Homecare Medicines Services (Public Services Committee Report)

Lord Shipley Excerpts

Thursday 2nd May 2024 Lords Chamber

[Lord Shipley (LD)]

My Lords, I was going to offer some of my time to the noble Lord, Lord Blencathra, because his contribution was so very important. It was a pleasure to listen to what he said because he has personal experience of the service, and I pay tribute to him for pointing the committee in the direction of this inquiry based on that personal experience. I also thank our chair, the noble Baroness, Lady Morris of Yardley, for her leadership of this inquiry and her forthright explanation of the problems we encountered.

This report shows the value of House of Lords committees, and I have rarely seen so much acknowledgement of a committee’s work in a government response. In this case, the words “We accept the recommendation” appear so often that the committee has clearly done something not just right but very important. There are some points of difference with the Government in their two responses, but often these are points about process or about the need to secure further information or consultation. The dialogue has been important, it will go on being important, and it is encouraging that the department is engaging positively on this and is clearly keen to do so.

As the noble Baroness, Lady Morris of Yardley, said, half a million NHS patients receive hospital-prescribed medication at home through private sector homecare medicines services. It avoids travel for the patient and is much more convenient for them, but it has to work properly since there are clear safety risks that must be avoided.

Indeed, the CQC said it had found evidence of missed deliveries and had concluded that some patients had suffered “avoidable harm”. But it seems that the Government still do not know the extent of that harm, and clearly more data is needed on how many patients have suffered a worse illness or other harm as a consequence of a service failure.

It has puzzled me why information cannot be made available on this before the summer; why does it take so long to gather the information on patient harms? It is an important matter, and it has not been helped by the Minister of State’s reply on 25 March, which seemed to hint at a problem. It said that individual supplier submissions on aggregated performance data will be collated to show aggregated market performance and that this will be in addition to existing and continued contractual reporting of performance data to relevant NHS contracting authorities, whether by local trusts or via regional framework operators. I find that very complicated; I am sure it may all be true, but it sounds very complicated. There are a lot of communication links and reporting, which it can be easy to break. It ought to be better, and it ought to be possible for the Government and the NHS to simplify that structure.

I am very glad that the Government did a desktop review via NHS England. It was urgently needed. As the noble Baroness, Lady Morris of Yardley, said, there has been no individual with overall responsibility for performance, so there is a lack of data on performance. There have been problems with regulation, on which we await further proposals in the summer update. We urgently need a consistent set of performance metrics, but I am pleased that the Government have agreed to one set. We said that the Government need to know how much is actually spent on homecare medicines services but, as the noble Lord, Lord Blencathra, pointed out, we got three different figures. It is important to know which is correct, because these are large sums of money.

I am glad that the National Audit Office will be involved in defining costs, assessing whether commercial confidentiality is justified and establishing whether the Government can be confident that the money is being spent well. We also ought to acknowledge that there is a lack of competition in the market and that, as the service expands, greater competition is needed. That should in turn lead to a reduction in costs.

I shall just address the commercial sensitivity of services by manufacturers which, as we have heard, account for 80% of the homecare medicines service. It is quite difficult to understand what value for money is being achieved because of commercial sensitivity. I just point out that we are talking about public money and the 80% of the homecare medicines service that we are talking about is a for-profit service for NHS patients.

I found the Government’s reply, in paragraph 8 of their second letter on 25 March, to be very strange. What exactly is commercially sensitive? How do we know that we are getting best value? Is it not possible to unbundle contractual matters that are genuinely confidential from those that are not? I hope that the Government will look at that and look forward to the NAO giving us advice on it.

In conclusion, the noble Baroness, Lady Morris of Yardley, was absolutely right to say that we are optimistic. There now has to be an optimism about some of the problems that we have identified, in a service that is clearly going to expand. Things have been learned about the way it has operated, but we can have optimism about it. As the noble Baroness, Lady Morris, rightly said, it is essential that those who are using the service, those who manage it and the clinicians involved all need to be consulted. Patient groups have a great deal to say, so we need and would benefit from their time and evidence.

I see this report as a trigger for action. The Government have committed themselves to delivering improvements and, if this is got right, it will improve care for a large number of people with fewer pressures on the NHS estate. But a lot of work needs to be done. If it is done properly, homecare medicines services can be a growing pillar for our future health service.

