Health and Care Bill

Baroness Bennett of Manor Castle Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

Given the chronic underfunding of mental health and the frankly egregiously low historical baseline, there is still far to go for mental health to reach parity with physical health services. The foundations provided by the £500 million Covid-19 recovery funding need to be built on in the coming years to ensure that the long-term planned trajectory is restored, the demand arising from the pandemic can begin to be addressed, the Mental Health Act reforms, which we have not heard very much about recently, are successfully implemented, and the waiting time targets arising from the clinical review of standards can be introduced effectively.

[Baroness Bennett of Manor Castle (GP)]

My Lords, this has been an extremely rich and informative debate on a diverse set of amendments. My contribution will be fairly brief, but I want first to reflect on the comments of the noble Lord, Lord Scriven, about the elephant in the room. He reflected on many other contributions about the lack of real integration of health and social care in the Bill, and the way the Bill is essentially written for health. I do not disagree with that identification of that elephant, but a second giant creature in the room is being ignored—let us call it a mammoth—which is the lack of adequate funding and numbers of people for health and social care. That means that those silos are seeking to defend their funding and resources, and reserve it for what they see as their core functions. They therefore find it very difficult to reach out and stretch into new areas even where that would have huge net positive impact overall.

To reflect on a couple of other things, I heartily endorse the call from the noble Lord, Lord Farmer, for a reverse Beeching for the NHS with the reopening of community hospitals. I am not sure whether he coined that phrase; I might borrow it, if he does not mind.

I will also comment on Amendment 51A in the names of the noble Baronesses, Lady Finlay and Lady Jolly, about emergency services going to everyone in the area. I see that the noble Lord, Lord Davies of Brixton, is in his place. This very much ties in with an amendment that he spoke to on Tuesday. He told a tale, which I will not repeat, about a case in which someone was denied a treatment in a neighbouring area that they desperately needed because of arguments about which area they were in. This is potentially a huge problem with the structure we are creating that has to be taken on board. Amendment 51A deals with the responsibility, but of course there also have to be funds to go with that responsibility.

It has not got a lot of attention, but I also commend Amendment 100 in the name of the noble Baroness, Lady Finlay, on the duty to promote rehabilitation. When we talk about dramatic medical interventions—the high-profile stuff—it is generally acknowledged, but always as an afterthought, that the person who has had that big dramatic intervention will not suddenly be cured tomorrow, in most cases. There is a long process of recovery. Indeed, I have put on my reading list Recovery: The Lost Art of Convalescence by Dr Gavin Francis, which has been glowingly reviewed in many places. That is something we all should be thinking about a lot more.

Finally, I come to Amendment 110, in the name of the noble Baroness, Lady McIntosh of Pickering, to which I attached my name because, as the noble Baroness said in her introduction, this is something that we have addressed again and again in the police Bill and the Domestic Abuse Act, but it is very acutely an NHS problem. I draw on an article from the Nursing Times on 24 December. It is an account of a nurse, who was called Claire in the article. When she was going through a checklist with a patient that had been provided by a charity—this was something extra added in from the outside, not core NHS—she realised that she herself was a victim of domestic abuse. She had said yes to more of the questions than the patient had. That is a demonstration of what the noble Baroness, Lady McIntosh, said: training is not given to medical professionals to see what is happening to themselves and to their patients. Maybe it is added in because a charity has managed to get something into the system, but it will certainly not be across the system.

We hope we are doing this Bill for the long term—although perhaps we are not so certain, as the noble Lord, Lord Hunt, said—but we have to note that this is happening in the context of the Covid-19 pandemic. I note that the NHS sexual assault referral figures for the first half of 2020 dropped significantly. That also picks up a great deal of domestic abuse, yet online searches for domestic abuse were up by 350% in the same period. We have an NHS that has been forced to focus on the Covid-19 pandemic, often drawing away resources that might have started to deal with domestic abuse anyway. We have a huge rise in the problem. Considering the moment we are at now, it is crucial that domestic abuse is in the Bill.

[Baroness Walmsley (LD)]

My Lords, this is an enormously important debate because it deals with my favourite word in health and care: prevention. Prevention is so important because it is cost effective. Although successive Governments give more and more to health services, no Government will ever be able to give enough to the NHS, because we have an ageing population and innovative medical interventions are getting more and more expensive, unless we do things differently and more cost effectively.

