Mental Health Bill [HL]

Lord Kamall Excerpts

Committee stage
Tuesday 14th January 2025 Lords Chamber

[Lord Kamall (Con)]

My Lords, I am sure the noble Lord is thinking, “If only all groups went as swiftly as this one”. I thank him for bringing forward these government amendments. We understand that although they are largely technical in nature, they address some important points regarding the delivery of aftercare services, tribunal reviews and the broader application of this legislation.

We see the point of Amendments 7, 14, and 127 to clarify the references to aftercare services under Section 117 of the Mental Health Act, including services arranged by public authorities in addition to those directly provided. We understand that this reflects the practical realities of service delivery and may help to avoid ambiguity in how these obligations are interpreted. If we have heard any lesson throughout this debate, it is about how we avoid ambiguity when it comes to the treatment of patients.

We understand also that Amendments 87 to 94 focus on tribunal reviews for patients subject to conditions amounting to a deprivation of liberty, which we have discussed in other groups. The proposal to commence these provisions two months after Royal Assent is pragmatic and necessary to provide patients with timely access to justice. The amendments also introduce a new clause requiring the Secretary of State to refer certain cases to the tribunal within defined timelines. We agree that this will ensure that patients who are conditionally discharged but not recalled to the hospital are not left in a state of indefinite uncertainty. Once again, that was covered in the last group of amendments as somewhere where the patient could fall between the cracks, as it were. Timely tribunal reviews are essential for safeguarding patients’ rights and ensuring that any conditions imposed remain proportionate and necessary.

We understand also that Amendments 161 and 162 propose adjustments to the commencement of specific provisions, including granting Welsh Ministers powers to make consequential provisions within their devolved competence. Though these amendments are largely procedural, they underline the importance of clarity in implementing the reforms set out in the Bill. Of course, we understand that healthcare is a devolved matter. I remember having to deal with the devolved Administrations when I was a Health Minister, and we always did so collaboratively. Welsh Ministers should indeed have the same right to make consequential provisions, although if I have a question for the Minister, it is: what safeguards and oversight mechanisms will be in place to ensure equal application of the Bill to Wales, as in England? I am sure he will be aware that we have sometimes had questions in this place as to why the standard of health or social care in another part of the United Kingdom might be different, even understanding that it is due to devolution. Are there any safeguards to ensure that one part of the UK is not seen as having an inferior service to the rest of the UK? How would the Government address that?

With that, we very clearly understand that these are technical amendments and we will not oppose them.

[Lord Cryer (Lab)]

I am grateful to the noble Lord and take his point about ensuring there are equal standards across the devolved Parliaments and Assemblies. However, nothing is guaranteed. As he undoubtedly did when in government, we will endeavour to collaborate with Welsh colleagues—as well as others—to ensure that equal standards are applied across England and Wales. That includes regular contact with the Senedd and the Welsh Executive on a variety of matters, including health. That may be a slightly vague answer, but at the moment it is the best I can do.

I thank the noble Lord for his other comments. I have spoken about the need for these minor, technical and necessary amendments, and I hope noble Lords can support them.

[Lord Kamall (Con)]

This raises another issue, which I know has been raised in other areas of healthcare, of families who live across borders—if the parents live in one part of the United Kingdom and the children live in another, or if someone who has lived away from home moves back. I do not expect an answer now, as that would be unfair, but if the noble Lord could write to noble Lords on cross-border issues, where someone has commenced care in one area but then they or their parents have moved to another area, that would be satisfactory. We had a number of issues around this in healthcare, particularly mental health care, and it is important to resolve them.

[Lord Cryer (Lab)]

I am happy to do that. I remember having those sorts of issues when I was a Member of the other place. Probably a number of us have experienced them. I suppose that, at present, it is how it has always been: you have to try to communicate with the respective authorities and bring them together so that there is some sort of continuity.

Mental Health Bill [HL]

Lord Kamall Excerpts

Committee stage
Tuesday 14th January 2025 Lords Chamber

[Baroness Berridge (Con)]

In supporting Amendment 1, I am delighted that the noble Baroness, Lady Tyler, began Committee with this focus on the impact of the Mental Health Act on racialised communities, because that is where this whole journey began, with the noble Baroness, Lady May, when she was Prime Minister, announcing it in that context—and then, of course, it became a wider reform of the whole Act.

I served on your Lordships’ Joint Committee with the other place, scrutinising the Bill. In the course of that, I became aware of the relative strengths of civil society among some of the groups. There were excellent civil society groups speaking on behalf of people with learning disabilities and autism; they were highly professional and articulate. We had one evidence session on the effect of the Mental Health Act on racialised communities, but I saw that the strength of civil society and of media coverage in that area was less—so I am sympathetic to Amendment 1, which would give a profile to one of the main issues under the legislation.

On whether the table should be in the Bill to be in the code or in the Bill sitting as primary legislation, I have sympathy for that proposition. We have learned that the code of practice merely reflects primary legislation. I am aware, of course, that the independent review came up with those four principles, and this fifth one was not part of that. I expect to hear the Minister say that it is already in the Equality Act, so we do not need to put it in the Bill—but I am persuaded of the merits of the amendment. During the whole process of an independent review, a White Paper, a response to a White Paper, a draft Bill, a Joint Committee and now the Bill before your Lordships’ Committee, it has become clear to me that many of the changes that ethnic minority communities need to see are in practice. They are in resources and training—people would not look to the Bill and see their needs as the first or an important priority in it. I would be grateful if the Minister would take seriously this consideration of putting this equity principle in the table and putting it in the Bill, full stop, and not within the code.