Adult Social Care: Staffing

Lord Shipley Excerpts

Tuesday 12th December 2023 Lords Chamber

[Lord Markham (Con)]

The noble Baroness is correct about that; it is a key pillar of this reform. This is why we have tried to learn one of the main lessons from last year, by putting the £600 million discharge fund out early, so we can get those sorts of measures in place. That is why we have expanded the virtual care ward network to 10,000 beds, with the idea that people can be cared for in their own home but with support from the staff there. That is absolutely the direction we are moving in.

[Lord Shipley (LD)]

My Lords, the Minister said a moment ago that three-quarters of local government spending is on adult social care. I would ask him just to check that figure, because if we add to it children’s social care, it basically means that every local authority will, before long, be issuing Section 114 notices. It is very important to get the facts absolutely clear here. What the Minister said demonstrates that local authorities are seriously underfunded for adult and children’s social care, and are cutting other public services as a consequence.

[Lord Markham (Con)]

I will absolutely clarify the number to the noble Lord in writing. It is of course a range, according to different local authorities, but I think we would all agree that it is a level that, as a percentage, is too high.

King’s Speech

Lord Shipley Excerpts

Thursday 9th November 2023 Lords Chamber

[Lord Shipley (LD)]

My Lords, it is a pleasure to follow the noble Lord, Lord Shinkwin, who talked twice of his obligation to speak truth to power. Perhaps I may say to the House and to him that I think he did that rather well.

This has been a wide-ranging and very interesting debate. I hope that the noble Lord, Lord Markham, will forgive me if I say that I thought his introduction, which was also wide-ranging, put a rosy gloss on the Government’s performance in the fields of health, education and housing in particular. The debate has rather demonstrated that the evidence for that is lacking and that in all those areas and others that we have heard about there are some serious structural and resourcing problems.

The gracious Speech proposed a number of Bills. I missed a proposal for audit reform and hope that it will appear in the not-too-distant future. I thought that we might get something on adult social care and children’s social care, and we did not, but it is possible that something is proposed for the Autumn Statement.

I had hoped for something to promote dentistry and healthy teeth, particularly in children. As my noble friend Lord Allan pointed out, NHS dentistry services are in serious trouble. Perhaps something will be said in the Autumn Statement because the Minister talked about the importance of prevention of illness. It is not happening in terms of the state of the nation’s teeth.

I had also hoped for something to promote real devolution in England. England is too centralised, but while all control of resources and tax raising lies with the Treasury, devolution to combined authorities will prove problematic, because they will end up competing with one another for the favours of the Treasury. What happened, I wonder, to the blueprint produced by the Northern Powerhouse Partnership in March this year on how to devolve tax to the regions of England, which was launched by the noble Lord, Lord O’Neill, a few months ago? It seems to be commanding support from members of all parties, but it may require a new Government to get implemented.

The Prime Minister said that the King’s Speech would not contain gimmicks, so I am pleased that it contained no proposals to ban tents occupied by homeless people. As we have heard from a number of speakers, homelessness is not a lifestyle choice; tents are given to homeless people for good reason. It can make them feel safer, and keeping people safe is a stated objective in the gracious Speech.

The noble Lord, Lord Howarth of Newport, reminded us that 130,000 children live in temporary accommodation; it is the highest figure ever. The cost of temporary homes, including bed and breakfast costs, has risen to £1.7 billion a year—which could, of course, be used to promote social housing. Demand from young people aged 16 to 24 for advice on homelessness has increased by 5% in the past year, with 135,000 young people a year accessing homelessness services. Homelessness among all ages rose by 50% between May 2022 and May 2023. We know that the affordable homes programme is not delivering the volume of homes needed. We know that we need more housing that is truly affordable, with rents tied to local income. That means that we need more homes for social rent.

Only the state can provide protection to citizens. A public housing crisis needs public, and not private, solutions. There are some appalling conditions in the private rented sector, which is not properly regulated. There have been record rises in rents—the fastest annual rate now since records started seven years ago. Private rents are up by 5.6%.

