Health and Care Bill

Lord Scriven Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Lord Scriven (LD)]

My Lords, I support the amendments in the name of the noble Lord, Lord Lansley, and declare my interest as a vice-president of the Local Government Association.

There has been a whole debate at Second Reading and in Committee about the equality of local government and the NHS in this regard. Importantly, local government focuses on place because it is used to doing so. If, as the noble Lord, Lord Lansley, has said, the legislation does not include powers to delegate right down to local government so that it can work with the NHS—which it sees as its key responsibility—then there will be a gap, and this will not be seen as a true partnership. More importantly, the powers that would unleash some of the issues central to the Bill—better integration, reducing health inequalities and improving health outcomes—will not be achieved. There will not be the powers of delegation that will be allowed to place when innovation starts.

That is why the amendments tabled by the noble Lord, Lord Lansley, are important, particularly Amendment 96, on the roles of the place board. If the Government do not take this forward, it will be a total abdication. Place will be important in unleashing innovation, and the noble Lord, Lord Lansley, has rightly pointed out this gap in the legislation.

[Baroness Walmsley (LD)]

My Lords, the noble Lord, Lord Lansley, has made some important and sensible points, and I look forward to hearing the Minister’s reply.

My noble friend Lord Scriven raised the important question of the role of local authorities. I simply want to add that I happen to know that some of the chairs-designate of the ICBs would really like to know the answer to the question posed by the noble Lord, Lord Lansley, early on in his speech. What is the relationship of the health and well-being boards to the ICBs? If those people are confused, it is not surprising that noble Lords are too.

Health and Care Bill

Lord Scriven Excerpts

Lords Hansard - Part 2 & Report stage
Tuesday 1st March 2022 Lords Chamber

So my amendment is there to ensure that this does not get forgotten in the way that services are commissioned and planned for, and so that rehabilitation is viewed as an integral part of the follow-on after the acute phase, as people get home, transition from hospital into the community and look towards resuming their life. It might well be very different from the life they had before, but this would enable them to fulfil their potential.

[Lord Scriven (LD)]

My Lords, I support the amendments in the name of the noble Lord, Lord Crisp, to which I have added my name. I think the noble Lord had to table these amendments because the Minister said when we discussed this in Committee that his challenge was to ensure that

“primary care is better represented and not dominated by acute trusts.”—[Official Report, 20/1/22; col. 1854.]

We expected something to come back that did exactly that, because the very fact the Minister said that suggested that the Government had accepted that there was a potential imbalance with the role of primary care.

I come back to the purpose of the Bill, which I did a number of times in Committee. The purpose of the Bill is to bring about effective integration, improve health outcomes and reduce health inequalities. That is underpinned by making primary care central to healthcare planning and ideas about healthcare, following through on those plans and having primary care as an equal partner in the ICB. So we moved away from who we want on the board to asking very simply for primary care to be treated as an equal in the planning, implementation and monitoring of what will happen in health and social care in the area. It is disappointing that, despite the Minister’s suggestion that he would go away and look at this, nothing new has come back since Committee to deal with that.

What new has come back on Report which makes sure that primary care can be better represented and not dominated by acute trusts in this new system? My worry is that the Bill giving this to NHS acute trusts and foundation trusts signals which are most important within the system. If primary care does not have that equity, there will be unrealistic expectations and uninformed decisions made in planning for final decisions and tactical, not transformational, systems and services, which will not represent the full view of primary care. It is for those reasons that I support the amendments of the noble Lord, Lord Crisp, and look forward to the Minister bringing to the House’s attention what new proposals are in here on Report to do with the challenge that he set himself: to ensure that primary care has a bigger voice and is not dominated by the acute sector.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I added my name to the amendments of the noble Lord, Lord Crisp, and echo the remarks of the noble Lord, Lord Scriven, on the Minister’s offer in Committee to go back to see how the potential dominance of acute trusts could be mitigated by ensuring that the voice of primary care was heard loud and clear in the various decision-making bodies.

It is a pity that it is a very late hour, because primary care warrants a much wider debate, given the challenges it undoubtedly faces. We are all aware of the workforce issues, such as the reluctance of many GPs to take on partnerships and that so many GPs will do only part-time work, partly because of the pressures. It is because of those challenges and because primary care is so valued in this country that we need some assurances that the people running the new system being introduced through this legislation will be concerned with and listen to primary care.

It is somewhat ironic. The noble Lord, Lord Lansley, is not here any more, but in a sense, we are seeing a transformation from what he hoped would be a GP-led system through clinical commissioning groups to one which looks very strongly acute care-led in the integrated care boards. As someone who was spent quite a lot of my time in the health service around acute trusts, I do not particularly worry about acute trusts being listened to, because we depend on them so much. We really need assurance that integrated care boards will take primary care seriously.