[Lord Kamall (Con)]

I begin by thanking all noble Lords who spoke to this first group of amendments in Committee. Before I comment, I refer noble Lords to my interests as set out in the register. I am not an honorary fellow of the Royal College of Psychiatrists, noble Lords will be relieved to know, but I should mention my previous work with a couple of think tanks—the Institute of Economic Affairs and Politeia, which have both published on health and social care issues. There is also my work at St Mary’s University, where I am a professor of politics and international relations, and which has recently applied to open a new medical school. I also sit unpaid on the advisory board of a start-up coalition, and I know that there are a number of start-up companies helping people with mental health conditions. I just wanted to cover those interests, in case anyone made any accusations.

This group addresses the principles that will guide the application of the Mental Health Act, as set out in the Wessely review. Sir Simon pointed out, rightly, that there are already guiding principles in the code of practice, but that

“there is limited awareness of these, and it seems very likely that they do not inform practice in the way they should”.

Clearly, as noble Lords said at Second Reading, the important aim of including the four principles is to improve their application and ensure the highest level of care and therapeutic benefit for patients, while ensuring that all patients are treated as individuals.

I thank the noble Baroness, Lady Tyler, for her Amendment 1. Of course, equity is at the heart of the Bill, as my noble friend Lady Berridge just said. The Wessely review was commissioned by my noble friend Lady May of Maidenhead with the intention of understanding why a disproportionate number of black people were being detained and receiving community treatment orders under the Mental Health Act. I think all noble Lords welcome the idea of including equity in principle, as long as it then feeds through into practice. That is the key here, and my question for the Minister is: would putting the principle in the Bill make a difference to practice? How do we make sure that it makes a difference to practice, rather than simply adding the words or adding the principle? One of the values in the NHS constitution is that “everyone counts”. Does this equality duty go further than that, and would it have a greater practical significance? That is one of the questions we need to dig out and probe the Government on.

The noble Baroness, Lady Tyler, makes an interesting observation with her Amendment 3. The principles were included in the Bill, as the Wessely review argued, to improve clinical practice. This is vital, because we know that the Mental Health Act is the legislation that is used to compel detention in hospital for treatment. This may very well raise awareness of the principles, but once again, how do we make sure that this is applied? We have to keep pushing this point, although I will not repeat it again, of making sure that this gets fed in to practice in the clinical setting.

I also note the amendments in this group of the noble Baroness, Lady Whitaker. I will not repeat the statistics that she read out about the impact of the lack of or inappropriate support for people with mental health issues or learning difficulties. Of course, it is not difficult to appreciate the complexities. Someone in my close family worked with speech and language therapists in his youth, and I could see the difference it made. It is almost too obvious to say, but how do you get your needs across if you cannot communicate them, or your needs are not understood by the person who is supposed to be offering treatment? As the noble Lord, Lord Patel, mentioned, this is included in the Explanatory Notes, but how do we make sure that it gets into the Bill and into practice? Obviously, it is a problem that is acknowledged by the Government, or it would not be in the Explanatory Notes, but why have the Government chosen not to go any further on this issue?

I was very struck by what the noble Baroness, Lady Murphy, said about Amendment 49 and her concerns. Will the Minister address that debate? Of course, we all want to make sure that patients feel that they are understood. We know that patients have to be supported as much as possible to make sure they get their point across and that they are understood, in order to give them adequate treatment, but I noted the concerns of the noble Baroness, Lady Murphy, even though the noble Lord, Lord Patel, intervened. Have the Government taken a view on this or does the Minister need to write to us? I look forward to her comments.

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

My Lords, I feel it necessary to start, instead of talking about the Bill, by offering our condolences to the noble Baroness, Lady Hollins, on the very recent loss of her dear husband, and to thank her, as I know all noble Lords will do, for her close engagement on these reforms over many years. I say to the noble Baroness, who said she would be watching if she could, that we absolutely understand why she cannot be with us today. We miss her and I know that the thoughts of all noble Lords will be with her at this very sad time.

If I may make a few general points, as we know, this legislation has been in development for many years. I put on record my thanks for the collaborative and constructive nature of that work and the discussions I have held in my post over the past few months with Peers on all sides of the House. I extend my appreciation to the former Prime Minister, the noble Baroness, Lady May of Maidenhead, for her highly significant role in commissioning the independent review which informed this Bill and to Sir Simon Wessely and all those who worked on this landmark review, which provided a blueprint for this Bill. Like other noble Lords, I am very pleased to have got to this point.

--- Later in debate ---

[Baroness Merron (Lab)]

I thank noble Lords for their interventions. I will take the point from the noble Baroness, Lady Berridge, first. Following Royal Assent, we will be drafting and consulting on a revised code of practice, which will be laid before Parliament. We will be working with key partners to ensure that everyone is trained in the new Act before the first major phase of reforms. I hope that that will be helpful.

I hear the disappointment in the comments of the noble Baroness, Lady Barker. On her request for specific examples, I will need to write to noble Lords on that. I hope noble Lords realise that not having the principles in the Bill, as the amendment refers to, does not mean that there is less intention that they apply. For me, it is about the way of getting there, rather than the commitment to it. However, I hear the question about that point.

