor diet, high blood pressure, obesity and alcohol and drug use.
I remind noble Lords that prevention is not simply also a matter for ICBs. It involves local authorities and sometimes law enforcement authorities. It is a multiagency approach, led by local authorities but with ICBs, the NHS and other agencies playing their role.
I acknowledge the point that my noble friend made about cannabis and young people and I will write in more detail about that rather than take up time now. But we also have to look at such issues in the round. For example, in the United States Michael Cannon of the Cato Institute wrote that a lot of drug enforcement or anti-drug policy disproportionately affects young black men who then get thrown into the criminal justice system. How do we tackle that? One of the interesting conversations I have had with the noble Lord, Lord Paddick, was about his experience as borough commander in south London, an area that my noble friend mentioned. He gave the example that young black men in possession of drugs were far more likely to be picked up than a white middle-class male or female.
We have to make sure that we look at this as a whole. When we look at the tackling inequalities strand that we all feel so strongly about, we have to make sure we get the right balance. It is, of course, very difficult on a case-by-case basis but we have to be aware of unintended consequences.
On the integration duty, we are sympathetic to the intent behind the amendment from the noble Baroness, Lady Hollins, and support greater integration between health and social care. We hope that we can make sure that stakeholders work together and that, with all the papers, we are able to push through this integration.
Baroness Thornton (Lab)
I hesitate to take the words of the noble Baroness, Lady Hollins, away from her, but she is talking about putting a duty for this integration in the Bill. That is the way forward. Assurance is not the point here. I think we have gone past the point of needing assurance. We have been assured about this for years. This is about the duty.
Lord Kamall (Con)
I was just about to come to duty, so I thank the noble Baroness for hurrying me along.
Lord Scriven (LD)
I do not think that the Minister really understands. Yes, there may be a duty on local authorities. The amendment tabled by the noble Baroness is basically a duty to promote integration. At the moment, the Bill says that:
“Each integrated care board must exercise its functions with a view to securing that”
health services are provided in an integrated way. The amendment says “and social care”. It then justifies at what point that integration must be done. Why does the Minister feel that not putting this in the Bill somehow strengthens the main aim of the Bill, which is to look at the integration of health and social care for individuals who are going through a health and social care episode?
Lord Kamall (Con)
The Bill complements these existing duties by placing an equivalent duty on ICBs to integrate the provision of health services with the provision of health-related services and social care services, where this will lead to improvements in quality or reductions in inequalities. Taken together with the wider introduction of integrated care boards and integrated care partnerships, this gives the NHS and local authorities the best platform on which to build new ways of working. New provisions in the Bill will also complement and reinvigorate existing place-based structures for integration between the NHS and social care, such as health and well-being boards, the better care fund and pooled budget arrangements. We will, of course, be listening throughout the passage of this Bill to other ways in which we can facilitate the NHS, local authorities and others to work together to deliver integrated care for patients and the public.
Lord Scriven (LD)
I am sorry and will not delay the House much longer, but this is a really important point: the heart of the Bill.
As the Bill is written at the moment, the only integration that the integrated care board is responsible for is to ensure that health services are integrated. That means integrating primary, mental health and acute. It does not say that it is for the integration of social care. That is exactly what the noble Baroness is trying to achieve. As this is written, is it not the case that the duty in the Bill is for the ICB to secure that only health services are integrated?
Lord Kamall (Con)
One of the reasons for the introduction of integrated care boards and integrated care partnerships is to give local systems, both NHS and local authorities, a platform on which to build new ways of working. That includes social care. If the noble Lord feels that this duty is not explicit enough or that we should bring it out, we should have further conversations.
Lord Hunt of Kings Heath (Lab)
The architecture is very curious regarding why we must have an integrated care board and integrated care partnerships. It has never been clear to me why the Government have not attempted to set up a health and care board to bring those services together. We know that the funding systems will be different and that there is a clear difference between free at the point of use and means-tested social care, but surely that is what an integrated board, jointly owned by the NHS and local government, with councillors at the table not officers, is trying to sort out. Why have we ended up with this nonsense of a structure? We are carrying on with health and well-being boards as well. That is the great puzzle here.
If the Government are not willing to move on that, we must come back to the point made by the noble Lord, Lord Scriven. By splitting it, you then must say to the integrated care board, “Ah, but in your duties, you must ensure that you integrate with social care as well.” It really is a mess. The Minister said earlier that this is what the NHS wanted. Yes, this is an NHS Bill designed by NHS managers with a focus on the NHS. I do not know why it is called a care Bill, because it has nothing to do with care.
Baroness Walmsley (LD)
I am so sorry to delay the Minister again, but briefly. After we have pushed this Bill through Parliament, we will have an integration Bill and a White Paper and legislation on social care. When we have had this, those and those, can we come back to this?
Lord Kamall (Con)
These are all building blocks. I thought that might get a laugh.
In response to the noble Lord, Lord Hunt, ICPs were the idea of the Local Government Association, and we want to ensure that they work with the ICBs. Also, we must recognise that local authorities are accountable to their local electorates and fund many of the services for which they are responsible from local taxation. While we encourage local authorities and the NHS to work together as much as possible and pool their budgets where it is beneficial for local people, we are not mandating this, as this would probably require significant shift in how local authorities are held accountable for managing their money. One of the reasons why we have this strange ICB-ICP partnership is to ensure that it is at the right level and, beneath that, to have the health and well-being boards at place level. I sense the strength of feeling in the Committee, and I see the noble Baroness, Lady Hollins, giving a wry smile.
Baroness Hollins (CB)
I love this debate—it is brilliant—but it makes the point that this is an ideal opportunity to pre-empt a later Bill and get on with the job now where it belongs. Given the strength of feeling in the Committee, if we cannot reach a solution to this, I will bring it back on Report.
Lord Kamall (Con)
I thank the noble Baroness for her sympathy for my role. Debates like this are important. They give the Government a measure of the strength of feeling on particular issues. It would be blind for me not to acknowledge the strength of feeling and the support for the noble Baroness, Lady Hollins. As I have done with some of the other issues discussed in this debate, I will take this back to the department and call a meeting of those who are interested, as we did for mental health, and hopefully we can have a discussion to find a way forward. I thank noble Lords for expressing the strength of their feeling. It is very helpful to know where we can focus time and resources as we try to get this Bill through and ensure that it is workable and leads to the integration that we all want to see.
I will also add that NHS England intends to assess ICBs, as I does CCGs. This may not be reassuring, given some of the strength of feeling about NHS England’s drive behind the Bill. The CQC will also make assessments of ICSs and systems, and part of that will be to consider how health and social care are working together.
I will now talk about rehabilitation—not of my career but of health. Our intention with this legislation is to establish overarching principles and requirements, while allowing ICBs space and discretion. This means avoiding being prescriptive, wherever possible. I am sure that noble Lords acknowledge that. Looking at the duties on ICBs that are relevant here, the first—in Clause 16—requires an ICB to arrange for the provision of the listed services it considers necessary to meet the needs of those for whom it is responsible. This includes aftercare which, in turn, includes rehabilitation. The ICB is also required to develop a joint forward plan, setting out how it will meet the health needs of its population—which should consider rehabilitation. ICBs are also under a duty to seek continuous improvement in the quality of care. That of course has to include rehabilitation. We hope that, without legislating for the production of a separate annual plan, ICBs will be required to provide, and improve provision of, community rehabilitation services.
I turn to Amendment 101B. I can assure noble Lords that the Government fully support the increased focus on mental health spending. I thank noble Lords who met with me earlier this week to discuss some of the issues around mental health and how we make sure that it gets the profile it deserves. We are trying to move towards parity between mental and physical health, and indeed all other types of health service. If I may, I will leave that there for now. If we have to continue the conversations about mental health, those who were not invited to this week’s meeting might like to drop me an email to let me know if they are interested in joining the meetings, and I will make sure that the Bill team invites them.
I am trying to get through this as quickly as possible. Turning to Amendment 110, I thank my noble friend Lady McIntosh of Pickering for the conversations we have had on inequalities, particularly in rural areas. A number of noble Lords alluded to this. I should also like to record my thanks to noble Lords in the Committee and in the other place who have campaigned so strongly on this issue. We have listened. The amendments already accepted in Clause 20 have directly addressed the need to consider victims of abuse, including victims of domestic and sexual abuse.
Clause 20 ensures that integrated care boards and their partner NHS trusts and foundation trusts set out a joint forward plan for any steps that the ICB proposes to take forward. As the noble Baroness, Lady Barker, said, we also have to make sure that this is not seen as just an NHS issue. We want to make sure that we work more widely with all agencies in the area to tackle these issues. For these reasons, we do not feel that a separate strategy is necessary in the Bill. Also, the accepted amendment is more comprehensive. It covers all forms of abuse. There are also duties on CCGs to consider the needs of victims of violence, including a joint strategic needs assessment. CCGs must respond to these, and this will be transferred to the ICBs.
Under the Government’s new Domestic Abuse Act, local healthcare systems will be required to contribute to domestic abuse local partnership boards. It is also worth noting that the Government are undertaking wider work to protect and support victims of domestic violence. Clearly, further action is needed beyond the NHS. In particular, the Police, Crime, Sentencing and Courts Bill will require action from across government, and we will ensure that this work is aligned as much as possible.
The proposed amendment would place a requirement on ICBs to have a domestic abuse and sexual violence lead. We agree with the principle, but we think we can do this effectively through existing legislation and guidance, as set out in the Government’s recent violence against women and girls strategy. My department will engage with ICBs and partnerships to make sure that we have appropriate guidance.
Beyond ICBs, there is a huge opportunity for ICPs to support improved services for victims of domestic abuse, sexual violence and other forms of harm through better partnerships. I hope that I have given noble Lords some assurance about this.
Lord Kamall (Con)
I thank all noble Lords who have spoken in this debate, both to the amendments and in making wider points about NICE. I take this opportunity to pay tribute to Gillian Leng, who recently stepped down as chief executive of NICE after a number of years.
I turn to Amendment 54. I am sure noble Lords will appreciate that we all want NHS patients to benefit from proven and cost-effective treatment; no one would want otherwise. That is why we see NICE as playing a vital role in supporting patient access to new treatments. I have heard the criticisms from previous Health Ministers, who were responsible for NICE. I sometimes feel in debates such as this, when I am with former Health Ministers, that it is like a special edition of “Doctor Who”, with previous regenerations. I hope we do not create a fracture in the space-time continuum. NICE recommends the vast majority of new medicines for use by the NHS. In fact, in 2020-21 100% of new medicines were recommended by NICE and many thousands of NHS patients have benefited from access to some of the most cost-effective treatments as the result of its work.
Another interesting thing is that when a decision is made and it is difficult to access medicines, patients will get frustrated—rightly so, given that they know it is available or maybe has been recommended. At the same time, on the global stage NICE has a well-earned reputation. It is one of my three priorities; I have mentioned technology, the second is life sciences and the third is international health diplomacy—how we use our position on health as part of UK soft power. One of the institutions people across the world look to and want to learn from is NICE. NICE is looking to be at the centre of a number of global networks on the issues where it has a reputation.
NHS England and clinical commissioning groups are already under a statutory obligation, under Regulations 7 and 8 of the snappily titled National Institute for Health and Care Excellence (Constitution and Functions) and the Health and Social Care Information Centre (Functions) Regulations 2013, to fund any treatment recommended by NICE through its technology appraisal or highly specialised technologies programmes, usually within three months of guidance being issued. As the noble Lord, Lord Stevens, mentioned, NICE also operates a separate medical technologies programme, which supports faster and more consistent adoption of medical devices, diagnostics and digital products.
I assure noble Lords that these funding requirements will apply to the ICBs once established. Therefore, we do not see the amendment as necessary at this stage for clinicians to prescribe NICE-recommended treatments for their patients. I also thank the noble Baroness, Lady Merron, for pointing out some of the unintended consequences and scope of such amendments. I remind your Lordships that, since April 2021, NHS England’s medtech funding mandate has supported faster access to some of these innovative technologies recommended by NICE.
I know that I am going to try to reassure noble Lords on a number of things but, on Amendment 74, I hope they note that the funding requirement on ICBs for NICE-recommended treatments goes even further than the requirement to promote what the noble Lords propose in the first part of the amendment. This will ensure that clinicians will continue to be able to prescribe NICE-recommended treatments for their patients.
The second part of the amendment would replicate existing arrangements that are in place to measure uptake and use of NICE-recommended medicines. Since 2013, NHS Digital has published an innovation scorecard that reports uptake of medicines that NICE has recommended in the last five years at a national and local level. Data on the uptake of NICE-recommended medical devices is not currently reported in the innovation scorecard as it has been more complicated to collect. However, I assure noble Lords that work is under way, by both NHS Digital and the Accelerated Access Collaborative, to address this gap. The Government consider that it is more appropriate and proportionate that this information is collected and published by a single national body using an agreed methodology, not by multiple organisations that will each have different ways of measuring and presenting the data.
On Amendment 97, I can tell noble Lords that NICE works closely with the MHRA—I thank the noble Lord, Lord Stevens, for pointing out the distinction —which issues marketing authorisations to ensure that licensing and appraisal timescales are aligned wherever possible. The NHS in England usually funds any treatment recommended through NICE’s programmes within three months of positive final guidance. We believe that three months is a realistic framework for providers to prepare for and introduce a new technology, and I hope I can assure the Committee that NICE and NHS England already work closely to facilitate the adoption of recommended technologies as quickly as possible.
As the noble Lord, Lord Stevens, again alluded to, there is a high level of transparency in the operation of local formularies. Formularies have their own public websites, which list the selected medicines and associated guidance, and area prescribing committees publish the minutes of meetings, which identify the medicines added or removed from formularies. We believe that there is therefore no need to publish an annual list.
Although healthcare providers are encouraged to use local formularies when prescribing, they are not restricted to them. The decision as to what to prescribe lies with the prescriber, who will act in the best interests of the patient. Indeed, some of the correspondence I get as a Minister for Health often refers to when people cannot get access to a medicine that is not recommended, but the clinician has the authority to suggest that that medicine can be available to the local area.
Lord Hunt of Kings Heath (Lab)
I am sure the Minister is right about how this system is meant to work, but there are far too many examples of clinicians seeking to prescribe medicines that have gone through the technology appraisal and then finding that CCGs have set up the various devices that the noble Baroness, Lady Brinton, mentioned to delay or stop it. Does he recognise that CCGs are engaged in a process of seeking to delay implementation for as long as possible? Will this be accepted under ICBs or will it be tackled?
Lord Kamall (Con)
I thank the noble Lord, Lord Hunt, and the noble Baroness, Lady Brinton, for raising this issue. I should be honest; I was not aware of the suggestion that CCGs often delay and whether that situation will be transferred to ICBs. I ask noble Lords whether I can look into that situation further to understand it more. I simply say that I was not under that impression.
Lord Warner (CB)
When the Minister is looking into that, will he also look at the issue of the usual suspects? The problem that the noble Lord, Lord Hunt, probably encountered—I certainly encountered it—was that many of these areas that are slow to implement NICE recommendations are the same areas where overall performance is pretty poor. There is an issue here about whether we can clearly identify the laggards and take action with them, rather than have a generalised look at the performance of particular areas.
