Health and Care Bill

Lord Stevens of Birmingham Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Warner (CB)]

My Lords, I support all the amendments in this group, particularly Amendment 74, to which I have added my name. I was one of the successors to the noble Lord, Lord Hunt, as a Health Minister responsible for NICE. I pay tribute to his sterling work in establishing it. However, I encountered the same difficulties as he encountered with the NHS speedily taking up NICE recommendations and had to wrestle with this same problem.

I had a long and slightly exhausting chat with the chief executive and the chairman of NICE about what they could do to help the NHS implement their recommendations. We arrived at a concordat, and the NICE people went away and developed a rather helpful system for enabling the NHS to prepare for a NICE recommendation and to implement it. As far as I am aware, looking at the NICE website, it still has that system in place, so it is not as though NICE is simply putting its recommendations in the public arena and leaving the NHS to get on with it; it has done its level best to produce a way of helping the NHS to prepare to implement those recommendations.

What I do not understand is why we have not moved faster over time to recognise that more action needs to be taken with the laggards within the NHS to make this happen. I think that one method is captured in the amendment from the noble Baroness, Lady Finlay.

If NICE is so important and it is so important that the NHS implements its recommendations, that ought to figure in the regulator’s assessment of the performance of those NHS bodies. I can see no reason it should not, and I wonder whether the Minister could tell us a little more than I know—and more, I suspect, than the Committee knows—about the current position on the failures of NHS bodies to pursue NICE recommendations. Do the Government accept that the regulator of these bodies should take account of their ability and willingness to implement NICE recommendations? Perhaps the Minister could clarify some of those issues. If he cannot clarify them today, perhaps he could write to us.

[Lord Stevens of Birmingham (CB)]

My Lords, I had not intended to speak but, animated by the contributions of colleagues who, like me, were there at the conception of NICE, I thought I would offer a couple of contextual remarks to this group of amendments, supporting their underlying motivation, which is to ensure the spread of best practice as fast as possible across the National Health Service.

I was also motivated by the noble Baroness, Lady Watkins, who spoke earlier about the Crimean War, to recall that this is not a new problem. The world’s first controlled clinical trial took place in 1754 on board HMS “Salisbury”, when the Royal Navy was trying out the use of citric fruit—in lemons and limes—to combat scurvy. That experiment showed that scurvy could be tackled with lime juice, and it took the Navy 41 years to mandate its introduction more widely—fortunately, just in time for the Napoleonic Wars, which is why some argue that, contrary to Winston Churchill’s dictum that it was “rum, sodomy and the lash” that contributed to the Navy’s success, it was in fact lemon and lime juice.

The point is that this is not a new problem. We have been grappling with this but, despite that, we have seen the remarkably quick adoption of new clinical practices over the last two years during Covid, as new randomised control trials, following in the wake of the 1754 example, have shown the benefits of treatments such as dexamethasone. My point of context is that we need to be clear, if this group of amendments is to advance, about the terminology incorporated in the amendments. These will inevitably be, if they find their way into the Act, litigated against in the High Court and Court of Appeal.

In the drafting, there is reference to the marketing authorisations given by NICE, although I think it is the MHRA that provides marketing authorisations. There is a clear distinction to be made between the technology appraisals NICE undertakes and the development of guidelines. Although a number of noble Lords have referenced the importance of the guidelines, it is worth saying that a quick look at the NICE website reveals there are 1,591 guidelines, pieces of advice, quality standards and all the rest of it—most of which have not been subject to the full cost-effectiveness and affordability assessments that the gold standard technology appraisal performs. Before there could be a legal mandate for those guidelines, there would be some very significant methodological considerations for NICE. Without those, the risk is that mandating those guidelines would take resources away from other parts of needed care, such as mental health and community nursing—Cinderella services that have not been subject to those same processes.