Amendment 49, on the matter of speech and language therapists, is in the name of my noble friend Lady Whitaker, supported by the noble Lord, Lord Patel, and my noble friend Lord Bradley. I turn first to the question raised by my noble friend Lady Whitaker. It is true that not all speech and language difficulties or differences would count as a disability under the Equality Act 2010, so my noble friend makes a relevant point.

The definition of who can and cannot be approved as an approved clinician was spoken to by the noble Baroness, Lady Murphy, and the noble and learned Baroness, Lady Butler-Sloss. That definition is set out not in primary legislation but in instructions issued by the Secretary of State, under the power in Section 12ZA of the current Mental Health Act. These instructions have the same status as secondary legislation, so it is our belief that it would not be appropriate to specify in primary legislation that speech and language therapists can be approved clinicians, because all other professional groups are covered only in the instructions.

For that reason alone—but noble Lords should bear with me—we will seek to reject this amendment. However, I can commit that we will be revising the statutory instructions under Section 12ZA following the passage of the Bill, and we are very happy to consider extending the criteria to include speech and language therapists. I offer an invitation to the royal college to discuss this matter with the department and to consider how it can work to support and encourage those of its members who may be interested in this role.

I am aware that time is not on my side. However, a number of amendments in this area have been tabled—

[Lord Kamall (Con)]

I wonder whether I can be of help to the Minister. The timing is advisory so, if there are important points that the Minister wishes to make, she should please go ahead.

[Baroness Merron (Lab)]

I have never had so much encouragement to carry on speaking. Noble Lords will be glad to know that the flashing clock always makes me very nervous. I thank the noble Lord, Lord Kamall.

--- Later in debate ---

[Baroness Berridge (Con)]

Perhaps I can clarify. I think that the noble Baroness’s amendment is to some extent based on the spirit of the Joint Committee’s report, which was about providing some kind of mechanism, after the 28 days—I am glad to see the noble Lord, Lord Bradley, nodding. There would be a specialist tribunal, and we said that it should be composed of people with experience of learning disabilities and autism, so that there was not a get-out for clinicians that they had not done the assessments properly. There would have to be grounded reasons to go beyond the 28 days and, in exceptional circumstances, you could authorise the detention, to make sure that the law covered that gap or group of people. No one wanted to see people detained for the reason that there was no community provision—that is ridiculous.

I accept that the reality is probably going to be that clinicians will find a mental disorder diagnosis to use the powers under Part II to do what is in the best interests of that person and their family at the time. But the law should also cover that situation and not force clinicians into those diagnoses—hence the need for accurate data, so that we can track what is happening when the law is enacted.

[Lord Kamall (Con)]

Once again, I am grateful to all noble Lords who spoke to this group of amendments. The purpose of today’s Committee is to probe the Government, but it is interesting that we find noble Lords probing each other—though I have learned a huge amount from these discussions. They say that discourse leads not only to liberty but to an increase in knowledge.

I add my words to those of the Minister and offer my condolences to the noble Baroness, Lady Hollins, who is not in her place today. I recall a debate in 2021 led by the noble Baroness—one of my first as Health Minister—in which she highlighted that people with learning difficulties and autism were being detained in secure settings, even when an assessment had recommended that they should live in the community. This goes back to the words of my noble friend Lady Berridge, who talked about how we can deal with the world as it is and not with the ideal world that we want to live in.

I was shocked at the time by what the noble Baroness, Lady Hollins, told the House about some of the findings from the oversight panel for the independent care (education) and treatment reviews. I bear in mind what the noble Baroness, Lady Bennett, said, when she gave some examples of other countries with much shorter detentions, but I will never forget the story that the noble Baroness, Lady Hollins, told about a Mr W, who had been detained in hospital for more than 20 years, spending most of his time in what amounted to solitary confinement. At the time of the debate, Mr W had been living in his own home for nearly three years, near his family, with his home environment and care being built around his needs. That is something that all noble Lords are trying to push for in this group of amendments. It was not only a heart-warming story but the point was made that, financially, it cost no more to support Mr W living in his own home than it did to detain him in hospital. More importantly, the noble Baroness shared the happy ending that, despite the trauma of being in the wrong environment for so many years, Mr W was, we hope, going to live happily ever after. That highlights the reasons for the amendments in this group.

I should add that I recall the noble Baroness who is now the Minister pushing the Government from these Benches on ending detention. I am sorry—I am going to be a little naughty here, but she can do it if we ever get back into government. She told the House that the average length of stay for people with a learning disability and/or autism in in-patient units was 5.4 years, saying:

“That is 5.4 years that no person will ever get back”.—[Official Report, 28/10/2021; col. GC 231.]


She asked how that could be justifiable when the cost of living in the community was the same as the cost of detention. I know that she is naturally sympathetic to ending these detentions. The detention of those with autism and learning disabilities was one of the central issues addressed by the Wessely review.

I was interested in Amendment 4, in the name of the noble Baroness, Lady Bennett, arguing the definition of “mental disorder” under the Bill. While I am sympathetic to the amendment, can the Minister confirm whether my understanding is correct that the World Health Organization defines a mental disorder as

“a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour”,

and whether the WHO includes neurodevelopmental disorders, which includes autism? If so, are the Government sympathetic to Amendment 4 and considering bringing forward their own amendment? How would they avoid running contrary to the definition accepted by the WHO and included in the Diagnostic and Statistical Manual of Mental Disorders, particularly DSM-5? I understand the point that these things can change, as the noble Lords, Lord Stevens and Lord Scriven, have very importantly alluded to.