Lord Kamall (Con)
Perhaps I may suggest, following the interventions of both noble Lords and their experience of being Health Ministers and of NICE, arranging a follow-up meeting with them to discuss this matter in more detail so that I can understand the situation more. As I am sure noble Lords will appreciate, I have been in this job for only four months and am still learning an awful lot. In fact, I am learning far more in this Committee than I have in my first four months. That shows that sometimes there is no substitute for learning on the job.
NICE has a suite of more than 300 guidelines and, as the noble Lord, Lord Stevens, said, more than about 1,900 medicines, spanning the whole of health and social care. It makes dozens of recommendations that can be complicated. We do not think it proportionate or feasible to require compliance with NICE guidelines but, given what I have just mentioned, I should like to consult previous Health Ministers with experience in this area and perhaps have further discussions to see what is relevant in the future.
I shall end with the CQC reviews of ICSs. We will look more broadly at the entire system of how the ICS areas are performing. A requirement for the CQC to specifically consider compliance with NICE guidelines as part of these reviews risks adding a considerable burden to this process. I can, however, assure the Committee that the Government expect the healthcare system to take NICE’s recommendations fully into account, subject to what noble Lords have told me about the performance of some CCGs. I am also aware that NICE works closely with system partners to support implementation where possible. It is probably best henceforth for me to have those conversations with the two noble Lords and any others with experience of this matter. There are more than two former Health Ministers in this House and we should have those conversations.
Let me see if I can answer some of the specific questions. As regards VPS—how do I put this in the most diplomatic way?—I have been asked to look at that issue. The industry has complained, for example, because we also have therapeutic tendering at the same time as expecting this. I am grateful to my right honourable friend the Secretary of State for asking me to look into this issue in further detail. I have asked what would happen, for example, when some of the life sciences companies ask whether it makes the UK less attractive in some ways. I am assured that it does not but I am looking into this issue as part of the life sciences aspect of my portfolio.
I think that I have covered all the questions but all that I ask at the moment is to let me have further conversations. That is probably best. In that spirit, I ask noble Lords to consider withdrawing or not moving their amendments.
Baroness McIntosh of Pickering (Con)
My Lords, I am grateful to all who have contributed to this debate and for the number of issues that have been raised.
At the outset, the noble Baroness, Lady Brinton, highlighted and a number of us focused on the hurdles—as the noble Baroness, Lady Merron, described them—to be overcome. However, there has been a lot of focus on the problems of the budgetary challenge. It would be incumbent on my noble friend the Minister to meet not just with the two noble Lords he highlighted but the drafters of the amendments: myself, the noble Baroness, Lady Finlay, the noble Lords, Lord Hunt and Lord Warner, and the noble Lord, Lord Patel, who sat so patiently through the whole of today’s proceedings and had to leave before this discussion was reached. As he had such success in the mental health meeting, I hope that we replicate that and take up a number of the issues raised here.
Lord Kamall (Con)
I thank all noble Lords who spoke in this debate for once again increasing my understanding of some of the challenges within the system, in addition to briefings I have had thus far. I thank the noble Lord, Lord Low, for his patience and his just-in-time mode of operation and, more than that, for his contribution to the debate today. We appreciate that people with learning disabilities experience a higher prevalence of visual impairment than the general population, and that this prevalence increases with the severity of the learning disability. Children with learning disabilities are, for example, 28 times more likely to have a serious sight problem, and over 40% require glasses.
NHS England continues to responsible for the contracting of the NHS sight testing service. This will eventually be transferred to ICBs. Sight tests are widely available across the country through our very dedicated primary ophthalmic services workforce. Those eligible for a free NHS sight test include children, those on income-related benefits and those at particular risk of eye disease. We expect that those with severe learning disabilities should meet the eligibility criteria in other ways, and for these reasons we do not believe that, at this moment, extending eligibility further is necessary. Where those with learning difficulties are unable to access NHS sight tests on the high street, hospital eye departments also provide routine eyecare services and ongoing care. Children are usually referred on to hospital eye services via visual assessments delivered by specialists in special schools. Others are referred by GPs, school nurses or high street practices. We have also seen the development of special pathways in some parts of the country that cater specifically for adults with learning disabilities and we want to make sure that, via the NHS England central team, we share best practice on a national level, so that all regional teams and all ICBs can benefit from learning from the local initiatives and pilots.
NHS England also tells me that it recognises that more needs to be done to ensure equality of access. That is why the NHS long-term plan committed to ensuring that children and young people with learning disabilities, autism or both in special residential schools have access to eyesight, hearing and dental checks. In order to fulfil this commitment, there is a proof of concept programme building on the work by SeeAbility in London, which was launched in 2021, to provide sight tests and dispense glasses on school premises. My honourable friend the Minister for Care is due to make a visit to one of the schemes.
I now turn to the amendments on primary care providers. I understand noble Lords’ interest and that it has been widely acknowledged that CCGs, for example, are dominated by trusts, particularly for acute care. I take the gentle encouragement of the noble Lord, Lord Scriven, to understand that more, and particularly to make sure that the voice of primary care providers is heard. That is also the Government’s ambition. We support the idea that primary care should be integral to ICB planning, which is why at the moment at least one member of the ICB will be nominated by primary care providers in the area.
We all know that primary care service providers are predominantly independent entities that hold contracts with the NHS, unlike NHS trusts and foundation trusts, which are largely statutory entities. If all types of primary care service providers were named in the Bill, it would mean that every provider in the area of the ICB would have a duty to contribute to the development of the joint forward plan. We do not believe it would be a feasible option for all primary care providers to contribute to the plans, but I acknowledge the points made by noble Lords about how we can raise the profile and contribution of primary care providers.
I turn briefly to Amendment 117. We agree that it is important to consult the relevant primary care local representative committees, which is why we already have a provision under new Section 14Z52 to introduce a duty to consult anyone the ICB and its partner trusts consider appropriate when preparing the plan. There should also be a summary of the views expressed by anyone consulted and an explanation of how those views were taken into account. We expect members of the primary care sector to be consulted and their views summarised in this way. We understand that NHS guidance will provide for that.
We also want to allow ICBs to focus on arranging safe, high-quality care, and making an additional, explicit requirement in the Bill does not align with our desire to reduce the bureaucratic burden on ICBs. I understand that this is all part of the general debate about whether, if we accepted every amendment about who should be on the ICB, it would be more inflexible and unwieldy. These are conversations we should have in the round about the priorities for ICBs, what should be mandated, what should be in guidance and what the ICB’s duties are expected to be. I hope that we will have those conversations in the round so that we can come to some sort of consensus across the Committee.
Lord Crisp (CB)
The amendment in my name specifically requires ICBs
“to work with the four primary care services … when preparing and revising their five year plans”.
It does not specifically ask for a seat on the ICB. That is a different request. I hope the Minister understand that and will respond to it.
Lord Kamall (Con)
I thank the noble Lord for that clarification and also for the advice he has given me in my first few months in this job. I do appreciate his experience. I will take the noble Lord’s point back and make sure it is clearly understood by the department when we consider how we respond to it. We believe in working with appointed ICBs, but we expect primary care to be consulted.
NHS England has also stressed the importance of ensuring that there are robust place-based structures in place. We hope that the ICB will exercise functions through place-based committees, where a wider group of members can take decisions, and we expect that primary care, including individuals from medical, dental, pharmaceutical and optical committees, will be particularly involved at the place-based level under the principle of subsidiarity. We will have some influence on the drafting of the forward plan of the ICB. Additionally, guidance that NHS England publishes for ICBs will include the commissioning of primary care at the place-based level.
Lord Warner (CB)
I have listened very carefully to what the Minister is saying in response to these amendments but, at the risk of being a historian again, is he aware that influence on key decision-making in the NHS is diminishing for primary care in general and GPs in particular? If we go back to 1990 and the GP fundholding changes to the NHS made by the noble and learned Lord, Lord Clarke of Nottingham, if we move through the Blair years of practice-based commissioning and go to the changes by the noble Lord, Lord Lansley, with clinical commissioning groups, these are three examples where GP influence on decision-making—strategic, local and tactical—is very considerable.
As far as I can see, that has been diminished in this Bill and they have been put back in their box without a lot of influence on key decision-making. They are poked down at the local place level. That is not right. What the Committee is saying needs to happen in the NHS. The Minister must go back to his department and talk through what is happening here, because it is diminishing the role of the GP in particular.
Lord Kamall (Con)
Anyone else want to come in? Look, I thank all noble Lords for their contributions and friendly advice, however put. Actually, I appreciate their passive-aggressive demeanour, in that way. I know it is all well-intentioned and that noble Lords speak from experience of previously tried schemes. The main point here is how we make sure that primary care is better represented and not dominated by acute trusts. I do not think I am going to have the answers to convince noble Lords completely or even partly tonight. Therefore, this clearly needs more discussion and for me to go back to my department, but also, once again, us to have another discussion on these issues between now and Report.
Baroness Cumberlege (Con)
My Lords, can I quickly intervene? Of course, it is absolutely right that one should learn from history. But looking to the future, I just wonder whether the Minister has heard about the movement there is by some foundation trusts to try to take over primary care. I just wonder what the implications of that would be for primary care, whether he and his officials have heard of that and whether they would like to discover what that would do to patient care.
Lord Kamall (Con)
I thank my noble friend; I was not aware of that. But at the end of the day, the result has to be the care that the patient receives. There will always be debates on how you can configure who should be involved at what level, but at the end of the day, it has to be the quality of the care the patient receives. To a wider point, we must also focus on prevention. We are seeing a lot of innovation in the primary sector; we are seeing GP services sometimes merge into primary care centres, taking on medical procedures that were previously considered the domain of hospitals. We have seen more blurring of the lines, and patients welcome that innovation in many cases.
What matters at the end of the day is the experience of the patient and making sure they have a decent service all the way through their life. It is one of the reasons we are talking about integration. In this country, care is literally from the cradle all the way to the grave, as we integrate social care more. That is why some of these discussions we have been having on social care and palliative care have been important. We are aware of that.
There are a couple more points I would like to make before I allow people to get in before the 5.30 pm deadline for getting a teacake. We support the idea that all areas should have an adequate number of GPs. That is why we launched the targeted enhanced recruitment scheme to attract doctors to train in locations that either have a history of under-recruitment or are currently finding it difficult recruiting. The scheme reflects the fact that trainees who are attracted to these areas usually stay on after training. Hundreds of doctors have trained in hard-to-recruit places since the scheme’s introduction, with 500 places available in 2021 and, we hope, 800 in 2022.
We also recognise that each community has different health needs, which emphasises the point noble Lords have made—that it is so important to hear the voice of primary care more loudly. We are taking steps to diversify the general practice workforce, such as by recruiting 26,000 more primary care staff. Making sure we have the correct mix of skills available in general practice is critical to delivering appropriate patient care across England.
One of the issues that we have to appreciate, though, is that as most GP practices are private partnerships and GPs are free to choose where they practise, a general medical practitioners equitable distribution board would have limited influence over the distribution of GPs across England, which is why we have to look at other ways to target those areas that are underserved. That is why it remains critical to continue encouraging trainees to train in hard-to-recruit areas and diversify the primary care workforce to support general practice in meeting the needs of its local community across England.
I have heard, once again, the mood of the Committee. That has become a familiar theme. I hope noble Lords will accept that I am open to further conversations in this area, particularly on how we hear the voices of all those in primary care, not just those of GPs but all of them, including those in ophthalmology, dental care and others. I hope that, in that spirit, noble Lords will feel it appropriate to withdraw or not move their amendments at this stage.
Lord Low of Dalston (CB)
My Lords, I thank the Minister very much for his response and all other noble Lords who have participated in the debate. I moved a rather modest little amendment but I am encouraged that it has stimulated such a rich discussion with so many knowledgeable contributions. If nothing else, my amendment has stimulated a discussion that has emphasised the importance of primary care. If we can take that message away, we will not have been wasting our time. I shall leave it there. I thank everyone for their contributions and the Minister for his response. I am sure he will have been enriched by the way the discussion has focused on the importance of primary care. It has been beneficial all round. I beg leave to withdraw the amendment.
Health and Care Bill
Lord Kamall ExcerptsTuesday 18th January 2022
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Lord Mackay of Clashfern (Con)
My Lords, I am sorry to intervene at this stage but I cannot let the opportunity pass to say, in my view, how important it is that children be particularly referred to and their circumstances be properly taken into account. We have very powerful legislation on the care of children, but the same is not true with health, and it is extremely important that that be kept in view. Apart from anything else, special staff and treatments are required for children, and I therefore strongly support this amendment. I am sorry that I was not able to do so at a more appropriate time, but I arrived a little later than I would have liked.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, I begin by thanking all the noble Lords who have tabled these amendments for debate, and noble Lords from across the House for their eloquent contributions. As the noble Baroness, Lady Wheeler, rightly said, it is important that, as the fifth-largest economy in the world, we treat all our citizens equally and give them the respect and access to services they deserve. As she also said, the strength of feeling across the House on the importance of this issue is clear, and this was amplified most eloquently by my noble and learned friend Lord Mackay of Clashfern.
With your Lordships’ agreement, I will look at some of these amendments from a different perspective. Each amendment touches on a different aspect of providing health and care for children. Before I turn to matters of detail, let me say that we believe that the Health and Care Bill’s proposals represent a huge opportunity to support and improve service planning and provision and ensure that they better meet the needs of infants, children and young people.
With your Lordships’ permission, I will start by addressing Amendment 20, which was spoken to so eloquently by the noble Baroness, Lady Meacher, the noble Lord, Lord Scriven, and my noble friend Lord Polak. It would clarify and prioritise how the Better Care Fund could be used to integrate services for children. I remind the Committee that the relevant legislation does not prevent the use of the Better Care Fund for the integration of children’s services. The disabled facilities grant within the BCF is already used to fund housing adaptation for individuals aged under 18 with disabilities. Some areas also extend the scope of their BCF-funded initiatives to include integrated services for children and young people.
However, we can go further. The Government believe that integrated care partnerships and integrated care boards represent a huge opportunity for partnership working. The Bill explicitly requires integrated care partnerships to consider whether needs could be met more effectively under Section 75 of the NHS Act 2006, which provides for arrangements to be made between NHS bodies and local authorities. The Government are also working on bespoke guidance on the measures that statutory bodies should take to ensure that they will deliver for babies, children and young people.
Turning to Amendment 51, I particularly welcomed the contribution of the noble Lord, Lord Hunt of Kings Heath, on vulnerable children. The amendment would require ICBs to share and collect information from partners when arranging for the provision of services for pregnant women, women who are breastfeeding and young children. I sympathise with the amendment, and in fact, I would go further: one of my three big priorities in my departmental portfolio, as the Minister for Technology, Innovation and Life Sciences, is to push digitalisation and sharing data. As all noble Lords have rightly said, that is not just for children’s services but right across the sector. We hear stories almost every day of something that could have been prevented, had data been shared more appropriately.
Baroness Thornton (Lab)
My Lords, I will speak to the amendments to Clause 14, which is a very important clause. There is absolutely no doubt about that, and the Minister can be in no doubt that that is exactly how we see it. It was touch and go whether we would have a clause stand part debate on this, and I am not sure that we were right not to do so, because this debate, particularly my noble friend Lord Hunt’s comments, has highlighted some serious problems.