Finally, whatever concerns and reservations we on this side of the House had about clinical commissioning groups, some GPs undoubtedly rose to the challenge of leadership within them. I should be very concerned if they were lost from the new arrangements. It would be good to know that the Government recognise that and will ensure that a place is found for them in the new system.

Health and Care Bill

Lord Scriven Excerpts

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

We have a world choked with plastic. We have a world wildly overheating. We have a world—as the noble Baroness, Lady Young of Old Scone, said—where biodiversity is in collapse. I think the NHS is starting to focus on these things, but we need to see, as the IPCC said, that health and environment are not two separate issues. We live in the environment, and we have to look after it in every part of our activities.

[Lord Scriven (LD)]

My Lords, I rise for the first time on Report and declare my interests as laid out in the register, particularly as a non-executive director of Chesterfield Royal Hospital NHS Trust and as a vice-president of the Local Government Association. We on these Benches welcome this suite of amendments, with a caveat of clarification that the noble Baroness, Lady Young of Old Scone, raised, to do with not just the climate but the implications for the environment.

The reason we welcome this suite of amendments is that it is vital that there is mandatory guidance from the centre to all parts of the system in the NHS. The only thing I seek to push the Minister on is that she said the guidance would be out within 12 months. I ask that, as we are in a crisis and this is important, it is done as soon as possible. The reason for this—I have experience of it from Chesterfield—is that some of the procurement or building decisions made today will not come around for maybe three or four years, but the design and implications that start today have life cycle implications for both the climate and environment over a long period. So, I strongly push the Minister to ask that the guidance is out as fast as possible, and we do not wait for the whole 12 months.

[Baroness Walmsley (LD)]

My Lords, I, too, am a member of Peers for the Planet and I congratulate the noble Baroness, Lady Hayman, and the noble Lord, Lord Stevens, on their engagement with the Government and thank them for taking their concerns on board.

I have previously raised the fact that a big way in which the NHS can reduce its emissions is by having energy-efficient buildings, and I should like reassurance that any new buildings and refurbishment of the NHS estate will involve highly insulated and low-energy buildings. There are so many things that the NHS can do by using low-energy lighting, reducing microplastics, using compostable single-use plastic or not using plastic at all and using microwaves to deal with clinical waste, because they are much more energy efficient. How will all this be reviewed after the Bill has passed? Will there be any reporting back on how well the NHS has been able to respond to this challenge?

Covid-19: Lateral Flow Tests

Lord Scriven Excerpts

Thursday 10th February 2022 Lords Chamber

[Lord Kamall (Con)]

I should perhaps start with some background on this and why we have reached the situation we are in. Her Majesty’s Government began the large-scale procurement of Covid-19 test kits at the height of the pandemic. To ensure supplies for the universal testing offer, Porton Down assesses tests offered to Government. It found that three-quarters of those offered failed to meet their stated performance in their instructions for use. For most testing technology, the manufacturer needed only to do self-assessment to meet the CE marking rules, but clearly, when they were tested, they were not meeting those standards. We considered that the current standard was insufficient and did not keep bad tests off the market. That is why we had a public consultation in April that showed strong support for a more rigorous regime. In terms of avoiding a cliff edge, as it were, if they have not been validated, we are looking at solutions.

[Lord Scriven (LD)]

My Lords, reports indicate that the Government are seeking to implement testing only in health care settings and for the most vulnerable people, along with stopping the requirement to self-isolate if a person has Covid-19, in the next two weeks. What evidence from SAGE and NERVTAG do the Government have to show that at present, this is in the best public health interest of the country?

[Lord Kamall (Con)]

I am not aware of any announcements or measures that accord with the noble Lord’s question.

Covid-19: Lockdowns

Lord Scriven Excerpts

Wednesday 9th February 2022 Lords Chamber

[Lord Kamall (Con)]

My noble friend raises an important issue about the trade-offs that had to be considered when the Government announced the lockdown and plan A measures. They also announced measures to restrict the transmission of the disease. Costs and benefits had to be weighed up. It was often a nuanced decision. We are clear about the backlog in tackling mental health issues. In debates on the Health and Social Care Bill, many noble Lords across the House have expressed the importance of tackling mental health issues in this country. We hope to put that at the forefront of future health policy.

[Lord Scriven (LD)]

My Lords, all papers with modelled counterfactuals are excluded from the report mentioned in the noble Lord’s Question. As this is the most common method used in infectious disease assessments, does the Minister agree that this has the practical effect of excluding most epidemiological research from the review?