Amendment 5, in the name of my noble friend Lady Browning, seeks to ensure that, if a person has autism or a learning difficulty but not a mental health condition, we should not be using deprivation of liberty safeguards to replace detention under the Mental Health Act. We fully support my noble friend’s amendment and the intention behind it.

I am grateful to noble Lady, Baroness Murphy, who has tabled Amendment 35, for the time she has taken to share her experience and expertise with me and my noble friend Lord Howe. She addresses an issue that we should all be aware of with any legislation: that of unintended consequences. While most noble Lords here today would accept and support ending these detentions, for all the reasons that we have all given, and particularly after the harrowing stories that the noble Baroness, Lady Hollins, told all those years ago, how will the Government ensure that anyone with learning difficulties who could potentially pose a considerable risk in the community receive the required supervision? That is the challenge here, and it is the challenge to which my noble friend Lady Berridge referred when she reminded us that we have to talk about the world in which we live and not the ideal world that we all want.

I am very grateful to my noble friend Lady Berridge for sharing some of the deliberations of the pre-legislative Joint Committee, particularly on the issue of the High Court DoLS. Given that, and the point of the noble Lord, Lord Scriven, if we are to have alternatives, how do we prevent detention by the back door or opening a massive loophole for detention?

Amendment 39, from my noble friend Lady Browning, would ensure that detention was for needs associated with the degree of psychiatric disorder, along with Amendment 40. We are sympathetic to that, and I look forward to the Minister’s response.

--- Later in debate ---

[Baroness Bennett of Manor Castle (GP)]

I thank the Minister for her rich and full response, and indeed all noble Lords who have taken part in this important debate. It has been long but that has been quite necessary. I thank the Minister particularly for responding directly to my question about the UN Convention on the Rights of Persons with Disabilities. I do not agree with her response but I appreciate that she engaged fully with it, so I thank her for that.

I will not go through and summarise all the contributions, but I just want to make two points, which are perhaps specifically directed to the noble Lord, Lord Kamall, and the noble Baroness, Lady Murphy. A phrase which has been missing from our whole debate is the “social model of disability”. That is the idea that society is discriminatory, and that people are disabled by the barriers in society, not by their difference. That position was endorsed by the Government Equalities Office in 2014, and so far as I know, that still holds, and it is preferred by most disability charities.

I invite noble Lords to consider another phrase in this healthcare space, which is “parity of esteem”. I think that when we come to the social model of disability and physical disabilities, most people have now accepted that if there are only steps and not a ramp, that is a failure of society, not the failure of the person in the wheelchair. However, we have not heard in this debate an acknowledgement of the same parity of esteem—the same approach to mental disability as we have accepted towards physical disability—and we should consider and think about that.

In that context, just to pick up a couple of points from the Minister, she talked about how people with autism or learning difficulties can be detained for aggressive or irresponsible conduct. The Trieste model—if I can call it that—which is being adopted by many countries around the world, asks: “Can we intervene before that point and ask what has provoked that person? Can we intervene before we need to detain someone?” That needs to be very carefully considered.

The other point that the Minister addressed, which I confronted myself with, asking why I did not table the broader amendment that I might have done, is what happens when people get to the point of being a danger to themselves or—I stress that this is extraordinarily rare—a danger to others as a result of a mental disorder. Again, how did people get to that point, and should there not be services and support and community wraparound in the Trieste style? I do not think that any nation or area is saying that it has totally got to that point, but surely we should be aiming at that.

[Lord Kamall (Con)]

The noble Baroness referred to the Trieste model, and I thought that led to quite a deal of interest from noble Lords across the House. Could she share some details on the Trieste model with other noble Lords but especially the Minister and the department, so we can all start learning those lessons?

[Baroness Bennett of Manor Castle (GP)]

I should absolutely stress at this point that I am not an expert, but I will certainly do my best to secure as much information as possible and share it with all noble Lords. The Minister may also have access to resources that may not be available to me. Reflecting on the intervention of the noble Lord, Lord Kamall, perhaps we could even arrange some kind of discussion—it might be useful—and perhaps even hear some testimony, because that would really inform our consideration of the Bill. But in the meantime, I beg leave to withdraw the amendment.

Prisons: Health Services

Lord Kamall Excerpts

Tuesday 14th January 2025 Lords Chamber

[Lord Kamall (Con)]

I start by thanking the noble Baroness, Lady Morgan, for sending me a briefing in advance of this Question. She rightly and importantly highlights that cancer outcomes for prisoners are poorer than for the rest of the population, while the cost of services is greater. However, given that we will be debating the Mental Health Bill later today, I want to ask a related question. Over 30% of prisoners have a learning disability, so what steps are the Government, the NHS and the Prison Service taking to protect and care for prisoners with learning disabilities? They may be there partly as a result of their learning disability, and while in prison are often at their most vulnerable. What care is there for prisoners with learning difficulties in order to protect the public and reduce the risk of reoffending when they are released?