My noble friend Lady Pitkeathley is quite right that the arrangements that we are seeking to put into statute, which have grown up over the last few years to allow areas to collaborate, were the right thing to do. In my area of the world, I have no doubt that it was important that the boroughs collaborated together, particularly in their relationship with and commissioning of services from the very big providers.
The question in Clause 14 is: what is going on with the arrangements that the Government are putting into statute? I am very pleased to follow the noble Baroness, Lady Walmsley, and to speak to Amendments 23 and 44 in my name. Amendment 23 addresses the vexed issue of boundaries for an ICB. In this Bill we are dealing with geography, whereas the 2012 Act dealt with GP lists. The area of an ICB is defined in terms of tier 1 local authorities.
Concerns have been expressed, because the NHS is often a bit clueless and sometimes very defensive about local government, its boundaries and its powers. Maybe the Minister will tell me I am wrong, but I suspect that one of the reasons why elected members have been precluded from the boards is that the NHS does not feel comfortable with the direct democratic accountability at that level. That is a great shame. I think it is wrong; accountability is extremely important.
How can we have an integrated service when social care is provided by local government, which is democratically accountable, and we want to integrate that with the NHS at a local level in an area to provide the best service that we can for that population and those patients? The almost offensive way of constructing a board that does not allow elected representatives is not acceptable.
My quite modest amendment seeks to change that situation for the future. There were exchanges in the Commons about this, and there have been meetings with disgruntled authorities that seem to have ended without agreement. We may need to take a step back and learn some of the lessons, perhaps from Scotland and Wales where more logical boundaries have been applied for their health boards.
We may learn a bit more about plans for integrated commissioning at this level when we get the promised but overdue White Paper on integration. It is possible that it will set up a third set of geographies, and who knows how that will line up? This seems to be the wrong way around. Our amendments at least elevate the need to consult with local authorities over boundaries to start off with. That is perhaps a pious hope, but we can agree that any future changes can be made only if the local authorities agree.
Amendment 159 arises out of lengthy discussions elsewhere. In the twin-striker model for ICS, we have the ICBs and the ICPs. We know almost nothing about ICPs; all that is said is that it is part of the “flexibility” and so should be valued. Referring back to my previous remarks, I just hope that local authorities will be genuinely involved in the ongoing discussions about ICPs, how they are set up and their governance. What we do know is that the ICPs will own the analysis of needs and the strategy that follows from that. What, therefore, is the role of local health and well-being boards?
There are echoes of 2012 here, as, during the consideration of the 2012 Bill, amendments were advanced on the same issue. In the 2012 version, it was the health and well-being boards that did the strategy and the CCGs that did the commissioning, at least of health. Nobody ever properly addressed how social care would be commissioned in any integrated way in a wider strategy. It was proposed in 2012 that the health and well-being boards had to approve the plans of the CCGs, and that was the glue that would hold the whole thing together. We know that that has not worked. It has sometimes worked on paper, but it is not the thing that has driven the work of the CCGs.
The answer so far for 2022 is that everyone will play nicely and it will all be resolved. I do not think that can possibly be the case when there is such a serious imbalance. Our Amendment 159 acknowledges that there just might be a dispute over whether some decision or plan of an ICB was genuinely aligned to the strategy that it was supposed to be following, so a process for resolution is needed.
I am not sure whether Amendment 44 sits easily in this group, but it is a matter on which assurance is needed. When foundation trusts came into being, they were rather bravely given the power to set their own terms and conditions for staff. One of them might have tried it, and it was not a great success. In general, despite whatever powers exist, almost every part of the NHS follows the Agenda for Change, the collective agreement that took 10 years to agree but which has stood the tests of time.
Now, as with CCGs, we have the power of ICBs to set their own terms and conditions. They are probably unlikely to do so, as it takes an enormous amount of work and the risks that it brings are probably not worth the effort. Without doubt, some staff are worried that they just might be the ones picked on for special treatment. The Minister will no doubt say that the ICBs need the flexibility, but surely, given the pandemic and everything else that faces the NHS, it would be much better to give staff certainty and confidence they will be treated properly.
We agree with the sentiments of Amendments 22 and 24, which try to ensure that agreement on ICB constitutions will be done promptly. We agree with the sentiments of Amendment 53, which echoes a previous amendment about the need to drive improvement. In my noble friend’s Amendment 45, he asks a legitimate question, which I think the Minister will need to answer.
Lord Kamall (Con)
Once again, I thank all noble Lords for bringing this debate before the Committee today. There have been a wide range of views on the establishment of the ICSs and on what is currently going on in the NHS.
I will start with Amendments 22 and 24 from the noble Baroness, Lady Walmsley, which were supported very strongly by the noble Lord, Lord Hunt of King’s Heath, and on the ICBs’ establishment. I am grateful to the noble Baroness, Lady Walmsley, for bringing the amendments, and I understand her concerns about ensuring that ICBs are established in a timely way. We agree. We have had an interesting debate here. A number of people have said that it is really important, given that ICSs have already been established, that you put it on a statutory footing, but we are also being asked how they dare to go ahead and do this, because the legislation is not there yet.
In recognition of the fact that ICSs have been set up in some areas and are being established, we are trying to get the right balance. That is why work is under way to prepare existing organisations, including CCGs, for the transition once the Bill comes into force.
The noble Lord, Lord Hunt of Kings Heath, rightly asked whether NHS England is pre-empting Parliament. He raises an important point but I assure him that the powers necessary for establishing each ICB and publishing any statutory guidance cannot be made until the Bill has been enacted and the relevant provisions commenced. However, to ensure that ICBs are ready to begin work, NHS England is producing a range of draft guidance, including a model constitution, so that system partners can start work on preparations—but this does not have the power of statutory guidance. The guidance and the model constitution are based on the proposed requirements—
Lord Hunt of Kings Heath (Lab)
My Lords, I accept that but how can NHS England give guidance to say that no local authority councillor can be on the ICB? That is not for NHS England to say, and how can it do it prior to the Bill going through Parliament? It is for Parliament to decide these matters, not a quango.
Lord Kamall (Con)
I apologise to the noble Lord because I was coming to answer that point, but maybe in too long-winded a way. One issue that was clearly raised, and very strongly felt in the contributions from more than one noble Lord, was about banning councillors from sitting on boards. There is nothing in the Bill that expressly bans this. We recognise the points raised in this debate and will raise them directly with NHS England. It is not statutory guidance.
Lord Hunt of Kings Heath (Lab)
I am sorry but this is a very important point. They have made the appointments and are not going to start again, which of course they should, because this is an absolutely hopeless position. No one from NHS England has ever had the guts to come here to explain why they are making this decision, and who will believe it? The chair of the ICB is appointed by NHS England. They know that NHS England does not want local authority councillors on the boards. Who are they going to take notice of? They are going to take notice of NHS England. The Minister has to tell NHS England to stop sending out this ludicrous guidance and telling the NHS that the new arrangements will start from 1 July. It cannot possibly do so if we go through what is contained in Clause 14.
I sympathise with the noble Baroness, Lady Walmsley, but the fact is that we must have a three-month consultation process on the proposals. This is the problem we are in: none of this stands up because Parliament is being treated with absolute contempt by NHS England.
Lord Kamall (Con)
I hear the strength of feeling from the noble Lord. I will take this back to the department and discuss it with my right honourable friend the Secretary of State. I hope noble Lords are reassured by that. I may not get the perfect answer, but I will try. I understand the strength of feeling on this issue; no one can fail to do so. Let us put it this way: it was not subtle but direct. It is really important that, as the Minister here, I take this back and reflect the feeling of the House in my conversations with the Secretary of State, and his subsequent conversations with NHS England. I will take that back and look at the consultation process and the CCGs consulting all the relevant local authorities.
I understand the point made strongly by the noble Lord, Lord Scriven, that we have to be careful about prescribing in a top-down way how to work locally. I have always been a strong believer in localism and making sure that powers go down to a local level rather than being taken away. Let me again assure the noble Lords, Lord Scriven and Lord Hunt, and other noble Lords that I will take this back, because clearly there is concern. I had not appreciated the strength of that concern. At Second Reading the noble Lords, Lord Stevens and Lord Adebowale, said, “We are already doing this. It makes sense to go ahead and put it on a statutory footing”. But I have now heard the other side of the argument, and it suggests that I should go back and have a stronger conversation with, in effect, my boss—my right honourable friend the Secretary of State. I hope that gives some reassurance.
On Amendment 44, in the name of the noble Baroness, Lady Thornton, I assure your Lordships that we intend to provide as much stability of employment as possible while ICBs develop their new roles and functions. I hope that noble Lords are aware that there is already an existing commitment that staff transferring into ICBs will transfer across on their current terms and conditions in line with the NHS Terms and Conditions of Service Handbook. NHS pension rights will also be preserved. As a result, staff transferring into ICBs will not see any change to their existing conditions.
However, the Government are concerned about forcing ICBs to adopt conditions and practices that the ICBs do not believe work best for new staff. We believe that it is important to give ICBs flexibilities relating to staff terms and conditions; they are there for a reason. For example, when it is difficult to recruit and staff are going elsewhere, this would include allowing ICBs the flexibility to diverge from collectively agreed pay scales in order to attract staff from elsewhere or with unusual or valuable skills, or to reflect local circumstances. It will also give ICBs the flexibility to support joint working and bring in staff currently working in local authorities or foundation trusts, for example, supporting integration and the joint working approach that the Bill hopes to encourage.
I also note that ICBs having the independence and flexibility to choose whether to adopt collectively agreed pay conditions and pensions for new staff is not unique, as the noble Baroness, Lady Thornton, acknowledged. NHS foundation trusts, which are already free to exercise their discretion in adopting such conditions, overwhelmingly choose to honour and apply such terms to their staff unless there are good reasons to diverge.
On the proposals for very senior managers, existing procedures are in place to ensure that the most senior staff within the NHS are appointed with fair and equitable salaries. Proposals to pay very senior staff more than £150,000 must be similar to those for other equivalent roles or be subject to ministerial oversight.
The Government are in the process of finalising the procedures that will apply for ICBs. The specifics may differ but the effect and intention will be the same: to afford ICBs agency in setting pay at competitive rates so that we can continue to attract the most senior and experienced leaders, while putting adequate checks and balances in place to ensure appropriate use of taxpayers’ money and keep senior public sector salaries at an appropriate level. The Government believe that this amendment, which also asks for ICPs to approve annual salaries in excess of £161,000, is unnecessary. I am happy to have further conversations.
I now turn to the amendments on how the ICBs will function once established, starting with that in the name of the noble Lord, Lord Davies of Brixton, which relates to the question of treatment outside the ICB area. The new clause in question provides that NHS England must publish rules for determining the people for whom integrated care boards have responsibility. Importantly, this clause ensures that everyone in England is covered by an ICB.
We intend that the rules set by NHS England should replicate the current system for CCGs as closely as possible. This means that the ICB will be responsible for everyone who is provided with NHS primary medical services in the area—for example, anyone registered with a GP. It will also be responsible for those who are usually a resident in England and live in their area if they are not provided with NHS primary medical services in the area of another ICB.
It is important to remember that no one will be denied healthcare on the basis of where they live. We want to ensure that, under the new model, bodies that arrange NHS services—decision-making bodies—are required to protect, promote and facilitate the right of patients to make choices with respect to services or treatment. This means allowing patients to choose to be treated outside their ICB area. Choice is a long-standing right in the NHS and has been working well for some time. The Bill continues to protect and promote it. However, I am afraid that we have concerns about this amendment, as it places a requirement on providers rather than commissioners. It would not be reasonable to expect providers to provide services regardless of whether they were funded by an ICB to do so, and it is important that ICBs should be able to make decisions about with whom they contract and where they prioritise their resources.
On Amendment 53, in the name of the noble Baroness, Lady Walmsley, I hope I can assure the Committee that the Government are committed to ensuring continuous improvement in the quality of services provided to the public. As your Lordships will be aware, there is already a wider range of duties in relation to the continuous improvement of services. Clause 20 imposes on ICBs a duty as to the improvement in quality of services. Furthermore, the ICB must set out how it proposes to discharge that duty at the start of each year in its joint forward plan and explain how it discharged the duty at the end of each year in its annual report. I hope this goes some way to meeting the noble Baroness’s concerns.
Clause 16, which this amendment seeks to alter, recreates for ICBs the commissioning duties and powers currently conferred on CCGs in the NHS Act 2006. It ensures that ICBs have a legal duty to commission healthcare services for their population groups. It also recreates Section 3A of the 2006 Act, which provides the commissioning body with an additional power to commission supplementary healthcare services in addition to the services they are already required to commission. This power enables ICBs to arrange for the provision of discretionary services that may be appropriate to secure improvements in the health of the people for whom it is responsible—or improvements in the prevention, diagnosis and treatment of illness in those persons—so it is important that the clause remains as it is currently drafted.
The Bill will ensure that the existing local commissioning duties conferred by the NHS Act 2006 will transfer over to ICBs. This is set out in proposed new Section 3, which is also to be inserted by Clause 16 on page 13. I hope that the noble Baroness, Lady Walmsley, will be reassured that it rightly uses “must” rather than “may” when referring to the arranging of services. I can therefore assure the Committee that ICBs will continue to commission the services previously delivered by CCGs. That will ensure that service delivery for patients is not impacted.
Amendment 159 in the name of the noble Baroness, Lady Wheeler, touches on the important relationship between ICBs and ICPs. I remember that, when we had an earlier consultation, the Bill team had a diagram about how ICBs and ICPs would work together; It might be helpful if I ask for that to be sent to noble Lords so that all of us can have more informed conversations about the intentions of the amendments and the issues that noble Lords want to raise. I will make sure that that is done.
This amendment would add a requirement for the Secretary of State to make regulations to establish a dispute resolution procedure if an ICB fails to have regard to an assessment of needs, an integrated care strategy or a joint local health and well-being strategy in respect of the ICB’s area. The Bill was introduced to ensure that existing collaboration and partnership, working across the NHS, local authorities and other partners, is built on and strengthened; I recognise the concerns raised by the noble Lord, Lord Scriven.
We intend for these assessments and strategies to be a central part of the decision-making process of ICBs and local authorities. That is why we are extending an existing duty on ICBs and local authorities to have regard to relevant local assessments and strategies. The ICB and local authorities will be directly involved in the production of these strategies and assessments through their involvement with both the ICP and health and well-being boards at place—that is, at a more geographical level. As a result, they have a clear interest in the smooth working of the ICP.
More widely, there are several mechanisms to ensure that ICBs and local authorities will have regard and not intentionally disregard the assessments and strategies being developed at place in their areas. First, health and well-being boards have the right to be consulted.
Lord Lansley (Con)
I just had a flashback moment. I remember being asked, or volunteering, a decade ago to produce a chart of the various organisations under the 2012 Act. I think that the King’s Fund did a rather good job of doing it back then; perhaps it might do it again, although it will find that it is more complicated this time.