[Lord Kamall (Con)]

Had I still been in academia and was asked to referee this paper for a journal, I would have pointed out a number of issues, including the focus and bias on one particular study, for example, and the studies that were excluded without justifying why.

Vaccination: Condition of Deployment

Lord Scriven Excerpts

Thursday 3rd February 2022 Lords Chamber

[Lord Kamall (Con)]

I begin by agreeing with the sentiments expressed by the noble Baroness that we should not necessarily be labelling people who decide not to take the vaccine. We should understand individual choice, but with freedom comes responsibility, and we always have to get that balance right. At the same time, I do not think that some of the characterisations that have been given are helpful. Having said that, if people have stopped other people being vaccinated, they should be dealt with by the law. The noble Baroness and I agree on individual choice, but, clearly, this was an emergency and people were dying and it was important that patients going into hospitals and care homes felt confident that they were being treated by staff who would not pass the virus on to them. There is always a difficult balance between liberty and responsibility.

[Lord Scriven (LD)]

My Lords, I come back to the really important issue raised by my noble friend Lady Brinton about the letter that went out last night to providers of CQC-regulated adult social care activities, except for care homes. My noble friend gave the Minister three hours’ notice of this question because, if care homes do not receive a letter by midnight tonight, under the law they will have to send out notices of termination to staff. Can the Minister give an absolute guarantee that, by midnight, or as early as possible, a letter will go out to stop the confusion whereby many care home providers do not know whether to keep their staff or send out a letter of termination? This is critical.

[Lord Kamall (Con)]

I hope that the noble Lord will forgive me, but I had a lot of meetings on the Bill today. When the questions came in and I saw the original answer, to be perfectly frank, I was not content with it and I pushed back, which is why I need more time to answer the question.

We are completely clear. We intend to revoke the requirement in its entirety for both care homes and the health and wider care sectors. The care home requirement has been in force since 11 November, but the requirement for health and wider social care was not due to come into force until 1 April. This means that first doses would have been needed by today in order for people to be fully vaccinated by 1 April. We wrote to the sector to clarify how the 3 February deadline would be impacted by the Government’s intention to revoke the regulations. While this particular question was specific to wider social care settings, not care homes, the letter was clear that we intended to revoke them for both care homes and wider social care.

--- Later in debate ---

[Lord Kamall (Con)]

One of the things we have constantly done has been to listen—I had daily calls over the Christmas period, for example—and follow the evidence. Clearly, one of the issues may well have been staffing and warnings of potential shortages, and we had to balance all that up. As the noble Baroness, Lady Finlay, said, these things are nuanced; there are number of different factors we have to consider.

As for professional responsibility, on more than one call I have been on with senior NHS staff, clinicians and senior practitioners, they have told me that in their codes—for example, the GMC code and the nursing code—there is a professional duty to be vaccinated against transmissible diseases. Clearly, that is an issue. The NHS has had to speak to individual clinicians, those who have been reluctant, to try to press that issue, but clearly it came up against freedom of choice. It is difficult and I may not understand it, but we all think differently, which is why we have such great diverse thoughts and debates. It is really important that we understand individuals’ concerns and we can address them, but we are not going to be able to persuade everyone.

[Lord Scriven (LD)]

My Lords, the Minister is an honourable man and tries his best. The letter that went out yesterday evening has literally caused confusion. People in care homes will be sending letters of resignation. Can he give a guarantee from that Dispatch Box that something is going to go out before midnight tonight, before notices go? It is really important.

[Lord Kamall (Con)]

I thank the noble Lord for raising this issue and emphasising its importance. As soon as I leave this Chamber, I will go back to the department and ask what is being done and notify him. I thank him for raising it.

Health and Care Bill

Lord Scriven Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Meacher (CB)]

My Lords, I added my name to Amendment 219, and I support all the amendment in this group. In view of the number of excellent speeches that have been made, I have given up on my speech and just want to ask the Minister a question. I am sure he finds it completely unacceptable that half of carers who provide significant care for a loved one say they have not even been consulted about a discharge from hospital and two-thirds of them say that they have not been listened to about whether they are able to care for their loved one when that person might be coming out of hospital. I ask the Minister to assure the Committee that he will be able to bring back an amendment on Report on this critical issue.

[Lord Scriven (LD)]

I support in particular Amendment 217. In so doing, I draw the attention of the Committee to my interests as set out in the register, particularly as a vice-president of the Local Government Association.