The noble Lord, Lord Black of Brentwood, outlined one very good, cost-effective intervention. It is an excellent example of something that has absolutely powerful evidence of its cost effectiveness but which is not being undertaken everywhere. I would like to know what evidence those areas that are not using fracture liaison services have that their way of doing it is better and more cost effective. I do not think they have that evidence. It is an example of where if you do not mandate it they will not all do it, and then they will not be spending their money effectively. I support the noble Lord’s amendment.

It is also very important that we prevent not just the second fall but the first, because, as the noble Baroness, Lady Finlay, said in her very important intervention, including what she said about tourist areas, which is very significant, people do die from falls. I had a very old friend who recently did. It was the first fall. I am afraid that person died because he had internal bleeding that nobody spotted. It is really important.

My noble friend Lord Rennard mentioned something really important that is pre-primary intervention: health education. If you know that you are likely to have good, strong, healthy bones from weight-bearing exercise and a diet that has enough calcium and vitamin D, you are much less likely to have the first fall. Fortunately for the Minister, that is beyond his remit. I am sure he is pleased about that, because he has quite enough to do. The Department for Education should listen to that.

My noble friends on these Benches have highlighted some other areas where effective prevention services are not being done properly. I think we were all struck by the chaotic situation that my noble friend Lady Barker highlighted; something really has to be done about that. A lot of good has been done but a lot more could be done, and, again, it would be cost-effective.

The noble Lord, Lord Layard, has suggested a very cost-effective intervention. If we diagnose and intervene on mental health issues early then we can prevent all kinds of more severe mental and physical health problems. I support the ratchet method that the noble Baroness, Lady Harding, referred to of increasing the amount of funding that goes there. Although the noble Baroness, Lady Watkins, rightly listed the number of times that the Government have put more money into mental health services, the question is: have they kept up with the demand and the backlog? I do not think they have.

We have an opportunity in the Bill to improve our measures to prevent ill health, as well as treat it, which is of course more cost-effective, especially when services are delivered by small social enterprises working at community level. I have added my name to the amendment from the noble Lord, Lord Farmer, because I believe these prevention services should be available as close as possible to those who need them most. If that does not happen then the people who need them will not access them, and health inequality will continue.

That is particularly important for those communities where health inequality is at its worst and where preventable diseases are most prevalent. For example, the services might include healthy weight management services, therapies to address less severe mental health conditions, and alcohol and drug addiction services, in addition to the usual GP services. The population groups are not just those in poverty but marginalised groups such as homeless people, those in temporary accommodation, refugees, Gypsy and Traveller communities, and others who may not be plugged into regular services, and that includes those in rural areas.

Many of these services are delivered very effectively by social enterprises or charities, where any surpluses are ploughed straight back into more services. Many of them also provide weekend services, which were mentioned as lacking by the noble Baroness, Lady Masham. Boards that do not ensure the survival of such services are really missing a trick that would help them to deliver their duty to level up health inequalities, because these organisations are usually very close to their communities and know exactly what is needed and where. They are not constrained by the regulations or the culture of large organisations, and are therefore more flexible and fleet of foot, and therefore very cost-effective.

On rural areas, I shall give your Lordships a brief example from my noble friend Lady Jolly, who lives in a very remote part of Cornwall. She says:

“We have a satellite surgery in our local village, it is in the ground floor of an old cottage. The pharmacist visits once a week, and a practice nurse visits once a week. When she is seeing a patient they have to switch the radio on so that no one can hear the conversation”—


because of patient confidentiality. In that village you have to drive 20 miles to reach a GP. That is the sort of place where we really need community access to health services of all kinds. It would be nice to think that the ICB would be aware of that and act accordingly, and it might perhaps be worth putting a duty in the Bill.

--- Later in debate ---

[Baroness Hollins (CB)]

My Lords, I have some brief points to add in support of my noble friend Lord Low’s Amendment 56A, which the noble Lord set out so clearly, and also in support of the amendments tabled by the noble Lord, Lord Crisp. It is very clear to me that primary eyecare has lagged well behind other areas of primary care in terms of any commissioned schemes for children and young people who are not in special schools and for adults with learning disabilities.

My experience with my son sound very similar to those described so well by the noble Baroness, Lady Uddin. The similarities are quite extraordinary, and my heart goes out to her. This week my son went to see the optician. He is visually impaired; he has a learning disability and autism. Fortunately for him, the optician responded well to the request for some reasonable adjustments to be made—which are required by law, but perhaps not well understood in local high street opticians.