[Baroness Merron (Lab)]

As the noble Lord rightly says, the Mental Health Bill is in Committee this afternoon and I know we will refer to that. Certainly, the reforms in the Bill will speed up access to specialist in-patient care and treatment, in particular by introducing a statutory 28-day time limit for the transfer of patients from prison and other places of detention to hospital. On particular needs, which may be learning disability and autism, as I know noble Lords are aware, the Mental Health Bill is very focused on ensuring that people are being cared for in the right places in the right way, and that in places of detention people are being not just held but supported and their healthcare needs met.

Adult Social Care: Long-term Workforce Plan

Lord Kamall Excerpts

Monday 13th January 2025 Lords Chamber

[Baroness Merron (Lab)]

Retention is absolutely crucial. I was looking—as I know the noble Lord also does—at the vacancy rates and they are currently running at some 131,000. However, I was interested to note that they are not actually the best measure of capacity, or lack of it, because those vacancies can reflect new roles and short-term vacancies because of anticipated staff turnover. So I have had to rein myself in when looking at the relevance of vacancy rates.

On retention, there is a whole range of factors. In the immediate, I say to the noble Lord that we are professionalising the workforce by expanding the national career structure and have developed and launched a level 2 adult social care certificate qualification.

[Lord Kamall (Con)]

My Lords, as the Government and the NHS introduce new workforce patterns to take account of changes, surely they should also take account of advances in technology. Recent years have seen the successful testing of virtual wards in the NHS to treat and monitor patients who can be discharged from hospital but who require further care. They can be monitored in their home, freeing up capacity in hospitals. Given this, what are the Government and NHS doing to extend virtual social care to monitor care for social care patients? It would allow them to remain in their home for longer, where they are more comfortable, and it could be one of the many ways to alleviate workforce shortages in the social care sector.

[Baroness Merron (Lab)]

I myself have seen some tremendous examples of the use of technology in allowing people to be in the right environment for themselves and their situation. I assure the noble Lord that we are continuing to work to develop medical technology, not just getting it rolled out and applicable but developing new medtech where necessary.

Perhaps I could use this opportunity to make an allied point. We have also published new guidance on safe delegation to care staff, which I hope will also help professionalise the workforce. We are working to support that across the country. That includes, for example, having care staff taking blood pressure. These are simple but obvious measures that I think work for everybody.

NHS: Single-sex Provision for Staff and Patients

Lord Kamall Excerpts

Wednesday 8th January 2025 Lords Chamber

[Baroness Merron (Lab)]

I am sorry to hear of the noble Baroness’s experience, which I have heard her speak of before. To me, as I said earlier, it points to the need to treat people with respect, with dignity and without making assumptions. I cannot emphasise enough the need for sensitivity and respect, which applies to everybody.

While we are talking about changing facilities, we should think about the huge difference in shops over the years. There used to be communal changing rooms, but you would be hard pushed to find them now. People have private spaces for changing and this again applies to everybody. I recognise the challenge of the NHS estate, of course, but I am talking about creative solutions and working with staff to get to where we need to be.

[Lord Kamall (Con)]

My Lords, the noble Baroness is absolutely right to talk about dealing with this issue very sensitively, by respecting people’s dignity and acting with compassion. However, some NHS staff and patients—the noble Baroness, Lady Fox, referred to this—have asked for single-sex provisions to protect their privacy and dignity. If the Government are planning further guidance, how do they intend to achieve that difficult trade-off and balance in potential conflicts between single-sex provisions for NHS staff and patients and the rights of individuals under the Equality Act 2010, while respecting their dignity and acting with compassion?

[Baroness Merron (Lab)]

The noble Lord raises an interesting point. In all cases with guidance, that is always the balance we seek to reach. I am also interested in the history of this, and I am sure the noble Lord will remember that the 2019 guidance on trans patients in single-sex spaces proved somewhat controversial, if I might put it that way. The guidance was meant to be updated under the last Government, but this did not happen. I am advised that it was delayed by a dispute between the previous Government and NHS England, which also delayed proposed updates to the NHS constitution. These again were consulted on under the last Government—which was a good thing—but nothing actually happened. So all these come to us as a new Government and will be given full consideration to get us into the right place.

Health and Adult Social Care Reform

Lord Kamall Excerpts

Tuesday 7th January 2025 Lords Chamber

[Lord Kamall (Con)]

My Lords, I begin by echoing the comments made by my right honourable friend the shadow Secretary of State in the other place in support of all those who worked in the NHS and social care sectors over the Christmas period. They sacrificed their time, which could have been spent with their friends and families, to care for those most in need.

On the NHS app, we support the digitisation of health and care to modernise the NHS, and support digital patient records to allow joined-up health and social care to deliver better outcomes for patients and to inform patients. However, the NHS app already sends appointments and updates on treatment to some patients, while some GP surgeries prefer patients to use their own website, not the app. I would be grateful if the Minister could expand on how the updated app will differ and offer up further information to your Lordships’ House. Also, where your GP cannot see you, is the plan to allow all patients to book an appointment with another GP without having to deregister from their current practice and reregister with another practice? Will that be allowed with the updated app? One of the problems was always where there were GPs who could not see their patients but other GPs in the same area had spaces on their lists.