The noble Baroness, Lady Thornton, asked a perfectly reasonable question that might simplify the process. If health and well-being boards do the same job as integrated care partnerships, in large measure, why cannot integrated care partnerships and health and well-being boards be the same organisation?
Lord Kamall (Con)
I remember hearing in an earlier discussion on the Bill that nothing prevents that where they coincide. My noble friend and I have had conversations about health and well-being boards and where they sit. Given that, and given my noble friend’s experience of this issue, perhaps we could have a further conversation on this matter before the next stage to clarify some of the issues that he rightly raised in previous conversations.
At this moment, we believe there are mechanisms to ensure that ICBs and local authorities have regard to and do not disregard the assessments of the health and well-being boards. As my noble friend points out, that is for further conversations.
As noble Lords know, NHS England must also consult each health and well-being board on how the ICB has implemented its joint health and well-being strategies, so there is another level of reassurance there. The ICB must also include in its annual report a review of the steps it has taken to implement any relevant joint local health and well-being strategy and must consult the health and well-being board when undertaking that review. NHS England has formal powers of intervention if an ICB is not complying with its duty in any regard. That is sufficient to ensure that ICBs will have regard to both ICP and health and well-being board plans, but I understand the concerns raised.
Health and Care Bill
Lord Kamall Excerpts(2 years, 7 months ago)
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Lord Kamall
That the instruction of 5 January be revoked and that it be an instruction to the Committee of the Whole House to which the Health and Care Bill has been committed that they consider the bill in the following order:
Clause 1, Schedule 1, Clauses 2 and 3, Clauses 5 to 14, Schedule 2, Clauses 15 to 17, Schedule 3, Clauses 18 to 27, Schedule 4, Clause 28, Schedule 5, Clauses 29 to 40, Schedule 6, Clauses 41 to 43, Schedule 7, Clauses 44 to 61, Schedule 8, Clauses 62 and 63, Schedule 9 ,Clauses 64 to 68, Schedule 10, Clause 69, Schedule 11, Clauses 70 to 74, Schedule 12, Clauses 75 to 80, Clause 4, Clauses 135 to 144, Schedule 17, Clauses 145 to 148, Clause 95, Schedule 13, Clauses 96 to 109, Schedule 14, Clauses 110 to 120, Schedule 15, Clause 121, Clauses 81 to 94, Clauses 122 to 134, Schedule 16, Clauses 149 to 154, Title.
Health and Care Bill
Lord Kamall ExcerptsTuesday 18th January 2022
(2 years, 7 months ago)
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Baroness Merron (Lab)
My Lords, I think it is fair to say that the debate today across your Lordships’ House has shown that it is impossible to understand how specialist palliative care can be regarded in any logical, practical or humane sense as something so different. I am sure that the Minister will do his very best to address that in his consideration of these important amendments.
I am grateful to noble Lords for making this debate possible by bringing forward these amendments and making sensitive, informed and often personal contributions to underline the need to ensure that specialist palliative care features in the Bill. I am particularly grateful to the noble Baroness, Lady Finlay, for setting out the fact that if we are to say that the NHS is cradle-to-grave, that must absolutely shape how we approach such services. The noble Baroness and others, including the right reverend Prelate, talked about inequality and the fact that, when we speak of specialist palliative care, inequalities are not just in the course of someone’s life but actually to the very moment they leave this world. That really had an impact on me, because that surely is an unfairness too far for us to just stand by.
Taking action could not be more pressing a need. We know that the UK’s population is ageing rapidly. The Office for National Statistics predicts that, in 20 years’ time, there will be twice as many people over the age of 85, while Marie Curie’s analysis for Cardiff University has concluded that the number of people needing palliative care will rise by 42% by 2040. This is a challenge to our society which will not go away. As the noble Lord, Lord Patel, said, we should be able to live our lives in anticipation of a good death. The right reverend Prelate spoke of the difference of witnessing a good death, as opposed to a death that is less than what it should be.
It is important to say that, even before the pandemic, experts at the Royal College of Physicians, the Care Quality Commission, the health service ombudsman and Compassion in Dying were all sounding the alarm on how those approaching the end of their life, and their loved ones, did not, in so many circumstances, feel supported to make the decisions that faced them and that it was impossible to turn away from. They did not know what choices were available, and, sadly, were not given an honest prognosis.
The amendments in this group offer dignity to the greatly increasing numbers who will need this care, and would bring in moral and well-evidenced measures essential to providing the tailored care that is needed in the final stages of one’s life. This includes sharing information about a person’s care across the different professionals and organisations involved in that care, and providing patients and their loved ones with specialist advice, 24 hours a day, every day of the week—which expert practitioners, including those at Cicely Saunders International, have been crying out for.
My noble friends Lord Hunt and Lord Howarth, the noble Baroness, Lady Finlay, the noble Lord, Lord Patel, and others underlined the work, role and contribution of the hospice movement, and also spoke about their incredulity at the reliance on charitable funding. Who in this Committee can be surprised at that feeling? I hope the Minister will be able to speak to that absolutely crucial point because, even before the pandemic, many hospices were suffering from poor decisions from clinical commissioning groups, poor practice, and a lack of support and recognition of the vital role that they play. That impacts on the individuals who so sorely need their services.
Marie Curie reported that 76% of carers who lost a loved one during the pandemic felt that they did not get the appropriate care that they needed. This is an opportunity to fix the problem. Every day, pandemic or none, the quality and personalisation of specialist palliative care will dictate how dignified and comfortable —or not—the end of a life will be, and how much of a burden will be borne by the carers and loved ones: whether, as the noble Baroness, Lady Hollins, reminded us, those left behind are adults or children. These amendments seek to get it right, and the feeling of this Committee could not be clearer. I look forward to the Minister’s response.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, as we reach the closing minutes of today’s debate and reflect on the wonderful contributions from across the Committee, perhaps it is fitting that we also talk about the final chapter of life, as the right reverend Prelate the Bishop of Carlisle said.
I thank all noble Lords who spoke very movingly today, particularly the noble Baronesses, Lady Meacher, Lady Hollins and Lady Walmsley, the noble Lord, Lord Patel, and my noble friends Lady Hodgson and Lady Fraser, who spoke about their own experiences. I also thank the noble Baroness, Lady Merron, for pointing out the 42% figure, which is very important to recognise. I thank the noble Baroness, Lady Finlay, for the engagement we had prior to this debate and for her helpful engagement with our officials and the Bill team. I hope that will continue.
What is interesting about this is that when I was younger, we as a society found it very difficult to talk about death. I was once told by my parents that the British find it very difficult to talk about death, except in faith groups. It is interesting that, over time, as we have become an ageing society, we are talking, as a matter of fact, about death. We talk about our wills, financial planning, and planning for care at the end of our life. It is appropriate that we recognise this. The fact is that, nowadays, when we look at the hospice movement, we do not think of it as a quaint little service or a charity; we think that it provides an essential service to help someone at the end of their life, and we recognise the difference between palliative care and end-of-life care.
I hope that I can reassure the Committee that the Government are committed to ensuring that people of all ages have the opportunity to benefit from high-quality, personalised palliative and end-of-life care, if and when they need it. I also pay tribute to the noble Lords, Lord Howarth and Lord Scriven, for their contributions. The noble Lord, Lord Howarth, talked about the role that the arts play in helping those at the end of their life, which he has talked about in a number of discussions we have had on this issue. Like the noble Lord, Lord Scriven, he made the point that while you want to see the state do more, you do not want to push or squeeze out the hospice movement, as we need the right balance.
Eating Disorders
Lord Kamall Excerpts(2 years, 7 months ago)
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Baroness Bull (CB)
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare my interest as a vice-chair of the APPG on Eating Disorders.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
We are working to ensure that people of all ages with an eating disorder, or who are at risk of developing one, have access to the right support in the right place and at the right time. We are delivering on the ambitious transformation plans outlined in the NHS Long Term Plan and children and young people’s mental health Green Paper and provided additional investment this year to address pressures arising during the pandemic.
Baroness Bull (CB)
Does the Minister agree that improving support for eating disorders depends on improving understanding of their causes, prevention and treatment? Eating disorders account for 9% of mental health conditions in the UK but receive only 1% of mental health research funding. This leads not only to major evidence gaps but to fewer researchers, less research and the ongoing stigmatisation of the illnesses as a niche concern. Will the Minister’s department consider working with the NIHR on a long-term eating disorder research strategy to break this underfunding cycle, as it has for other health challenges, so that more effective support can be targeted on their prevention and treatment?
Lord Kamall (Con)
First, I pay tribute to the noble Baroness for all the work she has done in this area, making sure that we are all aware of this issue and keeping it on the agenda. In answer to her specific question, the department has invested nearly £110 million in mental health research, including research on eating disorders through the NIHR, as she mentioned. This includes the Eating Disorders Genetics Initiative and a systemic review led by the Evidence for Policy and Practice Information and Co-ordinating Centre. UKRI has announced funding for a £3.8 million study on eating disorders to inform prevention and early prevention in young people. This research is being led by King’s College London and the University of Edinburgh.
Baroness Parminter (LD)
My Lords, the latest NHS data shows a continuing increase in the number of people being hospitalised for eating disorders, mainly in the 18 to 39 age group, yet there is still no adult waiting time standard for people with eating disorders. This is despite knowing that access to quality community care can reduce the number of hospitalisations and unnecessary deaths. When are this Government going to introduce an adult waiting time standard for people accessing treatment for serious eating disorders?
Lord Kamall (Con)
As noble Lords can imagine, because of the pandemic, sadly, waiting times have gone up, but we are making sure that we are doing as much as we can to address that. Longer term, we are focusing on prevention, not only cure. We are also making sure that we are able to understand the various forms of eating disorder better. It is very simple to lump them all together, but there are different elements and you can distinguish between them. Then we will, I hope, be able to tackle that as much as possible.
Baroness Janke (LD)
My Lords, given that many young people with eating disorders find it very difficult to seek help and identify themselves, what specific additional resources have been provided for schools to help and support young people with this actually life- threatening illness?
Lord Kamall (Con)
The noble Baroness raises a very important point about how we identify children and young people who are suffering from these disorders or may be a few steps away from it. We know that there are programmes from the Department for Education and our department to tackle mental health issues in schools, identifying pupils and encouraging them to come forward, to talk to a counsellor in the school, and making sure that there is signposting in the right place to ensure that we can tackle their issues.
Baroness McIntosh of Hudnall (Lab)
My Lords, the Minister mentioned that eating disorders do not always present in the same way. He will be aware that some fluctuate, moving from chronic to acute over a period and back again. When people seek treatment for eating disorders, at the moment those who can afford it are not even able to access treatment in the private sector. If they were able to, however, would they then be able to access NHS treatments at a later date, for example, should they not be able to afford to continue with private treatment?
Lord Kamall (Con)
The noble Baroness raises a really important point. It is an issue that was raised over the weekend, in an individual case. I know that we are always advised as Ministers not to get involved in individual clinical decisions, but in this this case a child had not yet got a bed and the parents wanted to take them out for private treatment until a bed became available. They were told that if they went to use the private sector they would be put at the back of the list. I am trying to get more details on this but it seems a lack of common sense. I want to understand why it is happening, but I have not had an answer yet.
Baroness Manzoor (Con)
My Lords, what are the Government doing with regard to working with industry, particularly the fashion industry? At the moment, there is great emphasis on size-zero models, which cannot really be helpful when linking it to the question that the noble Baroness asked previously. It is not a good image, or setting the right image for people—that is, for boys and girls.
Lord Kamall (Con)
The issue of poor body image that my noble friend raises is very important. The Government are addressing known risk factors through both universal and targeted interventions. At the top level, that means looking at the Better Health and Every Mind Matters content, which focuses on support for mental health and well-being. Poor body image and low self-esteem are topics addressed there. It is also about looking at what pupils expect and at the prevention concordat for better mental health programmes, as well as working as part of the anti-obesity strategy to make sure that we get the right balance. Sometimes when you focus on information on packets, for example, it can have unintended consequences for those with eating disorders. Every time we look at labelling, we have to make sure that we have addressed those unintended consequences on people with eating disorders, so that they do not react negatively to it and perhaps indulge in behaviour that we do not want to see them indulging in.
Baroness Merron (Lab)
My Lords, the Royal College of Psychiatrists has warned that the hidden epidemic of eating disorders has surged during the pandemic, with many community services overstretched and unable to treat the number of people who need help. Will the Minister publish data about the number of people waiting for eating disorder treatment better to understand and meet the scale of the demand? Will he deliver a workforce plan to tackle staff shortages in eating disorder services so that it may be possible to treat everyone who desperately needs this help?
Lord Kamall (Con)
I thank the noble Baroness for raising the issue of the backlog as a result of the pandemic. We have seen eating disorder services continue to face increasing demand, especially as a result of lockdown and its mental health impact. The number of young people entering urgent treatment has increased by 73% between 2019-20 and 2021, and the numbers waiting for treatment have also increased from 561 to 2,083. To make sure that we meet the standard and get those waiting times down, we have invested an extra £79 million this financial year, and we are working with systems across the country to see how we can make sure that we address young people and adults who need access to this treatment.
Lord McColl of Dulwich (Con)
My Lords, does the Minister agree that it is a very serious condition that 71% of the British people over the age of 30 are obese or overweight? The problem with this is that it interferes with the immune system, which makes them much more vulnerable to all kinds of diseases, not least infections. If we want to deal with the next pandemic now, we have to get people to reduce their weight so that obesity does not interfere with their immune systems.
Lord Kamall (Con)
The question from my noble friend highlights the difficulty of dealing with such a sensitive area. You have to be very careful how you address the issue of obesity. For example, it is quite right that we want to get the rates of obesity down, because it does lead to a number of other conditions that we have discussed many times here. One thing that you have to look at, however, is the unintended consequence of any laws. One possible unintended consequence is that some of the measures to tackle obesity, such as looking at food labelling, might affect people who have eating disorders. Every time we look at the obesity strategy, therefore, we make sure that we consult charities that look after people with eating disorders to ensure that we have the right balance. We will not always get it perfectly right, but we will try our best.
Baroness Wheatcroft (CB)
My Lords, anorexia nervosa is one of the most pervasive of mental health disorders. It can sometimes be successfully treated only in specialist in-patient units. What plans are there to grow the number of specialist in-patient beds? In 2019, the Government promised that people would not be sent to out-of-area beds after 2021, but I do not believe that that is currently the case.
Lord Kamall (Con)
I am sure that the noble Baroness will appreciate that we had a strategy to tackle obesity, but some of it has been knocked back a bit by Covid and having to tackle the backlog. However, we are looking at ways to ensure that the strategy gets back on track as we emerge from lockdown and there is, we hope, less pressure on the NHS.
Covid-19: Vaccinations for School Pupils
Lord Kamall Excerpts(2 years, 7 months ago)
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Lord Watson of Invergowrie
To ask Her Majesty’s Government what progress they have made on delivering vaccinations for Covid-19 to school pupils since the Christmas holidays.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
The Covid-19 vaccination programme continues rapidly, with nearly 52% of 12 to 15 year-olds vaccinated as of 15 January 2022. We vaccinated over 372,000 12 to 15 year-olds in England between 17 December 2021 and 15 January 2022—that is nearly 400,000 in a month, which included the Christmas break. Vaccinations for children aged 12 to 15 can be booked in out-of-school settings through the national booking service, alongside the ongoing school-based offer. We currently have 314 sites offering appointments that can be booked via the national booking service.