I want to make three very clear points about this. First, this amendment refers to assessment; it does not refer to the package of care. The assessment is the first stage, before the social workers and before adaptation or anything else can happen, so the person leaving hospital gets a sense of independence and support to lead as independent a life as possible and to help them in their recovery. Evidence shows that the best way to start the assessment is on the day that the person is admitted. It is not about waiting for an optimal time. The assessment may change as the person progresses, but all the evidence shows that assessment should start on admission. The concept that there is an optimum point does not stand up to the evidence.

Secondly, having this framework within the Bill, with timescales and so on, does not stop local innovation, it just gives a framework for local innovation and integration to take place.

My third point is a question. I know of no condition—unless the Minister can inform the Committee of one—where starting the assessment two weeks after a person leaves hospital is in the best interests of that person; they may have to wait six, seven or eight weeks for the package of care to be put in place. Can the Minister tell us for which conditions the suitable and optimum point at which to start the assessment is after a person has left hospital?

[Baroness Bennett of Manor Castle (GP)]

My Lords, after this rich and informative debate, I will briefly make two points and offer the Green group’s support for all these amendments.

I share the shock expressed by the noble Baroness, Lady Tyler, and others that we are in a situation where in the House of Lords we are trying to put the situation back to what it was before because the Bill is making it so much worse.

I particularly want to address Amendment 269 about young carers. I should perhaps declare that I have never been carer—I have not been in that situation. But I want to share a little bit of what I learned from Sophie Dishman, who I met in 2015, when she was a student at the University of Sunderland. She told me that she became a carer at about the age of 12, but that it was only when she was 18 that she realised that she was a carer—a point that many others have addressed. As well as continuing to care, she created a campaign at the University of Sunderland to inform others about the situation and perhaps help others identify themselves as a carer. She produced a very clever, witty, attractive tote bag, with the line, “Being a carer at uni can be a lot to carry around”, a check list of all the things that you might have to do being both a student and a carer, and a useful leaflet, designed for staff in particular, showing signs that a carer might need help.

I want to make the point, which I do not think anyone else has made, that young carers are by nature people who have developed an enormous amount of capability, knowledge and skills. They are amazing individuals. It is not only the right thing to do but in society’s interest to make sure they are able, as the noble Lord, Lord Howarth, said earlier, to flourish and develop those capabilities. It is in our interest to do that.

I want to point to an article that has been out for only a couple of weeks, in volume 27, issue 1 of Child & Family Social Work. The headline is

“It’s making his bad days into my bad days”,

and the article is about young carers in the Covid emergency. This is where we are now. It is about just how much more difficult the withdrawal of services has made it for carers, particularly young carers. We have a huge, as yet uncertain, but certainly large, burden from long Covid, and many people will be taking on huge caring responsibilities because of it.

Covid-19: Antiviral Pills

Lord Scriven Excerpts

Monday 31st January 2022 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for her question and for making people aware of the PANORAMIC study. One of the things that we are trying to do is look at the communication programme. If we look at the antiviral taskforce, we are looking at a number of different communication channels. For example, tomorrow morning, I believe, I will be co-chairing a webinar with many black and minority ethnic groups and activists to see how we can roll out and get their support in rolling out to those communities. We are looking at a number of different channels and particularly working with a lot of the charities which specialise in things such as chronic kidney disease, liver disease—I have a long list of conditions, which I will not read out now.

[Lord Scriven (LD)]

Priority test kits are meant to have been sent to people with immune conditions, so that they get the antivirals within five days of having Covid symptoms. Tens of thousands of people have not got these priority tests and, as Leukaemia Care has said, patients have been sent round in circles having to make up to 20 phone calls to get the test kits. Why has this mess arisen and what are the Government doing to solve it as a matter of urgency?

[Lord Kamall (Con)]

I thank the noble Lord for making me aware of this. I was not aware of this. I was told test kits were available to anyone who was considered immunosuppressed or vulnerable in advance. Given what the noble Lord has said, it is important that I investigate and write to him.

Health and Care Bill

Lord Scriven Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

I shall say a few words in support of the noble Lord, Lord Warner; I put my name to his original Amendment 285 and, obviously, I very much endorse what he said. Reading the Select Committee report again, I find it as fresh as ever and its analysis of the issues faced in the NHS are exactly the pressures we see at the moment. Let us be clear: it was a hard analysis. We are all proud of the NHS, but the report rightly pointed out that it performs poorly in comparison with many countries on many indicators. In acute care, we have worse outcomes for survival for stroke and heart attacks, we lag behind comparable European countries for cancer survival, and we have fewer beds, fewer doctors and fewer nurses per head than OECD averages. As capacity is so tight, it is no wonder, given the current pressures post pandemic, that the NHS is struggling to meet the challenges it faces. We have talked about dental access, but we could talk about the horrendous waiting times for treatment or the dreadful ambulance waiting times which are frightening for people with very serious illnesses.