I welcome the Renters (Reform) Bill. Section 21 has increased the number of evictions without a reason, and the proposals in the Bill will certainly help. But I am very concerned, as was the noble Lord, Lord Young of Cookham, about the delay in implementation of the ban on Section 21 evictions. How long is that likely to take? I hope that selective licensing schemes will continue to allow local authorities to improve private rented sector properties. I hope that a future Government will amend the Housing Act 2004 to remove the requirement for councils to seek approval for larger selective licensing schemes. I should declare my vice-presidency of the Local Government Association. The problem is that England is too centralised for everything to come to Whitehall for decision.

Finally, I am very pleased by the leasehold and freehold Bill. I think that is generally the view in your Lordships’ House, because it represents a huge step forward. It will make it easier for existing leaseholders to extend their lease or buy their freehold. As the Secretary of State said, the current system is reminiscent of a feudal system, which is against the interests of consumers. There will be many issues to test when the Bill comes before the House; it needs to be part of a major reform of property law. As we have heard from the noble Lord, Lord Truscott, we need better regulation of managing agents, and we must address the need for commonhold in flats.

I look forward in the months ahead to taking on many of these issues to improve the Bills we have, as the noble Lord, Lord Young of Cookham, said.

Recovering Access to Primary Care

Lord Shipley Excerpts

Tuesday 9th May 2023 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for reading out the Statement. No one can be in any doubt that patient access to primary care needs a great deal of recovering from the dire situation patients across the country find themselves in today. Millions of patients wait more than a month to see a GP—if they can get an appointment at all. Some 65% of the public think that access to GP services is getting worse, and over 40% report that they have to wait too long to see a GP. The 9 am rush and scramble to get an appointment, or even a response, is the reality for thousands of patients each day. Often, they are waiting in pain and discomfort, unable to go about their daily normal lives. While they wait, an illness goes undiagnosed and untreated, potentially getting ever more serious.

In today’s Statement the Government once again recognise the major role community pharmacies can play in relieving the pressure on GP appointments and primary care. As we have made clear, we fully support and welcome this extended role, including allowing pharmacies to provide prescriptions and routine health checks, and opening up more referral routes to NHS specialists, such as physios for back pain. However, only yesterday in the national media we heard that 670 community pharmacies have closed and the number of pharmacies across England is now the lowest since 2015, and about the impact caused by rising costs, major staff shortages and the 30% cut in government funding to date—all despite growing demand for services. The industry estimates a £1.1 billion funding shortfall each year, and that last year was the worst ever. Does the Minister acknowledge that, for many, today’s plan is too little too late when it comes to fixing the crisis in primary care?

The independent think tank the Health Foundation sums up the Government’s overall plan, saying that it

“falls well short of addressing the fundamental issues”

facing general practice. Of course, the key reason demand for GP services is so high is the sheer number of people on NHS waiting lists. The president of the Royal College of General Practitioners said recently:

“Patients are developing cancers and enduring so much pain that they cannot climb stairs”.


Do the Government acknowledge that, unless they urgently get a grip on waiting lists, the crisis in general practice will only deepen?

More phone lines and better mood music will not fix the fundamental issue: the shortage of GPs. Their numbers have been cut by 2,000 since 2015, and now the Government have abandoned their own target of 6,000 extra GPs by next year. The proposal to ease the current burden on hard-pressed GP reception staff with a £240 million investment in phone and call systems technology over the coming years is welcome, but does the Minister really think that this is a proportionate or urgent enough response to the scale of the crisis? Is the money for the new care navigator staff included in this funding? What role will these new staff play in GP surgeries? When will we have a detailed breakdown of how the overall funding will be spent, and when it will be allocated and delivered?

Even the Government’s own Benches in this House have accused them of being in total denial about the crisis facing community pharmacies. Much now needs to be discussed by the PSNC, the Department of Health and NHS England regarding the promised funding in the recovery plan, and to try to address the crisis; I hope the Minister will keep us as up to date as possible. Can he provide more detail on how the proposed new services for the seven common conditions and oral contraception are envisaged to operate and interface with GP and other primary care services?

Finally, we come back to the question of the all-important workforce plan—what else? We heard from the Minister in Questions today that he now thinks that spring runs to the end of June. On the radio today, the Commons Minister promised that we would have it in a couple of months. As with every other health and social care service and profession we speak about in this House, workforce is core. Pharmacy locum costs have increased by 80% in the past year alone. So I have two simple questions: why is the promised, fully costed workforce plan taking so long, and when will it finally be published?