Some years ago I did some research with SeeAbility, and together we created a visual, word-free resource. I declare an interest here, because this was with the charity I founded and chair: Books Beyond Words. We created a story called Looking After My Eyes and I read this with my son before he went to his optician’s appointment yesterday. It helped him and it helped the optician. But we need targeted improvements in optical care for everybody with a learning disability across the country. For this reason, I thoroughly support my noble friend’s amendment.

[Baroness Bennett of Manor Castle (GP)]

My Lords, in the wake of such a hugely powerful group of contributions, mine is very much a supporting role and I will be brief. I can only endorse the contributions to the amendment put by the noble Lord, Lord Low, and what we have heard about why it is so urgent. I will speak to Amendments 112 and 218, to which I have attached my name.

I attached my name to Amendment 112 because, as I was looking through the amendments, it struck me as such a crucial one. It was one that, even at this stage, it was really important to have four signatures on to show broad cross-party support. I am afraid I did not go for Amendment 113 and the rest of the list as well, on the grounds that I thought my name was there enough already, but I think the rest are—if not technically, certainly practically—consequential on Amendment 112.

After I had done that, I received a briefing from the Royal College of General Practitioners, writing also on behalf of the Royal Pharmaceutical Society and the Association of Optometrists. I will quote one sentence. The college says:

“We think this is a classic example of where secondary care is at the centre of decision-making, while GPs and primary care are ‘consulted’.”


I think that reflects what the noble Lord, who has a great deal of expertise, said, and this is one amendment that is a total no-brainer.

Moving to Amendment 218, the noble Lord, Lord Hunt of Kings Heath, outlined the technical background to this and the statistics. The only thing I will add is that many think tanks, including the Health Foundation, the King’s Fund and the Nuffield Trust have produced information about how extreme the variation in availability of GP services is and how much effect that has on inequality. As the noble Lord, Lord Warner, said, if the Government have a levelling-up agenda, this also is surely essential.

The reason I was personally attracted to this amendment is that in my days as Green Party leader I travelled around the country a lot and quite often ended up meeting GPs, very often talking about public health issues. I encountered so many desperately hard-working, utterly committed people who were exhausted and felt that they could not retire or cut back their hours. They were wearing themselves to the bone because no one was coming to replace them. I felt that I needed to stand up and speak for those people.

Sometimes people think of this as something that affects rural or remote areas. However, the Norfolk Park health centre in Sheffield nearly closed last year because, after extraordinary efforts, it had been unable to find an extra partner to come in. As the noble Lord, Lord Scriven, knows, this surgery is a fairly modest bus ride from the centre of a major city. It is a purpose-built health centre and only eight years old, but it could not find a GP partner to come in. Eventually, after a great deal of public campaigning, the surgery remained open. That is a demonstration of just how broad this problem is, yet, as the noble Lord, Lord Hunt, said, there are parts of the country—broadly the wealthier parts—that have expansive GP coverage.

Something has to be done, but, like the noble Lord, Lord Hunt, I am not sure that the proposal here is exactly the right way forward. We often say that something needs to be done, but we really need to see something done here. As with so many of the amendments that we discussed this morning, the Bill we have before us is the chance to sort out an urgent problem that must be sorted out.

[Baroness Cumberlege (Con)]

I would like to say a few words and will start by complimenting the noble Lord, Lord Crisp, on all his amendments. I agree with the noble Lord, Lord Scriven, that these are not contentious. In fact, I do not think it would harm the Government at all to include these amendments in the Bill. They are trying to reinstate the primacy of primary care.

We all know that the glamour is not in primary care but hospitals—you have only to see where politicians like to be photographed; when they produce newsletters, they are always pictured in a hospital with a very sophisticated piece of new machinery that that hospital has bought. It is understandable, because that is so easy to recognise. With a photograph of a GP in a consulting room, you do not know quite where this is, who it is, or what he is doing. One can understand why the media goes for the picture of the hospital, because that is what people recognise.

In this debate and these amendments, we know that the absolute foundation of the NHS is primary care. It is so important and we have to build its primacy. I am a child of primary care; I grew up in it. My father joined the NHS in 1948. He welcomed it and thought it was a marvellous innovation. I had a very happy childhood as Dr Camm’s daughter; I had status in the community. Then I segued into being Mrs Cumberlege and my status plummeted—because I had married a farmer. We celebrated our wedding 61 years ago last week, so have had a diamond wedding. My husband said to me, “Julia, what do you want?”, and I said, “Well, it is a diamond wedding”. He delivered, and I was just delighted.