Lord Watson of Invergowrie (Lab)
I thank the Minister for that very full response but the figures he has quoted are at odds with those issued just last week by the Department for Education on the vaccination of 12 to 17 year-olds. The number of pupils absent from school with a confirmed contraction of coronavirus was up by nearly 50% over the figure for December. It cannot be a coincidence that only 40% of 12 to 17 year- olds, in the DfE’s own figures, have been vaccinated. This shows, whether it is the Department of Health or the Department for Education, that the Government have really failed to get a grip on the measures necessary to keep children learning—whether it is the supply of testing kits or classroom ventilation. I ask the Minister: what urgent action will the Government take to increase the level of vaccination among school pupils?
Lord Kamall (Con)
I think the noble Lord is being slightly unfair in the sentiment of his question. We have to remember that, when it came to vaccinating children, there was a huge debate around, first, whether it was ethical to do so and, secondly, whether the vaccines used for adults were effective in children. We could not really do any of that until we had sufficient data. It would have been irresponsible just to have pushed ahead without the data. Once we got the data, we started the vaccination programme for 16 and 17 year-olds and then for 12 to 15 year-olds, and we are pushing through as much as possible. Parents can book for their children on a national booking service. We expect many more parents to do so.
Earl Howe (Con)
My Lords, the noble Baroness, Lady Brinton, has indicated her wish to speak virtually, and I think this is a convenient point for me to call her.
Baroness Brinton (LD) [V]
My Lords, many parents are still saying that they have not heard when their clinically extremely vulnerable five to 11 year-olds will get their vaccinations, despite the JCVI saying that they should. Last week’s update to the GP green book now includes severely CEV children as eligible for the third primary dose, which is progress. However, there is no news for CEV young children not classed as severe, so can the Minister please say what he will do to ensure that GPs will call all these children for their vaccinations as soon as possible?
Lord Kamall (Con)
As the noble Baroness says, the JCVI advised on 22 December that children aged five to 11 in a clinical risk group, or who are a household contact of someone who is immunosuppressed, should be vaccinated. GPs and hospital consultants are now urgently identifying the children eligible, and we expect rollout to have started by the end of this month, with children and parents starting to be called up for appointments by the NHS locally. The message here is that there is no need for parents to contact the NHS; the NHS will make contact with the parents or carers of those eligible. Just to further reassure parents, we will be using a paediatric Pfizer vaccine authorised by the MHRA for use in this age group.
Baroness Stuart of Edgbaston (CB)
My Lords, given that it is safest to administer the vaccinations in a school setting, and unlikely that this round of vaccinations is the last one, has the Minister given any consideration to expanding the specialist community health nurses, commonly known as school nurses? Their numbers have been decreasing over the last 10 years. They could play a role in the future administration of vaccines in school settings.
Lord Kamall (Con)
I recall well being sent to the school nurse—sometimes we have fond memories, and sometimes less fond memories, of being sent to the school nurse. The noble Baroness makes a really important point. I will make inquiries and get back to her.
Lord Udny-Lister (Con)
My Lords, can my noble friend the Minister update the House on what actions the Government have taken to protect school pupils and teaching staff from the reckless behaviour and damaging misinformation being propagated by anti-vax protesters?
Lord Kamall (Con)
My noble friend raises a very important point, which I know a number of other noble Lords have also raised. In a free society, we have to get the balance right between freedom of speech and ensuring that people have a right to say even those things with which we may disagree fundamentally, while ensuring that misinformation is not spread. The department has now provided information and guidance to schools on how to handle any misinformation, and who to contact if there are protests which step beyond the line of acceptability and contravene the law. The police now have comprehensive power to deal with the activities, especially those which spread hate or deliberately raise tensions through violence or public disorder. I am sure many people will be aware of the attacks on vaccination centres in Truro in October and in north Wales and at the Bromley Civic Centre earlier this month. That was going way too far on freedom of speech, and we want to make sure that we deal with the people who take part in these acts.
Lord Boateng (Lab)
My Lords, does the Minister agree with the World Health Organization that the vaccination of children in the wealthy world should not be at the expense of the vaccination of health workers and vulnerable adults in the developing world? If so, what more can the UK do to ensure that the developing world has access to vaccines and the capacity to manufacture them?
Lord Kamall (Con)
I once again pay tribute to the noble Lord, Lord Boateng, for raising this issue and for the number of times he has raised similar issues about the developing world over the years. Since I became a junior Minister of Health, I have been involved in many meetings with the G7 and G20, and in bilateral meetings with other Health Ministers. This item always comes up on the agenda and is something that the British Government have pushed. We are leading donors to the international COVAX programme and are working across the world, with other countries and with manufacturers, to make sure that we get the vaccines to those who really need them. While we here in this country complain about third and fourth doses, for example, there are still many people in many countries who have not even had their first vaccine. In the longer term, that is not right for anyone.
Lord Addington (LD)
My Lords, would the Minister give us a little bit more of an insight into the general policy for vaccination of children at schools? Although we have problems here, we have a history of people resisting and giving bad information. Is there a coherent strategy that will come out for school-age vaccination that we can refer back to as a model for the future?
Lord Kamall (Con)
One of the important things we all have to learn, from what we have been through and are still going through, are lessons for the future—not only for future Covid vaccines there may need to be but for all vaccination programmes and, perhaps, future pandemics. One of the really important things about this is making sure we get the right information. We are working with schools to make sure teachers and parents have the right information and also know the risks. Many people will know that, over the weekend, 16 and 17-year-olds were called for their booster if there was a sufficient space since their last dose, and we are now looking at how we vaccinate 12 to 15 year- olds. We are looking in more detail at whether it is safe for five to 11-year-olds, but at the moment the advice is not there.
Lord Blackwell (Con)
My Lords, as my noble friend has said, this country is behind some other countries in rolling out vaccinations to five to 11 year-olds. He will also be aware that the extent of Covid in that age group is a major source of infection for parents and, therefore, society as a whole. Have the Government taken account, or will they take account, of the wider social and economic benefits of vaccinating that age group and weigh them up alongside the medical evidence?
Lord Kamall (Con)
The JCVI will continue to look at the new data as it emerges and recommend whether we boost 12 to 15 year-olds. But when we look at the vaccination strategy, we look not only at the tackling of the specific coronavirus or variant but also at the wider implications. For example, many noble Lords have spoken eloquently about the unintended consequences for mental health issues of lockdown. Beyond that, we have to look at societal and social issues and the way people, businesses, charities, et cetera are affected in doing their work. We always make sure we take a balanced approach, looking at the science, the wider medical issues and the unintended consequences.
Viscount Stansgate (Lab)
My Lords, the House is united on the importance of children’s education continuing, but it is the lack of vaccinations not just among children but among the teaching workforce that may interrupt their education. Do the Government have any estimate of the proportion of the teaching workforce that has not yet been vaccinated or is off work for Covid-related reasons?
Lord Kamall (Con)
The noble Viscount raises an important point. As we are expecting our children to be vaccinated, it is important that teachers are also vaccinated. It is one of the reasons we are looking at VCOD—vaccination as a condition of deployment—in the health service. In answer to the noble Viscount’s specific question, I am afraid I do not have the information with me, but I will try to speak to the Department for Education and write to him.
Ambulance Queues: Health Outcomes
Lord Kamall Excerpts(2 years, 7 months ago)
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Lord Scriven (LD)
My Lords, I beg leave to ask the Question standing in my name and draw the House’s attention to my interests in the register.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
We recognise that waiting times can impact outcomes, so patients in queues remain under constant clinical supervision and care and are prioritised according to need. Delays tend to be concentrated in a small number of hospitals, with 29 acute trusts across 35 sites responsible for 57% of the 60-minute handover delays nationally so far this winter. These trusts are receiving intensive support to improve, including through placement of hospital ambulance liaison officers and the safe cohorting of patients.
Lord Scriven (LD)
My Lords, half a million acute bed days each year are lost due to delays in discharge directly attributable to non-availability of social care, which leads to bottlenecks in emergency departments and ambulances being unable to unload patients. Does the Minister agree that the split of money raised by the health and social care levy over the next three years therefore needs to be more generous to social care, so people stop having to wait up to seven hours in the back of ambulances?
Lord Kamall (Con)
As the noble Lord will be aware, when the charge was initially announced it was intended to help with social care, which has been neglected for a number of years under successive Governments. Given the pressures of the backlog, the NHS has decided to divert some of those resources to help tackle it. We have invested money in social care in the short-term winter plan, and in the longer term we have announced extra investment to ensure that social care is an attractive career and offers real prospects.
Baroness Finlay of Llandaff (CB)
My Lords, does the Minister recognise that his response, saying that this involves a small number of trusts, does not address the data from NHS England for the seven days to January 2, which showed that 23% of all arrivals by ambulance had delays of half an hour or more—that is over 19,000—and that some 10% of patients waited more than an hour to be handed over? This meant that those ambulances were also unable to deliver first aid and first implementation of treatment to people who were waiting. Therefore, when patients arrived at emergency departments, they were even sicker than necessary, and it may be that some lives were lost.
Lord Kamall (Con)
The noble Baroness makes an important point. In anticipation of the winter crisis, last year we published the Urgent and Emergency Care Recovery 10 Point Action Plan to look at the direct pressures on not only A&E but the call centres, and at some of the wider system issues. For example, when people cannot get access to their doctor, they tend to go to A&E. At other times, they cannot get the replacement medication they want and have to call an ambulance to go to A&E and get it. We are looking at some of the wider system problems to make sure we address the backlog.
Baroness Thornton (Lab)
My Lords, NHS workers on the front line have been warning for months and months that the service is under strain due to a combination of waning workforce, Covid, respiratory infections, a backlog of patients and a build-up of health problems over lockdowns. The Royal College of Emergency Medicine has been calling for months for a response from Ministers to provide short-term and long-term solutions. We called on the Health Secretary last summer for urgent additional support to be put in place. Why are we still waiting for that leadership and necessary support to materialise?
Lord Kamall (Con)
I am sure the noble Baroness will acknowledge that a number of people have been calling for ways to address this. The Government announced the Urgent and Emergency Care Recovery 10 Point Action Plan last year, which includes supporting 999 and 111 services, looking at primary care and community health services, greater use of urgent treatment centres, increased support for children and young people, better communications and call handling, improving inflow and hospital discharge, looking at mental health needs and a number of other issues. In each of those 10 points we have drilled down on working with trusts and the ambulance service to make sure we can address the issues that are currently being raised.
Lord Flight (Con)
My Lords, could the Government look at how many lives have been lost as a result of delays? I suggest this might be more of an issue than the Government are aware of.
Lord Kamall (Con)
We regularly talk to the NHS—every day, in fact. We have, for example, daily omicron calls. Looking at some of the data, over 925,000 calls to 999 were answered by the ambulance service in December 2021, which is nearly 30,000 calls a day. That is 2% more than in November 2021, 22% more than in November 2020 and 9% more than in December 2019. We have invested in more people in the call rooms, working with BT to better handle the calls, and ensuring we have more staff where we need them to handle the whole system and ensure we can respond quicker.
The Lord Privy Seal (Baroness Evans of Bowes Park) (Con)
My Lords, the noble Baroness, Lady Brinton, wishes to speak virtually. I think this is a convenient point for me to call her.
Baroness Brinton (LD) [V]
My Lords, yesterday NHS England data showed that trolley waits of more than 12 hours in A&E rose in December to just under 11,000, which is three times higher than in December 2020. One hospital reported that it had a dozen patients waiting on a trolley for a bed for over 24 hours. The Minister has talked about extra money, but without staff and bed capacity in both hospitals and care homes, the crisis remains. Can he say what the Government are doing right now to help alleviate the current crisis?
Lord Kamall (Con)
I thank the noble Baroness for giving me the opportunity to say what the Government are doing right now. We are working closely with ambulance services, NHS England and the Association of Ambulance Chief Executives to reduce the handover delays. The 10-point plan I referred to earlier goes into detail about how we handle this, both in handling calls at call centres—some calls are not emergencies, for example, and patients are directed elsewhere—and in making sure that the wider system is available to make sure that patients are unloaded within the 15-minute target and that ambulances are turned around as quickly as possible. Where we have spotted disproportionate pressures in the system, as in the 29 hospital trusts across 35 sites, we have focused more resources there.
Lord Forsyth of Drumlean (Con)
My Lords, I appreciate that my noble friend has to read out what he has in his brief, but would he take time to read the report on social care published by the Economic Affairs Committee of this House, which received pretty well universal endorsement? Will he then discuss with his colleagues whether we really have fixed social care and whether the resources he is claiming are sufficient to meet the problem?
Lord Kamall (Con)
I thank my noble friend for drawing my attention to the report and the work of that committee. I will commit to reading the report and look forward to future discussions with my noble friend and many noble Lords across the House.
Lord Bird (CB)
Would it be possible at this time to talk also about preventing the next crisis and the crisis after that? Are we not always chasing something? The NHS, which does not spend a large amount of money on prevention, is now being hoist by its own petard,
Lord Kamall (Con)
The noble Lord raises a very important point. One of the things the NHS is looking at in more detail, and something we will discuss in forthcoming debates on the Health and Social Care Bill, is how we move a system culturally to not only treat patients once they are ill or need treatment, and work in terms of prevention and encouraging healthier lifestyles. When patients are kept too long in hospital, they can lose certain facilities such as muscle function, so we need to look at prevention as opposed to just treatment. Getting the right balance is something that the NHS and the Department of Health and Social Care are looking at closely.
Baroness Jolly (LD)
My Lords, as a result of Covid’s impact, many A&E departments have reconfigured their internal infrastructure and their working practices. Could the Minister tell the House how best practice is being disseminated to other NHS trusts? What support, financial and otherwise, have trusts received to do this?
Lord Kamall (Con)
Given that it was identified that there were particular pressures on 29 trusts across 35 sites, extra resources have been targeted and teams have made site visits to work out, for example, the flows in those hospitals, and to make sure that they deal not only with the immediate issues that those departments face but also with the wider system issues. For example, as I have mentioned, sometimes patients cannot get hold of doctors and go to A&E as a substitute because they want a face-to-face appointment. We are looking at a number of those wider issues. We announced £55 million of winter funding for all ambulance services and have boosted staff numbers by 700, including for the availability of the ambulance fleet, through a £4.2 million investment to improve times. We have also invested nearly £2 million to support the well-being of front-line staff during these pressures; they have experienced increased pressures, so we must make sure we look after them as well.
Lord Lea of Crondall (Non-Afl)
My Lords, is there a breakdown on the difference between physical resources in hospitals and the shortage of staff?
Lord Kamall (Con)
I am not sure whether there is a breakdown. As my noble friend said, sometimes I have to read out what is in the pack and sometimes I freelance, as I am sure many will appreciate—or maybe will not appreciate when I divert from the government line. But I will endeavour to find out whether those stats are available.