We should also recognise that, vital though NICE is, the bigger contribution to the diffusion of best practice will probably be made in other ways. Certainly, reporting could help. Although one amendment makes the perfectly reasonable proposition of an annual report from integrated care boards on their adoption and uptake, that still feels a slightly 20th-century solution. If you go to Oxford University’s superb www.openprescribing.net, you can see your own GP practice and your own CCG’s prescribing patterns against the national norm, including, as the noble Baroness, Lady Finlay, said, for the DOACs, the anticoagulating medicines. Those technologies are already available, and the role that clinical pharmacists are now playing, including the thousands of new clinical pharmacists hired to work alongside GPs to improve their prescribing habits, is also likely to have an important influence.

Finally, there is this question of whether, just occasionally, conflicts of interest might arise on the part of prescribers or clinicians over the medicines or devices being used. The noble Baroness, Lady Cumberlege, has drawn attention to this in her important work, and that is perhaps something the House might return to at a later date.

[Lord Lansley (Con)]

My Lords, I want to intervene at not too much length. I welcome these amendments and am grateful to my noble friend Lady McIntosh of Pickering for bringing hers forward. It enables us to touch on a subject which those of us involved in the Medicines and Medical Devices Act will recognise. This is a short version of the debates we had then, but it gives us an opportunity to update a little on those and me an opportunity to ask my noble friend on the Front Bench a few questions arising from that. We are all grateful to the noble Lord, Lord Stevens of Birmingham, who clarified some of the terminology, which saves us going wrong. But I want to do a bit of clarification about some of the amendments as well.

The timing of this is terrific. We are discussing this today and NICE published the outcome of its methods review yesterday, so we can respond immediately. My starting point is to applaud NICE for having taken up and accepted the proposition that there should be a modifier in relation to its appraisals and assessments on severe diseases. We can argue about the precise detail, but it has taken that up.

Secondly, randomised control trials are terribly important but they are not the whole story. NICE has rightly accepted it should look at more real-world evidence and that, too, we can welcome, but it leads me directly to a question. Part of that real-world evidence, and one of the reasons it is not going directly to NICE, though NICE can use it, is the innovative medicines fund. NHS England published its proposal for the innovative medicines fund in July and said that it would consult on it, but it has not done so yet. My first question to my noble friend is therefore: when will NICE and NHS England consult on the innovative medicines fund?

The third point on NICE’s methods review is that it will take account of the wider impacts of the treatments it appraises. That is terribly important, especially given the present opportunities for personalised medicines and gene-based treatments, when one looks at how these can impact substantially on people’s lives from a relatively early stage and the contributions they can make to society and the economy. That is all good news.

The press release from NICE, however, did not draw specific attention to where it had proceeded in a way that its stakeholders did not support. It has maintained a reference-case discount rate of 3.5%, although NICE itself admitted that there was evidence that a lower discount rate would give significant benefits. It said that there would be wider implications for policy and fiscal complexities and interdependencies if it were to do this, which I think means “The Treasury said no”. We need to think very hard about whether a discount rate as high as 3.5% is appropriate for NICE’s application of its appraisals. I ask my noble friend, though he will not be able to give me the answer to this: who is telling NICE that it cannot adopt what it regards as the evidence-based discount rate for the appraisals it undertakes?

Health and Care Bill

Lord Stevens of Birmingham Excerpts

Lords Hansard - Part 2 & Committee stage
Thursday 13th January 2022 Lords Chamber

I look forward to the comments of my noble friend Lord Stevens of Birmingham on his Amendments 201 and 210, dealing with procurement and payment issues, to which I have added my name and which I support. Obviously, I look forward to contributions from the Committee and a response from the Minister, which I very much hope will be positive. I beg to move.

[Lord Stevens of Birmingham (CB)]

My Lords, it is a great privilege to follow the noble Baroness, Lady Hayman, and support all the amendments in this group in her name. I speak particularly to Amendments 201 and 210 which, as she said, refer specifically to using the purchasing power of the NHS to drive this agenda. Given how brilliantly she has set out the case, I shall be extremely concise.