I will not extol the virtues of my father’s practice, but want to think of the role of the GP in the future and how it has already changed. In our practice, all the GPs are now part-time. They are men and women, and they have other lives to lead. None of them is a full-time GP, and that makes continuity of care quite difficult, because you are never quite sure whether they will be there or not. If you want an urgent appointment, of course you can get one, but it will probably not be with your GP. So that has changed.

There has been another change. My father built a health centre. In fact, it was the county council that built it, but he put all the pressure on to build it, and it was called the “health centre”. Today, it is not called that; it is called the “medical centre”. That is because the doctors are transactional. They just do what is in front of them. Health is not part of their remit, and it is our community that provides the health. It is the church which has the social work and provides a huge amount of the social services for our community. So things really have changed.

A very good paper was produced by the Royal College of General Practitioners, in June of last year, The Power of Relationships: What Is Relationship-based Care and Why Is It Important? It is such a good paper, and I recommend that noble Lords look at it before we have the debate led by noble friend Lady Hodgson on relation- ship care and what it means. The statistics show that people live longer with relationship care. They are happier. We have some really good evidence, but I shall talk about that when we come to that amendment.

I have been working with Sir Cyril Chantler, whom many people in this House will know. We have been talking about community hubs. We think they are a very good way of moving forward and getting together not only doctors but social care, voluntary organisations and all the community facilities to ensure that they are in a hub. We know that, with integrated services and boards and the work that is going on in integrated care, the populations are enormous. We have to break it down a bit to make it more accessible to people. The next time we have a chance to debate this matter, which will be in the context of relationship care, I shall talk about community hubs with populations of about half a million. We are already establishing maternity hubs. I have said to them, “No, not maternity hubs—you’ve got to make them community hubs; you’ve got to bring in all the other resources that are in the community, because they’ve all got something to offer, and we would all benefit.”

I hope that my noble friend the Minister will think seriously and work with his colleagues to try to ensure that these amendments, or very similar ones, are introduced into the Bill, because we need to ensure the primacy of primary care. I am afraid that it is not there now; it is all about hospitals.

--- Later in debate ---

[Baroness Pitkeathley (Lab)]

My Lords, what I want to say follows on very well from what the noble Baroness, Lady Finlay, said. I want to quote Sir Michael Marmot. He said:

“We need to adopt a health and social care system which prioritises not just the treatment of illness but how it can be prevented in the first place. The pandemic has made it crystal clear … why public health and … social determinants of health are so important. The health and social care agenda must be rebalanced towards prevention.”


This is essentially what the noble Lord, Lord Howarth, is saying. It is not just about the treatment of illness but about preventing it happening in the first place.

I commend my own general practice in north London. In despair at the quantity of antidepressants being prescribed with very little result, it took to organising community groups to do cooking, set up friendship groups and put people in contact with each other. It puts on bring and buy sales—all with people who, perhaps, in the past, might just have been prescribed antidepressants.

I want to say a word about the charitable aspect—the voluntary sector—to which the noble Lord, Lord Howarth, referred. Charities cannot operate unless their core costs are met. My own GP practice which did this wonderful work had to go to the local authority and to the lottery to seek some funding. We have to remember that, if we want voluntary organisations to participate in these wonderful preventive services, we need to ensure that they are properly funded.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I join pretty much everyone else in commending the noble Lord, Lord Howarth, for tabling these amendments. I have attached my name to Amendment 67, although it could have been to any of them.

It is worth making two broad points. In her wonderful contribution on the last group, the noble Baroness, Lady Cumberlege, used the really key phrase,

“the community provided the health”.

That is what this group of amendments is talking about.

A couple of groups back, the noble Baroness, Lady Thornton, talked about how, if the health system is working for people with learning disabilities, it is working for everybody. If we bring in the kind of institutions, frameworks and supports that we are talking about here—if we think about stopping people getting ill and caring for ill people—we will make our communities vastly better for everybody. This is an important point to make.