[Lord Shipley (LD)]

My Lords, I support the comments made by the noble Baroness, Lady Wheeler, on the Statement. We on these Benches welcome the aspirational nature of what the Government are proposing. During the Covid pandemic, we all learned that community pharmacists play an absolutely key role in supporting the health system. In my personal experience of securing additional injections, I was very impressed by how well the whole NHS system worked in delivering the inoculation service through community pharmacies. One of the good things about it is that you can book a slot, in the same way you book a slot with a GP. However, for this to succeed—and to free up 30,000 GP slots, as the Government intend—booking an appointment with a pharmacist needs to be just as easy. We then need to be very clear about what pharmacists will do, and what GPs will no longer have a contractual obligation to do.

On the workforce shortages that have been referred to, it would help if the Minister could explain whether the manifesto commitment to deliver 26,000 more primary care staff by next March is deliverable. It is difficult to see how the Government will do that unless more money is made available, so I seek the Minister’s confirmation that more resource will be delivered on the back of this initiative to ensure that it happens.

I will ask the Minister three further questions. First, were patients of different backgrounds, genders and geographies involved in drawing up the plan, and can he outline the patient involvement? Secondly, is there sufficient qualified staff of all professions to deliver the multidisciplinary plan? Finally, as the noble Baroness, Lady Wheeler, asked, when does the Minister does expect the new plan to be up and running?

[Lord Markham (Con)]

I thank noble Lords for their comments and appreciate the general welcome for the tenets of the plan from all sides. I want to say that, rather than “too little, too late”, this is actually a plan that bolsters a service that is already on target for an increase of 50 million appointments from 2019—a service in which we are seeing a 10% increase per month versus pre-pandemic levels. I think that, on anyone’s reckoning, that is a pretty impressive achievement. The Pharmacy First plan that we talk about will free up another 10 million appointments a year in addition to that. Also, the use of digital technology will make it easier to get appointments and ensure that those who need them most can get them. It will ease the 8 am frustrations that we are all too aware of.

Addressing the comments on the pharmacy closures that have happened, this can only help pharmacists by increasing the income-generating services available to them and increasing the footfall into those pharmacies. This can only improve their income and so their overall viability. So I hope we will see, from all of this, an increase in the number of community pharmacies. To answer the point, we will be setting up booking systems so that you can digitally book your pharmacy appointment. Equally vital will be the use of the NHS app and other technologies, such as 111, to navigate through services, so you know when you should be booking an appointment with a doctor and when you should be booking it with a pharmacy. The use of technology will be a vital element in all that.

On the workforce, I absolutely acknowledge, as I think we all do, the importance of making sure we have the right workforce in place. That is why I think we are all pleased with and all supportive of the pension changes that will increase and retain the numbers of people. I am afraid I cannot give any more news on the date of the workforce announcement, but I can say that, as mentioned before, substantial work is going on in this place. Yes, we are committed to the increase of 26,000 staff, and this whole package has £1.2 billion of funding behind it, of which £645 million goes into the community Pharmacy First plan, because a vital part of all this, as noble Lords have said, is making sure that we have we have the qualified staff in place to do it.

So, I think we have a good plan here and it is probably best to hear what the industry has said. We have seen a welcome from across the board.

“This is the most significant investment in community pharmacy in well over a decade”


came from the Pharmaceutical Services Negotiating Committee. The Boots CEO said:

“We are really pleased … Our Boots pharmacy teams sit at the heart of communities, offering easy to access care and expert advice; it is great news that they’ll be able use their clinical expertise more widely to help patients”.


I really see this as a transformational step forward, united with the digital technology which will make huge differences. With that, I commend a plan that will make a real difference to patients and the services they receive from GPs in the community.

North East Ambulance Service

Lord Shipley Excerpts

Monday 23rd May 2022 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for raising those concerns. I completely agree with the sentiments she expressed; this is completely uncalled for. As I said previously, my honourable friend Maria Caulfield pledged that there would be an investigation into this. As to whether it will be a formal inquiry, it is too early for me to give a direct answer, but I will go back to the department and as soon as I have more information I will write to the noble Baroness. I understand that these are historic incidents and that the CQC has said that its service is improving, but as more information is still coming out—even today when I had the briefing, not all the information was there—I will of course commit to write to the noble Baroness.