There are two evidence-based reasons why these amendments are important. The first, as the noble Baroness said, is because the health consequences of the environmental crisis are increasingly clear. The Royal Society and the Academy of Medical Sciences laid all of those out. Whether on heat-related deaths, the disruption to care through climate emergencies, the increased risk of vector-borne infectious diseases, or the fact that up to a third of preventable asthma cases may be linked to the consequences of air pollution, the health case for action is clear. The second evidence-based reason, again as we have just heard, is that unfortunately healthcare itself is not blameless. It is part of the problem as well as part of a solution. By one estimate, if all the health systems in the world were their own country, they would be the fifth-largest greenhouse gas emitter on the planet. Therefore, the NHS must get its act together, given that it contributes 4% to 5% of our country’s emissions.

Those are the two evidence-based reasons. The NHS has stepped up in the way that the noble Baroness has set out. An expert panel led by the brilliant Dr Nick Watts made it the first health service in the world to charter a practical blueprint to net zero, but to do that, we must recognise that only about 28% of the carbon footprint of the NHS arises directly from care being provided. Another 10 percentage points are associated with travel on the part of patients, staff and visitors, but 62% of the carbon footprint arises from the supply chain—the medicines, the devices, the anaesthetic gases, the asthma inhalers, that the NHS uses, which it procures from 80,000-plus suppliers.

I am grateful to the noble Lord, Lord Prior of Brampton, and the noble Baronesses, Lady Young of Old Scone and Lady Hayman, for their support of my Amendments 201 and 210. Their purpose is simply to harness the £150 billion of purchasing power that will flow through either the new NHS payment system or the procurement rules to achieve the two evidence-based rationales that we have been discussing.

[Baroness Northover (LD)]

My Lords, this is my first foray into this Bill. I have a sense of déjà vu, having deputised for the noble Earl, Lord Howe, on the 2012 Bill. Despite our absolute confidence at the time, it seems that some things need to be tweaked and rectified, though I now find myself on this side and the noble Earl on the other.

From these Benches, I support these amendments. The noble Baroness, Lady Hayman, put it very effectively. Climate change needs to run through to the very foundations of the Bill, as does addressing the health inequalities which were the subject of the previous debate. We have had such a long-standing debate about them over the years.

As the noble Baroness has said, at the moment, the UK is taking the lead internationally on combatting climate change through COP 26 and in the year after. We have been urging the world to take urgent, deep-rooted action if the enormously damaging effects of climate change are to be tackled and reversed. We know that the poorest will be hardest hit and can already see that effect, but no part of the globe will be spared. We can already see this as well.

As the noble Lord, Lord Stevens, said, we also know the effects on human health worldwide. We can see them already in developed countries: we saw the effect of that heat dome in Canada and the deaths that resulted from it. We know that climate change might have played a part in seeding the pandemic from which we have suffered during the last two years. We know all that. We also know that we cannot lead internationally without addressing climate change nationally. I pay tribute to the staff supporting Peers for the Planet, a group of which I am a member, for making sure that we address climate change at every stage, in every Bill.

We are rightly proud of the NHS. It is the major employer in the United Kingdom. The health and social care of our ageing population will play an ever more important role in our lives. It is therefore right that, in the Bill, as in every other area of life, tackling climate change must run as a thread through all we do. The Climate Change Committee makes this clear. It is not something for only Defra or the COP team. It requires fundamental change in everything we do and the scrutiny of every area of life.

The NHS has already made strides forward. Here, I pay tribute to the noble Lord, Lord Stevens, in making sure that that was the case. At COP 26, the NHS made a commitment to net zero. As we have heard, 14 other countries followed the NHS’s lead. More than 50 countries, representing more than a third of global healthcare emissions, have committed to developing sustainable, low-carbon health systems. This is incredibly encouraging. It is also encouraging that, at COP 26, a new international platform was set up—to be hosted in partnership with NHS England and the WHO—to bring together those in the healthcare systems, so that people can learn from each other.

Why does this matter? As the noble Baroness, Lady Hayman, has said, the healthcare sector is responsible for almost 5% of global emissions. Of course, public health is assisted by tackling climate change. Although we pay tribute to what the NHS has managed to do so far—and it is ahead of its requirements under the Climate Change Act—we need to make sure that this is built in and sustained for the future. This is what these amendments are about. Progress is being made, but we need to ensure that it is locked in and does not necessarily depend simply on who is leading these organisations at any particular time.