Like most noble Lords, I could come up with a list as long as your arm of wonderful places I have visited. I will not, but I will mention one, which brings together three elements of this: creativity, nature and culture. The Green Backyard in Peterborough is the most wonderful space. I defy anyone to walk into it and not smile. It has amazing, colourful, moving sculptures powered by water, with food growing—amazing salads filled with flowers. When I visited, I spoke to the carer of another visitor. This visitor had very profound disabilities—she was blind and non-verbal—but her carer said, “I’ve never seen anything like it. After the first time we came to visit, the next Monday, which she knew was the day we visited, she was all packed up, dressed and ready to go out.” This was obviously catering to someone’s needs absolutely brilliantly, but it nearly got bulldozed and turned into a block of flats a few years ago. Luckily, it was saved, but that is the situation we so often find ourselves in.

I also want to mention Amendment 90, in the name of the noble Lord, Lord Howarth. The noble Lord, Lord Best, has already said a great deal on this, so I will seek to add just a couple of small points—well, one small point and one quite big one. There is something called the lifetime homes standard, which I learned about when I visited Derwenthorpe in York with the Joseph Rowntree Foundation. The thing I remember about it, because it was so simple and obvious, was that the two-storey houses there had all been built with a space between the joists so that, if you needed to put a lift in up to the first floor, where the bedrooms were, it was a really simple and low-cost thing to do. It was a very simple piece of design. This will not be covered in the Health and Care Bill, but this relates to so many aspects of our society. You could say that housing is a health issue. In the first group this morning, we talked about social care and how many people cannot leave hospital and go home because their accommodation is unsuitable. We need to think all the way along the line across our society to make sure that does not happen.

Finally, I want to pick out one or two words in this amendment, which talks about housing and urban environments. I thought here of the New Ground co-housing development in north London, which is for women aged over 50. One aspect of it is looking at how people can support each other, be good neighbours and form a community that can provide support. This morning, I attended a King’s Fund briefing talking about social care and there was a great deal of talk about the need for digital innovation and technology. I tweeted, “What about social innovation?” We have to think about how we organise our societies and urban environments so that people can form those kinds of communities. If you visit any area of new housing being built around the country, there is typically precious little in it to encourage that kind of community development. The housing point is obvious, as is the environment point, but let us not lose the community and urban structure points from that amendment either.

[Baroness Walmsley (LD)]

My Lords, it has been an excellent debate. We have heard about all the various kinds of arts and the effect of housing. We heard from the noble Baroness, Lady Morris, about sport and leisure. We heard about the importance of green spaces in helping us with our physical and mental health. The noble Baroness, Lady Finlay, rightly mentioned that loneliness kills. If one can address that, it affects not just one’s sense of worth and well-being, as has been said, but one’s sense of community.

Parliament is a community. It sometimes does not feel like it, because we have various groups, political parties, Members, staff and so on, but we also have a lot of all-party groups and this is significant. We have sports, arts and heritage, drama and music groups. I have been a member of the Parliament choir for 22 years and have found great solace in it—I really missed it during the pandemic.

--- Later in debate ---

I have spoken for rather a long time, but this is an important subject. I hope I have reassured noble Lords that it is very much part of health going forwards, but I regret that the Government cannot accept these amendments, and I ask noble Lords to withdraw or not move them.

[Baroness Bennett of Manor Castle (GP)]

Before the noble Baroness sits down, I would just like to go back to some of the earlier amendments and some of the words she used. She said this is included in the guidance on using social prescribing, and that it is expected that ICBs will work with local social enterprises, et cetera. I want to ask a question. If we were talking about NICE-recommended medical treatments or the best possible surgical procedures, would we be saying that it is expected that ICBs will do this as it is included in the guidance? This picks up on the point the noble Baroness, Lady Morris, was saying that this still seems to be somewhere in the second class, and it should be up there in the first class, treated in the same way as a medical treatment or a medical device.

[Baroness Chisholm of Owlpen (Con)]

Well, I think it is, actually. We all realise how important it is. Social prescribing is a key component of the NHS’s universal personalised care. It is a way for GPs or local agencies to refer people to a link worker. Link workers give people time to focus on what matters and take a holistic approach to people’s health and well-being. They connect people to community groups and statutory services for practical and emotional support.

For instance, a man had bad bronchitis and asthma and was continually going to the doctor and costing the NHS a great deal of money; and it was agreed that a humidifier would be prescribed to him for his house at £800, and that has been a huge success, with the result that he has not gone to the GP once for a whole year. I think social prescribing can work well for those who are socially isolated, whose well-being is impacted by non-medical issues and who routinely present to primary or secondary care as a result. We certainly are taking it seriously.