In the Statement, the Secretary of State said:

“We are rewarding trusts that cut waiting times fastest”,


and the carrot of “extra capital investment” is used as an incentive. This appears to make sense, but noble Lords will know that I have always been interested in potential unintended consequences. If the Government reward trusts with extra investment if they cut waiting times fastest, what will happen to those trusts that are not able to cut their lists as quickly? Will they see reduced investment, and will that simply lead to them continuing to perform poorly? What is the solution? Will hit squads—in the best possible terms—be sent in to turn them around? What other plans are there to tackle underperforming trusts which do not qualify for these extra incentives? How do the Government and NHS intend to avoid perverse incentives such as trusts prioritising certain patients over others—not necessarily based on medical needs—to cut waiting times to win this extra cash? How do we avoid that?

On social care, I appreciate the candour of the Statement in acknowledging that Governments of all colours, for decades, have not really dealt with this problem of long-term social care. As my right honourable friend the shadow Secretary of State said in the other place, we will work with the Government and the commission. However, I will put a few observations to the Minister. For decades, successive Governments have known about the ageing population, and Governments of all colours have commissioned report after report, which mostly gathered dust on the shelf. Although I have the greatest respect for the noble Baroness, Lady Casey, given that most commentators on social care agree that everything to be written about funding social care has already been written, I am curious to know what the Government expect to achieve by initiating yet another commission.

A solution was proposed in the Health and Care Act 2022. Noble Lords welcomed that we finally had a solution but disagreed on some of the details. But we had a solution to which the Treasury agreed. I remember the Opposition criticising the Government not for introducing the social care cap but for not doing it earlier, and they also suggested a number of tweaks. The incoming Government could have tweaked the numbers to address the concerns that they expressed at the time, and they could have grasped the nettle, but I am afraid that the announcement looks like yet another Government kicking the can down the road. So will the Minister write to noble Lords with the terms for the commission led by the noble Baroness, Lady Casey? This time, will the Department of Health and Social Care continue to work with the Treasury to ensure that whatever solution is finally proposed, even if it is likely not to be a new solution, has the agreement of the Department of Health and Social Care, other government departments and the Treasury? If not, it will simply find itself kicking the can down the road yet again when it comes to 2028.

My final point is on how to cut the backlog. These Benches welcome the Government continuing the policy of the last Government in opening new surgical hubs and community diagnostic centres at weekends and evenings. But, when we were in government, we found a potential workforce issue in opening community diagnostic centres at weekends and evenings. Of course, there are only so many staff who can be employed to keep these services open for longer, so have the Government made an assessment of how many staff they envisage will be available to keep these centres open for longer hours? What is the plan? Will it be a redeployment of existing staff, will existing staff be asked to work longer hours and overtime, or will they recruit new staff?

[Lord Scriven (LD)]

My Lords, we on these Benches welcome the Statement and can see some positives in the way forward, but we have some reservations about timescales and unintended consequences in the implementation that I would like to explore with the Minister.

On social care, we have already called for cross-party talks, as many noble Lords will know. Social care is in crisis and at a tipping point, and it is an unbearable pressure for many families. But we cannot understand why the review will take until 2028 and full implementation will probably not happen until 2029-30. It is a bit like calling the fire service when your house is on fire and asking it to attend once it is out. So what specific components of this review that are not already in the public domain have the Government already determined will take until 2028 to be dealt with? Will the review tackle all forms of social care, including continuing care and young people’s services?

The NHS elective reform plan marks a significant initiative for reducing waiting times and enhancing patient access to elective care. The plan introduces some welcome measures, but many are not new, such as the expansion of the diagnostic and surgical hubs, increased utilisation of digital platforms such as the NHS app and a commitment to meeting the 18-week referral to treatment standard by the end of this Parliament. Although these proposals are commendable, I have been of the view for many years that elective and emergency care need to be provided in different, and probably separate, ways. Several critical concerns warrant attention to ensure the plan’s success and sustainability.

A primary concern is that the plan focuses predominantly on elective care, potentially overlooking the broader health and social care ecosystem. The Nuffield Trust emphasises that, for the plan to be sustainable, there need to be concurrent reforms in social care, significant investment in community services and attention paid to the determinants of ill health, such as housing and education. The focus on throughput measures will mean that it will be focused purely on those. What outcome measures will be put in place, not just for the quantity and speed of care but for the clinical outcomes for patients?

The emphasis on meeting elective care targets should not overshadow other clinical priorities. It is critical to ensure that resources allocated to elective procedures do not detract from urgent and complex care needs. Indeed, the financial model set out in the plan on tariffs will create incentives to focus on elective cases when budgets are stretched. What measures will be put in place so that the expanded diagnostic and surgical hubs, along with the extra reported 3.5 million procedures in the independent sector, will avoid pulling staff away from urgent care and complicated patient needs? This must be based on a fully costed workforce plan, so when will that be presented?

The plan has been announced with little firm detail on funding, especially considering that the £3 billion ring-fenced for cutting waiting times this financial year will not be available from April. Will this ring-fenced scheme be reintroduced? While we welcome the thrust of this plan, there will be some unintended consequences, and we really need to see a detailed implementation plan to ensure that elective care does not overshadow emergency care and those seeking social care.

Health: Obesity

Lord Kamall Excerpts

Tuesday 7th January 2025 Lords Chamber

[Baroness Merron (Lab)]

The noble Lord raises a very interesting point. It is certainly the case that those who consume ultra-processed food have around 50% of their calorific intake through that matter. Where there is not clarity is on whether the foods are unhealthy due to processing or to their nutritional content. On that, the jury is out. We need to establish that. That is the why the Government’s Scientific Advisory Committee on Nutrition has concluded that the association between UPFs and health is concerning. We need to get to the bottom of why that is.