The noble Baroness, Lady Hayman, has explained how her first amendment affects the overarching structure within NHS England. The other amendments put in place the necessary pragmatic steps to make sure that this is addressed. Thus, we have identified individuals for these particular responsibilities. This is obviously of key importance.

It is fundamental that, in addressing climate change, we do not just see this as hosting a major meeting or siloed in one department—whether Defra or BEIS. I am a member of the Select Committee on the Environment and Climate Change. When our committee asked the different departments to report on what they were doing in advance of COP what came back to us, in many regards, was a kind of surprise that they were relevant to it. They felt that it was something for Defra, for BEIS in particular, or for the COP unit. They did not see it as their responsibility. Some of the responses were superficial in the extreme. That is why it is important to make sure that we mainstream this issue, and this is another opportunity to do so. I strongly support the amendments that the noble Baroness, Lady Hayman, and others have tabled.

Health and Care Bill

Lord Stevens of Birmingham Excerpts

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

Moved by

[Lord Stevens of Birmingham]

5: Clause 3, page 2, line 8, at end insert—
“(ba) in subsection (2) insert— “(c) whether for the period covered by the mandate NHS England must ensure that revenue expenditure on mental health services increases as a proportion of total NHS revenue expenditure.””Member’s explanatory statement
This amendment would require the Secretary of State to be explicit and transparent about whether NHS England is required to ensure funding for mental health services grows as a share of total NHS revenue expenditure during the period covered by its mandate from the Government.

[Lord Stevens of Birmingham (CB)]

My Lords, these amendments all relate to mental health, and I should perhaps start by following in the wake of my former colleague, the right reverend Prelate the Bishop of London, and declaring my former interest as an NHS chief executive.

I doubt whether anyone here needs persuading of the importance of mental health. Over the past decade, there has been a sea change in public awareness and attitudes and, at the same time, the NHS has begun to expand services to make good historic deficits, but it is not mission accomplished—far from it. The mission has just got a lot tougher. The pandemic has exacerbated and intensified mental health needs not just in this country but across the industrialised world. To take just one data point, we have seen a 69% increase in the number of young people being referred to specialist children and adolescent mental health services, including for eating disorders. At a time when, entirely appropriately, the focus is on cutting waits for surgical operations, we must make sure that mental health continues to get the focus, priority and constancy of commitment that it requires.

The purpose of this group of amendments is to ensure that that occurs. Having moved Amendment 5, I shall speak to related Amendments 12 and 136 in my name and those of the noble Baronesses, Lady Hollins, Lady Merron and Lady Tyler.

In a nutshell, our Amendment 5 would ensure that Government mandates to NHS England always contain explicit and transparent marching orders on mental health funding. I think it was a fellow called James Frick who said:

“Don’t tell me where your priorities are. Show me where you spend your money and I'll tell you what they are.”


That is why, in England, each year since 2015, mental health investment has been required to grow as a share of the NHS funding pie, and I am pleased to tell your Lordships that it has done so. The Minister should not take this amendment as a criticism; it is an encouragement to stay the course of putting our money where our mouth is, towards parity of esteem—or, if he prefers, levelling up between physical and mental health.

Of course, the mathematically minded among your Lordships might argue that if the share of NHS spending going on mental health keeps increasing, eventually we will have overshot what is needed. My response is twofold. First, in the real world, we are many years away from that happy state of affairs, and, in any event, the amendment does not require Governments to increase the relative share of resourcing for mental health; it simply requires them to be intentional and public about their mental health funding choices. It does not tie Ministers’ hands; it just requires them to reveal their hand. It means that the Government have to be clear about their asks of the NHS, and Amendments 12 and 136 mean that the NHS in turn has to be transparent in reporting on its delivery of them.

That is why these amendments command strong support outside this House from leading mental health charities, patients’ groups, and professions. Taken together, in practice the amendments represent spine stiffeners for the Government and accountability boosters for the NHS. I beg to move.