Vaccination Strategy
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Baroness Merron (Lab)
My Lords, I pay tribute to the staff of the NHS, volunteers and others, who have made extraordinary efforts during the vaccine rollout to save lives and build a world beyond Covid, while a particular debt of gratitude is owed to the Deputy Chief Medical Officer, Jonathan Van-Tam, who is standing down from his role.
To drive up vaccination rates, there is a growing need to tackle anti-vax propaganda and stop intimidation and abuse. Will the Minister commit to a communications campaign to tackle misinformation, particularly focusing on places and people with lower rates of take-up? Following the Labour amendment to the policing Bill that was agreed last night in your Lordships’ House, will the Government now take the opportunity to fast-track buffer zones around schools and vaccination centres?
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
I thank the noble Baroness for raising these issues. The first issue, that of anti-vaxxers, is really important. In a free society we always have to get the balance right between freedom of speech, making sure that people are free to go about their daily work, and making sure that those who want the vaccine get it as soon as possible. The Government are aware of this and are looking at it, but it is really important that we get the right balance. Whatever we think of the anti-vaxxers’ message, they have a right to say it, but we have to make sure that it does not impinge on the liberty of others to get their vaccine, especially since we are encouraging as many people as possible to get vaccinated.
I join the noble Baroness in paying tribute to the Chief Medical Officer, Jonathan Van-Tam. He appears on our daily omicron calls and I have had a number of conversations with him, and I know that there is incredible respect for JVT across the country. Indeed, I know that a number of people tuned in to his Christmas lectures on the virus; as the noble Baroness says, they were an excellent explanation of the virus and how to tackle it.
As for how we reach local communities, particularly those communities that have not come forward, I have had a number of conversations with noble Lords and Baronesses with their own experience of working with local communities in a bottom-up way. We have seen a number of local activities; indeed, my local masjid, or mosque, has a walk-in vaccination centre, and we have seen that in other faith places. A number of faith-based and interfaith networks have worked closely with the local community, because often some communities do not have the trust in authority that they have in priests, vicars, bishops—if I may say so—imams, et cetera. That is really important. We have also recorded promotional films in a number of languages, including Punjabi and Urdu in Birmingham, and got some celebrities to come up. I know I have gone on too long but I am very excited about what we are doing.
The Lord Speaker (Lord McFall of Alcluith)
The noble Baroness, Lady Brinton, is taking part remotely. I invite the noble Baroness to speak.
Baroness Brinton (LD) [V]
My Lords, I too echo the gratitude that this House and this country shows to Jonathan Van-Tam. Four months on, there are still severely clinically extremely vulnerable people eligible for a third primary dose and then a booster who cannot book their booster because the data system still cannot record this. Many CEV young children with underlying conditions are still waiting for their vaccines, as well as for guidance on how they, their families and their schools can keep them safe from Covid. This is important because there are now more children in hospital with Covid in the last three weeks than in the nine months of the first wave. Please can the Minister say how these people, who the Government say need the vaccines right now to keep them safe, can get them?
Lord Kamall (Con)
I thank the noble Baroness for making me aware of the issues. She will recall that we had a meeting on how we can address the concerns of the clinically extremely vulnerable, and I had hoped that a number of action points had flowed from that. If those have not been acted upon, I hope she will write to me and I can chase up the department and the NHS. I had assumed that that meeting, where we gave them some action points, was effective. I am sure she remembers that we requested a letter with action points, but if those have not been followed up, I will endeavour to chase that up.
The Lord Speaker (Lord McFall of Alcluith)
The noble Baroness, Lady Masham of Ilton, is taking part remotely. I invite the noble Baroness to speak.
Baroness Masham of Ilton (CB) [V]
My Lords, how much research is being done on persons who may have developed Guillain Barré syndrome after the coronavirus vaccine booster? Is the noble Lord aware that there have been several cases of this serious condition recently?
Lord Kamall (Con)
I thank the noble Baroness for the question. I will have to write to her with the answer.
The Lord Bishop of Gloucester
Can the Minister update us on global statistics on vaccination? This is not only about justice, equality and dignity; it is also about the fact that new variants will arise unless we address the issue of international vaccination. What are the Government doing to ensure that everyone across our world is offered full vaccination? What focus is being given to the international situation, beyond ourselves?
Lord Kamall (Con)
I thank the right reverend Prelate for raising this incredibly important issue. I know a number of noble Lords across the House feel very strongly about this. Indeed, many of us are part of diaspora communities and understand that many communities across the world are very concerned. From the start of the pandemic, the UK has worked to support access to Covid-19 vaccines. We helped to establish the international joint procurement initiative, COVAX. At the end of 2021, the Government confirmed that they had delivered more than 30 million Covid-19 vaccines to other countries, benefiting more than 30 countries. We have invested £71 million to help COVAX secure early supply deals. The UK is one of the largest donors to the COVAX advance market commitment, which supports access to Covid-19 vaccines for up to 92 low and middle-income countries. I have a list of a number of other initiatives that we have taken part in. In addition, in bilateral, G7 and G10 discussions, we have put this issue on the agenda, making sure that we are working in a multilateral way across the world to help those countries.
Lord Patel (CB)
My Lords, first, in relation to the question asked by the noble Baroness, Lady Masham, very few cases of Guillain Barré syndrome have been reported following vaccination with Covid vaccines. That is not so surprising because it occurs with any vaccination, so it is not a reason at all for anybody to be denied vaccination. Secondly, and much more importantly, social media is full of worries that young women are particularly affected, because of the nonsense perpetrated that it will make them infertile. There is no scientific reason behind this. Does the Minister agree that all young women should take the vaccine? Thirdly, there are many pregnant women now in hospital because they were not vaccinated because of wrong advice that pregnant women should not be vaccinated. Again, there is no reason why pregnant women should not be vaccinated, and the recent data which suggests that mothers who breastfeed will transfer their antibodies to the newborn is good news too.
Lord Kamall (Con)
One of the wonderful things about your Lordships’ House is its range of expertise. I thank the noble Lord for enlightening us on the earlier question. However, as I committed to the noble Baroness, I will check the department’s reply and hope it corresponds with the noble Lord’s response; otherwise, I am sure we will have more discussions.
On young women, the noble Lord is absolutely right that we should be encouraging as many people as possible to take the vaccine, even—I know this is being broadcast publicly—those who have not had their first or second vaccine. It is not too late. We urge everyone to have their first and second vaccine, but also to have the booster. It is the best protection, even for those who have previously had Covid. We know that almost all pregnant women who are hospitalised or admitted to intensive care with Covid-19 are unvaccinated. The latest data from the UK Health Security Agency shows that Covid-19 vaccinations provide strong protection for pregnant women against the virus. It shows that the vaccines are safe for pregnant women, with similar birth outcomes for those who have had the vaccine and those who have not. We have launched a new campaign that urges pregnant women not to wait to take the vaccine; it highlights the risks of Covid-19 to mother and baby and the benefits of vaccination.
Baroness Blackstone (Ind Lab)
My Lords, I declare my interests as set out in the register. Following on from the question of the noble Lord, Lord Patel, I want to pick up the issue of pregnant women. The Government have belatedly—very belatedly—announced a campaign to persuade pregnant women to get vaccinated. Had they done it earlier, some deaths would have been avoided. Is the Minister aware of the particularly low levels of vaccination among pregnant women from ethnic minorities? What are the Government doing to reach out to them in particular, to persuade them to get vaccinated and save their own lives and those of their unborn children?
Lord Kamall (Con)
The noble Baroness makes an incredibly important point that I am sure we all agree with. This is a combination of two issues. One is reaching those communities that generally, pregnant or otherwise, are not being vaccinated. The other is making sure that pregnant women are receiving the message that it is safe to have the vaccine. We are doing this through a number of channels, including through medical staff and the NHS, but we also have a number of targeted campaigns, looking at those communities to make sure we build trust, break those gaps down and give them the confidence to come forward and be vaccinated.
Health and Care Bill
Lord Kamall ExcerptsThursday 13th January 2022
(2 years, 7 months ago)
Lords ChamberRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: HL Bill 71-II(b) Amendments for Committee (Supplementary to the Second Marshalled List) - (13 Jan 2022)
Baroness Walmsley (LD)
My Lords, I shall speak more briefly than I had intended, because this has been a very long debate, absolutely full of expertise, about a suite of amendments all of which have considerable merit. I know that both Ministers on the Front Bench have been listening very carefully and have noted the consensus across the Committee that this Bill will not succeed unless it addresses very clearly the disgraceful health inequalities in this country at the moment.
Health inequality affects quality of life, life expectancy and, in particular, healthy life expectancy, which has now stalled across certain demographic groups. As we have heard, it has been analysed brilliantly by Professor Sir Michael Marmot. It affects the well-being of the patient and their family. The really sad thing is that much of it is preventable. These things are particularly rife in the poorer parts of the country, because that is where the social determinants of health such as housing, referred to by my noble friend Lord Shipley and others, have most effect. We have heard a number of statistics about health inequalities, but I shall give your Lordships just one. People living in the most deprived areas of the UK spend almost a third of their lives in poor health, compared to only about a sixth of those living in the least deprived areas. That says it all.
Unfortunately, inequalities were not at the forefront of the Government’s response to the pandemic. They suspended equality impact assessments for legislation, resisted publication of evidence of the impact of the virus on BAME individuals—as pointed out to them eloquently by the noble Baroness, Lady Lawrence—and failed to provide adequate isolation support for those on low incomes, forcing them to go to work. The Covid pandemic has therefore seen the biggest shift in life expectancy in the UK since World War 2: a fall of 1.2 years in males and 0.9 years in females. It is therefore essential to heed Sir Michael Marmot’s words and “build back fairer” and not just “better”.
The noble Baroness, Lady Greengross, kindly mentioned the report of the Science and Technology Committee on healthy ageing. I was a member of that committee under the capable chairmanship of the noble Lord, Lord Patel. It became very clear from our witnesses that unhealthy ageing happens years before the person is old and depends enormously on their demographic and their lifestyle. For their sake and for the sake of the future of the NHS, for which no Government will ever be able to provide enough funding unless something is done on prevention, we must do something to level up the health outcomes of the nation. This Bill is a very good place to start all over again on that agenda.
I have added my name to Amendment 11, so ably introduced by the noble Baroness, Lady Thornton, whom I must congratulate on the way she analysed these issues at the beginning of this debate. I thank her for that. Also crucial is Amendment 14, so ably promoted by the noble Lord, Lord Patel, and my noble friend Lady Tyler. Amendment 11 is an attempt to ensure that NHS England produces guidance about the collection, analysis, reporting and publication of the data which makes transparent the performance of various NHS bodies on health inequalities. Without collecting that, we cannot judge the performance of those organisations. If it is not done consistently, we cannot assess an organisation’s performance in comparison to other similar bodies. That is why such guidance must come from the top. I know that the Government want each ICS to do its own thing in a way which it considers most appropriate for its area. However, for the important objective of levelling up health outcomes across the population, judgment of performance can be made only if the data is comparable between one ICS and another or one trust and another, so we cannot leave it to them to collect the data in any way they like.
Of course, there are big issues about the resources available for the collection and analysis of data, but such information is essential if improvements are to be made. Therefore, a duty to “have regard” to guidance published by NHSE would put pressure on the organisations to so arrange their finances as to ensure adequate resources for this, and, of course, it would be cost-effective.
I also have Amendments 61 and 63 in this group. They would insert “assess and” into new Section 14Z35 inserted by Clause 20, which covers the duty of an integrated care board to reduce inequalities in access to health services across its population and in the health outcomes achieved. Although it is well known that, in general, the lower the demographic the greater the health inequalities, this is by no means uniform, even across a single local authority, let alone across a large ICS area. Indeed, even within a single local government ward, which may be fairly affluent in general, there are often pockets of deprivation. Every local councillor knows where they are. In order to devise policies and deploy services geographically in a way that improves access and outcomes for those deprived communities, the ICS needs to drill down and do the detailed work to identify where they are and what factors are damaging health. It may be poor or overcrowded housing. It may be lack of access to shops selling healthy food. It may be lack of access to leisure and sports facilities in which to take exercise. It may be poorly performing schools or overstretched primary care services. It may simply be poverty, preventing people heating their homes adequately or buying nutritious food. In rural areas, it may be lack of access to pretty well everything, as the right reverend Prelate reminded us. Whatever it is, you cannot fix it until you know what and where it is.
That is one of the reasons why we reject the new power of the Secretary of State to meddle in the reconfiguration of health services locally, but that is a debate for another time. In cases such as this, an overview will not do, and local knowledge is key. That is why we believe it is essential to mandate an ICB to do the detailed research on which to base its commissioning decisions, so that it can fulfil the duty to reduce health inequality put on it by this Bill—once it has been amended by a lot of these amendments.
Lord Kamall (Con)
You have not heard what I am going to say yet.
I thank all noble Lords who have taken part in this debate; it has been fascinating. It has touched on a number of things that I feel strongly about personally. Before we go further, and given my background and that of my right honourable friend the Secretary of State, I want to assure noble Lords that we both feel very strongly about inequalities. I say that as someone who grew up in a working-class immigrant community. I was born at Whittington Hospital; I also accessed North Middlesex hospital and Chase Farm Hospital, with which I know the noble Baroness, Lady Tyler, is associated, though I am not sure I will get any more points for that, to be honest.
One thing I feel strongly about, and saw in many areas when I was an MEP for London, is where the state has failed, whichever Government was in power. I have worked with non-state, local community, bottom-up projects which understood the issues in their communities far better than any national or local politician—there was sometimes even a distance between them and their local ward councillor, as the noble Lord, Lord Mawson, and I were discussing the other day.
I thank the noble Baroness, Lady Thornton, not only for the thoughtful way in which she opened the debate and introduced the amendments but for pointing out some of the people who are often forgotten; for example, the homeless. I have worked with a number of local community homeless projects, such as the Hope Foundation in Acton and Vision Care for Homeless People. Perhaps I may also do a quick advert for the Take One, Leave One project, which is based outside Vauxhall station on Fridays, between 12 pm and 3 pm —people can leave excess clothes and homeless people can pick them up. I urge any noble Lords passing through Vauxhall station on a Friday to support this.
Sex workers, the Traveller community and drug users have been mentioned. Sometimes we think that these issues are remote from us and will not affect us—but everyone is only one of two steps away from homelessness. A broken family, mental health issues, your friends saying, after a while, “Actually, you can’t stay on my sofa any more”—where do you go? When I have met homeless people, they have quite often come from a very different place, not the stereotype that we often hear. They have come from quite a stable family, a good relationship, a good job: but two or three things have gone wrong in their life and suddenly they are homeless. It happens to many people who resort to such desperate measures.
Another thing I am slightly concerned about, if I am honest, is that when I was a young child growing up in immigrant communities, there was a distrust of authority. We see the difficulty, for example with the vaccine schemes, in trying to reach some of those communities. It was not only authority that we were quite suspicious of and concerned about but—I hope noble Lords will forgive me for using this phrase—white, middle-class do-gooders who thought they knew best what was best for us as working-class immigrant people and could tell us what was best for us, rather than listening to us and our real concerns. Quite often we felt that they had captured the agenda, and that was why the money and resources which were supposed to be helping us did not reach the people who needed help: it got captured by the white, middle-class do-gooders.