[Lord Kamall (Con)]

My Lords, the Minister rightly talked about the importance of creating the right environment for people to eat healthily. Some noble Lords may have seen daytime television programmes that help families to eat healthily on a budget. The challenge has always been how we take these lessons into people’s homes. I recently spoke to BRITE Box, a local community charity which gives families the ingredients and a recipe card with instructions to help them to cook healthy meals together. This helps with not only budgeting but addressing obesity. Rather than a top-down approach from the Government, what steps are they and the NHS taking to work with existing projects such as BRITE Box to take a bottom-up, community-led approach to tackling obesity?

Hospice Funding

Lord Kamall Excerpts

Monday 6th January 2025 Lords Chamber

[Lord Kamall (Con)]

My Lords, I begin by wishing the Minister and all noble Lords a happy new year. The Minister will know that most hospices are charitable, independent organisations, which the Government have recently thumped with increased costs through the rise in employer national insurance and the increase in the minimum wage, which, while welcome, also adds to costs. Will the announced increase in funding fully cover the costs that hospices will face from the rise in employer national insurance contributions and the increase in the national minimum wage? Instead of imposing extra taxes on hospices then giving them back some of the money that they will have paid due to the increase in national insurance, would it not have been better to exempt hospices and other health-related charities from the national insurance increases in the first place? Can the Minister also confirm that increasing the costs imposed on hospices and other health-related charities is not a deliberate attempt to drive out non-state providers?

Puberty-suppressing Hormones

Lord Kamall Excerpts

Monday 16th December 2024 Lords Chamber

[Lord Kamall (Con)]

My Lords, I thank the Minister for the Statement and the right honourable Secretary of State for the careful and sensitive way in which he delivered the Statement in the other place. In line with my right honourable friend the shadow Secretary of State in the other place, from these Benches we welcome the Government’s announcement. Whatever your politics, most people believe that one of the first duties of any Government is to protect their citizens, especially our children.

As the Secretary of State said, there has been too much heat, and perhaps toxicity, around the issue of services for children experiencing gender dysphoria, so I welcome the tone with which His Majesty’s Government have approached this issue—less heat, more light—and that they continue to take an evidence-based but compassionate approach. I also take this opportunity to thank the noble Baroness, Lady Cass, for leading the review on gender services for children. The Cass review highlighted the importance of putting scientific evidence above ideology and laid out the fact that we simply do not know enough about the long-term impacts of puberty blockers on children. That is why my right honourable friend in the other place, the Member for Louth and Horncastle, when Secretary of State, banned the routine prescription of puberty blockers for gender dysphoria, and later extended that ban to private clinics.

We welcome the decision of the Government to follow the recommendations of the independent Commission on Human Medicines to extend the banning order until a safe prescribing environment can be established for these medicines. This is a common-sense approach, and allows time for more evidence to be examined to consider the holistic and long-term impacts of puberty blockers on children. The Secretary of State announced the clinical trials to gather evidence but, given understandable concerns about the risks of any clinical trial, can the Minister reassure your Lordships that these trials will have robust safeguards to ensure the well-being and safety of any children taking part, while recognising the importance of having these trials in the first place?

The Secretary of State in the other place also spoke about alternatives to puberty blockers for children suffering from gender dysphoria. As someone who takes an interest in social prescribing, I welcome the Government’s recognition that medication is not always the best solution, so will the Minister share details of some of the alternatives to puberty blockers that will be offered to children?

Finally, noble Lords will be concerned that, despite the lack of evidence, puberty blockers were prescribed to children with gender dysphoria when their safety could not be guaranteed. What steps are the Government and the NHS taking to ensure that a similar situation does not occur again and that future decisions are led by evidence? I look forward to the Minister’s responses.

[Baroness Walmsley (LD)]

My Lords, on these Benches we welcome the tone of the Secretary of State’s Statement. I have often said that there are many ways of being human. Growing up can often be a very trying time for teenagers. How much more difficult, then, for those young people with gender distress who are struggling with finding out who they are while being different from their peers, and all without adequate support? It is high time that proper services were put in place for young people struggling alone with these issues. Their families too need help to support them at this difficult time. For too long, children and young people who are struggling with their gender identity have been badly let down by a low standard of care, exceptionally long waiting lists, even by the standard of mental health waiting lists, and an increasingly toxic debate.

We always want to see policy based on the evidence. With any medical treatment, especially for children and young people, the most important thing is to follow the evidence on safety and effectiveness. It is crucial that these sorts of decisions are made by expert clinicians, based on the best possible evidence. It is also important that the results of the consultation and the advice of the Commission on Human Medicines are made public.

Some might wonder why the treatment is deemed not safe for gender dysphoria patients but safe enough for children with early-onset puberty. More transparency might clear up the confusion and give more confidence to patients and their families. However, the Secretary of State himself admits that he does not know what effect the sudden withdrawal of this treatment for young people already embarked on a course of puberty blockers will have. These are the young people with the most urgent need for other types of care in the current situation, so what clinical advice have the Government taken about the effect of withdrawing these drugs on the physical and mental state of young sufferers of gender incongruence already on the drugs, and what physical and psychological support will be offered to them?