[Lord Howarth of Newport (Lab) [V]]

My Lords, I welcome the amendments in the names of the noble Lord, Lord Stevens, and the noble Baroness, Lady Hollins. The emphasis on prevention in her Amendment 13 is particularly important.

I will make two points. There is abundant evidence that the engagement of the creative imagination can benefit mental health through improving well-being, confidence and self-esteem. The Creative Health report of the All-Party Parliamentary Group on Arts, Health and Wellbeing discusses, for example, the work of Artlift, a charity founded by a GP, Dr Simon Opher, which delivers arts on prescription in Gloucestershire and Wiltshire. One participant said:

“I had split up from my partner, found myself without anywhere to live and couldn’t see my children. I couldn’t work as I wasn’t physically able to do the job and wasn’t in a position mentally or financially to start a building business again after going bankrupt. Since going to Artlift I have had several exhibitions of my work around Gloucester. I find that painting in the style that I do, in a very expressionistic way, seems to help me emotionally. I no longer take any medication and, although I am not without problems, I find that as long as I can paint I can cope. It doesn’t mean that depression has gone but I no longer have to keep going back to my GP for more anti-depressants, I just lock myself away and paint until I feel slightly better. I now mentor some people who have been through Artlift themselves and they come and use my studio a couple of times a week to get together, paint, draw and chat and I can see the benefit to them”.


The World Health Organization scoping review of 2019 synthesises evidence of the efficacy of the arts in preventing stress and anxiety and building self-esteem and self-confidence. A report to DCMS in April 2020 entitled Evidence Summary for Policy: The Role of Arts in Improving Health & Wellbeing, by Dr Daisy Fancourt of UCL et al, draws attention to

“a large literature of RCTs”—

randomised controlled trials—

“on the treatment or management of mental illness through arts involvement”.

Creatively Minded, a Baring Foundation report of 2020, maps 170 examples of organisations running arts and mental health projects in the UK.

--- Later in debate ---

Having said all that, I have heard the passion and strength of feeling from noble Lords across the House. I want to reassure all noble Lords that I will continue to reflect carefully on the specific points raised in the amendments and in the debate today. I would be happy to meet noble Lords to discuss their ideas and proposals further. I hope that we can find some agreement. I thank your Lordships for the thoughtful debate on this important subject. I hope I have reassured noble Lords that this Government are committed to delivering parity of esteem between physical and mental health. In our conversations between this stage and Report, I hope that we can seek to reduce that gap in understanding. For these reasons, I ask noble Lords to consider withdrawing or not pressing their amendments.

[Lord Stevens of Birmingham (CB)]

I thank the Minister for that careful response. Across the Committee, we have all obviously heard the breadth and depth of concern for the issues surfaced through these amendments. It is obviously for other noble Lords to infer this for themselves, but my sense is that these were not simply explanatory or probing amendments but, significantly, amendments with a view towards testing the view of the House on whether we can change the wording in the Bill itself. That is obviously not a matter for tonight, but I anticipate that we will return to some of these issues, perhaps on Report. In the meantime, I beg leave to withdraw Amendment 5.

Amendment 5 withdrawn.

Health and Care Bill

Lord Stevens of Birmingham Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Stevens of Birmingham (CB) (Maiden Speech)]

My Lords, I thank noble Lords for the warm and generous welcome. I joined the NHS on its 40th anniversary, in 1988; it is therefore a huge privilege to participate in this important debate more than three decades later.

I know that time is tight so I will cut to the chase and make three brief points. First, the Bill does indeed go with the grain of what patients can see is needed and what people across the NHS have been trying to bring about for some time now. It is not a cure-all—no Act of Parliament ever could be—but it removes legal, bureaucratic barriers to more joined-up care. The fact is that, as we dig our way out of the consequences of the worst pandemic in a century, as your Lordships have just heard in Oral Questions, GPs, hospitals and community services will need to work together in radical and new ways. This Bill will facilitate that. It is also the case that, in an era when, despite fantastic advances in medicine and science, we are seeing growing inequalities and a far higher proportion of patients with long-term conditions, just about every health system in the industrialised world is trying to move towards more integrated and preventive care.