[Lord Shipley (LD)]

My Lords, in 2019, Matt Hancock MP, the then Secretary of State for Health and Social Care, vowed to end non-disclosure agreements in the NHS, yet earlier this year bosses at the North East Ambulance Service used non-disclosure agreements for the brave whistleblowers in return for settlement. What action will the Minister take with the North East Ambulance Service for flouting the very clear guidance and regulations relating to non-disclosure agreements?

[Lord Kamall (Con)]

As was said in the other place earlier today, the fact is that non-disclosure agreements have no place in the NHS, and the Government have been absolutely clear about that. I am afraid that I cannot give exact details, because it is obviously very recent, but I know that that is one of the issues that will be looked at. We are investigating, and all aspects will be looked at thoroughly.

Health and Care Bill

Lord Shipley Excerpts

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

[Lord Kakkar (CB)]

My Lords, in thanking the Minister for having introduced so thoughtfully and elegantly this important suite of government amendments that address the question of inequalities, I would like to pass to the Minister and the Front-Bench team the thanks of my noble friend Lord Patel, who regrettably is unwell, recovering from Covid-19, but who of course spoke with great insight and passion in Committee on this matter, and indeed has engaged actively with the Front-Bench team subsequently in ongoing discussions.

The noble Earl has done something quite remarkable and absolutely essential. There is no need to rehearse the very strong arguments that were made in Committee around the necessity at this particular time to ensure that every element of the National Health Service is able not only to focus its resource and thought quite clearly at the elements of the triple aim but to ensure that, in a tension with those important pan-NHS objectives, the system is never allowed to forget the importance of addressing the inequalities and disparities that regrettably continue to be an abject failure of the delivery of the healthcare system.

Her Majesty’s Government, in proposing these amendments, deal not only with questions of access and outcomes but ensure that data is appropriately collected and all NHS organisations are obliged to pay attention to those data and to act accordingly; that is a very powerful statement and a powerful act of leadership. But beyond that, in ensuring that the patient’s voice and the public’s voice is heard in these matters, this will set a new tone and new direction for the delivery of healthcare in our country, and Her Majesty’s Government are to be strongly congratulated.

[Lord Shipley (LD)]

My Lords—

[Baroness Armstrong of Hill Top (Lab)]

My Lords, I apologise; when there are so many amendments in one group I can never work out just when people who are moving subsequent ones further down the line, as it were, ought to rise.

I will speak to Amendments 63, 65 and 67, and begin with an apology that I was not able to be here to speak to those in Committee. I too had a positive test, although I have to say that I had no symptoms. None the less, I was self-isolating, and therefore was not able to be present in the Chamber.

I welcome the amendments tabled by the Government. I chair the Public Services Committee in this House. In our first report, we looked at public services through the mirror of Covid. We noted and reported, and indeed debated in this Chamber, the significant uncovering or rediscovery of the extent to which inequalities in our society affect people’s health. I am pleased that the Government are responding with some of their own amendments.

--- Later in debate ---

[The Deputy Speaker (Lord Geddes) (Con)]

As gently as I can, I must point out to the noble Baroness that this not the occasion to move her amendments; we will come to that later. She has correctly spoken to her amendments in this group but we will come to them sequentially later.

[Lord Shipley (LD)]

My Lords, now that we are on Report, I must remind the House that I am a vice-president of the Local Government Association.

I rise to speak to Amendments 63, 65 and 67 in this group, to which I am a signatory along with the noble Baroness, Lady Armstrong of Hill Top. I will not repeat the points made in Committee and this afternoon unnecessarily because I am confident that the Government are listening to what has been said and wish to see progress towards levelling up health outcomes and tackling health inequalities. It is the right thing to do.

I lend my support to three policy solutions in particular. The first is the significant opportunity presented by the forthcoming health disparities White Paper. The Government should not miss the opportunity that this presents because it can clearly set out how exactly they propose to lead on tackling the poor health outcomes of inclusion health populations. I hope that the Minister will work closely with the voluntary and inclusion health sectors to shape what the White Paper will say. Secondly, I support the idea of creating a task force from the Department of Health and Social Care and NHS England to help drive forward the Government’s work to reduce health inequalities for the most marginalised. Thirdly, I urge the Government to take this opportunity to update guidance to specify explicitly that the NHS does not exist in a vacuum and that secure, safe housing is critical to an individual’s health and well-being. I hope that the Minister will be able to confirm that statutory guidance and the White Paper will reflect all these matters.