I pay tribute to the noble Lord, Lord Howarth, and the noble Baronesses, Lady Greengross and Lady McIntosh of Hudnall, for the emphasis on the arts and creative industries. Sometimes, music and the arts are a way of overcoming this distrust, learning about the culture of those communities and also aligning the culture and the issues with some of the very real problems and tensions we face. The noble Lord, Lord Desai, talked about prevention being better than cure. It is an issue we talk about constantly in the department, and the NHS also talks about it. The noble Lord, Lord Desai, as an economist, will acknowledge that economics is often simply about the allocation of scarce resources and finding the most efficient way of achieving that.
My late father once told me, “Never forget where you came from and what you were”, and this is one of the reasons I feel very strongly, as do many noble Lords across the Committee, about the issue of inequalities. How do we tackle this, what is the best way to do it? Will putting it in the Bill solve all the problems? Actually, it will not, but we can discuss how we can make it more effective, and not just feel, “Great, we’ve got it in the Bill, job done”. It has to be more than that. As the noble Lord, Lord Scriven, said, it cannot just be an institutionalised Gladys; it has to be more than that. So, I am deeply grateful that we gave this issue the time it deserves. It is really important for me personally. We want to tackle health inequalities and ensure that everyone has the same opportunity to enjoy a long and healthy life, whoever they are, wherever they live and whatever their background or social circumstances.
I hope I can assure the noble Baroness, Lady Greengross, with whom I have had a number of conversations about music and dementia. I have volunteered, perhaps rather rashly, to organise a fundraiser with my band and other bands for that. I hope that does not give me an excuse to lay the YouTube link to my band in the Library: I shall try to avoid that temptation.
However, to deliver on the commitment on 1 October, we launched the Office of Health Improvement and Disparities within the Department of Health and Social Care—the noble Lord, Lord Scriven, anticipated that I would say this—and we also set up a cross-government ministerial group to identify and tackle the wider determinants of poor health and health disparities. It is important that this cannot be top-down; we have to go to some of the social enterprises and local communities, but also we must not prejudge, prevent or duplicate the work of the integrated care systems in this. NHS England is already tackling health disparities through the NHS long-term plan. That sets out a clear intention to set measurable goals and to make differential allocations targeted at reducing health inequalities and disparities. This has resulted in funding increases to some of the most deprived parts of the country.
As we know, making sure that these deprived areas get the most funding does not mean it will trickle down to those who really need it; it could well be captured by some of the do-gooders I mentioned earlier. The noble Lord, Lord Howarth, talked about those targeted interventions. NHS England and NHS Improvement is also taking forward the Core20PLUS5 initiative as an approach to addressing health inequalities. This will focus on improving outcomes in the poorest 20% of the population, along with inclusion health groups and five priority clinical focus areas.
Health and Care Bill
Lord Kamall ExcerptsThursday 13th January 2022
(2 years, 7 months ago)
Lords ChamberRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: HL Bill 71-II(b) Amendments for Committee (Supplementary to the Second Marshalled List) - (13 Jan 2022)
Baroness Wheeler (Lab)
My Lords, I congratulate the four noble Lords who have produced this excellent suite of amendments across the Bill to ensure that ICBs procuring or commissioning goods and services on behalf of the NHS are firmly focused on their responsibility for NHS England’s commitment to reaching net zero by 2040. It has been an excellent and informed debate, and one with much enthusiasm to reassure the noble Baroness, Lady Hayman.
We fully support the amendments and have little to add from these Benches following the expert contributions of those proposing the amendments and the other noble Lords who have spoken. I am sorry my noble friend Lady Young, who put her name to the amendments, cannot be here. She was a key member of our team during the recent passage of the Environment Bill, and her expertise and wisdom always guides and reflects our approach. The House is clearly interested in this vital matter, as we saw this week in an important Oral Question on the Prime Minister’s promise for a new, overarching net-zero test for new policies. Assuming the Government fully support the key commitment from NHS England, I hope that, in his response, the Minister will accept the need for the amendments and will not argue that the proposed new clause is unnecessary as NHS England already has a commitment that will percolate down to ICBs.
As we have heard, the power of public sector procurement is a massive issue and there is no bigger part of the public sector than the NHS. The NHS has such an important impact on other environment issues, such as waste, pollution and resource consumption, especially for plastics, paper and water. We should ensure we are on the front foot in using that impact to deliver the net-zero commitment.
The NHS has made a start, but there is much more to do. These amendments would reinforce the importance of action in these areas for the new bodies and processes that the Bill creates. The NHS is a big player and, as noble Lords have stressed, it can play a big role in tackling all of these climate change and environmental challenges. Procurement is a strong lever that the NHS can utilise in key markets, particularly in those areas where it is the sole purchaser. The noble Lord, Lord Stevens, was very eloquent on this issue and I look forward to the Minister’s response in the light of his contribution.
Like other speakers today, my noble friend Lady Young wanted to stress that action so far is only the beginning. In the light of the importance of climate change and other environmental challenges, we strongly support such a duty being in place for all the public and private bodies with significant impacts when future legislation comes through Parliament. We did that when inserting a sustainable development duty into the remit of every possible public body from the late 1990s onwards, but this time it has to be not only enacted but managed, delivered, tracked and reported.
As the Minister, the noble Lord, Lord Callanan, told the House this week, every sector of government needs to do its bit, and we need to hold them to that. These amendments are vital, since every public body will have to take further action this decade if we are to restrain temperature rises to two degrees—far less, 1.5 degrees.
Finally, I too thank Peers for the Planet both for its work and, especially for me, its excellent briefing. As noble Lords have stressed, the NHS has committed to net zero and aims to be the world’s first net-zero national health service. It is responsible for around 5% of the UK’s carbon emissions. That is why the NHS’s role and contribution to net-zero targets should be fully integrated into the Bill. I look forward to the Minister’s response and his detailing of how the NHS is to achieve its ambitions. I hope that he will acknowledge that its commitment must be in the Bill. These amendments present a vital opportunity to enshrine in law a commitment that I think most, if not all, would want to see delivered.
The Parliamentary Under Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
I thank the noble Lord, Lord Stevens, for the amendments and the noble Baroness, Lady Hayman, for her opening remarks. I also thank the noble Baroness for her suggestion yesterday that it might make my life a lot easier if I just accepted amendments. I understand that advice, having just gone through a two-hour debate on the previous group.
A number of noble Lords referred to how these amendments relate to our previous debate on inequalities. I point out that that is sometimes not quite in the way that we would expect. We might think there is a direct connection, but sometimes the green agenda can be seen to be for those who can afford it—as I explained before, for the white, middle-class, patronising people who tell immigrant working-class communities what to do and push up their costs. Anti-car policies push up costs for those in rural areas, and there are higher fuel costs as we replace gas boilers with potentially more expensive heat pumps. We have to be aware of those issues. In the long term, I am optimistic. I look forward to the day when we have solar power and wind power, with storage capacity, which will reduce costs.
Baroness Northover (LD)
Will the Minister look at this globally and recognise that the poorest are affected the worst? When he talks about those in poverty, he should think globally.
Lord Kamall (Con)
I accept that point, but I also accept that, sometimes, one can be patronised, and I do not accept being patronised as I was in the earlier debate. One day, there will be cheaper fuel, and we can look forward to it, but we have to make sure that the transition along the way is not seen to push up costs for working people, because we all feel passionately about this green agenda.
Baroness Bennett of Manor Castle (GP)
The Minister was talking about the impact of policies on the poor. Does he agree that many of the products—the fabrics, the chemicals—are manufactured in the poorest areas of the world, producing pollution that has disastrous impacts on some of the poorest people?
Lord Kamall (Con)
I was going to come to the noble Baroness’s points, and I am grateful to her for raising these issues directly with me previously.
Turning to the amendments, I thank the noble Baronesses, Lady Hayman and Lady Young of Old Scone, and the noble Lords, Lord Stevens and Lord Prior, for bringing this debate before the Committee. There is no doubt that the NHS has a significant carbon footprint. There is no doubt that a poor environment has direct and immediate consequence for our patients, the public and the NHS. There is no doubt that it has an impact on the health of the nation. As the noble Baroness, Lady Hayman, pointed out, the NHS accounts for around 4% to 5% of UK emissions. If we go further, as the noble Baroness, Lady Bennett, said, that is 40% of public service emissions. Noble Lords are right to highlight the critical role that the NHS has to play in achieving net zero.
To support that work, NHS England—thanks in part to work already started by the noble Lord, Lord Stevens, who I know has had conversations with my right honourable friend the Secretary of State for Health and Social Care—is leading the way through a dedicated programme of work, as many noble Lords acknowledged. This includes ambitious targets for achieving net zero for the NHS carbon footprint by 2045 and for its direct emissions by 2040. This is ahead of the target set by Section 1 of the Climate Change Act 2008; we welcome that ambition and will continue to support the NHS in that.
Lord Mawson (CB)
I thank the Minister. Can I just give an illustration about the local on this issue? I am certainly not an expert on climate change, but I am a practical person who worries a lot about granularity and the gap between a lot of talk I have heard over many years on all sides of this Chamber—with very large amounts of money cited, et cetera—and the realities in this building.
I am trying to buy an electric car at the moment, as a responsible citizen. When I went to have a look at the multi-storey car park below this building—the local—and wondered where I am going to plug it in when it arrives here, I ended up talking to one of the facilities managers, who was a very nice man. I asked him how many plug-in points there were underneath this building—again, the local. He said, “I don’t know, Lord Mawson, but I will look into this”.
He was diligent and came back to me. We started to have a conversation about it, and he began to suggest that I need to carry a cable in my car with a three-pin plug. I pointed out that my office is across St Margaret Street, in Old Palace Yard, on the third floor, so maybe I should run it across there with a carpet over it and up to the third floor to plug it in there. We had this amusing conversation. I said, “Well, go on then, tell me: how many are there in this building, where all this chatter and talk is taking place?” His answer was that there are two. I suggest that the gap between reality and rhetoric is very large indeed. If we are really going to deal with these issues—as we must—we must now become intensely interested in the NHS and in all the systems of government about practicality and the procurement machinery, which I suggest is not working.
I talked to one of the facilities people yesterday about my office, which has a light switch with a notice over the top of it telling you how to use it. It is completely ludicrous. She told me that that system is going to be different to all the systems here in the Palace of Westminster; none of it is joined up.
I think the Minister is right. The clue is in the local, but all our systems and our civil servants must now become interested in practicality and the local if we are really going to get serious about these matters. It is absolutely crucial to get procurement right, because without that, we will never deliver this.
Lord Kamall (Con)
I thank the noble Lord, Lord Mawson, for that intervention, and I completely agree. There are some incredibly inspirational projects going on in our local communities, tackling and addressing the green agenda, and sometimes, top-down, we may feel good about it in this place, but it really affects working people and those who face higher costs and we have to be very careful.
On the specific question of procurement, the NHS is already publicly committed to purchasing only from suppliers which are aligned with its net-zero ambitions by 2030, and last year, NHS England set out its roadmap giving further details to suppliers to 2030. This is supported by a broad range of further action on NHS net zero and we hope that by pushing this through at NHS England level, but also with ICSs, we can see some of that local innovation as local trusts and local care systems and even health and well-being boards respond to those local challenges—others could learn nationally. To respond to the question of the noble Baroness, Lady Walmsley, NHS England will publish the world’s first net-zero healthcare building standard; this will apply to all projects being taken forward through the Government’s new hospital programme, which will see 48 new hospital facilities built across England by 2030.
There is political consensus on green issues. and we should pay tribute to the noble Baroness, Lady Bennett, and the Green Party for making sure, over the years, that the green agenda has been put at the centre of British politics. We find green policies in all the election manifestos of the mainstream parties: that is in no small part due to the noble Baroness’s party and to the noble Baroness herself. So, even while we may disagree on how to achieve some of these things, there is no doubt that we are not going to reverse on our commitment. Whatever Governments are elected in future, all are committed to a carbon net-zero strategy and a cleaner environment. So, I must gently disagree with her that these amendments are necessary.
I would like to have further conversations with the noble Lord, Lord Stevens, given his experience, on why he feels that, despite all the great work that the NHS has been doing, these amendments are still necessary. I would like to have further conversations with him and others, but at this stage, I ask the noble Baroness to withdraw the amendment. Across the political spectrum, we must make sure that we are pushing the NHS to deliver, not only at the national level but at the ICS level and even lower, at the place level that the noble Lord, Lord Mawson, speaks so eloquently about.
Baroness Bennett of Manor Castle (GP)
Before the noble Lord sits down, will he respond to the question, of which I gave him prior notice, about the document?
Lord Kamall (Con)
I apologise to the noble Baroness—I am so sorry, but I am trying to juggle 300 devices. That is a slight exaggeration, if I am honest. We recognise the importance of ensuring that all chemicals in the NHS supply chain are appropriate and properly managed as part of the net-zero strategy. I think the noble Lord, Lord Stevens, even touched upon some of the chemicals that were used and some of the issues he looked at during his time at the NHS when it comes to chemicals. The NHS must also comply fully with the Control of Substances Hazardous to Health Regulations, the CoSHH regulations.
More broadly, although Defra is the lead department for harmful chemicals, the UK Health Security Agency feeds in its expertise in relation to restricting and banning chemicals, and we are grateful to it for that work. The UKHSA is also looking at each of those chemicals, which we hope in future can be replaced by less harmful materials and chemicals. I undertake to write to the noble Baroness in more detail than the short answer I have given her at this stage.
Baroness Walmsley (LD)
My Lords, like the noble Baroness, Lady Thornton, I shall start with those who I think should not be on the board before I turn to those who I think should. To a great extent I support the noble Baroness’s Amendment 29, but with a small caveat that, if she wished to press it, might require a bit of redrafting. I will explain.
Additional provider medical services are very useful in many areas to fill gaps in primary care capacity. They may provide additional services from which other NHS primary care services have opted out, such as out-of-hours services or enhanced services beyond the capacity of local NHS GPs to deliver. In some areas they have taken over primary care services where NHS GP practices have become too small to be viable or all the partners have retired.
Some APMS services are commercial businesses with a responsibility to their shareholders to make a profit, and I do not think these should be on the board. However, some APMS contracts go to NHS entities, and I would not want to exclude those. Of course, we must remember that for many years GP practices have also been small businesses, sort of, operating within the umbrella and ethos of the NHS. They too need to clear their costs or they will close down.
That is all well and good. However, if the Government are serious that they want to exclude private sector interests from ICBs, they must surely agree to include in that ban non-NHS entities that hold APMS contracts. A failure to accept the amendment of the noble Baroness, Lady Thornton, must surely make us a little suspicious about the Government’s claim that their amendment inserted in another place would successfully exclude private interests from the board.
Amendment 29 would extend the range of those involved in commercial enterprises from being members of the board of an ICS beyond those that we have just discussed in relation to the noble Baroness’s Amendment 28. Amendment 29 would specifically exclude NHS GP practices and voluntary or not-for-profit organisations from the ban. There are many types of organisations that would be included in the ban, although they could be heard on the board of the integrated care partnerships. Those include: pharmaceutical companies; providers of medical devices, equipment or premises; people who own care homes; and many other essential services without which our NHS could not survive. However, their importance should not entitle them to influence the constitution, strategy or commissioning principles of the board of the ICS. They are important providers that will be appropriately involved in planning at other levels, but they should not be able to steer fundamental decisions without the suspicion that they might have a commercial interest in such decisions. Indeed, the ban proposed in the amendment would protect such companies from such a suspicion, so perhaps it would be welcomed by them.