In that respect, I should perhaps depart slightly from the noble Baroness’s comments on fluoridation, if I am permitted to do so in a maiden speech. I welcome this move towards dental decay prevention. I should declare an interest on the part of my teeth, in that I happen to have had the good fortune to have been born in Birmingham just a few years after that great city introduced fluoridation. If the whole country now follows its lead, we have the potential to halve the dental decay of children in the poorest communities.

To get back to the point, my second observation is that a number of the concerns raised about the Bill are perhaps a little wide of the mark. It is hard to sustain the argument—it has not been made this afternoon, at least so far—that the Bill in some way advances the privatisation of the National Health Service when in fact it scraps the EU compulsory competitive tendering regime imposed on it. However, there is a case for the Government to consider potentially strengthening some of the safeguards in Clause 70, which would ensure that, where contracts are being let for the private sector, that is done in an open, transparent and fair way.

The Bill does not fragment the NHS. It brings together local funding for GP services, hospitals and community services. It removes the role of the Competition and Markets Authority, enabling hospitals to work together, as the pandemic has shown to be so necessary. It brings together the triple-headed Cerberus of Monitor, the Trust Development Authority and the Commissioning Board to create a unified and accountable NHS England.

The Bill puts on a statutory, transparent and accountable basis the informal local partnerships that have arisen between the NHS and local councils out of necessity. It rightly allows them local flexibility because, in a country as large and diverse as ours, one size does not fit all. To suggest that the mere existence of these local bodies somehow constitutes the fragmentation or destruction of a National Health Service makes sense only if you think that every decision in the NHS can be taken nationally. That has never been the case and would never work. As one commentator on the NHS said, in the event of a nuclear war, only two things will survive: cockroaches and the regional tier of the National Health Service.

My third and final point is that, notwithstanding its many merits, just like the NHS, the Bill is not yet perfect. There is an opportunity to strengthen the provisions in respect of social care and mental health. As a number of noble Lords have set out, just about everybody can agree that, in principle, the major challenge facing health and social care is the strength and resilience of the workforce. It is therefore ironic that, for many years now, we have been promised a detailed, funded and properly thought-through workforce plan for education and training, stretching out over five, 10 or 15 years, yet, on each occasion when that detailed plan is about to be produced, it is muzzled. Jeremy Hunt’s Commons amendment sought to remove the muzzle; I hope that your Lordships will consider something similar in this House.

Finally, in respect of the Secretary of State’s powers, care is needed to ensure that this does not end up inadvertently centralising a number of decisions on service configurations that are best made locally. I remember, early on in my NHS career, attending a public meeting at which the proposed closure of a small maternity unit in town was being discussed. It was a very well-attended public meeting; large numbers of people showed up. The director of public health tried to set out the case that there just were not enough births in this midwife-led unit. A voice came from the back of the hall: “How many do we need, then?” There was a bit of head-scratching and a puzzled look, then he spluttered an answer. The voice at the back of the hall came back: “In that case, give us 18 months”. I can tell your Lordships that, in 18 months, that town did produce the requisite number of babies and the maternity unit is still open. That is not a decision that should have been taken in Whitehall. Yet, lurking near the back of the Bill, in Schedule 6 on page 197, are provisions that essentially do that. Nye Bevan may have said that he would like the sound of the dropped bedpan to reverberate around Whitehall, but not even he suggested that each hospital should write to him personally for permission to move the cupboard in which the bedpans are stored.

To conclude, despite all I have just said, there is considerable merit in the Bill. I believe that it is pragmatic, modest and evolutionary. It builds on many of the changes that people across the health service have looked to put in place over the past decade. Nye Bevan, the patron saint of the NHS, said that

“legislation in this country … starts off by voluntary effort … by empirical experiment … by improvisation. It then establishes itself by merit, and ultimately at some stage or other the State steps in and makes what was started by voluntary action … a universal service.”

That is the legislative task before us.