Having said that, these three amendments—Amendments 63, 65 and 67—are still important. I welcome yesterday’s letter from the Minister, the noble Lord, Lord Kamall, explaining the package of government amendments now also proposed. I am pleased that that letter confirmed the Government’s commitment to tackling health inequalities. It is very positive to see the reference to “persons”, not just “patients”, in Amendment 3 as an important statement of principle both for inclusion health and to improve outreach, as the noble Earl, Lord Howe, said earlier.

Progress has been made following Committee but I still seek reassurance from the Minister that the Government will dedicate the necessary time and resource to tackling the poor health outcomes of inclusion health populations, who can all too easily fall through the gaps in provision.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to speak to this group of amendments. I declare my interest as chair of Look Ahead, a housing association that specialises in working with people with complex needs. I am delighted by the Government’s new amendments in this area—I believe that they go a long way—but I am disappointed that housing appears to have been omitted from the government amendments.

Health and Care Bill

Lord Shipley Excerpts

Lords Hansard - Part 3 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Lord Shipley (LD)]

My Lords, I am very glad I delayed my speech so that I could hear the noble Lord, Lord Stevens of Birmingham, because I agree with everything he said.

My name is on Amendments 179 to 183 in this group. I shall try not to repeat the comprehensive explanation by the noble Baroness, Lady Cumberlege, of the problems these amendments would address, which are similar to those that we debated in the previous group. I hope that the Minister will accept that the proposals in the Bill as they stand are overcentralising, and that this issue will have to be addressed by the Government on Report.

I agree very strongly with the noble Lords, Lord Howarth of Newport and Lord Stevens of Birmingham, who made unanswerable contributions. In the words of the noble Lord, Lord Stevens, these provisions are unnecessary, undesirable and unworkable, and they confuse and obscure accountability. I hope the Minister will take very seriously what is being said because the Bill’s ambition is to increase transparency and accountability. That is right, but it surely should be prioritised at a local level since that is where services are delivered. The Bill undermines that principle. It thinks accountability should lie in Whitehall, yet there has been no strong call to enable the Secretary of State to intervene earlier in the reconfiguration process and, anyway, there is already an established role for the Secretary of State in cases that are referred. Those processes should not be undermined.

Amendment 179 would change the definition of a reconfiguration of NHS services to ensure that only complex and significant changes to NHS services should be considered. Surely that is right. Amendment 180 would require the Secretary of State to consult all relevant health overview and scrutiny committees plus those organisations delivering relevant services locally along with the integrated care board. That must be right. Amendment 181 would require speedy decisions, and that must be right. Amendment 182 would require the Secretary of State to publish a statement demonstrating that any decision made by the Secretary of State on a reconfiguration proposal is in the public interest and has been taken with patient safety as a priority. That must be right. Crucially, Amendment 183 would prevent Secretary of State acting as the catalyst for a reconfiguration. That, too, must be right.

I hope the Minister will understand that there is much concern about the proposed new powers for a Secretary of State to intervene at any stage in a local service reconfiguration without any need to demonstrate the basis of the information on which their decisions might be reached. There is already a clear process for reviewing proposals for NHS reconfigurations, which are health overview and scrutiny processes charged with establishing whether proposals are in the best interests of their local communities.

What the Government are proposing is not in the spirit of the Bill, and I hope they will take note of the concerns expressed by the NHS Confederation and many others and bring back further amendments on Report to address them.

Health and Care Bill

Lord Shipley Excerpts

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

In December 2020, the Government announced that a new tobacco control plan would be published in July 2021 to deliver that ambition. This did not happen and last month, the Minister, the noble Lord, Lord Kamall, told Parliament that publication had slipped to 2022, with no date specified. With only eight years left until 2030, there is an urgent need for action to back up the Government’s rhetoric. This Bill is a great opportunity to get us on track to deliver a smoke-free 2030, and to tackle the severe health inequalities plaguing our society. I urge the Government not to squander this opportunity and to accept this amendment, along with the other amendments on smoking which we will come to later in Committee.

[Lord Shipley (LD)]

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

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

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

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

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

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

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

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

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

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

[Lord Kakkar (CB)]

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

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

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

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

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

Health and Care Bill

Lord Shipley Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Shipley (LD)]

My Lords, I should remind the House that I am vice-president of the Local Government Association. I want also to congratulate the noble Lord, Lord Stevens of Birmingham, on his maiden speech and on the depth of his analysis, which I hope we will draw on as the Bill progresses.