The Government’s approach is one initiative at a time on the whim of the Secretary of State at the time. We have already got the Messenger review which is bringing in a general to tell the NHS how to manage its services. How many times have we introduced people before? I think Secretary of State Hunt established the report by the noble Lord, Lord Rose. He clearly wanted Rose to say that NHS managers were useless. Of course, the noble Lord did not say that. He said that Ministers are useless at creating circumstances in which managers can thrive. Messenger will come out with the same response and his report will also be rejected because what these reports all say is that the way Ministers lead from the centre is non-conducive to the sensible management of the NHS at local level. Bringing some long-term planning to the NHS with the proposals that the noble Lord, Lord Warner, suggests seems to be eminently sensible. I hope this is one of the issues that we will take to Report because it is fundamental to the future.

I was a bit nonplussed because I was rising to support my noble friend Lady Thornton on her Amendment 281, but she is yet to speak to it. It is always good to see the noble Lord, Lord Lansley, in his place. When we debated the future of Public Health England in the 2011 Bill that led to the 2012 Act, we warned that placing PHE firmly within the department would lead to a complete misunderstanding among all of us about who was responsible for its performance. Lo and behold, we had the Covid crisis and that is what happened. Noble Lords will remember that at the beginning Ministers were briefing that PHE was hopeless and that they had lost confidence in it, and that led to the rushed announcement by the previous Secretary of State about the setting up of the UK Health Security Agency. No one knew, because Ministers kept quiet, that they were accountable for PHE and that PHE staff are officials. They are civil servants directly responsible to Ministers for their performance. The Joint Committee inquiry into Covid identified this. Yes, there were issues with Public Health England’s performance, but Ministers should take responsibility.

We risk repeating the problem with the UK security agency, because, again, it is being set up as an agency part of the department, under the control of Ministers. Once again, when trouble arises, we will see the same pattern of Ministers trying to escape their responsibilities for what is performed by this particular agency. The reason I support my noble friend is that I think she is absolutely right in seeking to place this agency on a more independent basis, so that it can be seen to account for what it does and we can avoid the ambiguity being built into the current situation.

[Lord Scriven (LD)]

My Lords, I also want to rise to support Amendment 285 in the name of the noble Lord, Lord Warner. I was very happy to put my name to that. As the noble Lord said, I was also a member of your Lordships’ Committee on the Long-term Sustainability of the NHS and Adult Social Care.

Noble Lords who have been following this set of Committee days will realise that this amendment goes to the heart of a lot of what we have been talking about, which is the conflict between short-termism and long-term planning. The Bill is about the integration of health and social care, improving health outcomes and reducing health inequalities. They are not short-term fixes; it is a long-term journey, which will mean long-term plans.

As an independent body, this body does not stop Ministers being able to control health policy. It sets out a framework of what is required in terms of staffing; what the issues will be in terms of disease profile; what will happen in terms of demand; and for seeing how successful the Government have been, not just in being able to give a press release about certain amounts of money going to a certain area but in whether the long-term benefits of that money are achieving better health outcomes, reducing health inequalities and getting the right staffing to the right places to get a better health and social care system for the people of England. That is what this body is about. I think that, of all the amendments we have discussed—I probably would say this, because my name is to it—this is one of the most important, because it deals with the conflict between the priorities of short-termism and long-term planning.

I also want to say, as the noble Lord, Lord Warner, did, that I was astounded, as a former health service manager, that no one in the Department for Health planned for long-term care in the healthcare system. We expected the answer that at least there was somebody in a darkened room doing it. But there was absolutely nobody doing it; it was all about the whim of the Minister. In reality, that was what came out.

I think this amendment actually helps with the central purpose of this Bill, of integrating healthcare, reducing health inequalities and improving health outcomes, because it is long-term. I think it is absolutely right that this House and the public understand how the Government are doing against independent reviews at five, 10 and 15 years. We will be able to see whether the right staff, the right money and the right focus on prevention versus dealing with the acute sector are actually happening, and whether Governments, of one or two or three colours, over a period of time, are improving the healthcare system the population and leading to better health outcomes.

I also support Amendment 281, which the noble Lord, Lord Hunt, has talked about. For me, public health has been kicked for too many years between different parts of the care and health system. In particular, when you have an executive agency whose primary responsibility is to plan and then co-ordinate public health—not just at government level, but within local government and across government—if it is not independent and is not a statutory body, yet again it just plays to the whim of Ministers. I will give an example of why it is not working in its present form, based on something that has just happened in the last few weeks.