Turning to those who should be on the board, I will not repeat what the noble Baroness, Lady Hollins, said in introducing her amendments, because she has done it extremely well, particularly emphasising the impact of integrated services on people with learning difficulties and people with autism and how they could benefit from better integrated services if we got it right. So, I support her amendments.
I turn to Amendment 37, to which I have added my name to those of the noble Baroness, Lady Thornton, and the noble Lord, Lord Patel, for the following reasons. According to the Explanatory Notes, each ICB and its partner local authorities will be required to establish an integrated care partnership, bringing together health, social care and public health. The constitution of the ICB as it stands in the Bill specifies that the board must include only a minimum of three types of people who the Government clearly believe are essential to the effective operation of the board. They are someone from NHS health trusts or foundation trusts, someone from primary care, and someone from one of the local authorities in the area. If it is okay to prescribe these members, would it not also be wise to prescribe a few other key people with appropriate knowledge in order to achieve the ICB’s objectives of bringing together health, social care and public health? This amendment therefore suggests five other nominees—not 15, bearing in mind the Government’s wish to keep the ICB to a manageable size. But given the powers of the board, I would think it essential to have people nominated from mental health, public health, social care, health trade unions, patients and carers to bring their knowledge to strategic decisions.
If the board is to comply with the ambition of parity of esteem for physical and mental health—which we talked about two days ago—it will be important to have someone with the knowledge of how mental health services are working, as my noble friend Lady Tyler emphasised. Public health is a very particular discipline, the importance of which has been amply shown during the pandemic, which also has a vital role to play if we are to improve the health of local people and level up inequalities. Social care provision should never be separate from or subsidiary to health, as it is intrinsic to the functioning of health services in every area, so it is inconceivable that any ICB should ever be without someone from that sector.
The NHS is a people business, which is why those who deliver the services and the patients who are on the receiving end should have a voice at the top. Similarly, those thousands of unpaid carers, without whom vulnerable people would use up more of the NHS’s scarce resources than they currently do, should be represented at the very top of these new organisations. Their contribution to the efficient use of the board’s financial resources is crucial.
If the objective is to encourage more integration and collaboration, how could it be right not to have these additional five or six groups of people helping to make the strategic decisions? If that is not the case, as has been said by other noble Lords, the board could be dominated by the large acute hospitals and primary care, and the integration objective of the Government, which I endorse, would fail. I look forward to the Minister’s reply.
Lord Kamall (Con)
My Lords, this has been an excellent and wide-ranging debate, and I really am grateful to all noble Lords who tabled amendments today.
With your Lordships’ leave, I turn first to Amendment 18 in the name of the noble Baroness, Lady Thornton. This amendment would mean that the relevant ICB and ICP would need to be consulted before NHS England is able to provide support and assistance to bodies other than NHS bodies. The NHS has, under successive Governments of all political colours—indeed, since its foundation in 1948—commissioned care from various sectors to help it be more responsive to patients’ needs, and particularly to help deliver the commitments set out in the NHS constitution.
The vast majority of NHS care has been—and will rightly continue to be—provided by taxpayer-funded public sector organisations. But experience before and during the pandemic has demonstrated how important it is for NHS England to have the power, as the Trust Development Authority currently does, to provide support and assistance to any providers of services on behalf of the NHS. This will ensure that independent providers can, if necessary, be commissioned to provide important additional capacity where needed.
Baroness Thornton (Lab)
I really rather hoped the Minister would not go into whether or not I was suggesting that we should or should not be using private services. This is about who commissions services; this is not about who provides services. In my opening remarks, I said that a variety of providers is exactly what we have and will continue to have.
Lord Kamall (Con)
I thank the noble Baroness for that clarification.
The amendment seeks to exclude individuals whose GP practices hold an alternative provider of medical services, or APMS, contract from being a member of an integrated care board. While APMS contracts may not be appropriate for all GPs, they offer the ICBs, as commissioners, greater flexibility than other general practice contract types. As the noble Baroness, Lady Walmsley, acknowledged, the APMS framework allows commissioners to contract specific primary medical care services to meet local needs. APMS contractors include some private and third sector social enterprises and GP partnerships, which provide outreach health services for homeless people, asylum seekers and others. It is quite clear that none of this diminishes the commitment to ensure that care is provided free at the point of use, paid for by taxpayers.
All contract holders providing NHS core primary medical services are subject to the same requirements, regulations and standards, regardless of the type of contract. The Care Quality Commission, as the independent regulator, ensures that all contracts meet these standards.
Some GP partnerships concurrently hold a general medical services contract for core medical provision, as well as an APMS contract. Some individual GPs provide services for a range of practices. The concern is that this amendment would exclude GPs working for one or multiple practices which operate under APMS contracts from being members of the ICB.
NHS England’s draft guidance states that nominated members of an ICB will be full members of the unitary board, bringing knowledge and a perspective from their sectors, but not acting as delegates of those sectors.
This amendment would prevent some individuals being on integrated care boards, based on what type of NHS GP contract their practice holds. This could limit the ability of primary medical service providers to appoint an ICB member who understands the health requirements of the local population. This could reduce the diversity of GPs who could be appointed, based on their contract type. If we think of the unintended consequences, this may inadvertently exclude representatives with much-needed expertise in serving specific local populations and addressing their health needs.
Earlier, we talked about tackling inequalities. I feel very strongly that there are sometimes unintended consequences, where people think that they know better what is best for their communities. It would be unfortunate to exclude APMS contracts, or anyone who had an APMS contract and who had the expertise needed for those communities that are not receiving an adequate service, or for poor, immigrant communities. This could go against the goal that we all want to see of tackling inequalities.
I now turn to Amendments 29 and 30. I am grateful to the noble Baroness, Lady Merron, and the noble Lord, Lord Davies, for bringing this issue before the Committee. I understand the interest in the role of independent providers in the integrated care boards. I also understand the concern across the Committee to ensure that independent providers, including companies seeking to produce health and care products, should not be appointed to the board of ICBs. We agree. Integrated care boards will be NHS bodies whose board membership consists of a minimum of individuals nominated by NHS providers, GP services and local authorities whose areas coincide with that of the ICB.
Although, as has been acknowledged, service provision by the independent and voluntary sectors has been an important and valuable feature of the system under successive Governments, it has never been the intention for independent providers as corporate entities to sit on integrated care boards, nor for an individual appointed to be there as a representative of an individual provider, in any capacity. People must therefore be assured that the work of ICBs will be driven by health outcomes, not profit. However, we recognise that this is a matter of concern to many noble Lords, as well as to the other place. We have been keen to put this beyond doubt, which is why we brought forward the amendment on this very point at Report stage in the other place. This amendment makes clear that no one may be appointed to an ICB who would undermine the independence of the NHS as a result of their interests in the private healthcare sector, social enterprise or elsewhere, including the public sector.
Baroness Walmsley (LD)
I apologise for interrupting the Minister, but I want to ask him a question going back to Amendment 28 and the APMS contracts. If we were to bring forward an amendment that made it very clear that we had no objection to NHS entities or not-for-profit organisations with APMS contracts being on the ICB, would he take a more friendly approach? It would just eliminate those that take profit out of the NHS.
Lord Kamall (Con)
I thank the noble Baroness for that suggestion and for trying to narrow the gap that there clearly is. If an amendment were put forward, we would look at it very carefully and consider the unintended consequences from the way it is drafted. We will consider it but, as I am sure the noble Baroness appreciates, I can make no promises at this stage.
I turn to the point made by my noble friend Lord Hunt of Wirral about how provider input in the work of an ICB will be reconciled with assessing both the suitability and performance of providers. As my noble friend correctly noted, each ICB must make arrangements on managing the conflict of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore, each appointee to the ICB is expected to act in the interests of the ICB. They are not delegates of their organisations, but are there to contribute their experience and expertise for the effective running of the ICB—a point made most eloquently by the noble Lord, Lord Mawson, my noble friend Lady Harding and the right reverend Prelate the Bishop of London. It is important that this is about expertise, not the trust or organisation that they are taken from, or their skills and knowledge, as the noble Lord, Lord Mawson, said.
We are also keen to allow ICBs to develop their own governance arrangements, which best take their local circumstances into account. We want to give them the flexibility to learn and develop as their best practice evolves, so that other ICBs could learn from that best practice where there are concerns.
To support ICBs, NHS England is working with them to issue guidance and to develop and make clear our expectations of ICB leaders—expectations that have been reflected in the discussions and fantastic contributions from many noble Lords. For these reasons, I regret that the Government cannot accept these amendments at this stage. However, I hope I have given noble Lords such reassurance that they feel able to withdraw their amendments.
Turning to the membership of integrated care boards, I will begin with Amendments 27, 37, 38, 39, 40 and 41. I am grateful to all noble Lords who have brought forward these amendments today. I understand the interest from all sides in this membership. Schedule 2 sets out the minimum membership of the integrated care board; it will need to include members nominated by NHS trusts and NHS foundation trusts, by persons who provide primary medical services and by local authorities of areas that coincide with or include the whole or any part of the ICB’s area.
I take the point of the noble Lord, Lord Bradley, about mental health. I am sure he recalls the debate on Tuesday, when noble Lords felt very strongly about this. I have offered to meet many noble Lords from across the Committee who indicated that they want to see this parity with mental health, which they do not believe is implicit at the moment, even if we believe that “health” refers to physical and mental health. Indeed, it refers to spiritual health in many ways. But we understand that we have to close that gap and I will make sure that the noble Lord, Lord Bradley, is invited to those meetings.
It is important for us that we are not overprescriptive, which is especially true of any membership requirement. Any extension beyond the proposed statutory minimum will risk undermining local flexibility to design a board, as my noble friends Lord Mawson and Lady Harding and others have said, in the most suitable way for each area’s unique needs, drawing on the best expertise, but not where they are from. It may also make the boards less nimble and less able to make important decisions rapidly if we overprescribe.
It is important to remind the Committee—I apologise if noble Lords do not appreciate the repetition—that we set a floor and not a ceiling. The ICB can appoint board members if it wishes. Local areas can, by agreement, go beyond the legislative minimum requirements. They will want to ensure they appoint individuals with the experience and expertise to address the needs and fulfil the functions. Areas are already doing this. For example, in south-east London the ICB is proposing to include three provider members—acute, community and mental health—and six place members, one for each borough. This approach is exactly how we want ICBs to use the flexibility available to them.
If, in time, some of the concerns expressed today by noble Lords become clear—such as issues being skated over, ignored or elbowed out by others with louder voices—we may need to add further requirements that relate to ICB membership, and there are regulation-making powers in place in Schedule 2 to allow the Secretary of State to do so. Furthermore, NHS England has the power to issue statutory guidance to ICBs. It could, for example, use this to recommend that each ICB should consider appointing a learning disability and autism senior responsible officer, as I know the noble Baroness, Lady Hollins, has asked for and has spoken about most eloquently many times, most recently in a debate a few weeks ago.
Taken together, our approach reflects our view and, I reiterate, the view of the NHS that we should not attempt to overlegislate for the composition of ICBs and instead let them evolve as effective local entities to reflect local need. Let us get the right balance between the top-down and bottom-up approach, and make sure that they are relevant to their local areas. I am afraid that these amendments are seen to take a different approach, by adding more people to the minimum requirements for the ICB, making them larger but not necessarily better. They also add additional complexity by introducing a significant number of members who are responsible for activity outside the NHS. We think these would be better represented on the integrated care partnerships, which have a broader remit. I come back to the point that it is about expertise, not which trust.
I will consider the comments made by noble Lords very carefully if some of the concerns have not been met, and will have future conversations, between this stage and the next, if they feel that we have not addressed their concerns completely. I regret that the Government cannot accept these amendments. I hope that I have given your Lordships some, if not complete, reassurance and that noble Lords will feel able at this stage to withdraw and not press their amendments.
Baroness Thornton (Lab)
My Lords, I thank the Minister for his detailed response. I was disappointed with the first remarks he made because he resorted to the mantra that the Government tend to go to when the question of private sector interests in delivering healthcare is raised by this side of the House. That is a shame, because the questions that we have raised are legitimate. In fact, his friends in the Commons accepted the conflicts of interest that could arise from private sector interests being represented on ICBs. We were seeking to make sure that that is watertight and there is no way of it changing. That is a legitimate question to ask.
I thank the noble Lord, Lord Patel, and the noble Baronesses, Lady Walmsley and Lady Meacher, for supporting Amendment 37, which is the key amendment in this group as to who may or may not be members of the board.
The noble Baroness, Lady Hollins, made a powerful case for the interests of people with learning disabilities and autism being represented. We know that where health systems make the health of people with learning disabilities a central priority, the whole health system benefits from it. That has happened in some places—for example, in Manchester—and it demonstrates how we improve the whole system. It is an important point.
My noble friend Lady Bakewell made the point about Centene and Operose, and that is partly why I put forward my amendment on APMS. The Minister may recall that we raised this matter in Questions a few weeks ago, when I asked him to write to me about what system had been used to give that contract to Centene, or Operose, in Camden, the area where I live. Having served on the CCG in Camden, I was aware of the importance of who runs primary care and of who the GPs in our surgeries are. Having right and proper people and organisations running our primary care was one of the criteria that you would use as a commissioner when you were looking at who was running, and who might wish to run, primary care and GP surgeries. I was involved in that process. As I learn about the history and background of this organisation now running primary care and GP surgeries in the UK, I do not think they are right and proper people to be doing that.
If this amendment does not serve the purpose of stopping that happening, I ask the Minister and the Bill team to reflect on what we might need to do to ensure that those from the private sector, social enterprises and charities whom we commission to run parts of our health service are right and proper people to do so. The remarks made in that regard by the noble Lord, Lord Hunt, were very interesting and useful, as they often are.
The noble Baroness, Lady Meacher, made the point about public health. That is the theme running through this Bill: the need for public health to be represented. She was also absolutely correct to bring us back to the idea that clinical leadership is very important. Of course it is. The right reverend Prelate the Bishop of London asked some pertinent questions.
My noble friend Lady Pitkeathley raised the issue of social enterprises, which is close to my heart. I am the honorary secretary of the All-Party Group for Social Enterprise, which I helped to found 20-odd years ago. The APPG has just completed an inquiry, chaired by the noble Earl, Lord Devon, about the impact of Covid on social enterprises, which absolutely illustrates the points made by my noble friend and which I will share with the Minister when it is available.
The noble Baroness, Lady Finlay, made relevant points about Allied Healthcare. I think that the noble Baroness, Lady Walmsley, and I agree that the problem with APMS is that there is a lack of clarity and it is a bit of a loophole, and we need to look at it again. This may not be the Bill to do it in, but it might be.
With those remarks, and hopeful that the issue of who the members of the ICBs will be will run through our discussions for the next few weeks, I beg leave to withdraw the amendment.