I want to say at the outset that I support the ambition of this Bill but also that I think it will work only if it is improved at further stages. I welcome the wish to make systems more effective in the delivery of services to patients and clients and more efficient in the use of public resources.

As a council leader some years ago, I knew from officers, from providers, from colleagues who worked in the NHS or in social care, from my own councillor surgeries and from door knocking at election time that there was a huge problem with the integration of health and social care support at the point it reached—or should have reached—individuals. We had growing demand for both residential care and domiciliary services, insufficient supported housing, constant bed blocking, lengthy delays in the installation of aids and adaptions, and worsening public health, not least through levels of smoking, rising alcohol consumption and obesity. All that meant that investing more in public health and in the integration of service provision to reduce the costs of administration became essential. For a while, public health did receive further investment and joint working was certainly encouraged, but I thought then that we would progress integration much faster than we have. Well, we now have another attempt, and the test of the success of this Bill is whether it will help with reducing bed blocking, improving public health, restoring the 25% cuts in spending of the past six years and increasing the number of staff working in social care.

The Bill may aim to level up health outcomes, but structures alone are not a solution in themselves but a means to an end. Poverty, low pay and poor housing all need to be addressed as well, because they contribute to poor health. Prevention of poor health in turn reduces demand for hospital beds.

The Care Quality Commission has said that successful care is when providers work well together in a place. That is right, but it is not just about working well together through the alignment of budgets. It must be about the pooling of those budgets to achieve real integration.

The Government must take care not to end up with just another reorganisation. The test is whether the Bill and related legislation will reduce administrative costs, increase capacity and improve service delivery. Will it help to reduce alcohol harm? Will it reduce obesity? Will it reduce the health inequalities of the homeless or of those suffering addictions? Place-based planning and budgeting with common administrative systems should be at the heart of this.

The Bill will need to be amended to ensure that we really do have integrated health and care systems founded on place-based partnerships with pooled budgets. I fear that if we do not do this, adult social care will be starved of essential funding, in turn forcing up council tax too much. We have too many regressive taxes in this country. Council tax is one of them, and it should not be used to make up deficiencies in mainline services.

Social Care Funding (EAC Report)

Lord Shipley Excerpts

Thursday 28th January 2021 Grand Committee

[Lord Shipley (LD) [V]]

My Lords, I should remind the House that I am a vice-president of the Local Government Association.

This is an impressive report and I congratulate the committee on its work in addressing the key issues so effectively and on trying to encourage some urgency in government thinking. I want to talk about resources and, in particular, the funding issues identified by the committee in paragraphs 156 and 157. I agree with the committee’s conclusion:

“Social care funding should not be reliant on locally raised revenue which has little connection to local demand for social care.”


I also agree with this:

“The additional funding needed for adult social care should be provided as a government grant, distributed directly to local authorities according to an appropriate national funding formula which takes into account differences between local authorities in demand for care and ability to raise funds from local taxation.”


That is the right approach. I just wish the Government would share the committee’s view that social care funding should not be as reliant on locally raised revenue as it is now.

Unfortunately, there has been a deliberate government policy to force up council tax well above the rate of inflation to help to pay for social care by means of the social care precept that the Government introduced in 2016. This has resulted in council tax payers being required to pay up to 15% more over the last five years. Presumably, in the absence of any solution to the funding crisis, council tax will go on being increased in this way through the life of this Parliament. This approach means that councils able to generate higher receipts from their council tax base can raise more money for social care than poorer councils, when it is often the poorer councils that have the greatest demand for social care.

At the general election in December 2019, the Conservative Party manifesto guaranteed not to increase income tax, national insurance or VAT in this Parliament. These three taxes bring in almost two-thirds of UK tax revenues, so the decision not to increase them means that the Government intend other taxes to bear the burden. Council tax is one of those, so, for a sixth year now, council tax is increasing well above the rate of inflation. Up to 5% is permitted from April, of which a maximum 3% increase is for the adult social care precept. We should be very concerned about this and the fact that this constant rise in council tax forced on councils impacts most of all on poorer families who are already facing greater financial pressures from the pandemic.