Health and Care Bill

Lord Scriven Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Warner (CB)]

My Lords, I will speak briefly in support of the amendments in the name of the noble Baroness, Lady Hollins. I had intended to put my name to them; I apologise to the noble Baroness for being so slow off the mark. I also strongly support the amendment in the name of the noble Lord, Lord Layard.

Both these amendments, in their different ways, go some way to righting what I consider to be two big wrongs inflicted on local government in the past, where responsibilities have been transferred to it but have not had their funding sustained into the future. The first was the closure of long-stay hospitals in the 1980s and 1990s. When I was a director of social services, I was the NHS’s favourite person when building provision and making available services for people coming out of long-stay hospitals. After a few years, I and my many colleagues became forgotten men and women because the money that was transferred was never maintained in real terms over a couple of decades.

Fast-forward to the 1990s and the setting up, with much enthusiasm, of the Roy Griffiths community care changes. These enabled the Government to get off the hook of an expanding social security budget. It was another repeat performance: the money was not maintained in real terms in the longer term. What we saw in both cases was local government having to pick up the tab without support from the Government—successive Governments, that is; I am not making a party-political point—to ensure that those services could be maintained for the people who became the responsibility of local government.

The amendments in the name of the noble Baroness, Lady Hollins, remind people that there is an obligation to make sure that both health and social care produce good outcomes for the people who are now primarily the responsibility of local government, which, as the noble Baroness, Lady Pitkeathley, gently reminded us, has been underfunded over a long time in terms of maintaining these services. The amendment in the name of the noble Lord, Lord Layard, is another righting of a wrong and we should all get behind it.

[Lord Scriven (LD)]

My Lords, I support Amendments 85 and 88 in the name of the noble Baroness, Lady Hollins.

We must be clear. The previous two speeches highlighted the elephant in the room: you cannot have integration on a sustainable basis unless you reform health and social care together. We have to be honest with ourselves that this Bill is predominantly about the reform of healthcare.

That was highlighted eloquently in the speech by the noble Lord, Lord Hunt, in response to my noble friend Lady Barker, about who should commission sexual health services. These have been lobbed to the side of the commissioning silo but it should be about how to break down this silo so that we have joint and sustainable commissioning around outcomes, rather than around which silo or which part of the health and social care framework should deal with it. It is the elephant in the room, but we are where we are so we must make this Bill better knowing that that is the real issue.

This is about three little words: social care services. It is clear to those who understand health and social care that the Bill has been written predominantly through the lens of healthcare. I do not blame anybody for that but clearly this is a healthcare commissioning reform Bill, with a little tinkering with the structure, and does not deal predominantly with those people who do not understand social care—unless they are asking for an NHS long-term care package, when the argument tends to be about not the care provided but the funding, including who is going to fund what part. That is when it affects people’s outcomes. Those three little words are really important, which is why the noble Baroness’s amendments are important. If they were accepted, the Bill would actually say that social care service and health outcomes are jointly important.

It is important that this is about integration. The noble Baronesses, Lady Pitkeathley and Lady Hollins, said that there is a significant difference between collaboration and integration. You can have two people collaborate but, if their silos send them in different directions, the outcomes will not be joint. The real issue is how we bring about integration. It will not solve all the problems but it will help to bring about the first stage of integration if you have a joint framework on outcomes for which both healthcare and social care are held accountable. That is why Amendment 88 is so important.

The Bill’s intention goes in the right direction but the three amendments in the name of the noble Baroness, Lady Hollins, will significantly help in that journey. They will not solve the problems fully but they are an important way to say to people who work in health and social care that they will be held responsible for the outcomes of individuals, whether their needs come under healthcare or social care. That is why I support these amendments.

[Baroness Tyler of Enfield (LD)]

My Lords, I support Amendment 101B in the name of the noble Lord, Lord Layard. Before I speak to it, I want to say how much I agree with the sentiment expressed by noble Lords on all Benches that true integration will be achieved only if the Bill is as much about social care as it is about health. It is such a fundamental point that I wanted to underline it.

I see Amendment 101B as an important continuation of our deliberations last week on parity of esteem because “parity of esteem” are simply meaningless words unless they are reflected in the provision of funding. First, like the noble Baroness, Lady Watkins, I acknowledge the welcome fact that NHS England has met its commitment to ensure that the increase in local funding for mental health is at least in line with the overall increase in the money available to CCGs through the mental health investment standard. It is also welcome that, from 2019-20 onwards, as part of the NHS long-term plan, that standard also includes a further commitment that local funding for mental health will grow by an additional percentage increment to reflect the additional mental health funding being made available to CCGs. I recognise all of that.