In the current circumstances, plans for a clinical trial are welcome, but we would like to know the criteria for those eligible to participate. What assessment have the Government made of the recent Council of Europe report, which raises the ethical and rights implications of offering participation in the trial to only a small group of patients? If the only way to continue access to these drugs is through participation in the clinical trial, whose scope, length and start date have yet to be announced, this lays the Government open to accusations of coercion and breaches of human rights.

We welcome the plans for additional treatment centres in Manchester and Bristol as well as London, but can the Minister say why they will not be up and running for two years? Is it lack of funding, lack of premises or lack of sufficient therapists with the appropriate specialist training? This is a very sensitive area, so the wrong people could do more harm than good. If that is the reason, is there a plan for training up more qualified therapists in time for the opening of the regional treatment centres? I very much look forward to the Minister’s replies to these questions.

NHS: Patients with Allergies

Lord Kamall Excerpts

Thursday 12th December 2024 Grand Committee

[Lord Kamall (Con)]

My Lords, I begin by thanking the noble Baroness, Lady Ramsey of Wall Heath, for securing this important debate, as well as for having some discussions before the debate so that I could better understand the issue. I am also grateful to the House of Lords Library for its briefing and to others who have sent briefings.

The noble Baroness and the noble Lord, Lord Mendelsohn, spoke passionately about their personal experiences as parents, and especially about the care that patients with allergies receive during the transition from childhood to being considered adults. I myself know family members whose children decided to go to a local university rather than go elsewhere because they knew that their local hospital had the best treatment and were not sure what the treatment would be like if they moved to another university town. Other noble Lords have alluded to a postcode lottery.

The noble Lord, Lord Scriven, said that such stories bring the statistics to life, but it is really important for us to talk about numbers. I read one report, I think by ITN, which said that 44% of adults in the UK have at least one allergy, but that includes asthma; other noble Lords have said it is one in three. Whatever the figure, it is far too high. We have seen, as the medical journal the Lancet has found, that the rate of food allergies has increased over the past decade. The noble Lord, Lord Mendelsohn, also mentioned that.

Plenty of those with allergies can continue to live normal lives, but there are an ever-increasing number of people whose allergies are debilitating. They cannot eat certain foods, and they are unable to use certain medications. They must constantly scan the list of ingredients of the food they wish to eat, either by reading the small print on labels or accessing companies’ or third-party websites, or, as the noble Baroness, Lady Keeley, said, they have to pay more for gluten-free or other foods according to their dietary requirements.

This may seem obvious, but food is one of humankind’s basic needs. It is an integral part of our daily lives, and so it is only right that we take the necessary steps to help those with allergies. It was reassuring to hear from the noble Baroness, Lady Burt, about the advice that was in her hotel room should you encounter someone suffering a severe allergic reaction. The question is how we spread that from hotel rooms to schools and more places.

The noble Lord, Lord Mendelsohn, and the noble Baroness, Lady Keeley, spoke about the sad story of Natasha Ednan-Laperouse, who tragically died in 2019 due to anaphylactic shock. Her case led to the so-called Natasha’s law, requiring all foods to carry a list of ingredients. I am proud, and I am sure that noble Lords are grateful, that swift action was taken by the previous Government. Indeed, it is a measure that has since helped countless sufferers of allergies to understand the food that they are consuming and the harms that they may cause.

We know, however, that more needs to be done. It is therefore welcome that the new Government are developing an allergy strategy. But what of the National Health Service’s role? As noble Lords will be aware, before the general election, Allergy UK published a list of steps that it wanted the new Government to take. As the noble Baroness, Lady Healy, has said, one proposal was that there should be an allergen specialist or dietician at the primary care level—the rationale behind this being that it would allow those with allergies to access specialised care, no matter where they may live. This seems a common-sense proposal, since it would enable those living with serious allergies to seek help with managing their allergies early in the process of diagnosis so that they can have a better quality of life and are not unnecessarily constrained by their allergies.

Noble Lords will also understand that there are resource constraints and that the Government of the day have to consider carefully where they allocate taxpayers’ money, given competing demands. I want to reassure the Minister that I understand from my time as a Minister the difficulties due to resource constraints and, sometimes, the practicalities of implementation, but that does not stop noble Lords asking the questions. Is this a policy idea that has been discussed within her department and with the NHS to work out its feasibility? I would be grateful for her assurances.

Like other noble Lords, I too wonder what more can be done within existing NHS structures. Some of the information is there, but how do we spread it nationally from ICB to ICB? How do we get it into schools? How do we get it beyond the hotel rooms? How do we make more people aware, so that when it is announced on a flight that nuts will not be served on a flight because someone has an allergy we avoid the collective groan and hear more understanding of those who suffer from these conditions?

Can the Minister explain what plans there are for all clinicians, including in primary care, secondary care and accident and emergency departments, as well as for other hospital employees, to be suitably trained and made aware of how to deal with patients who have serious allergies, as the noble Lord, Lord Scriven, alluded to? Has any thought been given to an allergy tsar, as the noble Lord, Lord Mendelsohn, mentioned? What safeguards are in place to ensure that no one with allergies slips through the net and is administered medication that contains ingredients they should not take? The noble Baroness, Lady Keeley, and the noble Lord, Lord Scriven, spoke about preventative strategies. What explicit preventative strategies are the Government and the NHS considering?

I know that all noble Lords are grateful to the noble Baroness, Lady Ramsey of Wall Heath, for securing this important debate and we look forward to the Minister’s responses.