But—and it is a big but—the investment standard relates only to CCGs, and that total spending had already declined in 2019-20 compared with 2018-19 as a percentage of total NHSE revenue spend. Also, given the urgent need for healthcare, which, as other noble Lords have said, has been much exacerbated by the pandemic, this amendment would help strengthen the consideration of mental health services when large amounts of money are announced for Covid recovery—this is welcome—but it all falls outside the remit of the mental health investment standard.

We need to know how much of the money is currently going to preventive and community services—prevention is the overarching theme of this group of amendments—as opposed to acute services. We also need to know whether the spending increases we are seeing are simply because crisis services are so in demand; indeed, they are overwhelmed in some cases. We know from a recent survey by the Royal College of Psychiatrists that two-fifths of patients awaiting mental health treatment contact emergency or crisis services, with one in nine ending up in A&E. That is not a sustainable position.

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The duty to promote quality social care services rests with local authorities. The Care Act 2014 already requires local authorities to integrate services where they consider that this will improve the quality of care or support in the local authority area, including the outcomes that are achieved for local people. However, I sense the strength of feeling on the duty from the Committee and given some of the conversations—

[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.

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[Baroness Uddin (Non-Afl)]

My Lords, I hesitate to rise. I had not originally intended to participate in this debate, but I feel obliged to speak and make some general points in support of the noble Lord, Lord Low, and his powerful and compelling arguments for his amendments. I declare an interest: the House will be well aware that my son, who is 43 years old, has a learning disability and is autistic, so I have some experience of the arguments spoken about by the noble Lord. I have also been a member of the All-Party Parliamentary Group for Disability for more than a decade, and I know of the fantastic work that SeeAbility has undertaken for its membership for many years.

I want to say something, because this group of adults has suffered dreadfully over the past two years, particularly during lockdown. They do not have the privilege of being at school or in early college education and being looked after by the system. I hope the Minister and the whole NHS system will agree with the suggestions made by the noble Lord, Lord Low, including the suggestion that these services should be available. I assume that making ophthalmic services available in schools and colleges is one of the easiest things to achieve. However, it is not so for adults with a learning disability and autism who have just left school and are at that age when nobody cares about them anymore. That is where the problem occurs.

I had enormous difficulties. I do not want to speak about myself in any way, because I am more than able to argue my case, find out where services are by ringing people and looking at services on the internet, and challenge when I face difficulty. I challenge more now than I was when my son was younger. I am also well attuned. I speak regularly with organisations on the ground that work with the parents and carers of people with learning disabilities and autism, so I know fully how much they struggle to ascertain and obtain information about ophthalmic care.

I want quickly to share the experience I had with my adult son. All his appointments were cancelled for nearly a year. I could see that his eyesight really suffered. He was not able to co-ordinate his way even around his own home where he is very comfortable. I had to push them hard. It was suggested that I should speak to the nearest ophthalmologist and look for these services. I admire all these services, which are trying hard to work with the NHS in the absence of patients being able to go to hospital for ordinary services, but they are not equipped or trained. They do not have the necessary equipment to produce the best results or give effective services to the people who need them. As the noble Lord, Lord Low, said, it is grossly unfair when there is sight and all someone’s eyes need are a little attention to make a fundamental difference and enrich their life. It is really important that the Government take the noble Lord’s amendments on board with the same passion that he argued with. I hope they also understand the passion of the millions of parents, carers and service users who stand behind him.

I thank noble Lords from all sides of the House for their leniency over this interruption.

[Lord Scriven (LD)]

My Lords, I have attached my name to a whole raft of amendments in the name of the noble Lords, Lord Crisp and Lord Hunt. I am pleased to follow the noble Baroness, Lady Uddin, who has explained powerfully and passionately why primary care in one area is so important to the health and well-being of people. I also thank the noble Lord, Lord Low, for introducing this suite of amendments with such a graphic and powerful explanation of why primary care, particularly for people with learning disabilities, is also important in relation to ophthalmology.

I wanted to put my name to these amendments, because they go right to heart of the purpose of the Bill. Let us be clear about the purpose of the Bill. Its purpose is to integrate healthcare to improve health outcomes and to reduce health inequality. You cannot do that if your focus is purely on the acute sector. The acute sector is the repair system. It is not the part of the system that can really deal with the prevention and innovation that keeps people out of hospital. I am sure that was never the intention of the drafters of the Bill, and I am sure that it is not the Government’s intention. However, the way the Bill is written, the power emphasis is with the acute sector in monitoring, reviewing and strategic plans.

I am sure the Minister will say that that is not the case, but the way the Bill is written it is the acute sector that will have the power over who sits in the ICB and whose plans they are. So I say to the Minister in a very friendly way that the noble Lords, Lord Crisp and Lord Hunt, and I have been involved in the management and leadership of health in different parts of the system. I was involved in acute and primary care myself. When I came into the health service, the noble Lord, Lord Crisp, was so powerful and mighty that he was the chief executive of NHS England. It was the same with the noble Lord, Lord Hunt. I feel in very esteemed and very grand company.

However, the point we are trying to make is that the real way in which healthcare works and how it is developed is that the acute sector is very powerful, even at place. If you do not give a voice and power to primary care, you will not have the innovation and the change that you require. These amendments are a way of trying to make sure that the purpose of the Bill at least moves faster and is eased by having that primary care voice right at the heart of the ICB, and, being statutorily in the Bill and having been there right at the beginning in the planning, monitoring and evaluating, being able to determine what is happening. That is what these amendments are about, nothing more. They are not amendments that should be deemed difficult or trying to slow things down. They are genuinely helpful amendments.

I say very gently but powerfully to the Minister that he really needs to incorporate these amendments. If he cannot incorporate and accept them now, the Government need to come back with a set of amendments that really crystalise the role of some great primary care people, whether they are in GP surgeries, ophthalmology, pharmacy or dental, who can actually help with the purpose of this Bill, which is to improve health outcomes, integrate healthcare and reduce inequalities. It is vital.

[Lord Warner (CB)]

My Lords, I will speak in support of Amendment 218, in the name of the noble Lord, Lord Hunt, to which I have added my name. Before I get down to that, perhaps I could make a few remarks about the amendments from the noble Lord, Lord Crisp, and the other remarks that have been made.

When I was sitting in Richmond House as a Minister, we had a description for the chief executives of the acute trusts. They were called “the barons”. When the House of Lords Select Committee, chaired by the noble Lord, Lord Patel, took evidence on the long-term sustainability of the NHS and adult social care, three or four of them—I cannot remember exactly how many—came in to give evidence. Their opening salvo was, “We need 4% a year real-terms increase every year, stretching into the future”. I suspect that culture has not changed that much since I was around in Richmond House, and it has to be changed—forcibly if necessary—if we are actually to deliver the sustainability of the NHS.

Since 1948, the acute hospitals have been magnificent in laying down the law about how much money they need. Even when money was short, they were pretty good at it. My personal experience as a Minister was that, if I wanted the go-to people on change, I would go to the GPs. They were much more flexible and willing to have a go at doing things differently. We need to bear some of that in mind.

About 90% of people’s encounters with the NHS are with primary care, not with acute hospitals. People’s vision of the NHS is those encounters. I just want to mention an encounter my wife and I had over vaccinations which illustrates some of this. Our very efficient, local general practice was fast out of the starting blocks and we had two jabs very quickly. Some months later, we were both individually approached by two NHS acute trusts, which shall remain nameless. They asked us when we were going to get round to having our vaccinations. There was absolutely no contact between these two parts of the NHS. One part had no idea that another had dealt with the patients perfectly satisfactorily. This is what we are up against. The least we can do is accept the amendments suggested by the noble Lord, Lord Crisp.

I turn to Amendment 218. I will not repeat the arguments set out by the noble Lord, Lord Hunt. The numbers speak for themselves. In any service that claims to be national, it cannot be right to have such a wide range in the per capita workloads of GPs. After all, these doctors are the gatekeepers of patient access to specialist diagnosis and treatment. They should not be required to handle case loads that vary from around 1,000 to more than 6,000 patients. Such variations are likely to create significant variations in patient treatment outcomes.

I will make two further brief points in support of the amendment in the name of the noble Lord, Lord Hunt. First, there have been many worthy amendments tabled about the long-standing, serious problem of health inequalities. Many places with the most serious health inequalities are places where the patient load of GPs is very high. So the patients with the most need of clinical attention and help have the doctors with the least time for individual attention. I have to say, that is a brilliant piece of public policy that we have managed to develop.

My second point relates to the Government’s worthy aspiration to level up the quality of life in many neglected areas of this country. We now have a Secretary of State for Levelling Up, and no doubt we eagerly await the game plan he has for living up to his title. A fairer share of the national supply of GPs would be a tangible piece of levelling up in many of those deprived areas. Can the Minister say whether the Government have considered a move in the direction of the amendment tabled by the noble Lord, Lord Hunt, as a useful part of their levelling-up strategy? I hope the Government will give that consideration on those grounds alone.